The care of children is as old as our species, but the discipline of pediatrics emerged barely a century ago. In this progression, the history the field of pediatrics follows the general pattern of the history of medicine: the timeless traditions of informal health care in the home; the roots of modern medicine in ancient Greece, Rome, and the Arab world; the gradual emergence of science in the 1600s; the provision of health care by medical professionals working in ever-larger institutions during the 1800s; and the recent faith that technically sophisticated medicine will cure disease and improve health. What distinguishes pediatrics from other branches of medicine is the notion that children are our future, and consequently that their health and well-being are a matter of broad social concern. Since antiquity, political and medical leaders have argued that healthy children are necessary to the well-being of the state. Each nation-state's response to such arguments has affected both the health of children and how societies have organized pediatric health services.
Ancient and Medieval Medical Writings
Although many observers in ancient and medieval eras may have viewed children as merely small adults, most medical writers focused on the special health concerns of children. The first few years of life, for example, were thought to require special care, especially during times when teeth were emerging. Hippocrates (c. 460–377 b.ce.) wrote a small treatise, "On Dentition," on the subject of teeth, and noted how children differ from adults in various ways in his "Aphorisms." Spring and full summer are the best seasons for children, Hippocrates suggested, while late summer and early fall are the healthiest seasons for adults. Soranus of Ephesus (2nd century c.e.) completed a more detailed work on children's diseases, which included explanations on how to feed, bathe, and swaddle an infant. Rhazes (c. 865–932), who studied and taught in Baghdad, was one of the first medical scholars to write an entire treatise on children.
Home and Foundling Asylums
These scholarly efforts had little affect on the vast majority of children. Most health care was delivered by family members in the home. When a child became more ill than the family could handle, they may have turned to local untrained specialists, usually religious leaders or women in the community with reputations for expertise in medical matters. There were no special medical services or providers for children. In 787 Archbishop Datheus opened one of the first
foundling asylums at Milan. Over the next thousand years, religious leaders opened many more places of refuge for abandoned or orphaned babies. Such institutions provided little or no medical treatment, however, and most infants and children died soon after being taken in.
Renaissance Medical Writings
With the invention of movable type in the 1400s, medical works became more accessible to scholars, at least to those who read Latin. The first medical book to be printed was a pediatrics treatise by the Italian Paolo Bagellardo (c. 1425–1495). It was based on Greek and Arab works, though it included some of his own experience, such as medicines that could be used to soothe a crying baby. In 1545 Thomas Phaer wrote the first English-language work on pediatrics. The Boke of Children included a long section on dentition: teething caused swelling of gums and jaw, crying, fever, cramps, palsies, etc. He advocated washing the child in camomile and applying oil of roses, fresh butter with barley flour or honey, or frankincense and licorice mixed in a fine powder. In their content and reliance on centuries-old Greek, Roman, and Arab sources, Bagellardo's and Phaer's books were typical of pediatric medical works prior to 1600.
Rise of Empiricism
In the 1600s, scholars eschewed traditional theories and supernatural accounts, and began to value their own observations of the natural world. The so-called scientific revolution was heralded by the empiricism of Francis Bacon (1561–1626) in his Advancement of Learning (1605). By the late 1600s the concept of a scientific fact, as distinct from theory, emerged as the basis for creating reliable knowledge about the natural world. In medicine, this meant more realistic studies of anatomy and physiology, including William Harvey's (1578–1657) experimental demonstration of the
circulation of blood through the body. In clinical medicine, classification and description of disease became central topics for medical scholars. Thomas Sydenham (1624–1689), for example, developed a sophisticated system for categorizing diseases, and his description of the movement disorder that accompanies rheumatic fever (Sydenham's chorea) is a model of clinical observation. To treat such fevers, Sydenham subscribed to the medical therapeutics espoused since ancient times: he would drain seven ounces of blood, then purge with senna, black-cherry water, and laudanum.
While the seventeenth-century clinical observations of Sydenham and others would still be familiar today, the blood-letting and purging regimens now appear barbaric. However, such therapeutics fit squarely with contemporary concepts of health and disease; they were rational responses to widely accepted theories of disease causation. Medical scholars and the general public agreed that the balance of various body humors (e.g., blood, bile, phlegm) was the key to maintaining health. Specific diseases were thought to occur when the humors were out of balance. If the blood ran high during fevers, then cutting open a vein or applying leeches was a logical response. With generally high mortality rates, most people were resigned to the frequent deaths of children and young adults. Physicians gained notoriety not for their ability to cure but for how accurately they predicted outcomes and how heroically they tried to rebalance the humors through bleeding and purging. When a patient survived such interventions, the therapy was deemed successful and the physician could take credit for his therapy; when the patient died, then the intervention was said to have occurred too late or to have been applied too gently. God's will was often invoked. Pre-nineteenth-century therapeutics was dramatic, and when someone died no one could argue that the doctor had not tried to intervene.
The most famous therapeutic intervention of the 1700s was a conceptual anomaly. Inoculation against smallpox had been practiced in India and parts of the Arab world for centuries, but it never fit the model of disease and cure implied by the balance of body humors. Lady Mary Wortley Montagu (1689–1762) brought the practice to the West when she had her son inoculated with material from a smallpox victim in Constantinople in 1718. She championed the idea of inoculation before physicians and royalty as a way to lessen the burden of smallpox: nearly every child contracted signs and symptoms of the disease and many were permanently scarred by the skin lesions. Some estimated that as many as 30 percent of all children died from smallpox. In the 1790s, Edward Jenner (1749–1823) noted that young women who milked cows and became infected with cowpox did not get smallpox. Since the consequences of contracting cowpox were less severe than those of inoculation with smallpox, vaccination with cowpox became common practice. Indeed, it was made compulsory in Bavaria in 1807 and in Denmark in 1810.
Rise of Hospitals
Modern therapeutics owes less to Jenner and Montague than to the hospitals of Paris, which became the center of medical research in the late 1700s. With large numbers of patients confined to institutions, French scholars such as Pierre-Charles-Alexandre Louis (1787–1872) were able to follow the natural course of specific diseases. Louis used clinical statistics to correlate the signs and symptoms of specific diseases with particular abnormalities found inside the body. He relied on the work of Xavier Bichat (1771–1802) and others who had previously matched clinical symptoms with pathological findings on autopsy. For example, a yellowish discoloration of the skin and eyes predicted an abnormal liver; microscopic analysis of liver tissues revealed disrupted cells and scarring. By routinely applying new technologies such as the stethoscope, the microscope, and statistical reasoning to hospitalized patients, French scholars created the basis for modern clinical medicine. Perhaps most importantly, they noted that medical interventions of the past two millennia—bleeding and purging–did not seem to improve survival.
When French medicine overturned centuries of faith in body humors as the cause of disease, physicians were left to pursue many different strategies to explain disease and heal their patients. Medical sects such as homeopathy, osteopathy, and hydrotherapy (water cure) flourished through the late 1800s, offering stiff competition to practitioners of "regular" medicine. Germ theory was just one of many plausible explanations for disease causation until the work of Robert Koch (1843–1910) and Louis Pasteur (1822–1895). In dozens of now-famous experiments, they demonstrated that specific germs (bacteria) caused specific diseases. Although Koch, Pasteur, and their many colleagues worked differently, in general the process was the same: the microbiologist obtained fluids from animals or people with a particular disease, isolated bacteria present in such body fluids, created techniques for growing the bacteria, then injected these bacteria into healthy subjects to recreate the signs and symptoms of the disease. Germ theory not only provided a way of understanding the etiology and patterns of many infectious diseases, but it also suggested therapies such as antibiotics and vaccines. The history of pediatric science in the twentieth century reads like a list of victories over specific infections (see Table 1), whether through the discovery of penicillin by Sir Alexander Fleming (1881–1955) or the disappearance of polio in the Western Hemisphere with the vaccines introduced by Jonas Salk (1914–1995) and Albert Sabin (1906–1993).
Emergence of the Field of Pediatrics
Although there had been pockets of scholarly focus on children for centuries, the field of pediatrics did not take shape until the mid-1800s. In part, the emergence of pediatrics as a medical specialty was merely one example of a broader trend in institutional medicine. Before 1800, physicians in most parts of the world claimed broad expertise for various diseases, populations, and therapeutic techniques. Surgery and dentistry were considered the only legitimate areas of specialization; doctors who claimed to be experts in specific fields were likely to be viewed as quacks. As medical knowledge expanded in the 1800s, many medical scholars found intellectual justification for focusing on particular areas of the body such as the brain (psychiatry, neurology) or on particular surgical techniques (orthopedics, ophthalmology). Even if they continued a general medical practice, groups of physicians gathered around shared interests at medical meetings, created specialty journals, and began to control medical school curricula and clinical teaching. In the mid-1800s, pediatrics was closely associated with obstetrics, but by the early 1900s, pediatrics had its own hospitals, journals, professional associations, and medical school professorships (see Table 2).
The Economics of Specialization
Given the intellectual plausibility of medical specialization, many physicians were also motivated by the economic advantages. Before 1900, medicine was not necessarily a lucrative profession. Indeed, in many parts of the world, only those physicians who tended to rich families found economic or social security in the practice of medicine. With the growth of concentrated populations in cities, a medical practice devoted exclusively to a medical specialty became economically viable. Specialization was one strategy for competing for the limited number of families who could afford to pay for medical care. A young physician could distinguish himself from his peers by affiliating with the specialty practice of a hospital, clinic, or medical school. In pediatrics, formal training programs have existed for more than a hundred years in Europe and North America. To certify pediatricians, each nation has developed its own criteria for training after graduation from medical school; most also require successful completion of a standardized written or oral examination. The American Board of Pediatrics, for example, was founded in 1933 to certify pediatricians in the United States.
Changing Emotional Reasons Underwriting Pediatrics
For physicians in the 1800s, the emergence of pediatrics may have seemed to be a logical response to economic pressures and to evidence from developmental biology and clinical medicine that distinguished children's bodies from those of adults. However, pediatrics emerged as a specialty in the context of a broader appreciation for the emotional value of children: no longer a mere economic asset of the father, each child was considered to be a priceless human being who deserved some protection by society. Although this new view of children emerged at different times in different places, by 1900 most nations had instituted laws providing education to children, protecting them against physical abuse from their fathers, and outlawing excessive or dangerous labor before a certain age. To some degree, the field of pediatrics owes its genesis to the new view of children as special and distinct from adults, along with a growing belief that children's deaths could and should be prevented.
Pediatric Specialists or General Medical Care
Specialization in pediatrics has deepened our scientific understanding of children and improved the training of physicians and nurses. The practice of pediatrics by specialists, however, has had little direct impact on most families. It is only in the last two hundred years or so that the average family might have access to a trained medical professional such as a physician, let alone a specialist. In many parts of the world medical care is still difficult to find, and pediatric specialty care an unusual luxury. Indeed, the specific configuration of the field of pediatrics in each nation depends more on social, political, and economic factors than on the intellectual content of pediatric medicine. In most nations children receive medical care from physicians or nurse practitioners with training in general medicine. Physicians with specialty training in pediatrics are consulted when a child or adolescent has a medical issue that goes beyond the expertise of the general practitioner. Even in industrialized nations, rural families and those living in poverty remain less likely to see a pediatric specialist.
Pediatrics in the United States
The United States is unique in that pediatrics has become a primary care specialty. In 1910 there were approximately one hundred physicians who confined their practice to pediatrics; by 1935 there were several thousand. The American Academy of Pediatrics' membership in 2000 was more than fifty thousand pediatricians, which means one pediatrician for every fifteen hundred children. This allows most children to visit a physician with specialty training in pediatrics for routine check-ups and mild illnesses. Other children are cared for by family medicine practitioners and pediatric nurse practitioners, but nearly all children in the United States have access to pediatric subspecialists. These are physicians who obtain two to three years of additional training after general pediatrics to gain expertise in areas such as pediatric cardiology, neonatology, and pediatric gastroenterology. Pediatric subspecialists may be found in academic centers in many other nations, but few families outside the United States would expect to be routinely referred to such practitioners.
Women and Pediatrics
Women have long had an important role in the field of pediatrics, especially in the United States. Many without medical training, such as Julia Lathrop (1858–1932), the first director of the U.S. Children's Bureau, held leadership positions in government and philanthropic organizations designed to improve the health and well-being of children. Within the field of medicine, women physicians accounted for 20 percent of practitioners in some U.S. cities in the early 1900s. They directed hospitals, medical schools, and city health departments. Because many women felt a special obligation to provide medical care to women and children, they often specialized in obstetrics and pediatrics; many took academic positions and some gained national prominence in pediatrics. Following the reforms in medical education in the early 1900s, the number of women physicians fell to approximately 5 percent of all doctors. As their numbers have increased since 1970, however, women have again moved toward pediatrics as a field of specialization. In the year 2000 approximately half of all pediatricians in the United States were women, and they represent about two-thirds of pediatricians-in-training.
Social Implications of Child Health
The science of pediatrics has rarely been divorced from the social implications of child health. Since antiquity, scholars and political leaders have assumed that healthy children were essential to the well-being of the state. Medical authorities have generally agreed, and they have consistently viewed the proper upbringing and education of children as within the province of medicine. Persian medical scholar Avicenna (980–1037) wrote that all the study and work of physicians should focus on forming and molding the character of the child. Medical writers over the centuries have echoed his remarks, and in the twenty-first century pediatricians frequently use their status as the experts in child health to suggest the most effective ways of raising and educating children. On the other hand, the importance of child health has also led philosophers and political writers to enter medical matters. Thus the Greek scholar Plutarch (c. 46–120) wrote The Education of Children to teach ruling-class families how to properly mold their children such that the future strength of the state might be secured. Among his many medical suggestions, he implored mothers to breast-feed because it makes a "bond of good feeling." Political leaders through the centuries have continued to approach the health of children as a social issue, whether through the extremes of eugenics programs aimed to secure the racial health of the state or through the emptiness of campaign slogans designed to emphasize a politician's commitment to the future.
Infant Mortality and the Fate of Nation-States
The history of the infant mortality rate is a good example of how the field of pediatrics combines science and social policy. As early as 1761, British physician William Buchan (1729–1805) noted that one half of the human race dies in infancy, with ominous consequences for the health of the state. In the 1800s, improvement in health statistics led to increased attention to the death rate of infants throughout Europe. Such deaths were seen not as mere medical failings but as indictments of the economic, political, and moral wellbeing of the nation. Theophile Roussel (1816–1903), the French physician and politician, was perhaps the most vocal of national leaders. He is credited with the loi Roussel, a set of laws that protected infants sent out to nurse (1874), protected abused and abandoned children (1889), and organized medical charity (1893).
Throughout Europe in the late 1800s, governments instituted programs to protect pregnant women (e.g., paid maternity leave) because they believed that healthy infants were crucial to the future economic and political well-being of the state. In 1892 Paris physician Pierre Budin (1846–1907) started the first infant consultations, when mothers would bring their well babies to be weighed and examined. Such well-child care was duplicated throughout Europe and the United States in hopes that advice and clean milk might prevent infant deaths. Such preventive health visits remain central to the practice of pediatrics, even as the infant mortality rate has dropped from three hundred deaths out of every one thousand births to less than ten per thousand in many parts of the world. The result–the regular check-up–is a huge change in the experience of children and parents alike in the more affluent groups and regions.
Emerging and Persisting Child Health Problems
Viewed as a medical discipline, pediatrics has shifted in response to each generation's understanding of which diseases seemed most important among children. While Hippocrates focused on climate and special vulnerable periods for children, later scholars wrote about the most common infectious diseases, from smallpox in the 1700s to infantile diarrhea in the late 1800s. The dramatic decrease in infectious diseases in developed nations over the last century has led pediatricians to focus on rare chronic illnesses and behavioral and developmental conditions. The mapping of the human genome promises new ways to eliminate disabilities and prevent chronic illness in the twenty-first century.
Some of this success has been shared by all the children in the world–the eradication of smallpox in 1970 is the crowning achievement of a public health system applying a specific therapy to a specific disease. Millions of children in Africa and Asia continue to die from measles, tuberculosis, and infant diarrhea, however, demonstrating that antibiotics, vaccines, and modern hospitals only go so far. Even as the incidence of AIDS decreases in the West, more and more African and Asian babies are born infected with HIV in the early twenty-first century. In these nations, pediatricians and public health officers continue to focus on nutrition, sanitation, and maternal education as the most effective ways to reduce mortality from common infectious diseases.
Pediatrics and Social Activism
Abraham Jacobi (1830–1919) is generally considered to be the "father" of modern pediatrics. A German physician who was once arrested for participating in the revolution of 1848, Jacobi moved to New York, where he built a career of scientific discovery, clinical practice, and tireless advocacy on behalf of children. He argued that the health and well-being of children required appropriately trained medical practitioners as well as social and economic investment in their lives and neighborhoods. His words have been remembered by pediatricians, scholars, and political leaders for over a hundred years, and perhaps best embody the science and social activism that characterizes the field of pediatrics: "It is not enough, however, to work at the individual bedside in the hospital. In the near or dim future, the pediatrician is to sit in and control school boards, health departments, and legislatures. He is the legitimate advisor to the judge and the jury, and a seat for the physician in the councils of the republic is what the people have a right to demand" (quoted in Burke).
See also: Children's Hospitals; Contagious Diseases; Epidemics; Obstetrics and Midwifery.
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Jeffrey P. Brosco