The origins of pediatrics as a clinical and academic specialty in the United States

Colin Phoon
New York, New York, United States (Winter 2018)

 

Children’s ward, Bellevue Hospital, New York, ca. 1897
(Courtesy of the National Library of Medicine, NLM ID#
101435915)

In the long timeline of medicine, pediatrics is a recent clinical field.  The first children’s hospital in the world was established in Paris in 1802, followed by the Hospital for Sick Children on Great Ormond Street in London in 1852.1  Rightfully so, many ascribe the birth of American pediatrics to the children’s hospitals of the latter half of the nineteenth  century.  Nevertheless, a focus on hospitals reveals only an incomplete picture.

Throughout history, children had been cared for in larger general hospitals.  For example, New York City’s Bellevue Hospital listed 126 children in its 1809 census.2  In 1846 Amos Lawrence established in Boston the nation’s first children’s infirmary, and the New York Nursing and Child Hospital opened in 1854; however, both closed after brief existences.3, 1 The first permanent US children’s hospital is thus widely acknowledged to be the Children’s Hospital of Philadelphia (CHOP), founded in 1855 and inspired by Great Ormond Street’s Hospital for Sick Children.4  Other children’s hospitals followed – including Boston Children’s Hospital in 1869 – and about two dozen existed by 1900.  During this era, pediatrics was typically a division in the department of medicine.  At Johns Hopkins, the Harriet Lane Home for Invalid Children opened in 1912, and this full-time department of pediatrics (separate from adult medicine) would become the prototype for modern academic pediatric departments.5

But buildings alone do not make a specialty; people do.  Until the middle of the nineteenth  century, most pediatric medical practice was unsound and unscientific.  The “fathers” of American pediatrics are considered to be Abraham Jacobi and Job Lewis Smith.6-9   Jacobi emigrated from Germany and would introduce the term “pediatrics” to unify the fields of childhood therapeutics, pathology, and physiology.8  He is credited with the establishment of bedside teaching in the US but was foremost an advocate for children.7  Quieter than the more outspoken Jacobi but easily as capable, Smith worked primarily at the Bellevue Medical School.1-6  Smith’s appointment in 1861 as Clinical Professor of Diseases of Children was believed to have been “the first time that a professorship in a first-class medical school was designated for pediatrics alone, antedating by some nine years the analogous appointment of Jacobi at Columbia.6  Among Smith’s signature accomplishments were his textbook of pediatrics – first published in 1869 and so esteemed it went through eight editions – and his founding of the American Pediatric Society in 1888.1, 7  The first pediatricians focused much of their energy on diseases and conditions associated with poverty, poor sanitation, and deplorable living conditions.  At Babies Hospital in New York, L. Emmett Holt is credited with establishing a scientific (biochemical) basis for the field of pediatrics in the US, and fittingly also played a key role in founding the Rockefeller Institute.9  Holt was “[a]lways immaculately dressed, he rarely smiled or laughed and appeared to be driven by a stern sense of duty… Hard working, efficient, thorough and meticulous in his work, he also possessed sound judgment, intellectual honesty, and a total dedication to the welfare of his patients”;10 he is considered the “Osler” of pediatrics.11  Devoted clinicians, advocates, gifted teachers, keen investigators, and prolific writers all, it is notable that even these first American pediatric leaders did not necessarily devote their full-time efforts to the care of children.  It was not until 1912 that John Howland (whose mentor was Holt) arrived at Johns Hopkins to lead the first full-time department of pediatrics in the US, establishing the second scientifically-based academic department in the US at the Harriet Lane Home.1, 5, 12

Beginning in the 1930’s, pediatric subspecialty care emerged through the vision of Edwards A. Park.9, 12  Pediatric cardiology (Helen Taussig), pediatric endocrinology (Lawson Wilkins), and child psychiatry (Leo Kanner) were among the earliest pediatric medical subspecialties.  Yet even decades before, hospitals had already naturally subspecialized, the physical separation of medical and surgical patients already documented at CHOP in 1874.4  Pediatric surgery saw its beginings in the early twentieth century, founded by disciples of William Halsted and including William Ladd in Boston.1, 3

In the late 1880’s, American pediatrics “in any organized sense was in the doldrums,” but its evolution as a medical specialty would soon lead to dedicated professional organizations.5 The first American journal devoted solely to pediatrics was the Archives of Pediatrics, initially published in 1884.9  Some forty years after the American Pediatric Society, the American Academy of Pediatrics (AAP) was founded in 1930 with a focus on education, public health, and social issues affecting children.1 To bestow certification by establishing specific training requirements and an examination, the American Board of Pediatrics was founded in 1933.1, 9

As compared to buildings and people, surprisingly little is written about the evolution of training in pediatrics.  The first formal medical school course and the first faculty appointment in the diseases of children in the US were at Yale in the early 1800’s.9  CHOP’s medical staff added its first resident physician in 1872; by 1877 its clinics were made accessible to students for medical and surgical instruction.4  House officers were appointed as “internes” and “externes” starting in 1882 at Boston Children’s Hospital.3  Naturally, the first residency programs trained clinicians simply by providing patients as clinical material, under the longstanding apprenticeship model.  Howland’s training program at the Harriet Lane Home was still based on an apprenticeship model but critically, academic rigor guided clinical care and produced “scientific practitioners.”5, 11, 12  A master clinician and “exceptionally gifted” teacher, Howland could also be conservative in accepting new clinical ideas, was known to be sarcastic with students, and controlling within departmental hierarchy.  Nevertheless, Howland “was the life and inspiration of the clinic…. His great drive was motivated and powered by his faith in the investigative approach, both clinical and experimental.”12 The importance of such academic training is highlighted by the career paths of Howland’s trainees: most would go on to become heads of departments around the country.5, 11, 12

Research and investigation as a core mission of a pediatrics department began with Holt at Columbia and Howland at Hopkins, and blossomed in the early twentieth century.  The establishment of the NIH’s National Institute for Child Health and Development (NICHD) in 1962 underscored the importance of investigating human development throughout the entire life process, starting even before birth and with a critical role of health in childhood.  Robert Cooke, of Johns Hopkins and the Harriet Lane Home, was instrumental in founding this unusual institute, which did not focus on a particular disease or group of diseases.12  The NICHD’s broad mission is reflected in the now-widely-accepted tenet that maternal-fetal health, pediatric care and child health, and adult health and disease, all constitute a continuum.13

Within a few short decades of the birth of American pediatrics, the US would itself make extraordinary contributions to pediatrics – fueled by advances in clinical care, modernization of pediatric facilities, specialized pediatric training, and research – and continues to do so to this day.

 

References

  1. Cone TE Jr. 1979.  History of American Pediatrics. Boston: Little, Brown and Company.
  2. Carlisle RJ, ed. 1893. An Account of Bellevue Hospital, with a Catalogue of the Medical and Surgical Staff from 1736 to 1894. (Reprinted 1986, on the oaccasion of the 100th Anniversary of the Society and the 250th Anniversary of Bellevue Hospital.)  New York: The Society of the Alumni of Bellevue Hospital.
  3. Archives Program of Children’s Hospital (co-editors: Jason T. Larson; Mark A. Rockoff; David R. Breakstone; Patrick Bibbins; Michelle R. Davis; Patrick Taylor; Frederick H. Lovejoy, Jr.). 2005.  Children’s Hospital Boston (MA).  Charleston: Images of America Series, Arcadia Publishing.
  4. Bell M. 2015. The Children’s Hospital of Philadelphia. Charleston: Images of America Series, Arcadia Publishing.
  5. Harvey AM, Brieger GH, Abrams SL, McKusick VL. 1989. A Model of Its Kind, Volume I: A Centennial History of Medicine at Johns Hopkins.  Baltimore: Johns Hopkins University Press.
  6. Faber HK. Job Lewis Smith, forgotten pioneer.  J Pediatr. 1963; 63(Suppl):794-802.
  7. Burke EC. Abraham Jacobi, MD: The man and his legacy. Pediatrics. 1998; 101:309-312.
  8. Mahnke CB. The growth and development of a specialty: the history of pediatrics. Clin Pediatr. 2000; 39:705-714.
  9. Pearson HA. “The history of pediatrics in America”. 2006. In Oski’s Pediatrics: Principles and Practice, edited by McMillan JA, Feigin RD, DeAngelis C, Jones MD Jr., 2-13.   Philadelphia: Lippincott Williams & Wilkins.
  10. Dunn PM. Dr. Emmett Holt (1855-1924) and the foundation of North American paediatrics. Arch Dis Child Fetal Neonat Ed. 2000; 83:F221-223.
  11. Ludmerer KM. 2015. Let Me Heal: The Opportunity to Preserve Excellence in American Medicine. Oxford: Oxford University Press.
  12. Park EA, Littlefield JW, Seidel HM, Wissow LS. 2006. The Harriet Lane Home: A Model and a Gem.  Baltimore: Johns Hopkins University Press.
  13. https://www.nichd.nih.gov/about

 


 

COLIN K.L. PHOON, MPhil, MD, is Associate Professor of Pediatrics at New York University School of Medicine.  A clinical pediatric cardiologist and philomath, Dr. Phoon is also active in medical education and diverse research areas.  Academic interests include Barth syndrome and mitochondrial biology, heart development, and history of medicine.  Avocations include amateur radio (call sign AE3A) and lacrosse.

 

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