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FUHRMAN & ZIMMERMAN’S
PEDIATRIC
CRITICAL CARE
SIXTH EDITION
PEDIATRIC
CRITICAL CARE
JERRY J. ZIMMERMAN, MD, PhD, FCCM ALEXANDRE T. ROTTA, MD, FCCM
Faculty, Pediatric Critical Care Medicine, Seattle Children’s Division Chief, Pediatric Critical Care Medicine Duke
Hospital, Harborview Medical Center, University of Children’s Hospital; Professor of Pediatrics; Duke University
Washington School of Medicine, Seattle, Washington School of Medicine, Durham, North Carolina
Joseph D. Tobias, MD
Chair, Department of Anesthesiology and Pain Medicine,
Nationwide Children’s Hospital; Professor of Anesthesiology
and Pediatrics, The Ohio State University, Columbus, Ohio
Elsevier
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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid ad-
vances in the medical sciences, in particular, independent verification of diagnoses and drug dosages
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contained in the material herein.
Previous editions copyrighted 2017, 2011, 2006, 1998, 1992 by Elsevier, Inc.
Printed in Canada
P. David Adelson, MD, FAAP, FACS, FAANS Matthew N. Alder, MD, PhD
Diane and Bruce Halle Chair of Children’s Neurosciences Assistant Professor
Director, Barrow Neurological Institute at Phoenix Children’s Critical Care Medicine
Hospital Cincinnati Children’s Hospital Medical Center
Professor, Department of Child Health Cincinnati, Ohio
University of Arizona College of Medicine;
Professor, Department of Neurosurgery Omar Alibrahim, MD, FAAP
Mayo Clinic Chief, Pediatric Critical Care Division
Phoenix, Arizona John R. Oishei Children’s Hospital
Associate Professor of Pediatrics
Rachel S. Agbeko, FRCPCH, PhD Jacob’s School of Medicine
Consultant University of Buffalo
Paediatric Intensive Care Unit Buffalo, New York
Great North Children’s Hospital
Newcastle upon Tyne Hospitals NHS Trust Veerajalandhar Allareddy, MBBS, MBA
Newcastle upon Tyne, United Kingdom Section Chief, Pediatric Cardiac Intensive Care
Duke University Medical Center
Michael S.D. Agus, MD Professor of Pediatrics
Chief of Medical Critical Care Duke University School of Medicine
Department of Pediatrics Durham, North Carolina
Division of Medical Critical Care
Boston Children’s Hospital Melvin C. Almodovar, MD
Boston, Massachusetts The George E. Batchelor Chair in Pediatric Cardiology
Chief, Pediatric Cardiology
Mubbasheer Ahmed, MD University of Miami Miller School of Medicine;
Cardiac Intensive Care Unit Director, Children’s Heart Center
Texas Medical Center Director, Cardiac Intensive Care
Texas Children’s Hospital Hotz Children’s Hospital, Jackson Health System
Houston, Texas Miami, Florida
v
vi Contributors
From our home working spaces, in the midst of the COVID-19 For pediatric critical care medicine fellows who may read the
pandemic, welcome to the sixth edition of Pediatric Critical Care. textbook cover to cover, and for others who need an updated
The world has finally been provided a realistic glimpse of intensive reference for anything related to pediatric critical care, the new
care units, the work that occurs there, and the dedicated providers edition will not disappoint. Each color-coded section provides
who provide critical care, sometimes at their own peril. This sixth best-evidence clinical approaches to pediatric critical care issues
edition, which now reflects a lifetime work product for many based on contemporary genetic, biochemical, and physiologic
contributors, is dedicated to the multidisciplinary team that infrastructure. Because authors typically want to include all rele-
makes critical care a reality. vant details in their discussion and a hard copy textbook has
What the pandemic has taught all of us is the importance of physical limitations, readers are encouraged to make use of the
being able to adapt to change. As readers page through this new expanded electronic content included with the sixth edition.
edition, many changes will become apparent. Brad Fuhrman, who Board review questions, composed for most chapters, will be
ultimately deserves the credit for creating this publishing adven- valuable for new and repeat readers and are also available in the
ture, decided to move from Co-editor to Section Editor. More electronic content.
than once, likely while sipping single malt scotch together, Brad Finally, all of us must honor the children and families who
noted that Pediatric Critical Care might be our most important provide the meaning for our life work. With the publishing of the
professional contribution. Quality and sustainability over six sixth edition of Pediatric Critical Care, we collectively acknowledge
editions prove his prediction correct. the clinical challenges that critical illness presents. However, these
Meanwhile, Alex Rotta, appropriately one of Brad’s early challenges facilitate curiosity and imagination, growth and experi-
apprentices, has provided outstanding organizational leadership ence, and ultimately personal enrichment. Hopefully the sixth
as Co-editor for the sixth edition. Thanks also to Section Editors edition of Pediatric Critical Care can serve as a valuable tool for
Bob Clark, Sapna Kudchadkar, Monica Relvas, and Joe Tobias. addressing longstanding as well as novel critical care challenges.
Perusing the list of contributors similarly ascertains established
and burgeoning pediatric critical care contributors. Accordingly, Jerry J. Zimmerman, MD, PhD, FCCM
the sixth edition is truly a multigenerational effort. Alexandre T. Rotta, MD, FCCM
xxv
Contents
5 Leading and Managing Change in the Pediatric 15 Ultrasonography in the Pediatric Intensive Care
Intensive Care Unit 29 Unit 114
John C. Lin Erik Su, Akira Nishisaki, and Thomas Conlon
8 Challenges of Pediatric Critical Care in Resource- 17 Pediatric Critical Care Ethics 144
Poor Settings 51 Mithya Lewis-Newby, Emily Berkman, and Douglas S. Diekema
Amélie von Saint André–von Arnim, Jhuma Sankar, Andrew
Argent, and Ericka Fink 18 Ethical Issues Around Death and Dying 154
Meredith G. van der Velden and Jeffrey P. Burns
9 Public Health Emergencies and Emergency Mass
Critical Care 59 19 Palliative Care in the Pediatric Intensive Care
Katherine L. Kenningham and Megan M. Gray Unit 158
Alisa Van Cleave, Eileen Rhee, and Wynne Morrison
10 Lifelong Learning in Pediatric Critical Care 66
Stephanie P. Schwartz, Laura Marie Ibsen, and David A. Turner 20 Organ Donation Process and Management of the
Organ Donor 163
Thomas A. Nakagawa, Mudit Mathur, and Anthony A. Sochet
xxvii
xxviii Contents
33 Disorders of Cardiac Rhythm 329 47 Diseases of the Upper Respiratory Tract 524
Frank A. Fish and Prince J. Kannankeril Todd Otteson, Clare Richardson, and Jay Shah
57 Pediatric Lung Transplantation 679 71 Fluid and Electrolyte Issues in Pediatric Critical
Carol Conrad Illness 866
Idris V.R. Evans and Emily L. Joyce
Section VI: Pediatric Critical Care:
72 Acid-Base Disorders 882
Neurologic 689 Michelle C. Starr and Shina Menon
58 Structure, Function, and Development of the
Nervous System 690 73 Tests of Kidney Function in Children 896
Robert S.B. Clark and Michael Shoykhet Rajit K. Basu
59 Critical Care Considerations for Common 74 Glomerulotubular Dysfunction and Acute Kidney
Neurosurgical Conditions 710 Injury 907
Peter F. Morgenstern, Robert H. Bonow, Isaac Josh Abecassis, Timothy E. Bunchman, Vu Nguyen, and Michelle L. Olson
Samuel R. Browd, and Amy Lee
75 Pediatric Renal Replacement Therapy in the
60 Neurologic Assessment and Monitoring 720 Intensive Care Unit 923
Mark S. Wainwright and Sue J. Hong Raj Munshi and Jordan M. Symons
80 Biology of the Stress Response 971 95 Disorders and Diseases of the Gastrointestinal
Stephen Wade Standage System 1141
Lauren Bodilly and Samuel A. Kocoshis
81 Inborn Errors of Metabolism 976
Cary O. Harding and Amy Yang 96 Acute Liver Failure 1155
Hengqi (Betty) Zheng, Mihaela A. Damian, and Simon Horslen
82 Progress Towards Precision Medicine in Critical
Illness 991 97 Hepatic Transplantation 1162
Mary K. Dahmer and Michael W. Quasney Patrick J. Healey, Britt Julia Sandler, Abigail Apple,
Thomas V. Brogan, and Jorge D. Reyes
83 Molecular Foundations of Cellular Injury 996
Jocelyn R. Grunwell and Craig M. Coopersmith 98 Acute Abdomen 1170
Robert Sawin, Rebecca Stark, and Derya Caglar
84 Endocrine Emergencies 1003
Katherine Ratzan Peeler and Michael S.D. Agus 99 Nutrition of the Critically Ill Child 1177
Ben D. Albert and Nilesh M. Mehta
85 Diabetic Ketoacidosis 1016
Ildiko H. Koves and Nicole Glaser Section XI: Pediatric Critical Care:
Immunity and Infection 1189
Section IX: Pediatric Critical Care:
Hematology and Oncology 1023 100 Innate Immunity 1190
Samiran Ray, Rachel S. Agbeko, and Mark J. Peters
86 Structure and Function of the Hematopoietic
Organs 1024 101 Adaptive Immunity 1199
Seth J. Corey and Julie Blatt Jennifer A. Muszynski, W. Joshua Frazier, and Kristin C. Greathouse
87 The Erythron 1033 102 Critical Illness and the Microbiome 1208
Allan Doctor, Ahmed Said, and Stephen Rogers Rafael G. Ramos-Jimenez, Dennis Simon,
and Michael J. Morowitz
88 Hemoglobinopathies 1040
M.A. Bender and Anne Marsh 103 Congenital Immunodeficiency 1215
Hannah Laure Elfassy, Troy Torgerson, and Christine McCusker
89 Coagulation and Coagulopathy 1052
Robert I. Parker 104 Acquired Immune Dysfunction 1229
Brent J. Pfeiffer
90 Thrombosis in Pediatric Critical Care 1073
Sally Campbell and Paul Monagle 105 Immune Balance in Critical Illness 1242
Mark W. Hall
91 Transfusion Medicine 1082
Jacques Lacroix, Marisa Tucci, Oliver Karam, 106 Pediatric Rheumatologic Disease 1249
and Philip C. Spinella Marla Guzman, Timothy Hahn, Alexandra Aminoff, and Kristen
Hayward
92 Hematology and Oncology Problems 1101
Jesse Wenger, Corinne Summers, and Joan S. Roberts 107 Bacterial and Fungal Infections 1263
Deborah E. Franzon, Emily R. Levy, and Matt S. Zinter
93 Critical Illness in Children Undergoing
Hematopoietic Progenitor Cell 108 Life-Threatening Viral Diseases and Their
Transplantation 1113 Treatment 1273
Prakadeshwari Rajapreyar, Jennifer McArthur, Surabhi B. Vora, Alpana Waghmare, Danielle M. Zerr,
Christine Duncan, Rachel Phelan, Robert T. Tamburro Jr and Ann J. Melvin
Contents xxxi
109 Healthcare-Associated Infections 1284 124 Adverse Drug Reactions and Drug-Drug
Alexis L. Benscoter, Richard J. Brilli, Derek S. Wheeler, Interactions 1464
and Erika L. Stalets Jessie O’Neal, Lauren Dartois, Anny Chan, Wade W. Benton,
and Christa Jefferis Kirk
110 Pediatric Sepsis 1293
Matthew N. Alder, Lauren Bodilly, and Hector R. Wong 125 Principles of Toxin Assessment and
Screening 1486
111 Multiple-Organ Dysfunction Syndrome 1310 April Clawson and Lawrence Quang
Pierre Tissieres and Melania M. Bembea
126 Toxidromes and Their Treatment 1496
Section XII: Pediatric Critical Care: Prashant Joshi
114 Accidental Hypothermia 1332 128 Anesthesia Effects on Organ Systems 1535
Björn Gunnarsson and Christopher M.B. Heard Lindsay M. Stollings, Peter J. Davis, Alison M. Ellis,
and Antonio Cassara
115 Drowning 1337
Jamie L. Bell, Ajit A. Sarnaik, and Ashok P. Sarnaik 129 Anesthesia Principles and Operating Room
Anesthesia Regimens 1544
116 Burn and Inhalation Injury 1347 Joseph D. Tobias
Christian Tapking, Linda E. Sousse, Karel D. Capek,
and David N. Herndon 130 Malignant Hyperthermia 1560
Christopher M. Edwards and Barbara W. Brandom
117 Evaluation, Stabilization, and Initial
Management After Trauma 1363 131 Neuromuscular Blocking Agents 1567
Jessica A. Naiditch, Michael Dingeldein, and David Tuggle Joseph D. Tobias
118 Traumatic Brain Injury 1375 132 Sedation and Analgesia 1583
Patrick M. Kochanek, Michael J. Bell, Dennis W. Simon, Christopher M. B. Heard, Omar Alibrahim,
Hülya Bayır, Jessica S. Wallisch, Michael L. Forbes, and Alexandre T. Rotta
Randall Ruppel, P. David Adelson, Travis C. Jackson,
and Robert S.B. Clark 133 Tolerance, Dependency, and Withdrawal 1611
Joseph D. Tobias
119 Pediatric Thoracic Trauma 1401
Tamara N. Fitzgerald and Christopher R. Reed 134 Pediatric Delirium 1617
Chani Traube and Bruce M. Greenwald
120 Pediatric Abdominal Trauma 1408
Adam M. Vogel and Michael Dingeldein 135 Procedural Sedation for the Pediatric
Intensivist 1624
121 Child Abuse 1417 Nir Atlas, Rahul C. Damania, and Pradip P. Kamat
Tom Kallay and Carol Berkowitz
1
1
History of Pediatric Critical Care
Medicine
DANIEL L. LEVIN AND JOHN J. DOWNES
“In critical care, it strikes one that the issues are three: realism, dignity, and love.”
Jacob Javitz, 1986 (Posthumous Inspirational
Award Honoree, Society Of Critical Care Medicine)
PEARLS
• The evolution of pediatric critical care medicine reflects long starting in the 1970s. This retrieval medicine holds great promise
progress in anatomy, physiology, resuscitation and ventilation, for future improvements in care.
anesthesiology, neonatology, pediatric general surgery, • In pediatric critical care medicine, there have been remark-
pediatric cardiac surgery, and pediatric cardiology. able achievements in the ability to understand and treat criti-
• The role of nursing is absolutely central to the evolution of cal illness in children as well as progress in the organization
critical care units. of pediatric critical care medicine, education, and research in
• Until the 1950s and 1960s, intensive care units were organized the field.
by grouping patients with similar diseases. However, in the • Increasing use of improved technology has advanced the care
1960s, neonatal intensive care units grouped children accord- of critically ill children but has not eliminated errors, complica-
ing to age and severity of illness, and pediatric intensive care tions, or potentially long-term sequelae, and it is associated
units followed this example. with a need for greater focus on establishing a humane, caring
• Sophisticated interhospital transfer services proved significant environment for the patients and their families.
in reducing morbidity and mortality of critically ill children
Evolution of Modern Medicine the development of cardiorespiratory support, and eventually led
to the establishment of intensive care.
The evolution of pediatric critical care medicine (PCCM) reflects Andreas Vesalius (1514–1564), the Flemish anatomist, cor-
a long series of contributions from anatomy, physiology, resuscita- rected many previous mistakes in the understanding of anatomy
tion and ventilation, anesthesiology, neonatology, pediatric gen- and provided positive pressure ventilation via a tracheotomy tube
eral surgery, pediatric cardiac surgery, pediatric cardiology, and to asphyxiated fetal lambs. Michael Servetus of Spain (1511–1553)
the many individuals responsible for the discoveries and innova- correctly described the pumping action of the heart’s ventricles and
tions.1,2 Intensive care units were originally organized by grouping the circulation of blood from the right heart through the lungs to
together patients with the same or similar diseases. However, the left heart. Matteo Realdo Columbo (1515–1559) described
when neonatologists grouped children according to age and sever- pulmonary circulation and the concept that the lungs added a
ity of illness, pediatric intensive care units (PICUs) followed their spirituous element to the blood by the admixture of air. William
example. Transport, or retrieval medicine, developed and nurses Harvey (1578–1657) confirmed the function of the heart and arte-
took on a major role in providing care to critically ill and injured rial and venous circulations through both animal experiments and
children. observations in humans. He published De Motu Cordis3 (On the
Motion of the Heart) in 1628. Because he did not yet have the
Anatomy and Physiology microscope, he could not see the capillaries and thus could not
include the mechanism for transfer of blood from the arterial to
What seems simple and obvious today took a great deal of time, the venous systems of the pulmonary circulation. Capillaries were
effort, and insight to understand. This section discusses some of first described by Marcello Malpighi (1628–1694, Italian) in De
the contributions that advanced the practice of medicine, enabled Pulmonibus (On the Lungs) in 1661. Thomas Willis (1611–1675)
2
CHAPTER 1 History of Pediatric Critical Care Medicine 3
and, eventually, William Cullen (1710–1790) led the way to the provided artificial ventilation to both animals and dead humans
understanding of the role of the nervous system as the site of con- using a bellows.6 Andreas Vesalius, the aforementioned Flemish
sciousness and the regulation of vital phenomena. Richard Lower professor of anatomy, in De Humani Corporis Fabrica, reported
(1631–1691) proved that it was the passage of blood through the ventilating open-chest dogs, fetal lambs, and pigs using a trache-
lungs, ventilation of the lungs, and gas exchange with blood that ostomy and fireplace bellows in 1543.7–9
vivified the blood and turned it red. Stephen Hales (1677–1761) The French obstetrician Desault, in 1801, described how to
measured blood pressure with a brass tube connected to a 9-foot successfully resuscitate apneic or limp newborns by digital oral
glass tube in a horse. Joseph Black (1728–1799) identified carbon tracheal intubation with a lacquered fabric tube and then blow-
dioxide as a gas expired from human lungs. ing into the tube.1 In 1832, Dr. John Dalziel in Scotland devel-
Karl Wilhelm Scheele (1742–1786) isolated oxygen, as did oped a bellows-operated intermittent negative pressure device
Joseph Priestley (1733–1804), who named it “dephlogisticated to assist ventilation.8 In 1864, Alfred F. Jones, of Lexington,
air” and determined its vital role in supporting combustion. Kentucky, built a body-enclosing tank ventilator; in the 1880s,
Antoine-Laurent Lavoisier (1743–1794) identified oxygen as the Alexander Graham Bell developed a so-called vacuum jacket
vital element taken up by the lungs that maintains life and gave it driven by hand-operated bellows.8 In 1876 in Paris, Woillez built
its name (literally “acid generator”). Oxygen’s essential role in what was probably the first workable cuirass ventilator, which
physiology and biochemistry was not clarified until the late 19th was strikingly similar to the “iron lung” respirator introduced by
century when Felix Hoppe-Seyler (1825–1895) described the McKhann and Drinker in 1929 and manufactured for wide-
transportation of oxygen in blood by hemoglobin. spread use by Emerson in 1931.10 Braun developed an infant
Giovanni Morgagni (1682–1771) initiated the field of ana- resuscitator, as described by Doe in 1889, which was used suc-
tomic pathology in his classic book De sedibus et causis morborum cessfully in 50 consecutive patients. A respirator developed by
per anatomen indagatis, published in 1761. He described in detail Steuart in 1918 in Cape Town, South Africa, apparently success-
his observations of the diseased organs in more than 700 autopsies fully treated a series of polio patients, but he did not report it.8
of persons with a wide variety of disorders and made correlations In 1888, Joseph O’Dwyer, a physician working at the
with the patient’s appearance and symptoms, the initial clinical- New York Foundling Hospital who was concerned about the high
pathologic basis of medicine. death rate in croup and laryngeal diphtheria, instituted the man-
In 1842, Crawford Long in Georgia and in 1846, William ual method of blind oral laryngeal intubation using short, tapered
Morton in Boston demonstrated the efficacy and safety of ether brass tubes that entered the subglottic lumen. Despite severe
anesthesia, thereby opening the era of modern surgery. Joseph criticism, he persisted in developing a series of various-diameter
Lister (1827–1912), one of the founders of modern surgery, tubes for the palliation of severe adult and pediatric laryngeal
reasoned that bacteria were the source of pus in rotten organic edema due to infections, including diphtheria. They were
material and in 1865 used carbolic acid in surgical fields and in used until the 1930s. George Fell, another New York physician,
wound dressings to eliminate bacteria. This technique dramati- devised a method of ventilation with a foot-operated bellows
cally improved patient outcomes after surgery. Robert Koch and exhalation valve connected by rubber tubing to the
(1843–1910) developed his postulates in 1882 in order to at- O’Dwyer tube.8
tribute the etiology of a disease to a particular microorganism in In 1898, Rudolph Matas of New Orleans adapted the Fell-
a logical, scientific manner. He also identified the tubercle bacil- O’Dwyer technique to ventilate patients’ lungs during chest wall
lus as the cause of tuberculosis and was awarded the Nobel Prize surgery. In the early 1900s, George Morris Dorrance of Philadelphia
in 1905. Wilhelm Conrad von Röntgen (1845–1923) discov- used the technique to perform resuscitations.8 In 1910, at the
ered x-rays in 1895. Scipione Riva-Rocci (1863–1937), in 1896, Trendelenburg Clinic in Leipzig, two thoracic surgeons. A. Lawen
measured blood pressure using the sphygmomanometer, and and R. Sievers, developed a volume-preset, positive-pressure, elec-
Nikolai Korotkoff (1874–1920) introduced his auscultation trically powered piston-cylinder ventilator with a draw-over hu-
method of determining systolic and diastolic pressure in 1905.1 midifier. It was used successfully with a tracheotomy tube during
and after thoracic surgery and for a variety of disorders causing
respiratory failure.1
Resuscitation and Ventilatory Support Chevalier Jackson (1858–1955), a surgeon at Temple Univer-
sity in Philadelphia, developed a highly specific series of tech-
The key to understanding the present practice of intensive care for niques for laryngoscopy, bronchoscopy, and tracheotomy.1 He
children lies in knowing the history of scientific study of cardio- revolutionized the procedure of tracheotomy and developed a
respiratory anatomy and physiology and the discovery of detailed protocol of airway care. His design of tubes, made of
techniques to support ill patients. Although one could think that silver, for patients of all ages set the standard for tracheotomy
current practice suddenly emerged with the late 20th century, tubes for more than the first half of the 20th century.
technical discoveries and accomplishments in the development of In 1958, Peter Safar, then at the Baltimore City Hospital,
resuscitation and ventilation taken for granted today date back to published studies proving that the long-standing pulmonary re-
the Bible, and numerous events and contributions led to current suscitation technique of chest pressure and arm lift was virtually
practice. In a biblical story,1,4,5 Elisha resurrected a young boy worthless. In effect, he went back to Elisha and proved jaw thrust
who was dead when “he climbed onto the bed and stretched and mouth-to-mouth resuscitation superior.11 Soon after, W.B.
himself on top of the child, putting his mouth to his mouth, his Kouwenhoven and James Jude at Johns Hopkins published work
eyes to his eyes, and his hands to his hands, and as he lowered on the effectiveness of closed-chest cardiac massage.12 In 1946
himself onto him the child’s flesh grew warm....Then the child Beck and his team demonstrated open-chest electrical defibrilla-
sneezed and opened his eyes.” In 117 CE, Antyllus performed tion. In 1952, Zoll and coworkers proved the efficacy of external
tracheotomies for patients with upper airway obstruction.6 Para- defibrillation and, in 1956, the effectiveness of external cardiac
celsus, a 16th-century Swiss alchemist and physician, first pacing.13
4 SECTION I Pediatric Critical Care: The Discipline
TABLE
1.1 Some Early Pediatric Intensive Care Units and Programsa
TABLE
1.1 Some Early Pediatric Intensive Care Units and Programsa—cont’d
Ped., Pediatrics; Ped Anesth., pediatric anesthesiology; Ped Pulm., pediatric pulmonology.
a
This is not intended to be a complete list. It is primarily composed of units well documented in the literature and personally known to the authors.
b
Primary specialties (not all-inclusive).
c
Although conceptual development of unit started in 1965, Dr. Berlin states that the first year of operation of the present ICU was in 1969 (opened December 1968).
d
Columbia Hospital District of Columbia was a precursor of Children’s National Hospital Medical Center.
e
This 20-bed state-of-the-art unit followed an experience with four designated beds in the PACU beginning in 1964.
Data from references 1, 4, 14–23.
development of many techniques to operate on noncardiac con- was established in the 1880s in Paris by obstetrician Etienne
genital malformations. His protégé, Dr. Robert Gross, first suc- Tarnier and his young associate Pierre Budin at the Hôpital la
cessfully operated on patent ductus arteriosus in 1937 and later Charitre with a unit that had a full-time dedicated nursing staff,
on other congenital cardiac lesions. an antiseptic environment, incubators, and gavage feeding of
Dr. C. Crawfoord in Sweden and Dr. Gross in Boston both breast milk. The practices reduced hospital preterm infant mortal-
successfully repaired a coarctation of the aorta in 1945. In the ity in less than a decade from 197 per 1000 live births to 46 per
same year, at Johns Hopkins, Dr. Alfred Blalock (surgeon) and 1000 live births. Their work presaged the development of modern
Dr. Helen Taussig (cardiologist) with Mr. Vivien Thomas (labora- neonatal intensive care in the 20th century. In 1914, the first
tory assistant) created the subclavian-to-pulmonary artery shunt premature infant center in the United States was opened at Mi-
for tetralogy of Fallot. Dr. John Gibbon at Jefferson Medical chael Reese Hospital in Chicago by Dr. Julius Hess (1876–1955).
College Hospital in Philadelphia performed the first successful Canadian pediatrician Dr. Alfred Hart performed exchange trans-
open-heart surgery using cardiopulmonary bypass for closure of fusions involving peripheral artery cannulation in 1928. In 1932,
an atrial septal defect in an adolescent girl in 1953.1 These Drs. Louis Diamond, Kenneth Blackfan, and James Batey at
advances in pediatric surgery created the need for excellent and BCH determined the pathophysiology of hemolytic anemia
often complex postoperative care. and jaundice of erythroblastosis fetalis. In 1948, they described
Dr. C. Everett Koop, who had completed surgical residency at exchange transfusions using a feeding tube inserted into the
the University of Pennsylvania in 1945, then trained in Boston umbilical vein.
with Dr. Gross for 6 months. He returned to the University of In the 1950s and 1960s, Dr. Geoffrey Dawes at the Nuffield
Pennsylvania and the Children’s Hospital of Philadelphia (CHOP) Institute for Medical Research at Oxford University described for
in 1946. With the help of Dr. Leonard Bachman, director of an- the first time the fetal and transitional circulation of mammalian
esthesiology, and the nursing staff, Dr. Koop developed the first newborns using fetal and newborn lambs. In the late 1950s,
neonatal surgical ICU in 1962. Dr. Bachman and his young as- Columbia University’s obstetrical anesthesiologist, Virginia Apgar,
sociate, John J. Downes, subsequently set up North America’s first who had devised the Apgar score for assessing birth asphyxia,
PICU service with a full-time medical and nursing staff in 1967 recruited Dr. L. Stanley James to develop animal and human in-
at CHOP. vestigation of transitional pulmonary-cardiovascular adaptation
during labor, delivery, and the postnatal period. Dr. James and his
Neonatology team at Columbia and Dr. Abraham Rudolph, a South African
pediatric cardiologist, and his team at Albert Einstein Medical
Pediatric critical care owes a great debt to neonatologists and their Center in New York City and subsequently at the Cardiovascular
special care nurseries.1,4,24 The first and most prominent of these Research Institute in San Francisco, performed extensive studies
6 SECTION I Pediatric Critical Care: The Discipline
in fetal lambs, rhesus monkeys, and term and preterm human Neither specifically designed pediatric ventilators nor small-volume
newborns that defined the human cardiopulmonary adaptation to blood gas analysis was available. Dr. Smythe had to overcome
delivery and postnatal life. They also determined the biochemical these obstacles by innovation. Due to local cultural practices,
factors and time course of birth asphyxia and recovery. In 1959, a Bantu children from tribal areas were particularly prone to de-
research fellow at Harvard, Dr. Mary Ellen Avery (with mentor velop tetanus. On July 13, 1957, at Groote Schuur Hospital, he
Dr. Jere Mead), discovered deficiency of alveolar surfactant in performed a tracheostomy and began intermittent positive pres-
lungs of newborns dying from respiratory distress syndrome sure ventilation for these infants with the assistance of anesthesi-
(RDS). This discovery led to a better understanding of neonatal ologist Dr. Bull. This was truly a landmark event in the evolution
pulmonary disorders and eventually led to the intratracheal instil- of PCCM. Although considered a success story in that it was the
lation of surfactant in newborn preterm infants to prevent or first time that infants survived up to weeks of positive-pressure
mitigate the severity of RDS. In the 1960s, state-of-the-art neo- mechanical ventilation, the first seven of nine patients died. Even-
natal ICUs were established at Columbia-Presbyterian Hospital tually, their survival rate reached 80% to 90%. Drs. Smythe and
(Dr. William Silverman), University of Pennsylvania (Dr. Thomas Bull commented, “No praise can be too high for the nursing staff,
Boggs), Vanderbilt University (Dr. Mildred T. Stahlman), who were all student nurses and without any special training.”
Toronto Hospital for Sick Children (Dr. Paul Swyer), and the David Todres, a medical student at that time, was giving curare to
University of California at San Francisco (Dr. William H. Tooley). and observing these infants, sparking his interest in critical care.
In 1963 to 1964 in Toronto, Drs. Paul Swyer, Maria Delivoria-
Pediatric Cardiology Papadopoulos, and Henry Levison were the first to successfully
treat a series of moribund premature infants with RDS and respi-
As previously indicated, the vision of Dr. Taussig in devising a ratory failure. They used positive-pressure mechanical ventilation
method to treat “blue babies” and successful cardiac operations and supportive care27 and emphasized the importance of a full-
led to infants and children who survived surgery and needed time team, including dedicated nurses and therapists as well as
postoperative intensive care. Advances in technology, especially in physicians. In 1968 Dr. George Gregory and colleagues at the
imaging, have allowed clinicians to “see” into living patients with University of California at San Francisco demonstrated improved
astounding accuracy. Increased understanding of anatomy and survival with early use of continuous positive airway pressure
physiology has led to improved surgical and nonsurgical care for without assisted ventilation or with positive end-expiratory pres-
children with complex cardiopulmonary problems. Develop- sure added to the mechanical ventilation regimen.28
ments in cardiac catheterization and interventional radiology have An important contribution to the development of intensive
enabled clinicians to treat many lesions without open-heart sur- care and long-term mechanical ventilation was the use of plastic
gery and potentially difficult postoperative intensive care. This endotracheal tubes for prolonged intubation and ventilation.
concept was introduced in 1968 by Dr. William Rashkind at the Dr. Bernard Brandstater, an Australian working at the American
Children’s Hospital of Philadelphia (CHOP) with the introduc- Hospital in Beirut, Lebanon, reported prolonged nasotracheal
tion of the balloon atrial septostomy for infants with transposi- intubation as an alternative to the tracheostomy at the First
tion of the great arteries. Growth of techniques that allow effective European Congress of Anesthesia in Vienna in 1962.29
intervention in many complex cardiac conditions, both nonsurgi-
cal and surgical, has resulted in many pediatric centers creating
specific cardiac ICUs, often run by pediatric cardiac intensivists. Poliomyelitis and Creation
Cognitive impairment in some infants with complex lesions or of the First Intensive Care Units
chromosomal abnormalities and the occasional development of
chronic respiratory failure with dependence on mechanical venti- Poliomyelitis epidemics occurred worldwide in the early 20th century
lation for months or years are two of the occasional major se- but seemed especially severe in Western Europe and North America.
quelae of these highly successful endeavors. The value of PCCM There was no treatment and, until the late 1920s, no effective life
for these cardiac patients and other critically ill children has been support for those victims with respiratory failure. Fortunately, the
well documented by Dr. Jacqueline Noonan, who noted, “Much confluence of great scientific and clinical minds and the organiza-
success of the surgery can be attributed to a group of pediatric tional efforts of physicians, nurses, and therapists addressing the
intensivists, pediatric intensive care units, improved ventilator needs of polio patients led to the creation of dedicated polio respira-
support, and trained respiratory therapists.”25 tory care units for patients of all ages. In 1929, Philip Drinker, an
engineer—with pediatricians Louis Shaw and Charles F. McKhann at
BCH—published their experience with an electrically powered
Early Use of Mechanical Ventilation negative pressure, body-enclosing mechanical ventilator, later termed
in Neonates and Children the iron lung.10,30
Polio outbreaks occurred in the summer months worldwide in
The first series of carefully observed infants and children treated the 1930s and 1940s. The polio epidemics of the early 1950s were
for respiratory failure was published in 1959. In that year, Drs. very severe in Los Angeles and Copenhagen. In 1952, Dr. H.C.
P.M. Smythe (pediatrician) and Arthur Bull (anesthesiologist) re- Lassen, the chief epidemiologist at Blegdam Hospital in Copen-
ported the first real success in mechanical ventilation of a series of hagen, described treating 2772 patients with polio. Of these, 316
neonates with respiratory failure caused by neonatal tetanus. were in respiratory failure and initially received assisted ventila-
These infants were paralyzed with curare to relax the tetanic tion with iron lungs in a large respiratory care unit. During that
muscle spasms and ventilated for 4 to 14 days using tracheotomy summer, they had as many as 70 patients in respiratory failure in
and a modified Radcliff adult ventilator.26 Until that time, infants that unit. Unfortunately, the mortality of patients supported by
or children were rarely given ventilator support for more than a an iron lung ventilator was nearly 90%, with the cause of death
few hours, with either adult ventilators or manual ventilation. frequently being unrecognized upper airway obstruction. When
CHAPTER 1 History of Pediatric Critical Care Medicine 7
the number of patients in respiratory failure exceeded the avail- Pediatric Intensivist
able number of iron lung ventilators, Bjorn Ibsen, the chief of
anesthesiology at the hospital, with the help of his medical staff Randolph and coworkers40 defined a pediatric intensivist (in the
and nurse anesthetists, performed tracheal intubation and then United States) as “any one of the following: (a) a pediatrician with
tracheostomy along with manual positive pressure ventilation subspecialty training in PCCM and subspecialty certification
with 50% oxygen and tracheal suctioning. This treatment was from the American Board of Pediatrics (ABP); (b) a pediatric
carried out in 200 patients with respiratory failure. To provide anesthesiologist with special competency in critical care with
continuous manual ventilation on a 24-hour basis, Ibsen re- subspecialty certification from the American Board of Anesthesi-
cruited, trained, and used 200 nursing students and aides along ology; (c) a pediatric surgeon with special competency in critical
with 200 medical students, each working 8-hour shifts to provide care with subspecialty certification from the American Board of
manual ventilation, as well as 27 technicians per day to care for Surgery; (d) a physician (as above) eligible for subspecialty certifi-
the patients. The mortality in patients receiving this treatment cation by the appropriate respective board.” Similar requirements
decreased from 90% to 40%.31–33 for training exist or are in development elsewhere in the world.
At that time, patients from outlying areas were transported to
hospitals in ambulances without sufficient attendants or airway First Pediatric Intensive Care Units
care and arrived moribund. Lassen and Ibsen started to send so-
called retrieval teams in ambulances out to pick up the patients in In 1955 Dr. Goran Haglund at the Children’s Hospital of Göteborg,
the countryside, with marked improvements in status on arrival. Sweden,18 developed the first PICU, which he called a pediatric
They also started passing stomach tubes early on for nutrition, emergency ward. The patient who inspired Dr. Haglund to organize
and the rubber-cuffed tracheostomy tubes were replaced with a the unit was a 4-year-old boy who was operated on in 1951 for a
silver cannula that caused less tracheal mucosal damage. Even ruptured appendix. Postoperatively, he lapsed into a coma; his sur-
with all of these improvements, Dr. Ibsen noted, “Naturally we geon declared that he had done all he could and the boy would die
ran into a lot of complications.”33 of bacteriotoxic coma. The anesthesiologist offered to help and the
Drs. Ibsen and Lassen also received help from other people boy was intubated, given manual positive-pressure respiration with
who were focusing their efforts on treating polio. The clinical generous oxygen, tracheostomized, and given a large blood transfu-
biochemist Dr. Poul Astrup developed a micro method to mea- sion. After about 8 hours, the boy’s bowels started to function, and
sure capillary arterialized pH and PCO2 in infants, children, and 4 hours later he was out of coma. After 20 hours, he had spontane-
adults. C.G. Engstrom, a Swedish anesthesiologist, designed and ous respiration and had been successfully treated for respiratory in-
clinically tested the first modern volume-preset positive pressure sufficiency and shock.
mechanical ventilator. This spectacular and thrilling story culmi- This new unit had seven acute care beds with full-time nurses
nated in a cohort of patients with respiratory failure being treated and nursing assistants providing 24-hour coverage. In the first
in a single geographic area and cared for by full-time physicians, 5 years, the team treated 1183 infants and children, with a mor-
nurses, and technicians: the first modern ICU. Although these tality rate of 13.6%. Haglund went on to state, “But what we did
units tended to disband after the summer-fall polio season, they was something else. It was the application of the basic physiology
led to the creation of full-time respiratory care units at the to clinical practice. Our main purpose was not to heal any disease;
Radcliff Infirmary of Oxford University and elsewhere in Europe it was to forestall the death of the patient. The idea was—and
and North America in the 1950s. is—to gain time, time so that the special medical or surgical
Soon after these events, in 1958, Peter Safar led development therapy can have desired effects.”18 Haglund was also careful to
of the first multidisciplinary ICU in North America at Baltimore point out: “There are few jobs more exciting, demanding, and
City Hospital.34 In 1960, Barrie Fairley and colleagues created the taxing than emergency nursing. Our nurses and nurse assistants
ICU at Toronto General Hospital, followed in 1962 by the ICU are tremendous. They must be!”18
at Massachusetts General Hospital under Drs. Henning Pontop-
pidan and Henrik Bendixen. Central Role of Critical Care Nursing
Definitions Although many sources emphasize the role of advanced technol-
ogy in the creation of adult, neonatal, and pediatric critical
Some of the difficulty in relating the history of PCCM is defining care,1,19 skilled nursing care was even more important in this
a PICU and pediatric intensivist. The current definitions are as evolving process. Porter41 and others remind us of the vital role of
follows. nursing in triage and organization of care for patients by degree of
illness. Long before the organizational efforts of the 20th century,
Florence Nightingale (1820–1910) organized a volunteer service
Pediatric Intensive Care Unit with 20 nurses and created a clean environment at the British
An ad hoc committee of the American Academy of Pediatrics (AAP), military hospital at Skutari, Turkey, in 1854 during the Crimean
Diseases of the Chest Section established Guidelines for the Organi- War. Although the care consisted mostly of hygiene and nutrition,
zation of Children’s Intensive Care Units in July 1975.35 In 1983, within 6 months of her arrival the mortality rate dropped from
the AAP and Society of Critical Care Medicine (SCCM) published 40% to 2%.42 Nightingale provided the definition of nursing as
Joint Guidelines for Pediatric Intensive Care Units,36 which were “helping the patient to live.”42 These efforts were continued in the
updated in 199337 and 200438 and then retired in 2013.39 The com- United States by Dorothea Dix (1802–1887) and Clara Barton
mittee defined a PICU as “a hospital unit which provides treatment (1821–1912), the “angel of the battlefield” during the American
to children with a wide variety of illnesses of life-threatening nature Civil War. Barton also brought the Red Cross to America in 1882.
including children with highly unstable conditions and those requir- As the complexity of medical and surgical care evolved in the
ing sophisticated medical and surgical treatment.” late 19th and early 20th century, the need to cohort sick patients
8 SECTION I Pediatric Critical Care: The Discipline
and provide skilled nursing care became apparent, especially for America. During the prior decade, Dr. Conn and his colleagues
premature newborns and victims of poliomyelitis, as cited earlier. had treated critically ill infants and children in a sequestered area
Then, as now, the recovery of the critically ill pediatric or adult of the postanesthesia care facility where they had developed con-
patient depended on the skilled nurse at the bedside who was siderable expertise in critical care. The new state-of-the-art PICU
trained to use the life support and monitoring equipment at hand was the forerunner of units developed in major pediatric centers
but to remain focused on the stability and comfort of the person throughout North America spanning the 1970s and beyond.
in the bed.43 Dr. Geoffrey Barker, who went on to develop one of the largest
In the mid- to late 1970s, as pediatric cardiovascular surgery multinational fellowship training programs in the world, followed
for more complex lesions in infants was developing, nurses pro- Dr. Conn as director of the PICU.
vided postoperative care in designated units. Children with Reye Also in 1971, Dr. David Todres, an anesthesiologist and pedia-
syndrome suddenly appeared, requiring complex multisystem trician, and Dr. Daniel Shannon, a pediatric pulmonologist,
care. In addition, in the 1980s, emergency medical services sys- founded a 16-bed multidisciplinary unit for pediatric patients of
tems began transporting severely injured children to hospitals, all ages at the Massachusetts General Hospital.1,4 The units in
where they required rapid assessment and intervention by nurses Philadelphia, Toronto, and Boston established vibrant training
and physicians and initiation of cardiorespiratory and neurologic programs in critical care medicine and conducted clinical re-
support.44 search. Among their numerous accomplishments, Dr. Conn be-
Pediatric critical care nurses joined the SCCM from its begin- came a noted authority on the management of near-drowning
ning in 1970 and the American Association of Critical Care victims, and Dr. Todres and Dr. Downes pioneered long-term
Nurses emphasizing the care of children. In the mid-1990s, pedi- mechanical ventilation for children at home with chronic respira-
atric critical care nurses founded their own society and established tory failure. These early PICUs and their training programs had a
a peer-reviewed journal. Also in the 1990s, advanced practice favorable impact on mortality and morbidity rates, particularly
nurses and nurse practitioners began to specialize in pediatric those associated with acute respiratory failure, leading to the de-
critical care. They continue to function as important critical care velopment of similar units and programs in most major pediatric
team members to augment both physician and nursing care as centers in North America, Western Europe, and Japan during the
well as conduct clinical research.43,44 1970s and early 1980s.
The development of the PICU at Children’s Memorial Hospi-
Role of Pediatric Anesthesiologists tal (CMH), Northwestern University Medical School, Chicago,
illustrates how many of the early PICUs evolved. The unit was
and Pediatricians in Founding Pediatric first started as a four-bed area set in one of the postoperative care
Critical Care Medicine wards by pediatric anesthesiologists David Allen and Frank
Seleny. Anesthesiologist Dr. John Cox arrived in August of 1964
An important early physician-directed multidisciplinary PICU in and was named director. He has stated that the unit never for-
North America was established at CHOP in 1967 as an out- mally opened. It began in the four-bed unit in the postoperative
growth of a hospital-wide respiratory intensive care service.1,45 ward in 1964 and became a 14-bed separate designed unit in
The unit consisted of an open ward of six beds equipped with late 1967. Dr. Cox was the director until 1975, when he was
bedside electronic monitoring and respiratory support capabilities succeeded by Dr. Richard Levin. During this time, Dr. Hisashi
and an adjacent intensive care chemistry laboratory staffed Nikaidoh, who was a surgery resident from 1966 to 1967, re-
24 hours per day. The nurses were assigned full-time to the unit; members taking care of a renal transplant patient; the care was
most had previously served in the recovery room, infant ICU, or provided by nephrology, general surgery, and immunology
cardiac surgery postoperative ward. Dr. John Downes was the without a centralized PICU service. Dr. Zehava Noah, who was
medical director and worked closely with two other anesthesiolo- educated in Israel and trained in the United Kingdom, did a
gists, Dr. Leonard Bachman, chief of anesthesiology, and critical care fellowship in anesthesia at CMH, developed a closed
Dr. Charles Richards, and a pediatric allergist/pulmonologist, medical-surgical PICU in 1979, and was named the director in
Dr. David Wood. Four pediatric anesthesiology/critical care fel- 1981. There was also an associate surgical director.46–49
lows provided 24-hour in-unit service. Dr. C. Everett Koop (chief Some of the early PICUs were directed by pediatricians. In
of surgery), Dr. William Rashkind (the father of interventional 1966, Dr. Max Klein joined Drs. H. de V. Heese and Vincent
pediatric cardiology), Dr. John Waldhausen (one of the nation’s Harrison in a two-bed neonatal research unit at the Groote Shuur
few full-time pediatric cardiac surgeons), Dr. Sylvan Stool (a pio- Hospital in Cape Town. Their research resulted in many signifi-
neer in pediatric otolaryngology), and other staff and residents cant papers, not the least of which was “The Significance of
provided close collaborative patient care, education, and clinical Grunting in Hyaline Membrane Disease,”50 demonstrating that
research. By 1975, with the establishment of the new CHOP oxygen tensions fell when infants had tracheal intubation, elimi-
building, the acute PICU was expanded to 20 beds with an adja- nating the ability to grunt on exhalation. By 1969, at Red Cross
cent 10-bed intermediate step-down unit. War Memorial Children’s Hospital in Cape Town, South Africa,
In 1969, Dr. Peter Safar and his trainee, Stephen Kampschulte, pediatric patients with respiratory failure (e.g., Guillain-Barré
developed a 10-bed PICU at the Children’s Hospital of Pitts- syndrome) were ventilated on the general wards. Although out-
burgh. That same year, James Gilman, a pediatric anesthesiologist, comes improved, deaths were still common. Dr. Max Klein en-
and Norman Talner, a pediatric cardiologist, established a six-bed couraged Dr. Malcolm Bowie (consultant) to start a six-bed ICU,
PICU at the Yale–New Haven Medical Center. or “high-care ward.” After further training in South Africa and at
In 1970, at the Hospital for Sick Children in Toronto, the University of California San Francisco (UCSF), Dr. Klein re-
Dr. Alan Conn resigned as director of the Department of Anes- turned to Cape Town in 1974, where he combined the neonatal
thesiology to become director of a new multidisciplinary 20-bed tetanus ward of Dr. Smythe and the six-bed ICU of Dr. Bowie
PICU, by far the largest and most sophisticated unit in North into the first full-time PICU in South Africa.51
CHAPTER 1 History of Pediatric Critical Care Medicine 9
The path for pediatricians providing care for the sickest pa- training with Dr. Peter Safar in Pittsburgh, who welcomed him as
tients on a full-time basis remained unclear for an extended pe- a fellow in critical care medicine. In 1975, Dr. Holbrook and
riod. Subsequent early leaders in the field each carved out their pediatrician Dr. Alan Fields, who also trained in Pittsburgh, were
own path. Dr. Daniel Levin completed pediatric cardiology and recruited to the new, modern Children’s Hospital National Medi-
neonatology fellowships to learn the care of sick children. How- cal Center (Washington, DC) as pediatricians in the Department
ever, he found few Chairs of Pediatrics interested in hiring an of Anesthesia to direct the PICU.
“intensivist.” Then, in 1975, Drs. Levin and Frances Morriss Dr. Bradley Peterson,52 after pediatric and neonatology train-
(trained in pediatrics and pediatric anesthesia) were recruited to ing and an anesthesiology residency at Stanford University,
start a PICU at Children’s Medical Center of Dallas. became director of the new PICU at Children’s Hospital of
There were so few of this new breed of intensivists that many San Diego in 1977. Dr. Bradley Fuhrman, following pediatric
became directors upon completion of residency and fellowship. At cardiology and neonatology fellowships, started the first PICU at
the beginning, few other physicians wanted to be responsible for University of Minnesota Hospital in 1979.53
pediatric intensive care.23 Eventually, more pediatricians decided Dr. George Lister,54 after a pediatric residency at Yale and a
to devote their careers to being members of a multidisciplinary fellowship in cardiopulmonary physiology at UCSF, joined the
team taking care of the sickest children in hospitals on a full-time staff at the UCSF Moffitt Hospital San Francisco in 1977 as an
basis. In 1975, the CHOP program started to accept PCCM attending in its combined adult-pediatric ICU. Due to the direc-
trainees who were pediatricians without anesthesia training. tor’s illness, he quickly found himself the co-director of the unit.54
In 1967, Dr. Peter Holbrook as a medical student at the Uni- He eventually returned to Yale as an attending in the PICU.
versity of Pennsylvania began a part-time job in the PICU at Dr. Mark Rogers, after completion of a pediatric residency at
CHOP and developed a strong interest in PCCM. Informed at BCH, an anesthesiology residency at Massachusetts General
the time that one needed anesthesia training to successfully work Hospital, and a pediatric cardiology fellowship at Duke, became
in the PICU, Holbrook shelved the idea and entered pediatric director of the first PICU at Johns Hopkins Hospital in 1977.55
residency training at Johns Hopkins. When the PCCM idea Subsequently, in 1980, Dr. Rogers became chair of the Depart-
resurfaced, he found that many still felt a physician needed anes- ment of Anesthesiology and Critical Care Medicine at Johns
thesia training to function in the PICU. Disagreeing with the Hopkins and chief editor of a major textbook of pediatric inten-
reasoning behind such a requirement, he pursued critical care sive care (Table 1.2).
TABLE
1.2 Textbooks in Pediatric Critical Care Medicine
Continued
10 SECTION I Pediatric Critical Care: The Discipline
TABLE
1.2 Textbooks in Pediatric Critical Care Medicine—cont’d
Growth of Pediatric Critical Care Medicine American College of Graduate Medical Education (ACGME)
and for the subspecialty of PCCM by the American Board of
The field of PCCM grew rapidly in the late 1970s and 1980s. Pediatrics (ABP). Legitimization of the subspecialty was achieved
However, there was a struggle for authority in both adult and with establishment of a new subboard of Pediatric Critical Care
pediatric units. The culture of intensive care was changing from Medicine of the ABP in 1985 and the first certifying examination
one in which each specialty service cared for its part of the patient in 1987, at which time 182 subspecialists were certified.95 Certi-
to one in which a full-time critical care service cared for the whole fication provided a clear basis for hospital credentialing of
patient, with help of consulting specialties.2,94 PCCM physicians.96 In addition to certification by the ABP, the
For PCCM to achieve its full potential, it required several ele- American Board of Anesthesiology and the American Board of
ments: a national organization to provide a venue in which to Surgery confer subspecialty certification with special competency
meet and communicate, acceptance and validation of pediatric in critical care. In 1989, special requirements for training in
critical care as a subspecialty, nationally approved training require- PCCM were developed by the ACGME, with formally accred-
ments, and academic credibility with meaningful research. ited programs first recognized in 1990.97
A small group of interested physicians met at the SCCM Na-
tional Meeting in 1979 and decided to petition the SCCM to Growth in Numbers of Pediatric Intensive
form a section on pediatrics. The society had no subsections, but
the petition was successful. The pediatric section with Dr. Russell
Care Units
Raphaely as chair was formed in 1980.1 In 1983, a committee of In 1979, there were 150 PICUs of four or more beds identified,
the SCCM developed guidelines for organization of PICUs36 that and another 42 thought to exist.98 Most were just special care
were regularly updated37,38 until January 2013, after which time nursing units, and only 40% had a pediatric intensivist available
they were retired.39 at all times. Forty percent of the units had fewer than seven beds
In 1984, after petitions by pediatric intensivists, a Section and only one half had affiliated transport systems. Pediatric
of Critical Care Medicine was established in the AAP with ward beds decreased by 22.4% between 1980 and 1989—by
Dr. Russell Raphaely as chair.95 These organizations then 10.8% between 1990 and 1994 and by 15.7% between 1995
petitioned for recognition of PCCM fellowships from the and 2000. During the same three time periods, PICU beds
CHAPTER 1 History of Pediatric Critical Care Medicine 11
increased by 26.2%, 19.0%, and 12.9%, respectively.40 Between In April 2004, the Eunice Kennedy Shriver National Institute
2001 and 2016, the US pediatric population grew 1.9% to of Child Health and Human Development (NICHD) established
greater than 73.6 million children, and PICU hospitals de- funding for the first federally supported network for pediatric
creased 0.9% from 347 to 344 (58 closed and 55 opened). In critical care research, the Collaborative Pediatric Critical Care
contrast, PICU bed numbers increased 43% (4135 to 5908 Research Network. The network is a multicentered program de-
beds). Sixty-three PICU hospitals (18%) accounted for 47% signed to investigate the safety and efficacy of treatment and
of PICU beds.40a According to the FY2017 American Hospital management strategies to care for critically ill children as well
Association (AHA) survey database, there are 399 hospitals as the pathophysiologic basis of critical illness and injury in
in the United States and territories that have a PICU in their childhood.114–117
hospital.100 Although not all children’s hospitals are members The NICHD has also supported research in PCCM by devel-
of the Children’s Hospital Association, of the 155 children’s oping and supporting young investigators in the field through
hospitals that contribute data to the fiscal year 2017 Children’s the Pediatric Critical Care and Trauma Scientist Development
Hospital Association Annual Benchmark Report Survey, 128 Program (PCCTSDP), a K-12 research training program. The
(82%) stated they had staffed PICU beds.101 PCCTSDP has been funded since 2004 and is directed by
Dr. Heather Keenan at the University of Utah. Eligible applicants
are board-eligible or board-certified PCCM faculty, or pediatric
Growth in Training Programs and Education trauma surgery faculty.114
In 1983 to 1984, there were 32 PCCM training programs; the Perhaps most notably, in 2013 the NICHD created an inde-
ACGME accredited 28 of them in 1990. By 2018 to 2019, the pendent branch, the Pediatric Trauma and Critical Illness Branch,
number had increased to 68 accredited training programs with to further support research in pediatric critical illness and injury.
527 enrolled fellows, of whom 336 (63.8%) are women.99 Since The mission of the new branch is to prevent and reduce all aspects
its inception, the subboard has certified 2693 subspecialists.99 of childhood trauma and critical illness and to enhance health
Educational programs in PCCM have progressed consider- outcomes for all children across the continuum of care.114,116,117
ably at the annual SCCM, AAP, Pediatric Academic Societies, The growth of education and research in PCCM has coincided
American Thoracic Society, and American College of Chest with, and presumably resulted in, better care for children as re-
Physicians meetings, as well as at independent meetings such as flected in the decrease in mortality from septic shock. Between
the Pediatric Critical Care Colloquium and the World Federa- 1958 and 1966, in patients younger than 16 years of age at the
tion of Pediatric Intensive Critical Care Societies (WFPICCS). University of Minnesota, mortality in septic shock was 95%; now,
Dr. Barker envisioned the need to bring together pediatric inten- with PICU care, it is less than 10%.118 Drs. Murray Pollack and
sive care from many parts of the world. This led to his founding Timothy Yeh established the basis for studying severity-adjusted
directorship of the WFPICCS, which has done much to foster mortality in pediatrics and demonstrated that patients do better
development of pediatric critical care around the world, bringing when cared for by pediatric intensivists.119 Although many would
vital critical care skills and experience to benefit multiple coun- attribute these improvements to technology and scientific ad-
tries. Numerous textbooks on PCCM have appeared in many vances, Dr. Yeh and others remind us that the presence of a full-
languages (see Table 1.2), and the journal Pediatric Critical Care time nursing and medical team and attention to basic principles
Medicine was launched in 2000.102 rather than exotic high technology improve outcomes.120 This is
Academic credibility that results from meaningful scientific echoed by Dr. Shann’s two rules of PCCM: (1) “the most impor-
research has come slowly. In the early days, intensivists were tant thing is to get the basics exactly right all of the time,” and
mostly consumed by clinical care and research and administrative (2) “organizational issues are crucially important.”23 In addition,
responsibilities. High-quality basic science, epidemiology, and Yeh as well as Ibsen33 and Orr have emphasized the important
translational studies addressing a broad range of problems have contributions of regionalization and the quality of PCCM trans-
gradually emerged. Multiinstitutional organizations have allowed port teams in improving outcomes.121,122
studies that require more patients than can be drawn from a single Modern medical simulation originated in pediatrics and has
institution to be designed, funded, and completed. In the early made significant contributions to education. In 1960, shortly af-
1990s, the Pediatric Critical Care Study Group was formed.103 It ter resuscitating his 2-year-old son following a drowning, Asmun
was followed by the Pediatric Acute Lung Injury and Sepsis Inves- Laerdal, the owner of a Norwegian doll factory, partnered with
tigators (PALISI) network,104–106 which employed the successful the Red Cross to create the first medical simulation mannequin.
programming model of research developed by the Canadian In 1988, Laerdal partnered with the American Heart Association
Critical Care Trials Group.107–109 PALISI has grown and pros- and the AAP to create Pediatric Acute Life Support simulation-
pered through the voluntary collaboration of currently 94 mem- based training. Since that time, evolving pediatric residency and
ber PICUs110 and has supported more than 200 articles address- fellowship requirements, duty hour restrictions, and an increased
ing the spectrum of PCCM.111 focus on medical safety have catalyzed exponential growth in simu-
The virtual PICU was started in 1997 to bring data manage- lation training.123–125 The International Network for Simulation-
ment technologies to critical care. In 2004, Virtual PICU Based Pediatric Innovation Research and Education has docu-
Systems (VPS) was formed by Drs. Thomas Rice and Ramesh mented an increase in pediatric simulation centers from
Sachdeva (Children’s Hospital and Health System of Milwaukee) 50 to 268 in the past 7 years. A recent meta-analysis documented
and Dr. Randall Wetzell (Children’s Hospital Los Angeles) in 57 studies and over 3500 learners engaged in pediatric simula-
conjunction with the National Association of Children’s Hospi- tion education. Studies compared simulation education with no
tals and Related Institutions to develop a PICU registry to facili- intervention and found large effects for outcomes of knowledge,
tate quality improvement and research. VPS currently has more behavior with patients, and time to task completion.126
than 125 members and a massive database describing more than Dr. Elizabeth Hunt along with pioneers in simulation at Johns
1 million critical care admissions.112,113 Hopkins have been able to document progressive acquisition of
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that?” applies far more strongly to blank verse than to Campion’s
artificial metres. Custom and Nature, those greater Cæsars to whom
Daniel so triumphantly appealed, had already settled it, as they were
to confirm it later, that rhymed and unrhymed verse, each obeying
the natural evolution of English prosody, should be the twin horses to
draw its car. But Milton never developed his antipathy to rhyme
(which in all probability arose, mainly if not merely, from the fact that
nearly all the most exquisite rhymers of his time, except himself,
were Cavaliers) in any critical fashion, contenting himself with
occasional flings and obiter dicta.[484]
Another poet of the time, Cowley, ought to have given us criticism
Cowley. of real importance. He had the paramount, if not
exclusive, literary interests which are necessary to a
great critic; he had the knowledge; and he was perhaps the first man
in England to possess the best kind of critical style—lighter than
Daniel’s, and less pregnant, involved, and scholastic than Jonson’s
—the style of well-bred conversational argument.[485] But he was a
little bitten with the scientific as opposed to the literary mania, and, in
his own person, he was perhaps too much of a Janus as regards
literary tastes to be able to give—or indeed to take—a clear and
single view. There were, as in Lope, two poets in Cowley, and each
of these was wont to get in the way of the other. The one was a
“metaphysical” of the high flight, who at least would, if he could, have
been as intensely fantastic as Donne, and as gracefully fantastic as
Suckling. The other was a classical, “sensible,” couplet-poet, who
was working out Ben Jonson’s theories with even less admixture of
Romanticism than that which tinged Ben Jonson’s practice. The
entanglement of these was sufficiently detrimental to his poetry; but
it would have been absolutely fatal to his criticism, which must either
have perpetually contradicted itself or else have wandered in a
maze, perplexing as perplexed.
It is with Davenant’s Preface to Gondibert, in the form of a Letter
to Hobbes, and with Hobbes’s answer to it,[486] that England strikes
once more into the main path of European critical development. And
The Prefatory it is of capital importance that, both the writers being
matter of exiled royalists, these documents were written at
Gondibert. Paris in the year 1650. There was much interest
there in English affairs, while, as we have seen, the habit of literary
discussion had, for more than a generation, become ingrained in
Frenchmen. When Davenant set himself to write Gondibert, he was
doing exactly what Chapelain and Desmarets and the rest were
doing; and when he and his greater friend exchanged their epistles,
they were doing exactly what all the French literary world had been
doing, not merely, as is commonly thought, from the time of the Cid
dispute, but from one much earlier. Taking all things together, it was
natural that the subject should be the Heroic Poem, which had been
a favourite of Italian and French critics for some seventy years and
more, but had been little touched in England, though the conclusion
of Ben’s Discoveries shapes a course for it. Hints have been given
before in this History that in the opinion of its writer the “Heroic
Poem” had much in common with that entity which was long without
a literary name, but which an admirable humourist has now enabled
us to describe scientifically as a Boojum[487]—that is to say, it was not
only something undiscoverable, but something which had a malign
and, indeed, destructive influence on those who thought they had
discovered it.
The “Heroic Poem” was to be neither pure Romance nor pure
The “Heroic Epic, but a sort of medley between the two. Or,
Poem.” rather, it was to be a thing of shreds and patches,
strictly epic (or at least Virgilian-epical) in theory and rules, but
borrowing from Romance whatever it could, as our Elizabethans
would say, “convey cleanly” enough in the way of additional
attractions. The shreds and patches, too, were not purely poetical:
they were not taken simply from Homer and Virgil, nor even from
Horace, Virgil, Lucan, Statius, and the rest down to that Musæus
whom Scaliger thought so superior to the Chian. A great deal of
ancient critical dictum was brought in, and as Aristotle and Horace
had said less about Epic than about Drama, they were to be
supplemented from others, especially by that treacherous and
somewhat obscure passage of Petronius which has been
commented on in its place. In fact the whole of this Heroic-Poem
matter is a sort of satire on criticism by Kinds, in its attempt—and
failure—to discover a kind. If the founders of the novel (who, indeed,
in some notable cases were by no means free from the obsession)
had persisted in constructing it on the lines of the Heroic Poem, it
would indeed have been all up with Fiction. To read Tasso (who, as
we might expect, is not the least reasonable) and others, from
Ronsard and Du Bellay down to Desmarets and Le Bossu (both of
whom, let it be remembered, wrote some time after Davenant)—to
find even Dryden a Martha of “machinery,” and comforting himself
with a bright new idea of getting the deorum ministeria out of the
limited intelligences of angels, so that you might not know at once
which side was going to win, as you do in the ordinary Christian
Epic[488]—is curious. Nay, it is more—humorous, with that touch of
“the pity of it” which humour nearly always has.
The ingenious knight, in explaining his performance and its
principles to his friend the philosopher, takes a very high tone.
Homer, Virgil, Lucan, and Statius are passed successively in review,
and receive each his appropriate compliment, put with dignified
Davenant’s reserves, especially in the two latter cases. Only two
Examen. moderns are admitted—Tasso of the Italians—“for I
will yield to their opinion who permit not Ariosto—no, not Du Bartas
—in this eminent rank of the heroicks, rather than to make way by
their admission for Dante, Marino, and others”[489]—and Spenser of
our own men. But Tasso is roundly taken to task for his fairy-tale
element, Spenser for his allegory and his archaism. And the faults of
all from Homer downwards are charged against “the natural humour
of imitation.”[490]
After a by no means despicable, but somewhat rhapsodical,
digression on this—it is to be observed that Davenant uses
“Imitation” in the frank modern sense—and an apology for it as “the
dangerous fit of a hot writer,” he gives reasons, partly no doubt
drawn from Italian and French sources, why he has made his subject
(1) Christian, (2) antique but not historical, (3) foreign, (4) courtly and
martial, (5) displaying the distempers of love and ambition. Then he
expounds in turn his arrangement of five books (to correspond to
acts), with cantos to answer to scenes,[491] his arguments, his
quatrain-stanza. He asserts that “the substance is wit,” and
discusses that matter at some length, and with a noteworthy hit at
conceits, which reminds us that Davenant was à cheval between the
First and the Second Caroline period. He indulges in not
unpardonable loquacity about his poetic aspirations, with a fresh
glance at the great poets of old, and brings in thereby, with some
ingenuity but at too great length as a finale, the old prefatory matter
of the Arts Poetic about the importance and dignity of poetry in the
world, concluding exactly where most begin, with Plato and that
“divine anger” of his which some have turned to the “unjust scandal
of Poesie.” And so a pleasant echo of Sir Philip blends agreeably
with the more prosaic tone, and time, and temper of Sir William.
Hobbes, as we should expect, is much briefer; and those bronze
sentences of his (though he had not at this time quite brought them
to their full ring and perfect circumscription) give no uncertain sound.
Hobbes’s He is not, he says, a poet (which is true), and when
Answer. he assigns to Gondibert “various experience, ready
memory, clear judgment, swift and well-governed fancy,” it is obvious
enough that all these might be there and yet poetry be absent. He
divides the kinds of poetry “swiftly” enough, and ranges himself with
his customary decision against those who “take for poesy
whatsoever is writ in verse,” cutting out not merely didactic poetry,
but sonnets, epigrams, and eclogues, and laying it down that “the
subject of a poem is the manners of men.” “They that give entrance
to fictions writ in prose err not so much,” but they err. And
accordingly he begins the discussion of verse. He does not quarrel
with Davenant, as Vida would have done, for deliberately eschewing
Invocation; and rapidly comments on the plot, characters,
description, &c., of the poem. On the head of diction he would not be
Hobbes if he could or did spare a sneer at words of no sense, words
“contunded by the schools,” and so forth. And since he is Hobbes,
there is piquancy in finding him at one with Walton in the objection to
“strong lines.” He is rather striking on a subject which has been
much dwelt on of late, the blunting of poetic phrase by use. And
when he says that he “never yet saw poem that had so much shape
of art, health of morality, and vigour of beauty and expression” as
Gondibert—when, in the odd timorousness he had caught from
Bacon, he adds, that it is only the perishableness of the modern
tongues which will prevent it from lasting as long as the Æneid or the
Iliad—let us remember that, though criticism is one thing and
compliment another, they sometimes live in a rather illicit
contubernium. At any rate, there is criticism, and real criticism, in the
two pieces; and they are about the first substantial documents of it in
English of which as much can be said for many years.[492]
Thus, although two of these four were of the greatest of our
writers, the third an interesting failure of greatness, and the fourth far
from contemptible, they were in all cases prevented, by this or that
disqualification, from doing much in criticism.
Dryden, on the contrary, started with every advantage, except
those of a body of English criticism behind him, and of a thorough
Dryden. knowledge of the whole of English literature. He was a
poet nearly, if not quite, of the first class: and though his
poetry had a strong Romantic spirit in virtue of its perennial quality, it
took the form and pressure of the time so thoroughly and so kindly
that there was no internal conflict. Further, he had what by no means
all poets of the first class have had, a strong, clear, common-sense
judgment, and a very remarkable faculty of arguing the point. And,
finally, if he had few predecessors in English, and perhaps did not
know much of those few except of Jonson, he was fairly, if not
exactly as a scholar, acquainted with the ancients, and he had
profited, and was to profit, by the best doctrine of the moderns.
His Moreover, from a certain not unimportant point of
advantages. view, he occupies a position which is only shared in
the history of criticism by Dante and (in some estimations, though
not in all) by Goethe,—the position of the greatest man of letters in
his own country, if not also in Europe, who is at the same time the
greatest critic, and who is favoured by Fortune with a concentration
of advantages as to time and circumstance. His critical excellence
has indeed never been wholly overlooked, and, except by the
unjuster partisanship of the early Romantic movement in England,
generally admitted with cheerfulness.[493] The want, however, of that
synoptic study of the subject, which it is the humble purpose of this
book to facilitate, has too often prevented his full pre-eminence from
being recognised. It may even be said that it is in criticism that
Dryden best shows that original faculty which has often been denied
him elsewhere. He borrows, indeed, as freely as everywhere: he
copies, with a half ludicrous deference, the stock opinions of the
critics and the criticasters in vogue; he gives us pages on pages of
their pedantic trivialities instead of his own shrewd and racy
judgments. But, despite of all this, there is in him (and with good luck
we may perhaps not fail to disengage it) a vein and style in “judging
of Authours” which goes straight back to Longinus, if it is not even
independent of that great ancestry.[494]
This vein is perceptible[495] even in the slight critical essays which
precede the Essay of Dramatic Poesy, though of course it is much
The Early more evident in the Essay itself. In the preface to
Prefaces. the Rival Ladies (written, not indeed when Dryden
was a very young man, but when, except for Juvenilia, he had
produced extremely little) we find his critical path clearly traced, and
still more in the three years later Preface to Annus Mirabilis. The
principles of this path-making are as follows: Dryden takes—without
perhaps a very laborious study of them, but, as has been said
already, with an almost touching docility in appearance—the current
theories and verdicts of the French, Italian (and Spanish?) critics
whom we should by this time have sufficiently surveyed. He does not
—he never did to the date of the glorious Preface to the Fables itself
—dispute the general doctrines of the sages from Aristotle
downwards. But (and this is where the Longinian resemblance
comes in) he never can help considering the individual works of
literature almost without regard to these principles, and simply on the
broad, the sound, the unshakable ground of the impression they
make on him. Secondly (and this is where the resemblance to Dante
comes in), he is perfectly well aware that questions of diction, metre,
and the like are not mere catchpenny or claptrap afterthoughts, as
ancient criticism was too apt to think them, but at the root of the
pleasure which literature gives. Thirdly (and this is where, though
Aristotle did not deny the fact, the whole criticism of antiquity, except
that of Longinus, and most of that of modern times, swerves
timorously from the truth), he knows that this delight, this transport,
counts first as a criterion. Literature in general, poetry in particular,
should, of course, instruct: but it must delight.[496]
The “blundering, half-witted people,” as in one of his rare bursts of
not absolutely cool contempt[497] he calls his own critics, who charged
him with plagiarising from foreign authors, entirely missed these
differences, which distinguish him from every foreign critic of his day,
and of most days for long afterwards. He may quote—partly out of
that genuine humility and generosity combined which make his
literary character so agreeable; partly from an innocent parade of
learning. But he never pays for what he borrows the slavish rent, or
royalty, of surrendering his actual and private judgment.
In the Preface to the Rival Ladies the poet-critic takes (as indeed
he afterwards himself fully acknowledged) a wrong line—the defence
of what he calls “verse” (that is to say, rhymed heroic couplets, not
blank verse) for play-writing. This was his mistress of the time; he
rejoiced in her caresses, he wore her colours, he fought for her
beauty—the enjoyment authorising the argument. But as he has
nothing to say that has not been better said in the Essay, we may
postpone the consideration of this. There is one of the slips of fact
which can be readily excused to (and by) all but bad critics,—and
which bad critics are chiefly bound to avoid, because accuracy of
fact is their only title to existence—in his mention of “Queen”
Gorboduc and his addition that the dialogue in that play is rhymed;
there is an interesting sigh for an Academy (Dryden, let it be
remembered, was one of the earliest members of the Royal Society);
and there is the well-known and very amiable, though rather
dangerous, delusion that the excellence and dignity of rhyme were
never known till Mr Waller taught it, and that John Denham’s
Cooper’s Hill not only is, but ever will be, the exact standard of good
writing. But he knows Sidney and he knows Scaliger, and he knows
already that Shakespeare “had a larger soul of poesy than any of our
nation.” And a man who knows these three things in 1664 will go far.
The Preface to Annus Mirabilis[498] is again submissive in form,
independent in spirit. Dryden obediently accepts the prescription for
epic or “Heroic” poetry, and though he makes another slip of fact (or
at least of term) by saying that Chapman’s Homer is written in
“Alexandrines or verses of six feet” instead of (as far as the Iliad is
concerned) in the fourteener, he is beautifully scholastic on the
differences between Virgil and Ovid, the Heroic and the Burlesque,
“Wit Writing” and “Wit Written.” But he does it with unconquerable
originality, the utterance of his own impression, his own judgment,
breaking through all this school-stuff at every moment; and also with
a valuable (though still inadequate) account of “the Poet’s
imagination.”[499]
Yet another point of interest is the avowed intention (carried out in
the poem, to the disgust or at least distaste of Dr Johnson) of using
technical terms. This, one of the neoclassic devices for attaining
propriety, was, as we have seen, excogitated in Italy, and warmly
championed by the Pléiade; but it had been by this time mostly
abandoned, as it was later by Dryden himself.
The Essay of The Essay of Dramatic Poesy is much better
Dramatic known than it was only a couple of decades ago,[500]
Poesy. and it is perhaps superfluous to say that it is a
dialogue in form, and that the interlocutors are Dryden himself
(Neander), his brother-in-law Sir Robert Howard (Crites), Sir Charles
Sedley (Lisideius), and Lord Buckhurst (Eugenius). The two last,
though at the time the wildest of scapegraces, were men of distinct
poetic gift and varied literary faculty. And Howard, though no great
poet, and possessing something of the prig, the coxcomb, and the
pedant in his composition, was a man of some ability, of real learning
of a kind, and of very distinct devotion to literature.
The Essay was first published in 1668, but had been written,
according to Dryden’s statement in his Preface to Lord Buckhurst, “in
the country” (at his father-in-law Lord Berkshire’s seat of Charlton
near Malmesbury), when the author was driven out of London by the
Its setting and Great Plague three years before. He had, he says,
overture. altered some of his opinions; but it did not much
matter in an Essay “where all I have said is problematical.” The
“Address to the Reader” promises a second part dealing with Epic
and Lyric, which never appeared, and of which only the Epic part is
represented by later works. This is a pity, for while we have treatises
on Drama and Epic ad nauseam, their elder and lovelier sister has
been, “poor girl! neglected.” It begins with a picturesque setting,
which represents the four interlocutors as having taken boat and
shot the bridge, attracted by the reverberation of the great battle with
the Dutch in the early part of June 1665, when Admiral Opdam’s
flag-ship was blown up. Eugenius augurs victory from the gradual
dying away of the noise; and Crites observes (in character) that he
should like this victory better if he did not know how many bad
verses he should have to read on it. Lisideius adds that he knows
some poets who have got epinikia and funeral elegies all ready for
either event, and the dialogue proceeds for some time in the same
way of literary banter, especial set being made at two poets (one of
whom is certainly Wild, while the other may be Flecknoe) with
incidental sneers at Wither(s) and Cleveland. At last Crites brings it
to something like the quarrel of Ancient v. Modern. Eugenius picks
up the glove, but consents, at Crites’ suggestion, to limit the
discussion to dramatic poetry,[501] and so the “dependence” is settled.
Eugenius thinks that though modern plays are better than Greek
or Roman, yet those of “the last age” (1600-1660) are better than
Crites for the “ours.” As for epic and lyric, the last age must yield.
Ancients. And all the quartette agree that “the sweetness of
English verse was never understanded or practised” by our fathers,
and that some writers yet living first taught us to mould our thoughts
into easy and significant words, to retrench the superfluities of
expression, and to make our rhyme so properly a part of the verse
that it should never mislead the sense. Lisideius having (with the
consent of the company, subject to a slight scholastic objection from
Crites) defined or described a play as “A just and lively image of
human nature, representing its passions and humours, and the
changes of fortune to which it is subject, for the delight and
instruction of mankind,” Crites takes up his brief for the ancients. His
speech is a set one, extolling the classical conception of drama, and
especially the modern-classical Unities,
but rather a panegyric than an argument, and particularly weak in
this—that it takes no critical account of the modern drama at all.
Except Ben Jonson, “the greatest man of the last age,” not a single
modern dramatic writer of any country is so much as named.
Eugenius, though his discourse is livelier, falls into something the
Eugenius for same fault, or at least the counterpart of it. He rallies
the “last age.” the ancients unmercifully, and has very good game
of the stock plots and characters in Terence; but his commendation
of the moderns has a disappointing generality, and he lays himself
rather open to the good-humoured but forcible interruption of Crites
that he and Eugenius are never likely to come to an agreement,
because the one regards change as in itself an improvement, and
the other does not.
Still, Lisideius gives a new turn to the discussion by asking
Eugenius why he puts English plays above those of other nations,
and whether we ought not to submit our stage to the exactness of
Lisideius for our next neighbours. Eugenius in reply commits the
the French. further and especial defence of the English to
Neander, and Lisideius begins his part as eulogist of the French. For
some forty years, he says, we have not had leisure to be good poets.
The French have: and, by Richelieu’s patronage and Corneille’s
example, have raised their theatre till it now surpasses ours, and the
rest of Europe. Who have kept the Unities so well? Who have
avoided “that absurd thing,” the English tragi-comedy, so
completely? In tragedy they take well-known stories, and only
manageable parts of them, while Shakespeare crams the business
of thirty or forty years into two hours and a half. They make only one
person prominent, they do as much as possible behind the scenes,
keep dying off the stage altogether, and never end their plays with a
conversion, or simple change of will. Nobody, with them, appears on
the stage, unless he has some business there: and as for the beauty
of their rhyme, why, that is “already partly received by us,” and it will,
no doubt, when we write better plays, “exceedingly beautify them.”
To him, Neander—that is to say—Dryden himself.
There is a reminder (though the matter is quite different) of Daniel,
and a comforting augury for English criticism, in the swift directness
with which “the new critic” (as a Webbe of his own day might have
Dryden for called him) strikes at the heart of the question. The
England and French are more regular, he grants, and our
Liberty. irregularities are, in some cases, justly taxed. But,
nevertheless, he is of opinion that neither our faults nor their virtues
are sufficient to place them above us. For Lisideius himself has
defined a play as a lively imitation of nature. And these beauties of
the French stage are beauties, not natural, but thoroughly artificial.
Before Molière, where are the humours of French comedy, save,
perhaps, in Le Menteur and a few others? Elsewhere they work in
comedy only by the old way of quarrels and reconciliations, or by the
conventions of Spanish intrigue-drama. “On which lines there is not
above one play to be writ: they are too much alike to please often.”
Then, as to tragi-comedy. What is the harm of this? why should
Lisideius “imagine the soul of man more heavy than his senses?”
The eye can pass, and pass with relief, from an unpleasant to a
pleasant object, in far less time than is required on the stage. He
must have stronger arguments before he concludes that compassion
and mirth destroy each other: and in the meantime he will hold that
tragi-comedy is a more pleasant way than was known to the
ancients, or any moderns who have eschewed it.
Next, and closely connected, as to single-plot v. plot + underplot.
Why is the former to be preferred to the latter? Because it gives a
greater advantage to the expression of passion? Dryden can only
say that he thinks “their” verse the “coldest” he has ever read, and
he supports this by a close and pleasant beating-up-the-quarters of
Cinna and Pompey, “not so properly to be called plays as long
discourses on reason of state”; of Polyeucte, “as solemn as the long
stops on an organ,” of their mighty tirades and récits. “Whereas in
tragedy it is unnatural for any one either to speak or listen long, and
in comedy quick repartee is the chiefest grace.” Yet again “they” are
praised for making only one person considerable. Why? If variety is
not mere confusion, is it not always pleasing?[502]
The question of narrative against represented action is treated
with less boldness, and, therefore, with less success: but he comes
to the sound, if not very improving, conclusion that, if we show too
much action, the French show too little. He has an interesting
rebuke, however, here to Ben Jonson, for reprehending “the
incomparable Shakespeare.”[503] And he rises again, and makes a
capital point, by citing Corneille’s own confession of the cramping
effect of the Unities, enlarging whereon himself, he has an admirable
exposure of the utterly unnatural conditions which observance of
these Unities brings about. Then, after some remarks on prosody
and the earlier use of rhyme in English—remarks partly true, partly
vitiated by imperfect knowledge—he undertakes to produce plays as
regular as theirs and with more variety, instancing The Silent
Woman. Of this he is proceeding to a regular examen when
Eugenius requests a character of the author: and Neander, after a
little mannerly excuse, not only complies with this request, but
prefixes similar characters of Shakespeare and Fletcher.
The first of these is universally, the second and third should be
Coda on pretty well known. It must be sufficient to say here
rhymed plays, that nothing like even the worst of the three (that of
and Beaumont and Fletcher, which wants the adequacy
conclusion.
and close grip of the other two) had previously been
seen in English, and not many things in any other language, while to
this day, with all faults, the character of Shakespeare is one of the
apices of universal criticism. The characters are followed by the
examen—also admirable and quite new in English, though with more
pattern elsewhere. And he ends with a short peroration, the keynote
of which is, “I ask no favour from the French.” Lisideius is going to
reply; but Crites interrupting, diverts the discussion to a particular
point already glanced at—the use of rhyme in plays. He (sensibly
enough) declines to investigate very carefully whether this was a
revival of the old English custom or an imitation of the French, but
attacks its legitimacy with the usual, obvious, and fairly sound
argument that since no man without premeditation speaks in rhyme,
he ought not to do it on the stage, anticipating the retort, “neither
does he speak blank verse” by urging that this at any rate is “nearest
nature” or less unnatural. Neander, taking up the glove for “his new-
loved mistress,” practically admits the weakness of his case by first
advancing the very argument as to blank verse which Crites has
disallowed by anticipation. The rest of his answer is a mixture of true
and not so true, of imperfect knowledge and ingenious argument,
constantly open to reply, but always interesting as a specimen of
critical advocacy. He represents himself as pursuing the discourse
so eagerly that Eugenius had to remind him that “the boat stood still,”
and that they had come to their destination at Somerset stairs. And
with a pleasant final patch of description the dialogue closes.
In reading it we should keep in mind what he says a quarter of a
century later to the same correspondent,[504] that he was at this time
seeking his way “in a vast ocean” of criticism without other help than
the pole-star of the ancients and the rules of the French stage
Conspicuous amongst the moderns. He has given the reading of
merits of the the pole-star to Crites, and has pointed out the
piece. dangers of mere dead-reckoning by it. He has put
into the mouth of Sedley (with a touch of malice which that ingenious
good-for-nothing must have noticed, and which it is to his credit that
he did not resent) a similar reading of the bearings of the different
French lights, and has shown how little they assisted the English
mariner—indeed, how some of them actually led to rocks and
quicksands, instead of warning off from them. In the mouth of
Buckhurst, and in his own, he has put the patriotic apology, inclining
it in the former case towards laudation of the past, and in the latter to
defence of the present: and he has allowed divers excursions from
the immediate subject—especially that on “verse,” or rhymed
heroics, as a dramatic medium. One of the chief of the many merits
of the piece is precisely this, that at the time Dryden had read less
than at a later, and was less tempted to add quotations or
comments. He was following chiefly a very safe guide—Corneille—
and he bettered his guide’s instruction. It may be said boldly that, up
to the date, nothing in the way of set appreciation—no, not in
Longinus himself—had appeared equal to the three characters of
Shakespeare, Jonson, and Fletcher; while almost greater still is the
constant application of the “leaden rule,” the taking of book, author,
kind, as it is, and judging it accordingly, instead of attempting to force
everything into agreement or disagreement with a prearranged
schedule of rules.
After the publication of the Essay of Dramatic Poesy, Dryden
(English literature can hardly give too many thanks for it) had more
than thirty well-filled years of life allowed him; and to the very last,
and at the very last, criticism had its full share of his labours. The
The Middle “Prefaces of Dryden” never fail to give valuable
Prefaces. matter; and we shall have to notice most, if not all of
them, though the notices may be of varying length. The immediate
successor and, in fact, appendix to the Essay, the Defence thereof,
was only printed in one edition, the second, of The Indian Emperor,
and is very far from being of the best. Sir Robert Howard was, as
has been said, a man conceited and testy, as Shadwell’s nickname
for him in The Sullen Lovers, Sir Positive Atall, hints. He seems to
have been nettled by his part of Crites, and replied with some heat in
a Preface to his own play, The Duke of Lerma. Dryden, who never
quite learned the wisdom of Bacon’s dictum, “Qui replicat
multiplicat,” and who at this time had not yet learnt the easy disdain
of his later manner, riposted (1668) with more sense but with not
much more temper. The piece (which was practically withdrawn
later) contained, besides not too liberal asperities on Sir Robert’s
own work, a further “defence of Rhyme,” not like Daniel’s, where it
should be, but where it should not. It is redeemed by an occasional
admission, in Dryden’s usual and invaluable manner, that he is quite
aware of the other side, and by an unhesitating assertion of the
primacy of Delight among the Objects of Poetry.
In none of the next three or four of the pieces do we find him quite
at his best. For some few years, indeed, the popularity of his
splendid, if sometimes a little fustianish, heroics, the profits of his
connection with the theatre (which, added to other sources of
revenue, made him almost a rich man in his way), and his
association with the best society, seem to have slightly intoxicated
him. He saw his error, like other wise men, all in good time, and even
the error itself was not more than human and pardonable.
The Preface to An Evening’s Love promises, but for the time
postpones, an extension of the criticism of “the last age,” and
intersperses some valuable remarks on the difference between
Comedy and Farce, between Wit and Humour, with a good deal of
egotism and some downright arrogance.[505] The Essay of Heroic
Plays prefixed to The Conquest of Granada (1672) is as yet
unconverted as to rhyme on the stage; but contains some interesting
criticism of Davenant’s essays in the kind, and a curious defence
(recurred to later) of supernatural “machinery.” The main gist of the
Preface, besides its defence of the extravagances of Almanzor, is an
elaborate adjustment of the Heroic Play to the rules of the much-
talked-of Heroic Poem. But though there is a good deal of self-
sufficiency here, it is as nothing to the drift of the Epilogue to the
second part of the play, and of an elaborate Prose “Defence” of this
Epilogue. Here Dryden takes up the position that in “the last age,”
when men were dull and conversation low, Shakespeare and
Fletcher had not, while Jonson did not avail himself of, access to that
higher society which delighted to honour him, Dryden. Divers flings
at the “solecisms,” “flaws in sense,” “mean writing,” “lame plots,”
“carelessness,” “luxuriance,” “pedantry” of these poor creatures lead
up to a statement that “Gentlemen will now be entertained with the
foibles of each other.” Never again do we find Dryden writing like
this; and for his having done it at all Rochester’s “Black Will with a
cudgel” exacted sufficient, as suitable, atonement in the Rose Alley
ambuscade, even from the lowest point of view. From a higher, he
himself made an ample apology to Shakespeare in the Prologue to
Aurungzebe, and practically never repeated the offence.
The curious State of Innocence (1677) (a much better thing than
rigid Miltonists admit) is preceded by an equally curious Apology of
Heroic Poetry, in which, yet once more, we find the insufficient sense
in which Imagination (here expressly limited to “Imaging”) was used;
while the Preface to All for Love (1678) is a very little ill-tempered
towards an anonymous lampooner, who was, in fact, Rochester.
Troilus and Cressida (1679) was ushered by a set preliminary
Discourse on the Grounds of Criticism in Tragedy. No piece
illustrates more remarkably that mixed mode of criticism in Dryden,
to bring out which is our chief design. On a canvas, not it must be
confessed of much interest, woven out of critical commonplaces
from Aristotle and Longinus down to Rymer and Le Bossu, he has
embroidered a great number of most valuable observations of his
own, chiefly on Shakespeare and Fletcher, which culminate in a set
description of Fletcher as “a limb of Shakespeare”—a thing happy in
itself and productive of happy imitations since. The Preface to the
translation of Ovid’s Epistles (1680) chiefly consists of a fresh
defence of that ingenious writer (for whom Dryden had no small
fancy), and the Dedication to Lord Haughton of The Spanish Friar
(1681) is mainly notable for an interesting confession of Dryden’s
changes of opinion about Chapman and Du Bartas (Sylvester
rather), and a sort of apology for his own dallying with these Delilahs
of the theatre in the rants of Almanzor and Maximin.
But that to the Second Miscellany, five years later, after a period
chiefly occupied with the great political satires, ranges with the
Essay, and not far below the Fables Preface, among Dryden’s
critical masterpieces. The thing is not long—less than twenty pages.
But it gives a coherent and defensible, if also disputable, theory of
translation, a singularly acute, and, it would appear, original contrast
of the faire of Ovid and of Claudian, more detailed studies of Virgil,
Lucretius (singularly good), Horace, and Theocritus, and the best
critical stricture in English on “Pindaric” verse. After it the note of the
same year on Opera, which ushered Albion and Albanius, is of slight
importance.
The Dedication of the Third Miscellany (specially named Examen
Poeticum, as the second had been sub-titled Sylvæ) contains some
interesting protests against indiscriminate critical abuse, the final
formulation of a saying sketched before (“the corruption of a poet is
the generation of a critic”), illustrated from Scaliger in the past and
(not obscurely though not nominatim) from Rymer in the present;
and, among other things, some remarks on prosody which might well
have been fuller.
Between this and the Fables, besides some lesser things,[506] there
appeared two of the longest and most ambitious in appearance of
Dryden’s critical writings, the Essay [strictly Discourse] on Satire
prefixed to the Juvenal, and the Dedication of the Æneis, with,
between them, the first writing at any length by a very distinguished
Englishman of letters, on the subject of pictorial art, in the shape of
the Parallel of Poetry and Painting prefixed to the translation of Du
The Essay on Satire and Fresnoy De Arte Graphica. All, being
the Dedication of the Dryden’s, are, and could not but be,
Æneis. admirably written and full of interest. But
the Juvenal and Virgil Prefaces are, in respect of permanent value,
both intrinsically and representively injured by an excess of critical
erudition. The time was perhaps not yet ripe for an honest and
candid address straight to the English reader. The translator was
bound to recommend himself to classical scholars by attention to the
paraphernalia of what then regarded itself as scholarship (“other
brides, other paraphernalia” no doubt), and to propitiate wits, and
Templars, and the gentlemen of the Universities, with original or
borrowed discourses on literary history and principle. Dryden fell in
with the practice, and obliged his readers with large decoctions of
Rigaltius and Casaubon, Dacier and Segrais, which are at any rate
more palatable than the learned originals, but which make us feel,
rather ruefully, that boiling down such things was not the work for
which the author of Absalom and Achitophel and of The Essay on
Dramatic Poesy was born.
As for the Parallel, it is of course interesting as being nearly our
first Essay, and that by a master hand, in a kind of criticism which
The Parallel of has later given excellent results. But Dryden, as he
Poetry and most frankly admits, did not know very much about
Painting. the matter, and his work resolves itself very mainly
into a discussion of the principles of Imitation in general, applied in
an idealist manner to the two arts in particular. Again we may say,
“Not here, O Apollo!”
We have nothing left but the Preface to the Fables, the
extraordinary merit of which has been missed by no competent critic
The Preface to from Johnson to Mr Ker. The wonderful ease and
the Fables. urbanity of it, the artfully varied forms of reply to the
onslaughts of Collier and others, are not more generally agreeable
than are, in a special division, the enthusiastic eulogy of Chaucer (all
the more entertaining because of its lack of mere pedantic accuracy
in places), and the interesting, if again not always rigidly accurate,
scraps of literary history. It winds up, as the Essay had practically
begun, a volume of critical writing which, if not for pure, yet for
applied, mixed, and sweetened criticism, deserves to be put on the
shelf—no capacious one—reserved for the best criticism of the
world.
We have seen, over and over again, in individual example; have
already partially summed more than once; and shall have to re-sum
with more extensive view later, the character and the faults of the
critical method which had been forming itself for some hundred and
Dryden’s fifty years when Dryden began his critical work. It
general would be absurd to pretend that he was entirely
critical superior to this “Spirit of the Age”—which was also
position.
that of the age behind him, and (with rare
exceptions) of the age to come for nearly a hundred years. But,
although it may be paradoxical, it is not absurd at all, to express
satisfaction that he was not so entirely superior. He was enabled by
his partial—and, in so far as his consciousness went, quite sincere—
orthodoxy, to obtain an access to the general hearing in England,
and even to influence, long after his death, important literary
authorities, as he never could have done if he had set up for an
iconoclast. Furthermore, it was not yet time to break these idols.
Apollo winked at the neo-classical ignorance and heresy because it
was useful. We are so apt—so generously and excusably apt—to
look at the Miltons without considering the Clevelands, that we forget
how absolutely ungoverned, and in some cases how near to puerility,
the latest Elizabethan school was. We forget the slough of shambling
verse in which true poets, men like Suckling in drama, men like
Lovelace in lyric, complacently wallowed. The strait waistcoat was
almost necessary, even after the fine madness, much more after the
madness not so fine, of mid-seventeenth-century verse, and, in a
less degree, prose. And so, when we find Dryden belittling the
rhymes of Comus and Lycidas,[507] shaking his head over
Shakespeare’s carelessness, unable with Chapman, as Ben had
been with Marlowe, to see the fire for the smoke, we need not in the
least excite ourselves, any more than when we find him dallying with
the Dowsabels of Renaissance school-criticism. In the first place, the
thing had to be done; and in the second place, his manner of doing it
went very far to supply antidote to all the bane, as well as to
administer the “corsives,” as they said then, in the mildest and most
innocuous way possible.
His special Dryden’s moly, an herb so powerful that—herein
critical excelling its original—it not only prevented men like
method. Addison from becoming beasts like Rymer, but had
the virtue of turning beasts into men,—of replacing the neo-classic
jargon by the pure language of criticism,—was that plan of actual
comparison and examination of actual literature which is not merely
the via prima but the via sola of safety for the critic. By his time there
was assembled a really magnificent body of modern letters, in
addition to classical and mediæval. But nobody in the late
seventeenth century, except Dryden, really utilised it. Italy and Spain
were sinking into premature senility. The French[508] despised or
ignored all modern literatures but their own, and despised and
ignored almost equally their own rich and splendid mediæval stores.
Dryden’s freedom from this worst and most hopeless vice is all the
more interesting because, from some of his utterances, we might
have expected him not to be free from it.[509] That theory of his as to
Mr Waller; that disastrous idea that Shakespeare and Fletcher were
low people who had not the felicity to associate with gentlemen,—
might seem likely to produce the most fatal results. But not so. He
accepts Chaucer at once, rejoices in him, extols him, just as if
Chaucer had taken lessons from Mr Waller, and had been familiar
with my Lord Dorset. Back his own side as he may in the duel of the
theatres, he speaks of the great lights of the last age in such a
fashion that no one has outgone him since. He cannot really take an
author in hand, be he Greek or Latin, Italian or French or English,
without his superiority to rules and systems and classifications
appearing at once, however he may, to please fashion and fools,
drag these in as an afterthought, or rather (for Dryden never “drags”
in anything save the indecency in his comedies) draw them into the
conversation with his usual adroitness. And he is constantly taking
authors in hand in this way,—we are as certain that this, and not
twaddling about unities and machines, was what he liked doing, as
we are that he wrote comedies for money, and satires and criticism
itself for love. Now this,—the critical reading without theory, or with
theory postponed, of masses of different literatures, and the
formation and expression of genuine judgment as to what the critic
liked and disliked in them, not what he thought he ought to like and
dislike,—this was what was wanted, and what nobody had yet done.
Dryden did it—did it with such mastery of expression as would
almost have commended a Rymer, but with such genuine critical
power and sympathy as would almost have carried off the absence
of merits of expression altogether. He established (let us hope for all
time) the English fashion of criticising, as Shakespeare did the
English fashion of dramatising,—the fashion of aiming at delight, at
truth, at justice, at nature, at poetry, and letting the rules take care of
themselves.
Perhaps in no single instance of critical authorship and authority
does the great method of comparison assist us so well as in the case
Dryden and of Dryden and Boileau. This comparison is
Boileau. absolutely fair. The two were almost exact
contemporaries; they represented—so far at least as their expressed
and, in both cases, no doubt conscientious, literary creed went—the
same sect. Enfin Malherbe vint is an exact parallel, whether as a
wonderful discovery or a partly mischievous delusion, to the exploits
on our numbers by Mr Waller. Both were extremely powerful satirists.
Both, though not comparable in intrinsic merit, were among the chief
men of letters of their respective countries. Both had a real, and not
merely a professional or affected, devotion to literature. Both applied,
with whatever difference of exclusiveness and animus, a peculiar
literary discipline, new to the country of each. And in the case of both
—it has been decided by a consensus of the best judges, with all the
facts before them up to the present time—there was an insufficient
looking before and after, a pretension to limit literature to certain
special developments.
We have seen what, in carrying out the scheme which was in
effect the scheme of both, were the defects of Boileau. Let us see
what, in contra-position to them, are the merits of Dryden.
That, though he makes mistakes enough in literary history, these
mistakes are slight in comparison with Boileau’s, matters not very
much; that, though his satiric touch was more withering even than
the Frenchman’s, he has no love of lashing merely for the sport, and
never indulges in insolent flings at harmless dulness, suffering
poverty, or irregular genius; that, though quite prone enough to
flatter, he declined to bow the knee to William of Orange, while
Boileau persistently grovelled at the feet of William’s enemy,—these
things matter even less to us. The fact, the critical fact, remains that
the faults of his time and his theory did the least harm to Dryden of
all men whom we know, while they did the most to Boileau. And the
reason of the fact is more valuable than the fact itself. Boileau, as we
have seen, has not left us a single impartial and appreciative
criticism of a single author, ancient or modern. Dryden simply cannot
find himself in presence of a man of real genius, whether he belongs
to his own school or another, without having his critical lips at once
touched by Apollo and Pallas. He was sadly ignorant about Chaucer,
—a board-school child might take him to task; but he has written
about Chaucer with far more real light and sympathy than some at
least of the authors of the books from which the board-school child
derives its knowledge have shown. His theory about Shakespeare,
Fletcher, and Jonson was defective; but he has left us criticisms of
all three than which we have, and are likely to have, no better. About