Pediatrics, or at least the medical care of infants and children, began in America shortly after the founding of the English colonies in the early seventeenth century. In 1677, Rev. Thomas Thacher of Boston, a pastor and part-time physician, wrote the first medical publication of the English colonies, a broadside on smallpox. In 1721, Dr. Zabdiel Boylston, working with Cotton Mather, the great Massachusetts Puritan preacher, introduced variolization (inoculating his own son as well as others) to abort a smallpox epidemic in Boston. John Winthrop, Jr., governor of Connecticut from 1657 to 1675, conducted an extensive medical practice through the colonial mails. The lack of physicians and Winthrop’s willingness to prescribe free of charge led to his being consulted frequently. Winthrop’s medical letters described a wide range of pediatric problems, such as rashes, jaundice, seizures, and diarrhea, and one of the letters contains a description of child abuse.

Colonial physicians, often uneducated, poorly trained practitioners, wielded a variety of ineffective herbal remedies and anecdotal treatments against the formidable assaults of disease and death. These were perilous times for children. As Dr. Ernest Caulfield, an important American pediatric historian, wrote:

Some early American physicians were careful observers and recorders. Dr. Hezikiah Beardsley, writing in the Cases and Observations by the Medical Society of New Haven County in 1788, described the clinical course and autopsy findings of a child with a “scirrhus” of the pylorus. In 1903, this early report was rediscovered by Sir William Osler, who said that Beardsley had described the disease of hypertrophic pyloric stenosis clearly and accurately. Early American universities and colleges emphasized classical and theological curricula; training in secular subjects, such as medicine, came later. The first American medical schools were the University of Pennsylvania in Philadelphia, founded in 1765; King’s College of Medicine, established in New York in 1768, which became the College of Physicians and Surgeons in 1814; Harvard, established in Boston in 1783; and Dartmouth, in Hanover, New Hampshire, founded in 1798 by Dr. Nathan Smith, a Harvard graduate who became Dartmouth’s one-man faculty.

Teaching about the diseases of children was done sporadically, if at all, and then under the aegis of physic (medicine) or midwifery (obstetrics). At the University of Pennsylvania, Dr. Benjamin Rush, a preeminent American patriot-physician and a signer of the Declaration of Independence, was a professor of medicine between 1789 and 1813. Rush was the most influential American physician of his day. Rush’s medical teaching included lectures on “Diseases peculiar to children.” He wrote articles describing pediatric diseases, including spasmodic asthma, diseases of the mind, and diphtheria. Rush also coined the term cholera infantum for the lethal summer diarrhea that killed thousands of American children well into the middle of the twentieth century.

In 1825, Dr. William Potts Dewees, a professor of midwifery at the University of Pennsylvania, published his Treatise on the Physical and Medical Treatment of Children. This text had eight subsequent re-editions and was arguably the first American textbook of pediatrics. The first formal medical school course and the first faculty appointment in the diseases of children in the United States were at Yale College in Connecticut. For nearly 40 years, between 1813 and 1852, Dr. Eli Ives lectured on the diseases of children to an estimated 1,500 Yale medical students. His motivation for teaching this subject was because “diseases and remedies of the infantile state [are] a subject that has received little attention from Enlightened
Physicians.… The difficulty of acquiring a knowledge of disease in infants results from their inability to communicate their sensations by language.”

Ives’ course, recorded by hand in student notebooks, consisted of lectures on subjects ranging from angina to worms. Ives ascribed many medical illnesses to offending substances in the gastrointestinal tract, which had to be removed by inducing vomiting or by purging. Accordingly, Ives’ therapeutic anchors were calomel (mercury) and ipecac, plus a variety of herbal remedies. According to Ives, teething either caused or aggravated many diseases of infants, and lancing of the gums was considered essential.

During the latter half of the nineteenth century, American pediatrics began to take on a more defined presence. Children’s hospitals were established, some evolving from asylums and foundling homes. The first American children’s hospitals were the New York Nursing and Child Hospital, which opened in 1854; the Children’s Hospital of Philadelphia, which opened in 1855; and the Boston Children’s Hospital, which opened in 1869.

Pediatric progress was most evident in New York City, where Drs. Abraham Jacobi and Job Lewis Smith were contemporaries in the second half of the nineteenth century. Jacobi received his medical training at the University of Bonn, Germany. Imprisoned for 2 years as a suspected revolutionary, he emigrated to New York in 1853. In 1860, he established a children’s clinic at the New York Medical College, where he was appointed Professor of Infantile Pathology and Therapeutics. He later became Professor of Pediatrics at Columbia’s College of Physicians and Surgeons. Among Jacobi’s many contributions were his founding of the Section of Pediatrics of the American Medical Association (AMA) in 1880, and his selection as the first president of the American Pediatric Society (APS) in 1888. He established pediatric services in several New York hospitals and effectively championed causes that promoted the welfare of children. In 1896, he wrote an important textbook, Therapeutics of Infancy and Childhood. His drive and enthusiasm were instrumental in establishing pediatrics as a separate discipline in the United States.

Job Lewis Smith, who entered practice in Manhattan at about the same time as Jacobi, also played a major role in early American pediatrics. Smith worked primarily at the Bellevue Medical School, where he was appointed Clinical Professor of Morbid Anatomy in 1861 and Clinical Professor of Diseases of Children in 1876. Smith was a prolific writer, publishing papers on infectious diseases, rickets, and neonatal tetanus.

Between 1869 and 1896, Smith published eight editions of his A Treatise on the Diseases of Infancy and Childhood. One of Smith’s signal accomplishments was the founding of the APS: In 1887, Smith invited a group of pediatricians to join him in establishing the APS, a goal that was achieved in the following year. Forty-three American physicians were elected as “Founders.” For more than 50 years, the APS was the preeminent pediatric organization in the United States. The presentations and discussions that took place at the annual meetings, as recorded in the Society Transactions, documented striking progress and advances in the specialty. Smith was very concerned about the dangers of bottle feeding and vigorously promoted milk sterilization. The appalling consequences of the hand (artificial) feeding of foundlings in New York were described poignantly by Smith at the 1889 meeting of the APS: “The steamboat every morning brought foundlings to the (Randall’s) Island and every afternoon removed an equal number for burial in Potters’ Field.”

The availability of safe, pure milk for infant feeding was an overriding concern of pediatricians in the United States. Breast-feeding was advocated strongly, and some foundling hospitals employed wet-nurses. However, the large numbers of abandoned and orphaned infants necessitated cow’s milk feeding. In American cities, much of the milk supply was contaminated and adulterated. Between 1870 and 1920, the need for safe milk for infant feeding became a crusade for the leaders of American pediatrics, and the campaign for safe milk was the first concerted involvement of pediatricians in issues of social welfare and reform.

Nutritional diseases were prevalent among American children in the last decades of the nineteenth century. In 1898, the APS conducted a national survey on the cause of scurvy, the first national study of a pediatric disease. Clinical and dietary information was collected on nearly 400 cases of scurvy. The study concluded that scurvy was probably caused by the extensive use of artificial foods for infants. Although the curative value of orange or lime juice had been described by James Lind in 1757, most American pediatricians did not accept scurvy as a simple dietary deficiency. In 1928, Dr. Albert Szent-Györgyi isolated hexuronic acid which, in 1932, was identified by biochemists Waugh and King as the antiscorbutic factor, vitamin C.

At the turn of the twentieth century, rickets was epidemic in American children, particularly those living in the northeastern cities, where as many as two-thirds of infants were rachitic. An investigative team at Johns Hopkins, Drs. John Howland, Benjamin Kramer, Edwards Park, and Elmer V. McCollum developed those micro-methods for the measurement of phosphate and calcium that defined the biochemical profile of rickets. They developed a rat model of human rickets in which they demonstrated the antirachitic properties of cod liver oil. In 1923, vitamin D was identified as the antirachitic factor in cod liver oil. In 1936, Dr. Philip Jeans persuaded the Committee on Foods of the AMA to recommend the fortification of milk, including evaporated and dried milks, with vitamin D. This was nationally implemented, and rickets was rapidly transformed from a common chronic disease of childhood to a rare one in the United States. Application of the principles of the burgeoning science of bacteriology to infant nutrition in the early twentieth century provided a scientific basis for safe infant feeding. Gastroenteritis was a major contributor to high infant mortality at this time; that the pasteurization of milk could prevent milk-transmitted diseases was appreciated by about 1895. However, some practitioners opposed pasteurization because they believed that heating of milk made it indigestible. It was not until 1908 that Chicago became the first American city to mandate the pasteurization of milk. Soon, pasteurization became nearly universal, and the lives of tens of thousands of children were saved.

In Boston, pediatrics was taught at Harvard Medical School as early as 1871. In 1893, Dr. Thomas Morgan Rotch was appointed Professor of the Diseases of Children. Rotch is remembered best for his textbook Pediatrics, published in 1895, and for his “percentage method” of infant feeding. This system was based upon the concept that cow’s milk was relatively indigestible and, therefore, had to be diluted. Because dilution reduced fat and carbohydrate content, cream and sugar were added. This logical concept became exquisitely convoluted in Rotch’s percentage method, which mandated complex formulations with varying percentages of protein, fat, and carbohydrates, with changes frequently made on a day-to-day basis. (European physicians often wonder why Americans call milk mixtures for infant-feeding formulas; the nomenclature derives from the formulas of Dr. Rotch.)

The Rotch system required “almost the equivalence of an advanced degree in higher mathematics employing algebraic equations to compute the food mixture of a baby.” This system ultimately collapsed under its own complexity. As Oliver Wendell Holmes quipped, “A pair of substantial mammary glands has the advantage over the two hemispheres of the most learned professor’s brain in the art of compounding a nutritious fluid for infants.” Jacobi is said to have commented to Rotch at a
meeting of the APS, “You can’t feed babies with mathematics; you must feed them with brains.”

By the end of the first decade of the twentieth century, physicians in the United States developed and employed much more simplified feeding techniques based on the changing caloric needs of growing infants (calorimetric method). The increasing availability of evaporated milk, and later of commercially prepared infant feeding mixtures, reduced the complexities of feeding infants who were not breast-fed. A decreased emphasis on the technicalities of infant feeding resulted in the elimination of the term “baby feeders” to describe pediatricians.

Infectious disease was the other major concern of pediatricians during this era. Diphtheria, scarlet fever, measles, whooping cough, and infant diarrhea were endemic. Diphtheria was particularly lethal because of the laryngeal obstruction caused by the diphtheritic pseudomembrane. Tracheotomy was associated with considerable morbidity and mortality. Dr. Joseph O’Dwyer, a physician at the New York Foundling Hospital, developed a device for laryngeal intubation—the O’Dwyer tube—that reduced the mortality of laryngeal diphtheria from virtually 100% to only 75%. (Intubation became largely unnecessary after the introduction of diphtheria antitoxin.) The discovery of diphtheria antitoxin in 1890 by Dr. Emil von Behring provided the first effective therapy, and von Behring received the first Nobel Prize in Medicine in 1901 for his discovery. Large collaborative studies of the treatment of diphtheria were conducted by the APS in 1896 and 1897, analyzing the records of nearly 6,000 cases of diphtheria. These studies showed that antitoxin treatment decreased the mortality of diphtheria from 27% to 7%. The incidence of diphtheria was subsequently further reduced by active immunization, first with toxin-antitoxin mixtures and, after 1920, with diphtheria toxoid. An intradermal test to determine susceptibility was introduced by Dr. Bela Schick.

Infant diarrhea, or the “summer complaint” (the cholera infantum described by Benjamin Rush) was epidemic in American cities well into the twentieth century. It had a distressingly high mortality. Therapy, as summarized by Dr. Grover Powers, was largely symptomatic: “tea, barley water, protein milk, floating hospitals, or country sanatoria.”

The Boston Floating Hospital had its origin in 1894, when a rented barge was loaded with hundreds of mothers and infants and towed around Boston harbor for a day. It was believed that sick infants would benefit from a day of clean salt air and cool ocean breezes.

Major advances in the management of fluid and electrolyte disorders of childhood occurred during the first half of the twentieth century. These advances were made possible by the investigations of Drs. L. Emmett Holt Sr., James L. Gamble, Daniel C. Darrow, Allan M. Butler, William McKim Marriot, Alexis Hartman, and Oscar Schloss, among others. The effective treatment of dehydration and electrolyte imbalance greatly reduced the morbidity and mortality of childhood gastroenteritis.

Dr. L. Emmett Holt, Sr. of New York is credited with establishing a scientific basis for pediatrics in the United States. Holt, a 1878 graduate of the College of Physicians and Surgeons, entered private practice in midtown Manhattan and worked in the New York Foundling Hospital. In 1889, he became the medical director of the New York Babies Hospital, which was in danger of closing. Holt’s efforts culminated in the opening of a new Babies Hospital in 1910. In addition to outpatient facilities and 70 inpatient beds, the Hospital also had dedicated research laboratories, and Holt appointed experienced chemists to the hospital staff. Holt also played a major role in the founding of the Rockefeller Institute, and he worked with Rockefeller scientists publishing collaborative papers dealing with the chemical analysis of milk and milk proteins, salt and water balance, and the absorption of nutrients and electrolytes in diarrheal diseases. One of his greatest accomplishments was the authorship of a classic pediatric textbook, The Diseases of Infancy and Childhood. First published in 1897, it had 11 subsequent editions during Holt’s lifetime (and had its twenty-first re-edition as Rudolph’s Pediatrics in 2003). It was the standard pediatric textbook of its day, and it was considered the equal of Sir William Osler’s monumental Textbook of Internal Medicine. Even more widely read than his textbook was Holt’s The Care and Feeding of Children, a widely distributed and influential manual written for parents.