y
Histor
Growth and Development
Historical Of a Specialty:
Perspectivies in
Pediatrics
The Professionalization of Child
Elizabeth Ahmann, ScD, RN
Health Care
Cindy Connolly
n this issue of The Presence of the Past in Pediatrics, the
I origins of childrens hospitals and of pediatrics as a nurs-
ing and medical specialty will be traced. The purpose of
this exploration is to consider the way in which profes-
sional values, beliefs, and practices have been shaped over
time and how the past contin-
ues to shape the present. Circus Day at Bostons
A Nineteenth Century
Innovation: Hospitals for
Children
In early 1879, a concerned
citizen who called himself or
herself Fireside penned an
impassioned letter to the edi-
tors of Bostons Evening
Transcript. The paper pub-
lished the heartfelt appeal to
the citizens of Boston on
behalf of the citys Childrens
Hospital on January 22. Note: From Goostray. S. (1969). Memoirs: Half a century in providing spiritual guidance
Fireside wrote of the nursing. Boston: Boston University Libraries.
poverty encountered by the
casual onlooker on Bostons streets:
Men whose brutal faces made me shiver, women from
whom every grace of womanhood had departed; and oh!
More pitiful than all, the child faces that looked at me as I
passed-the poor, wan faces, so pinched and pale with
want and sickness, yet with a childlike innocence in their
eyes. (Fireside, 1879).
Fireside begged those who could afford it to send money
to Childrens Hospital. Donations were a necessity since the
institution was supported wholly by private funds. The writer
may have also wanted to publicize the hospitals existence
since the idea of an institution devoted to the needs of chil-
dren was a new concept. Until the mid-nineteenth century,
there were no facilities dedicated to the care of sick children
in the United States. Like their parents, if they could not be
cared for at home, children went to municipal almshouses,
Cindy Connolly, PhD, RN, PNP, is Assistant Professor, Yale
University School of Nursing and Assistant Professor, History of
Medicine, Yale University School of Medicine, New Haven, CT, and
Series Editor for this department.
The Historical Perspectives in Pediatrics section focuses on
specific individuals, events, and issues pertaining to child
health care in the past. The purpose is to interpret, analyze,
and evaluate selected historical topics with contemporary
resonance to pediatric nurses in order to interpret, analyze,
and evaluate the past in its context. To obtain author guide-
lines or to submit queries or manuscripts, contact Cindy
Connolly PhD, RN, PNP; Section Editor; Yale University School
of Nursing; 100 Church Street South; PO Box 9740; New Haven,
CT 06536-0740; 203- 737-2416; cindy.connolly@yale.edu
PEDIATRIC NURSING/May-June 2005/Vol. 31/No. 3
also known as poorhouses. Orphaned or abandoned babies
often ended up in infant asylums, which had been patterned
after similar British institutions where the mortality rate
approached 100%. By the 1860s in the United States, spe-
cial hospitals for children were becoming a necessity since
many of the newly founded
Childrens Hospital general hospitals simply re-
fused to admit children (King,
1993).
The earliest childrens hos-
pitals admitted indigent or
abandoned children, some of
whom, but by no means all,
were also ill. Many people
during this era believed that
the need for charitable assis-
tance was caused by
immorality and poor charac-
ter. Since sickness represent-
ed a prime cause of poverty,
and moral uplift to the ill, in
addition to offering food,
clothing, and whatever other material provisions were need-
ed, was supposed to help them rise above their condition
and facilitate better health.
Stratifying the needy into deserving versus undeserv-
ing categories helped charitable organizations and hospi-
tals decide which individuals to aid. Because indigent chil-
dren were considered the innocent victims of their parents
bad choices or inappropriate lifestyles, they were, by defin-
ition, always deserving of assistance and aiding them
engendered little controversy (Katz, 1986).
Hospitalized children often resided at the institutions for
months, and beyond fresh air and food, there were few ther-
apeutics, at least according to todays standards. One of the
most important interventions for the children was consid-
ered to be their exposure to the wealthy Trustees who ran
the institutions. These individuals, usually socially promi-
nent, were presumed to have better character than indigent
parents and they hired staff who they felt could help imbue
children with the qualities they felt were important. Staff and
Trustees often discouraged or made it difficult for parents to
visit, hoping that prolonged contact with staff would facili-
tate Americanization in immigrants, and inculcate middle
class behaviors and health practices among the native born
poor (Brosco, 1994; Vogel, 1980).
Fireside, in his or her description of the hospitals envi-
ronment, illustrated this practice:
While there, in addition to their medical treatment and
nursing, they are carefully taught cleanliness of habit, puri-
ty of thought and word, and as much regard is paid to their
moral training as can be found in any cultivated family.
Think what a widespread influence this becomes when the
children return to their homes (Fireside, 1879).
211
Inventing Pediatric Medicine
Compared to nursing, medicines Stella Goostray, 1917
road to professionalization and special-
ization was direct. State licensing acts,
passed in every state by 1900, clearly
defined the practice of medicine.
Between 1864 and 1880, a number of
medical specialty organizations began
to appear, including ophthalmology,
neurology, otology, dermatology,
surgery, gynecology, and laryngology.
Founded by white males with elite
medical educations, being a member of
a specialty conferred much prestige
upon them as physicians. Specialists
had access to appointments at teach-
ing hospitals, a mechanism through
which distinguished careers could be
built by overseeing the medical needs
of private patients, caring for and trying
new therapies on the sick poor, and
teaching medical students (Numbers, Note: From Goostray. S. (1969). small allowances in addition to room and
1985). Memoirs: Half a century in nursing. board, and in return nurses worked, often
Boston: Boston University Libraries.
The first medical lectures on the dis-
eases of childhood were offered in 1860 by physician
Abraham Jacobi, considered by most to be founder of mod-
ern pediatrics. Until the Civil War, pediatrics was considered
part of obstetrics in the United States. Before Jacobi, spe-
cialties centered around a particular organ or technology.
Jacobi felt that pediatrics should have a broader, more con-
ceptual, focus. His vision was that pediatricians should con-
cern themselves with child health well beyond mere disease.
He advocated for pediatricians to become involved in infant
feeding, child hygiene, and disease prevention in well chil-
dren. The pediatrician, he argued, could also use his talents
to facilitate the Americanization of immigrants. Jacobi artic-
ulated a model for pediatrics with a focus well beyond spe-
cific diseases, one that involved disease prevention in
healthy children, educating parents about child rearing, and
social activism for childrens rights.
In 1880, Jacobi and a few other interested physicians
founded the American Medical Associations section on the
Diseases of Children. In 1888 a new organization, the
American Pediatric Society, helped to solidify pediatrics as
a distinct branch of medicine. Jacobi served as the first
president of both groups. Framers of the American Pediatric
Society recruited prominent physicians into their member-
ship ranks to advance pediatrics acceptance. Articulate
early pediatricians such as Jacobi wrote prolifically in new
journals and textbooks that focused exclusively on child-
hood diseases, the need for more childrens hospitals, and
for the expansion of pediatric content in medical school cur-
ricula. By 1900, 10 schools of medicine had full-time pedi-
atricians (Halpern, 1988; Meckel, 1990; Viner, 2002).
Creating Pediatric Nursing
Though the first pediatric nursing text was not published
until 1923, articles addressing the needs of children
appeared in nursing journals early on (Farrar, 1906; Pierce,
Cutler, & Bancroft, 1923). Florence Nightingale herself empha-
sized childrens nursing care needs, in her seminal 1859 book Notes
on Nursing writing: It is the real test of a nurse whether she can
nurse a sick infant (Nightingale, 1859/1992). Early publications
highlighted practices such as infant feeding techniques and
pediatric nursing procedures.
Pioneering pediatric nurses such as Anna Haswell (1908)
also stressed the special personality type required for chil-
212
drens nursing asserting that:
The nursing of young children stands
out as a division of our work needing spe-
cial study. We have no branch that is
more important.... Let us be willing to do
anything which will accomplish the great-
est good for the child, and honor our pro-
fession by becoming more and more effi-
cient in our ability to care for sick chil-
dren (p 115).
Just what skills were necessary to effi-
ciently care for sick children in those
days? Though the early nursing literature
recognized that nurses needed education-
al preparation, the form of that training
looked different than it does today. Until
the twentieth century, nurses who special-
ized in childrens health trained in much
the same way their adult-oriented counter-
parts did. Adopting Nightingales British
model, hospitals usually paid pupil nurses
largely unsupervised, on the wards caring
for patients.
Students usually toiled 12 hours a day, 6 days a week for
50 weeks a year. Training was variable, ranging in some
schools from a few weeks, to others that lasted 1 or 2 years.
Since the concepts of a standard nursing education curricu-
lum, registration, and licensure, did not become a reality
until the 1920s in most states, nurses who wanted to spe-
cialize in child health either tried to get their training at a
hospital with a childrens ward or at one of the few childrens
hospitals. Once graduated, a few nurses assumed leader-
ship positions in hospitals, but most sought private-duty
positions in middle and upper class homes. The pay was
poor and the hours irregular (Reverby, 1987).
A shift in the understanding of disease causation evolved
over the course of the late 19th century. This change altered
the role of the hospital in American life (Rosenberg, 1987).
In the 1870s and 1880s, Robert Koch, Louis Pasteur,
Joseph Lister, and others forged the germ theory of disease
causation. These changes reshaped pediatric nursing and
medical care in the ensuing decades. By 1900, the organ-
isms responsible for typhoid, leprosy, malaria, tuberculosis,
cholera, diphtheria, and a host of other conditions were
identified. No longer was illness considered purely in the
context of morality or religion as it had been in the past. It
gradually evolved, at least for infectious diseases, to receive
its identity in the laboratory (Rosen 1958/1993).
Almost as soon as the first childrens hospitals opened,
the tension between their social welfare and medical mis-
sions became apparent. An understanding of the bacterial
origins of infectious diseases encouraged the development
of advances in the late nineteenth century such as surgical
gloves and sterilization. When coupled with anesthesia,
these interventions made pediatric surgery safer. Better sur-
gical therapeutics helped make hospitals more medically
oriented. As early as the 1870s at the Childrens Hospital of
Philadelphia, for example, physicians pressured the lay
Trustees, who managed the hospital, to increase patient
turnover and accept more acutely ill, especially orthopedic
surgical, patients who had something to offer physician edu-
cation and on whom new surgical techniques and therapies
could be trialed (CH0P, 1870-1880).
Childrens hospitals were highly visible in the communi-
ties in which they were founded. The individuals who worked
there deservedly prided themselves for providing a social
PEDIATRIC NURSING/May-June 2005/Vol. 31/No. 3
safety net for the ill or abandoned child who needed care.
But childrens hospitals were also good for the burgeoning
specialties of pediatric nursing and medicine (Golden,
1989). The development of childrens hospitals helped pedi-
atrics to evolve more quickly into a specialty branch of
medicine and nursing because of the opportunities for train-
ing, the feeling of shared identity and unity, and the research
opportunities indigent hospitalized children provided (in an
era in which no ethical guidelines governed research).
Over time, the proportion of children admitted for social
welfare reasons began to fall relative to those suffering from
chronic medical conditions or youngsters who required
surgery. More hospitals also began to accept children with
infectious diseases for the first time. For example, until the
1890s when the Childrens Hospital of Philadelphia (CHOP)
developed accommodations to isolate potentially infectious
children, the institution avoided admitting children with con-
tagious diseases, a policy that may sound strange to todays
nurses (CHOP, 1893).
The nurses work became even more complicated when
caring for children on one of these new infectious disease
wards. As Boston Childrens Hospital nurse Stella Goostray
noted:
When a child was admitted or transferred to a commu-
nicable disease unit, the (student) nurse went into isolation
also. She ate and slept there and looked upon the assign-
ment as a sort of disciplinary measure, although the super-
intendent (of nurses) always pointed out the educational
experience to be gained, said one who had that experience.
Our food was sent up to us in an enormous dumb waiter.
We did all the housework even to washing the floor. We saw
no one but the house officer, and the superintendent of nurs-
es who peered at us through a window. (Goostray, 1950).
In other words, when a child went into isolation, so did the
nurse! Antibiotics would not be available until the 1940s, so
the flaxseed poultices used to treat pneumonia, typhoid
fever, and tuberculosis of the bones and lymph nodes, had
to be prepared from scratch by the nurse. For the child with
pulmonary congestion, the nurse rigged a tent from tin and
used an alcohol lamp to heat the water in a tea kettle
(Goostray, 1950). Caring for ill children under such cir-
cumstances, especially wearing a long, cumbersome uni-
form, and working in an un-air-conditioned environment,
required real stamina!
Nurses also were at high risk for infection themselves.
For example, a few weeks after Stella Goostray entered
Childrens Hospital training school in 1915, she fainted while
attending the required morning church services with the
other nursing students. It was quickly determined that Stella
had a fever of 104 degrees and was suffering from typhoid
fever.
Stella had been caring for children on the medical ward a
few days earlier when she was called to the typhoid ward.
The large toilet into which the bedpans were emptied had
flooded the entire room in which it was located. Stella was
instructed to clean up the mess, and because she had not
yet received her lecture on medical asepsis, she did not
wash her hands after performing this duty and contracted
typhoid. Fortunately, after a tortuous 18-month convales-
cence, she recovered and went on to work for 50 more years
as a pediatric nurse (Goostray, 1969).
In addition to the attention paid to the infectious diseases,
the late nineteenth and early twentieth century nursing liter-
ature also emphasized the unique age-related considera-
tions of child health care. Though pediatric nurses did not
use growth and development-related terminology in the
same way we do today, their ideas were nonetheless cre-
ative and demonstrated the practical utility underpinning the
PEDIATRIC NURSING/May-June 2005/Vol. 31/No. 3
new field of psychology. In an 1893 article in The Trained
Nurse, for example, the author, identified only as Miss
Robin, discussed how nurses designed their care in ways
that acknowledged the cognitive and physical differences
between children and adults (Miss Robin, 1893).
The Presence of the Past
Today we practice in a world in which late nineteenth and
early twentieth century pediatric nurses could have only
imagined. Because of the efforts of nurses such as Stella
Goostray, Anna Haswell, and other pioneers, our specialty
matured. Now, as then, pediatric nursing takes stamina and
nurses have to be careful to protect their own health and
think quickly in emergency situations. Though we dont
make flaxseed poultices, we use the scientific knowledge,
intuition, and ingenuity required by our era to restore and
maintain childrens health. Now, as then, we recognize
knowledge of growth and development, love for children,
and an up-to-date understanding of health and disease are
essential for the provision of quality nursing care to children
and families.
Pediatric nursing and childrens health care has come a
long way from those early days but many of the problems
that stymied our nineteenth century predecessors seem
almost as intractable today as they did a century ago. Poor
children, for example, living in unsafe, unhealthy environ-
ments abound. Violence against children is lamented with
the same fervor that infectious disease once was. Poverty is
frequently equated with immorality. Some sharp moral dis-
tinctions are made between the lifestyles and health prac-
tices of the upper and lower classes.
We need to remember that although we are in the midst
of shifts in health care delivery, and a changing array of dis-
eases, technologies, and curative strategies, we face no
greater challenges than did our predecessors. We have their
shoulders to stand on as we continue to refine our role to
meet the needs of todays children and families. Pediatric
nurses should serve as the nations conscience when soci-
etys rhetoric does not match its actions with regard to child
health and social welfare. Let us continue and extend the
efforts of our forebears, so that 100 years from now, in a
world that is beyond our imagination, our successors can
say as much about us!
References
Brodie, B. (1989). A commitment to care: The development of
clinical specialization in nursing. ANNA Journal 16, 181-86.
Brosco, J.P. (1994). Sin or folly: Child and community health in
Philadelphia, 1900-1930. Unpublished doctoral dissertation,
University of Pennsylvania.
Childrens Hospital of Philadelphia. (1867-1899). Annual Report of
the Board of Managers. Philadelphia: Childrens Hospital of
Philadelphia.
Cuttler, B.I., Pierce, E., & Bancroft, M.C. (1923). Pediatric nursing.
New York: Macmillan.
Farrar, I.L. (1906). The care and feeding of infants and children.
Trained Nurse and Hospital Review, 37, 220-3.
Fireside. (1879, January 22). Untitled letter to the editor, Boston
Evening Transcript.
Golden. J. (1989). Infant asylums and childrens hospitals: Medical
dilemmas and developments, 1850-1920. New York: Garland.
Goostray, S. (1950). Pediatric nursing at the turn of the century.
American Journal of Nursing 50, 624-5.
Goostray. S. (1969). Memoirs: Half a century in nursing. Boston:
Boston University Libraries.
Halpern, S. (1988). American pediatrics: The social dynamics of
professionalism, 1880-1980. Berkeley, CA: University of
California Press.
continued on page 215
213
the past year when he had two
episodes of otitis media not associat-
ed with respiratory infections. He
received antibiotic therapy (amoxi-
cillin) for the otitis media and both
episodes resolved without problems.
Michaels Mom states that he takes no
prescribed medications or OTC med-
ications, but he admits that he has
been taking his dads OTC Pepcid
sometimes when he gets heartburn.
Upon further examination, he reports
taking Pepcid when he eats pizza or
Mexican food. He does complain of
sore throats sometimes and often feels
burning in his throat when he goes to
sleep at night after a late evening
snack.
Nutritional History
Michael eats cereal bars or pop
tarts with milk for breakfast most
days. He takes his lunch (usually a
sandwich and chips or yogurt and
fruit) for lunch. Mom or his sister
cooks supper in the evening. The fam-
ily goes out to eat once or twice a
week and he only gets fast food
once or twice a week according to his
Mom. He says he eats a lot espe-
cially after a wrestling meet.
Physical Exam
Height/weight: Michael weighs
109 pounds (60th percentile) and is
69 inches tall (93rd percentile). He is
following the growth pattern he estab-
lished in infancy. Vital signs: BP
110/60, T 99.2, HR 70, R 16.
General: Alert, cooperative but a bit
shy.
Neuro: DTRs symmetric, 2+, nega-
tive Rhomberg, able to perform sim-
ple calculations without difficulty,
short-term memory intact. He
responds appropriately to verbal and
visual cues, and movements are
smooth and coordinated.
HEENT: Normocephalic, PEERLA,
red reflex present, optic disk and ocu-
lar vessels normal. TMs deep red, dull,
landmarks obscured, full bilaterally.
Post auricular and submandibular
nodes on left are palpable and slightly
tender.
Lungs: CTA, breath sounds equal
bilaterally, excursion and chest config-
uration normal.
Cardiac: S1, S2 split, no murmurs,
pulses equal bilaterally.
Abdomen: Soft, rounded, reports
no epigastric tenderness but states
that heartburn begins in epigastric
area and rises to throat. Bowel sounds
active in all quadrants. No
hepatospleenomegaly or tenderness.
No CVA tenderness.
Musculoskeletal: Full range of
motion, all extremities. Spine straight,
able to perform jumping jacks and
duck walk without difficulty.
Genital: Normal male, Tanner
stage 4. Rectal exam small amount
of soft stool, no fissures or masses.
Labs: Stool negative for blood and
H. pylori antigen. Normal CBC and
urinalysis. A barium swallow and
upper GI was scheduled for the follow-
ing week. It showed marked GE reflux.

Historical Perspectives
continued from page 213
Katz, M.B. (1986). In the shadow of the poorhouse: A social histo-
ry of welfare in the United States. New York: Basic Books.
King, C.R. (1993). Childrens health in America: A history. New
York: Twayne.
Meckel, R. A. (1990). Save the babies: American public health
reform and the prevention of infant mortality 1850-1929.
Baltimore: The Johns Hopkins University Press.
Miss Robin. (1892). Memories of Bellevue and Bellevue chil-
dren. Trained Nurse and Hospital Review, 8, 567-578.
Numbers, R. (1985). The fall and rise of the American medical pro-
fession. In Judith Walzer Leavitt and Ronald L. Numbers
(Eds.). Sickness and health in America: Readings in the his-
tory of medicine and public health. 2nd ed. (pp. 185-194).
Madison, WI: University of Wisconsin.
Reverby S. (1987). Ordered to care: the dilemma of American
nursing, 1850-1945. New York: Cambridge University Press.
Rosen, G . (1958/1993). A history of public health. (Baltimore: The
Johns Hopkins University Press). (Original work published
1958).
Rosenberg, C. (1987). The care of strangers. New York: Basic
Books.
Skretkowicz V. (1992). Florence Nightingales notes on nursing.
(Revised, with additions). London: Scutari Press (Original
work published in 1859).
Viner, R. (2002). Abraham Jacobi and the origins of scientific pedi-
atrics in America. In Alexandra Minna Stern and Howard
Markel (Eds). Formative years: Childrens health in the United
States, 1880-2000. (pp. 23-47). Ann Arbor, MI: University of
Michigan Press.
Vogel, M.J. (1980). The invention of the modern hospital. Chicago:
University of Chicago Press.
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PEDIATRIC NURSING/May-June 2005/Vol. 31/No. 3 215