On the Evolution of Pediatrics and the Emergence of Pediatric Nephrology

Pediatrics is a relatively young specialty; its existence spans less than the past 2 centuries of the history of medicine. By extension, pediatric nephrology is an even younger specialty; it came into existence only in the second half of the twentieth century.

As with most specialties of medicine, both emerged when changes circumstantial to increasing knowledge of diseases in children necessitated further commitment to and specialization in the field by interested members of the medical profession. These clinicians then organized themselves into a special discipline, thanks to the vision, guidance, and leadership of thought leaders of the time.

As with other specialties also, the corpus of information that led to the emergence of pediatrics evolved over time and existed as part of the general discipline of medicine long before the very term pediatrics was coined. By the same token, reference to diseases of the kidneys in general, and in children in particular, is recorded in ancient texts long before pediatric nephrology emerged as a specialty.

Importantly, the study of pediatric diseases in the first half of the twentieth century was instrumental in begetting the body of knowledge that led to the emergence of nephrology and, shortly thereafter, of pediatric nephrology as separate organizations with overlapping coverage of diseases of the kidney in adults and children, respectively.

The Emergence of Pediatrics

Stories of child sacrifice in antiquity notwithstanding, the care of infants and the care of sick children must have been part of the concerns of populations from the very beginnings of human history. What may have begun as animal instincts was gradually refined into the emotional bonds and natural affections that constitute the very basis of civilization.

In time, the care of sick children took shape in shared observations and experiences passed on orally in the priestly and folk medicine of antiquity. By the time recorded medicine began, a body of knowledge already existed that related to the care of children. Most texts of this period center around the care, feeding, and growth needs of infants.

However, buried in these early text, and receiving increased attention over time, are descriptions of afflictions of children and reference to how their treatment differs from treatment of the same diseases in adults. Treatments of diseases likely to affect children that appear among the prescriptions listed in the Ebers Papyrus (ca. 1500 B.C.) are those for teething, running nose, ascites, and disorders of the abdomen and urinary tract. Specific recipes are given for the retention of urine, to regulate urination, and for excessive urination.

Because these ancient writings are consigned to symptoms rather than diseases, speculation on the actual diseases and the treatments administered is not possible. Hippocrates (459 –355 B.C.) devotes several of his Aphorisms (Section III, 24 –29) to diseases of children and refers to them in several of his other texts.

Pertinent to nephrology are his comments on bladder stones: “Children get stone from milk if it is not healthy, but is too hot and bilious . . . and I say that it is better to give children wine, much diluted, for it has a less heating and drying effect. . .” The special care of children is mentioned also in extant medical texts of antiquity such as the De Medicina (ca. 50 A.D.) of Celsus (25 B.C.–50 A.D.), which states that “children require to be treated entirely differently than adults” but does not really detail how.

Among ancient texts, the first to devote a section to children is that of the gynecological text of Soranus of Ephesus (98 –138 A.D.), in which the care of infants and selected diseases of children receive full attention. Two features characterize this milestone text. First is the devotion of most of its text to the rearing of infants and care of the healthy child (feeding, teething, itching, rashes, enuresis, running nose, and ear), a feature that was to remain the major component of most pediatric texts that followed.

Second is the association of diseases of children with those of women that was to persist well into the nineteenth century, when pediatrics was still taught in medical schools by professors of obstetrics. Indeed, one of the first journals in the United States dedicated to diseases of children was the American Journal of Obstetrics and Diseaes of Women and Children established in 1868.

Diseases of Children and Emergence of Nephrology

The single most common cause of hospital mortality during this evolutionary period was diarrhea of childhood, which had a mortality as high as 80% to 90%. Actually, the problem was an ancient one mentioned by Hippocrates in one of his aphorisms: “They that often pass bloody and indigested stools from the belly are specially liable, amongst the symptoms of fever, to drowsiness.”

The study of diarrheal diseases of children that had begun in the eighteenth century, assumed increased urgency at the end of the nineteenth century. Because a considerable amount of blood (200 mL) was needed for chemical analysis, analysis of the whole body of infants postmortem was done instead, but this approach failed to detect chemical abnormalities, and death came to be attributed to such causes as “decomposition” that resulted from “intestinal intoxication,” or, in their original German, “toxikosis” caused by “coma dyspepticum.”

The changes in the urine of these patients had been noted and recorded in 1752 by Rosenstein (1706 –1773): “The urine in a diarrhea, is in much less quantity than before, and is also redder than usual; it is therefore a good sign, when it is discharged in a greater quantity, and its color is clear. This shews a less flux towards the intestines, and a more equal division of the fluids, in order that they also dilute the urine.

By this we learn the reason of our being obstipated by drinking mineral water when it is carried off too soon.” Analysis of the composition of urine and blood of these cases was to come much later. In the meantime, the symptoms of diarrhea had come to be attributed to “acid intoxication” and treated with alkali. Ultimately, it was the solution of what came to be known as the “Milk Question” that provided chemical answers.

In the closing years of the nineteenth century, social, economic, and cultural forces consequent to increased urbanization had prompted mothers to substitute bottlefeeding for breast-feeding in the era before refrigeration and pasteurization. The subsequent conflict between physicians in general, and pediatricians in particular, concerned over the high mortality among bottle-fed infants and mothers seeking self-control was resolved by advances in the pediatric sciences and by public policy that instituted pasteurization and sterile sealing of milk in the 1930s,12 a period that corresponds to the increased professionalization of pediatrics. Of the many institutions and pediatricians who participated in the resolution of the Milk Question, three names stand out.

The first is John Howland (1873–1926), founder of the first department of pediatrics in the United States in the medical school at Johns Hopkins University. His studies of diarrhea introduced quantitative analytical techniques to pediatrics. Importantly, Howland’s vision in recruiting the second key player, James Gamble (1883–1959), led to an important part of the solution to the Milk Question and, in the process, contributed to the foundation of renal physiology that preceded the emergence of nephrology.

Gamble had begun research in 1915 and spent most of his life in the laboratory studying diarrheal dehydration. As a student of Lawrence J. Henderson (1878 –1959), he was well prepared for the task. The processes of preserving constancy of the environment surrounding cells and tissues was conceived and developed by Henderson in his physicochemical description of acid– base balance, which finally began to provide an explanation to what had been termed the “acid intoxication” of diarrhea.

Gamble adapted this structural model to the study of volume depletion, which he depicted in his now classic bars that became famous as Gamblegrams and are still used to illustrate changes of urine and blood electrolytes in metabolic-balance studies. His initial report was on the blood and urine changes of four children with epilepsy who were treated with fasting, then with a traditional therapy to induce acidosis.

This study and his subsequent studies began the unraveling of the then mysterious adaptation of the kidneys, lungs, and extracellular volume to changes induced by dehydration. Gamble was the first to use the flame photometer, which he helped develop.

Author: Garabed Eknoyan

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