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John Howland: Turning point of American pediatrics
The Journal of P E D I A T R I C S
865
John HowlanJ: Turning point of American pediatrics H o w l a n d A w a r d Address
L. Emmett Holt, Jr., M.D. NEW
YORK~
NEW
YORK
I D O N ' T H A V E to tell you how touched I am to be given this award today. Of all the organizations I have belonged to, the American Pediatric Society comes closest to m y heart. I owe it a debt that I wish I could repay. I owe Dr. W a r d a debt also--for his kind mention of my assets with a most tactful omission of m y deficiencies, but more particularly for the help and support he has given me through the years we were together at New York University. T h a n k you, Bob, for your kind words, your good deeds, your, lasting friendship ! I am going to depart a little from the tradition of talking about some aspect of one's own work. Instead, I shall talk about one of the three men who have played a dominant part in m y life. The three were my father, John Howland, and Ned Park. It is fitting on this occasion that I talk about Dr. Howland. T h e number of those who knew him is steadily shrinking, and for the sake of the m a n y who did not know him, it seems worthwhile to tell a little something about his life, why we have a medal named for him, and what his legacy is to American pediatrics today. I know in advance that I shall fail in this task. Others have written about Dr. Howland: Wilburt Davison, 1 David Edsall, 2 G r a h a m Lusk, 3 James Gamble, 4 and none better than Dr. Park 5 in
the first H o w l a n d lecture where, in his inimitable style, he really brought Dr. Howland to life, touching upon his foibles as well as his greatnesses. Nevertheless, I shall try. I knew Dr. H o w l a n d from my earliest childhood. I n the early 1900's he was my father's office assistant, and was in our house every day. In the summer, when he visited our camp in the Adirondacks, he was to us children our most glamorous visitor. It is hard to say what it was that made h i m so. Perhaps it was because he liked us and paid some attention to us. As Gamble pointed out, he always remained a boy at heart. Then, he was a star athlete. He had been an oarsman in college, and rowing was important in our lives--that was before the days of motorboats. He had also been intercollegiate tennis champion. O n one of these visits, Dr. Howland reached the conclusion that he would give up tennis, t h a t championship tennis and medicine were incompatible, and that golf was more suitable for a busy doctor, and he formally presented my teen-age sister with the racquet that had won the intercollegiate championship. It was a specially built racquet, made from designs by the Doherty brothers, who w e r e English champions of that day, and it was much too heavy for m y sister, but would she ever play tennis with anything else? Figs. 1 and 2 are pic-
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Fig. 1. John Howland at camp in the Adirondacks, some time in the early 1900's.
Fig. 2. John Howland at the time of his association with the Johns Hopkins School of Medicine.
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tures of Dr. Howland taken at about that time. Perhaps you can get some idea of his personality from them. For many years I did not see Dr. Howland, but when I went to medical school in Baltimore, I spent, a great deal of time at his house; most of my Sunday evenings were spent there. They were wonderful evenings. Dr. Howland was a great raconteur, interested in everything under the sun, and full of interesting experiences. A young medical student sitting at his feet could not help but imbibe some of his philosoptfy--his enthusiasm for adding to medical knowledge, not just applying it. I have to thank Ren6 Dubos for pointing out the derivation of the word enthusiasm: "a god within." I was just one of many who came under Dr. Howland's spell. One wanted to be like him, to do the kind of things that he was doing. I had always intended to be a practitioner like my father. I went back to New York for two years of hospital training--they were good years, too, but I had been inoculated, and I went back to Baltimore to work with Dr. Howland and try my hand at academic pediatrics in the only place where it existed in this country. I can't say that I have regretted it. Dr. Howland came from a rugged New England background. He was born in New Hampshire, but brought up in New York City, where his father was an eminent judge and his mother a talented musician. At Yale his career was not marked by academic distinction, although his standing was good. He was interested in sports and in social life, and was editor of the Yale News. The decision to study medicine came late in his college career, the result apparently of a warm contact with Dr. Sanford, the leading practitioner in New Haven. It may have been that feminine influence was responsible for this contact, for Dr. Sanford eventually became Dr. Howland's father-in-law. But when college was over, he lost no time in getting to work. From New York University you could get a degree in three years, as contrasted with Columbia, and New York University he chose. In those days medicine was
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learned not so much in medical school as from a private "quiz." A famous one was that of Dr. Ellsworth Eliot, whose graduates never failed to get good hospital appointments. Dr. Howland was no exception, and obtained a much sought-after appointment in medicine at the Presbyterian Hospital. This was followed by two years as resident physician at the New York Foundling Hospital under my father. There was a brief interlude during the Spanish-American War when he served as ship's surgeon in charge of typhoid patients returning from Cuba. He then went to study in Germany--the mecca at that time for all ambitious American doctors. The year, spent partly in Berlin and partly in Vienna, was an eye-opener. Here in the university clinics were doctors adding to knowledge, not just acquiring accepted knowledge. Heubner was a leading figure in Berlin pediatrics, and he and the famous Max Rubner were trying to put infant feeding on a firm scientific basis. Energy metabolism studies, undertaken by indirect calorimetry, promised to tell what infants really needed to be fed. The young visiting American was inspired to do likewise. He was, as Lusk put it later, possessed of a demon which gave him no peace unless he could conduct scientific research--which was difficult in New York. There was then no living for a pediatrician except practice. It was a busy life. Howland had a teaching appointment at Columbia and appointments as attending pediatrician at several hospitals. It was at Bellevue, however, that he found the opportunity and the stimulus to undertake metabolic work. Graham Lusk , the professor of physiology at Cornell, had been a pupil of Carl Voit and of Rubner, and had collected about him an enthusiastic group of students of metabolism : Murlin, Hoobler, Eugene Dubois, and others. C. A. Herter and his assistant, A. N. Richards, were actively engaged in neighboring facilities under the aegis of Columbia, and biochemistry was beginning to bud. Richards told me that one day in the early 1900's he found Dr. Howland 'in the laboratory testing the urine of an infant with
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recurrent vomiting. Richards was a trained chemist, which Howland was not. The prevalent idea at that time was that most diseases were due to unidentified toxins which affected body oxidations. Howland was sure that such a toxin could be found, and they agreed to work together, studying the chemical effects of known poisons which might affect oxidations. The resulting collaboration involved studies of indote, of chloroform, and of cyanide poisoning in animals with a variety of chemical techniques. The results were not startling, and did not go far to solve the problem of recurrent vomiting, but it was careful, painstaking work; in the course of it, Howland learned a great deal of the chemistry which stood him in good stead later. It was in Lusk's laboratory, however, that the start was made of his work on calorimetry. One of Lusk's younger staff' members was constructing a calorimeter for use with small animals, and plans were made that Howland should use it for babies from the children's medical service at Bellevue to clear up some of the imperfections in the work of the early German investigators. The calorimeter was duly constructed and put to use, and is shown in Fig. 3. It provided for both direct and indirect calorimetry. Direct heat production was measured with an accuracy of approximately 2 per cent, indirect calorimetry was carried out by measurements of the expired gas mixture, and the nonprotein respiratory quotient was calculated in many of the studies from urinary nitrogen. A number of significant observations came out of this work: 1. They were the first observations by direct calorimetry ever made in infants and they showed that the correlation between tile direct and indirect method was excellent, making it unnecessary in the future to employ the more cumbersome direct method. 2. They provided the first observations of "basal" metabolism during sleep, which German investigators had not successfully a c complished. The technique adopted was to stimulate the :infants during the morning hours, making Si~re that they got no sleep;
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Fig. 3. Calorimeter used by John Howland in the early 1900's.
they were then fed and put in the chamber, in which they slept happily for hours. 3. The effect of mild exercise (casual movements while awake) in contrast to crying was measured and found to be much larger than had been supposed. 4. The specific dynamic action of a high protein meal was studied and found to be of the order of magnitude of 10 to 26 per cent, and it was shown that only a part of this increased heat production resulted from the combustion of pro.tein; fat and carbohydrate contributed a substantial part of it. 5. A number of observations were made on greatly undernourished infants, who were found to have a surprisingly low metabolic rate. The rigid Heubner standards for feeding normal infants (100 calories per kilogram) it now appeared were not universally applicable, for this work demonstrated the great variability among individual infants, depending on how much they slept or cried. The observations were relatively few in
number, but they were pioneer observations, the prelude to the more extensive ones of Talbot and Benedict and the definitive ones of Levine and his collaborators (notably Gordon) that came with the succeeding decades. It was appreciated as early as the 1870's by Rubner that energy requirements were proportional to surface area. This was known as Rubner's law, and Meeh developed the formula relating surface area to body weight, a' Direct observations of surface area had up until then been confined to measurements made in Germany on three infants. Howland felt that the Meeh formula was not sufficiently well established for infants and he and Richard Dana undertook a series of direct measurements of surface area. They made observations of 14 infants, including premature infants. The bodies were covered "~Ru}~ncr's law: caloric requirements oo surface area Meeh: S.A. : K Wt.2/~ • Ht. ~ Dubois: S.A. ~ K ( W t . ~
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largely from d a t a on adults. I t m a y well be t h a t the H o w l a n d a n d D a n a g r a p h is the m o r e accurate for infants. Dr. H o w l a n d ' s interest during these years was not confined to energT requirements. H e was interested in the m a j o r calorigenic foods t u f f s - - t h e i r tolerances a n d their requirements. T o g e t h e r with Dr. R o b e r t A. Cooke, w h o later became a well-known allergist, he designed a metabolism bed for infants in which balance studies of fats a t different levels of intake were carried out. T h e y showed that in a n u m b e r of n o r m a l infants
with pieces of p a p e r fitted to patterns inked on the body surface a n d the papers were then weighed. I t was f o u n d t h a t the constant employed in the M e e h f o r m u l a was indeed not applicable to infants, a smaller constant fitting the d a t a better. A simple g r a p h was presented, showing the relation of surface a r e a to body weight which would relieve the n o n m a t h e m a t i c a l l y m i n d e d physician from the necessity of working with exp o n e n t i a l functions (see Fig. 4 ) . I t was app r e c i a t e d by Dr. H o w l a n d t h a t height as well as weight influenced surface area, but he felt t h a t the influence of height in infants was a small one a n d m a d e no effort to evaluate it. I t was somewhat later that Dubois developed the f o r m u l a which is employed in current nomograms, in which both weight a n d height are taken into consideration. I have m a d e comparisons from Dr. Howland's d a t a on surface area as d e t e r m i n e d from his g r a p h a n d from the Dubois f o r m u l a (see T a b l e I ) . T h e r e is a discrepancy, as you can see, b u t it does not follow t h a t the Dubois f o r m u l a gives the m o r e nearly correct answer. T h a t f o r m u l a was derived
T a b l e I. C o m p a r i s o n of d a t a on surface area
Average height (cm.) 50.4 52.4 56.0 59.2 62.8 66.0 69.6 73.0
Weight &g.)
3.4 4.0 5.0 6.0 7.0 8.0 9.0 10.0
Weight in grams.
0)
f
,N
Fig. 4. Relation of surface area to body weight
Surface area (M e) Crawford and asso- Howland ciates graph (1950) (1912) 0.208 0.218 0.225 0.248 0.28 0.30 0.30 0.35 0.32 0.40 0.37 0.45 0.40 0.50 0.43 0.54
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high-fat intakes were well tolerated, and led to no disaster, but he never quite freed himself from the view that certain other infants might be harmed by such intakes and might develop fat intolerance. ' Dr. Howland's metabolic studies brought him prompt recognition. Before they were completed, he had been appointed the head of the Children's Medical Service at Bellevue. He was elected to the American Pediatric Society at this time, one of the youngest members ever elected, being only 10 years out of medical school. H e was invited to give a Harvey Lecture, on the Scientific Basis of Infant Feeding, which makes good reading today. The first decade of this century must have been a very exciting time to be in medicine. Work in pathology there had been Dr. Howland's first two publications represented pathological observations--but research in this country on live patients with the tools of biochemistry and immunology was something new. The early 1900's saw the formation of the Rockefeller Institute (my father had played a part in that), of the Society of Experimental Biology and Medicine (the "Meltzer Verein"), and of the "Young Turks" (the American Society for Clinical Investigation). Dr. Howland was a charter member of that and a moving spirit. The ferment was going on all over the country. But it was difficult for a clinician who had to make a living by practice to devote tile necessary time to do first-class scientific work, and there began to be talk of the need for full-time posts. Washington University in St. Louis was the first to put this into practice. In 1910, three full-time clinical chairs were created, in medicine, surgery, and pediatrics, and Howland was an obvious choice for this last one. In preparation, he was given a year of study abroad, which he spent at Strassburg. Czerny and Keller were then at the height of their productive period, and it must have been a most stimulating atmosphere. Dr. Howland worked with Stolte, carrying out prolonged balance studies of infants at different levels of nitrogen intake and showing the adjustments that took place
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with time. The observations included measurements not only of nitrogen, but also of sulfur, phosphorus, and various minerals. It was a first-class piece of work. The data were left with Stolte, who was to arrange for their publication. But years went by and they were not published. Howland could get no answer from letters to Stolte. Whether Stoke had lost the data or had turned antiAmerican, no one knew. Seven years later, toward the end of World War I, when the German pediatric journals were running short of material, the paper by Stolte and Howland appeared in the Jahrbuch. Dr. Howland was so disgusted by the delay that he told me he couldn't bear to read the paper. I n the fall of 1911, he went to St. Louis, but the new era there proved to be a false dawn. It was a period of continuous disappointments and frustrations. Promised research facilities did not materialize. The Children's Hospital was run by a group of women who were continually interfering in matters medical, and the final straw was added when he was severely reprimanded for admitting two Negro infants to the wards. Within six months he called it quits, returned the money that had been given him for the year abroad, and returned to New York--without a job, without a practice (for in two years it had e v a p o r a t e d ) - - b u t to a place where he felt he had friends and was appreciated. He did not have long to wait. Dr. Welch had been negotiating with the Rockefeller Foundation to set up full-time clinical medicine at Johns Hopkins, and within a few months Howland was installed as the new full-time professor, a post he held until his death in 1926. The last phase of Dr. Howland's c a r e e r - I think it could be called the crowning phase--was the 14 years he spent in B a l t i more. It was marked by two major scientific achievements: the demonstration of acidosis in infantile diarrhea, and the joint study with MeCollum's department of experimental rickets which culminated in the discovery of vitamin D. Acidosis had been suspected by German
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pediatricians as an accompaniment of diarrhea, but had not been demonstrated. The Kussmaul type of breathing was known to be associated with experimental acidosis in animals. But, as knowledge began to unfold about acid-base equilibrium, Dr. Howland became intrigued with the idea that acidosis was perhaps the underlying chemical basis for what the European pediatricians had called "alimentary intoxication." Perhaps this was the toxic factor, and he was going to find it. The convenient tools of today were not at hand; there was no Van Slyke apparatus, no p H meter. But with the aid of Marriott, whom Howland had brought to Baltimore, acidosis was diligently searched for and in time was effectively demonstrated by four different techniques: (1) by the increased tolerance to alkali, as judged by the amount needed to make the urine alkaline, (2) by the decreased CO2 tension of the alveolar air, (3) by the characteristic alteration of the hemoglobin dissociation curve, and (4) by a colorimetric procedure applied to blood serum. The proof was conclusive. While the work was in progress in Baltimore, a distinguished investigator in New York was also at work on the problem. Oscar Schloss was in touch with Van Slyke and the apparatus he was developing to measure the CO2 content and capacity of the serum, and, with the new Van Slyke apparatus, he too had independently demonstrated t h e existence of acidosis in diarrhea. When he learned of the work of Howland and Marriott, he generously withheld his own paper until after the publication of their work, in order to give them the priority which he felt they deserved. It was a disappointment that the correction of acidosis failed to correct the "alimentary intoxication," as had been hoped. The role of dehydration in bringing out that symptom complex remained to be clarified and in that Marriott, Gamble, and Schloss played leading roles--the first two after they had left Baltimore. The Work on experimental rickets was a remarkable demonstration of what can be accomplished by a mass attack on a prob-
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lem. It is hard for us today to realize how important a problem rickets was in those days. Clinical rickets was evident in at least one-third of all pediatric hospital admissions and autopsies showed the incidence in infants to be over 90 per cent. From time to time severe chest deformities were encountered that threatened life. There were numerous bone deformities that we now still see occasionally in the metabolic forms of rickets, and dystocia resulting from early rickets was an important obstetrical problem. In magnitude, though not in mortality, rickets was certainly the number one pediatric problem. The arrival of Dr. McCollum in Baltimore was a godsend to Dr. Howland, and they soon joined forces. McCollum had pioneered in studies of dietary diseases, using rats. An experimental approach to the study of a bone disease, however, needed expert knowledge of bone pathology and microchemical methods for the study of the minerals concerned in bone metabolism. These last, the pediatric department was in a position to supply. Shipley and Park supplied the pathological talent and K r a m e r the micromethods. (See Fig. 5 for a picture of Drs. Park and Howland at about this time.) They must all have worked together in the planning of the studies, and no doubt Dr. McCollum's fertile brain was an important ingredient of their success, but an outstanding success they were. Rickets was produced in rats, the dietary conditions which gave rise to it were well defined, the potency of cod-liver oil and o f ultraviolet radiation were established beyond a doubt, and the findings were beginning to be applied clinically. The chemical diagnosis of rickets had been added to the roentgenological diagnosis, and therapy was being worked out quantitatively. I think that Dr. Kramer's contribution to this study is one that has not been generally appreciated; without the microchemical methods Which he supplied the work would not have b e e n so fruitful. When I arrived in Ba!timore , in the fall o f 1922, the Harriet Lane H o m e was 10 years old. The firgt crop o f its graduates had moved on: Marriott to St. Louis, taking
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Fig. 5. Drs. Park and Howland at the Harriet Lane Home in 1916.
Clausen with him; Park and Powers to New H a v e n ; Blackfan to Cincinnati; Gamble to Boston; G r a h a m Ross and Tisdall to C a n a d a ; Rivers to New York; Sisson to Boston. The existing members of the permanent staff, besides Dr. Howland, were four: Kramer, Shipley, Davison, and Josephs; to this group were added six neophytes, of which I was one. T h e investigative effort was still heavily oriented toward the problems of rickets and bone calcification. Dr. H o w l a n d asked me what I wanted to work on. M y interests were chemical, and he suggested that I work on fats. But fats for some reason had little appeal for me then, although I became interested in them later. The rickets work was glamorous; I wanted to have some part in it, and a place was found for me. We six neophytes were assigned to the chemical laboratory with Ben K r a m e r as our boss. We were organized into two teams: Bill Orr, Frank Boone, Lawson Wilkins, and myself were one team, whose job it was to do bal-
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ance studies and blood studies on rachitic babies to see if ultraviolet light would effect the same chemical changes as cod-liver oil. Joe Pincus and Gittleman were to do the same in rats. Before we did anything experimental, though,, we were given an exceedingly thorough ctrilling in routine methods, including all the recently devised Kramer-Tisdall methods of microanalysis for blood. We all worked in the cellar of" the Harriet Lane H o m e ; the six of us in one room, Dr. Howland and Dr. K r a m e r in another. T h e laboratory floor was built onto the Harriet Lane several years later in order to induce Dr. Howland to remain in Baltimore instead of accepting a call to Hapeard. Dr. Howland always insisted in doing some laboratory work himself (Fig. 6). I think he and K r a m e r were then analyzing rat bones for their carbonate-phosphate ratio. Dr. Howland wanted all his research team to be mathematically oriented, and a professor from the university campus was induced to come over once a week to give us a course in calculus. It was an interesting pastime, but I doubt if it did us very much good. I never used it, and I think about all it accomplished for me and perhaps for some of the others, too, was to dispel the inferiority complex some of us felt when we encountered a paper with an integral sign in it. Dr. K r a m e r used to give us talks on physical chemistry, which were very stimulating. W e discussed the solubility product principle, and how it had been applied by Howland and K r a m e r to ascertain whether or not bone would be deposited from a given concentration of calcium and inorganic phosphate in the blood: if the Ca x P product was 40 or more, rickets could not occur; if the product was below 30, rickets was inevitable. It occurred to me that this formulation was not a correct expression of the solubility product principle: If, as was then believed, the bone phosphate was tertiary calcium phosphate, the true ion product controlling its deposition should be not Ca x P but (Ca++) ~ • PO4~) 2, a relationship which needed to be evaluated. I think Dr. H o w l a n d v~as a little upset by this. I was treading a sacred ground, and I was still a
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Fig. 6. John Howland in the laboratory at the Harriet Lane Home. neophyte, but when I told him I wanted to knock off for a year and study the solubility of the calcium phosphates and work out the equilibria responsible for their deposition, he was wonderful to me. He arranged for a special laboratory and equipment for me to carry out that work and relieved me for a whole year of clinical responsibilities so that I could pursue the laboratory work without interruption. For several years, Dr. Kramer and I used to have polite differences of opinion about the ion product in the serum which was concerned in calcification of bone (this was after he had moved to New York), I maintaining that the first salt deposited was the tertiary phosphate and that the proper product was (Ca++) a x (PO(--) 2, and he that the first salt was the secondary phosphate and that the simple product Ca x P was the valid one. Later it turned out that we were both wrong. When x-ray analysis of crystal structure came along, it was clearly established that bone salt was neither secondary nor tertiary calcium phosphate; it was ap-
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atite, a double salt. The process was furthermore complicated by adsorption phenomena which neither of us had taken into consideration. Forty-four years ago these things seemed very important. They seem much less so today. Working all by myself apart from clinical duties was probably not good for me. I became interested in thermodynamics, and wanted to apply its laws to the phenomena of bone calcification, but Dr. Howland thought I was getting too far away from pediatrics. He made the point that, as far as he knew, the important advances in medicine had been made by observations, not by calculations. I think the advice is worth repeating. Under Dr. Howland, the Harriet Lane Home was a success from the start. Its graduates were sought after, and the list of those who occupied positions of distinction in other institutions is an impressive one (Table I I ) . Full-time medicine was a success, full-time pediatrics was a particular success, and the idea spread. I had not, however, realized it until Dr. Park pointed it out to me that of the three departments at Johns Hopkins in which full-time was started, it was the result in pediatrics rather than in medicine and surgery that persuaded the Rockefeller Foundation that full-time was a success, and that they should institute it elsewhere. The department of surgery was very little affected by full-time; there were peculiar difficulties faced by Theodore Janeway in the Department of Medicine, and he lived only a few years after his appointment there, but pediatrics flourished. What were tile ingredients that made it such a success? Dr. Howland combined in an extraordinary degree the attributes that are sought after today in department heads: He was a superb clinician (there was none better), a talented teacher, and an outstanding scientist. He was not burdened with having to raise money for research grants. He was perhaps the last of the great clinicians who could cover the field of pediatrics as a whole. The age of specialization in pediatrics had not yet arrived. His 90 publications
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Table II. Graduates of the Harriet Lane Home trained by Dr. Howland (1912-1926) Department heads
Biackfan Casparis Chown Clausen Davison Dodd Gamble Holt Marriott Park Powers Sato Weech Wilkins
(Cincinnati, Harvard) (Vanderbilt) (Winnipeg) (Rochester) (Duke) (Arkansas) (Harvard) (New York Univ.) (Washington Univ.) (Yale, Johns Hopkins) (Yale) (Sendal) (Cincinnati) (Johns Hopkins)
cover the whole range of pediatrics: nutrition, infectious disease, respiratory disease, heart disease (he wrote an outstanding paper on idiopathic hypertrophy of the heart which had not then been differentiated into several different entities), and surgical pediatrics (these are two excellent papers on the diagnosis of appendicitis in children). Dr. Howland's clinics were memorable. They made the students think, and they were often dramatic. He loved to open a retropharyngeal abscess with his fingernail, hoidding the child by the feet to prevent aspiration. Eventually the E N T department prevailed upon him to let them open the abscesses with more modern surgical tools. They were not as successful as Dr. Howland, and they lost their first four cases before they learned the danger of opening the mouth too wide with a mouth gag and of hyperextending the neck. The day of the pedagogic questionnaire did not come in Dr. Howland's time---the urge on the part of educators to increase the number of pediatric hours in the medical curriculum. When it did come, some time after Dr. Howland's death, it turned out that the man who had trained more pediatric teachers than anyone else had done so with a smaller number of hours reserved for pediatrics than was provided by any medical school in the United States--96 hours in all as contrasted with over 200 in the national
Some pediatricians who achieved academic distinction
H. W. Josephs B. Kramer W. B. McClure J. B. Pincus T. M. Rivers A. J. Schaffer A. T. Shohl W. R. S i s s o n
(Johns Hopkins) (State Univ., N. Y.) (Univ. of Chicago) (State Univ., N. Y.) (Rockefeller) (Johns Hopkins) (Yale) (Harvard)
average. Elective students, about a fourth of the class, got more than this; pediatrics was far and away the most sought-after elective. It was Dr. Howland's belief that one should concentrate on the few. There were other outstanding teachers and clinicians besides Dr. Howland, and I do not think that the success of the department and the demand for its graduates stemmed from this. It came from Dr. Howland's personal qualities, his ability to inspire others with his own enthusiasm, and his unerring judgment as to who would be creative and who would not. And his men were creative. They were not necessarily highly trained, but they had picked up techniques. Marriott, for example, was not a highly trained chemist, but Dr. Howland told me that Marriott was the most facile man he had ever worked with; he could put every bit of his knowledge to use. Dr. Howland was inclined to take a dim view of women in medicine. He appreciated the talents of a number of outstanding women, such as Katherine Dodd and Margaret Handy, whom he had on his staff, but he had little sympathy for what he liked to call "aggressive feminism." On one occasion the superintendent of nurses at Johns Hopkins made an impassioned plea to the executive medical faculty that nurses be given academic status and be granted a B.N. (bachelor of nursing) degree. Dr. Howland spoke up and said that by all means they should have a
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degree, but it should be not a B.N. but an S.N--"spinster of nursing." T h e project was not pursued. I n Dr. Howland's day, nutritional problems occupied the center of the pediatric stage; the era which was then called the "newer knowledge of nutrition" was just beginning. Some of his pupils, a m o n g them myself, have stayed with that field and have watched the multiplication of the essential nutrients and of their interrelationships. I a m tempted to digress for a m o m e n t to raise the question that comes home to me and to others who have taken this road: what lies ahead for nutrition? Is the end of the road in sight, and should we steer our successors into paths more rewarding in terms of child health? As I see it, despite the abuses of nutrition that beset u s - - t h e exploitation of unnecessary nutrients, the dietary f a d s - - n u trition has a real future. There would seem little of importance to be learned about the nutrition of the healthy person. A few more vitamins and trace minerals will doubtless be discovered and be exploited in their turn, but the real problem of the future is that of nutrition in disease. T h e more we learn about intermediary metabolism and its derangements, the greater are the opportunities for circumventing them by dietary means as well as by pharmacological agents. Congenital metabolism anomalies are responding one after another to a dietary approach, and the congenital anomalies, one after another, are being aped by temporary disturbances. There would seem to be no end to the possibilities here. I n the past, nutrition concerned us only in regard to the disturbances of the alimentary tract, but we
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now know that metabolic anomalies may affect any system in the body. Those of the nervous system are particularly enticing at the m o m e n t as subjects for investigation. The metabolic defects associated with prematurity would also seem to offer a wide field for research and correction. Nutrition should grow parallel to advances in intermediary metabolism. To return to Dr. Howland, I have given you a ve~3r cursory sketch of him. You can learn a lot more from Dr. Park's beautiful essay. There are m a n y lessons to be learned from his career. H e was one of the "slow maturers," who are seldom appreciated by admitting officers of medical schools because they have diversified their interests in college. There is the point which Dr. Howland himself made, that the ability to use what knowledge one has is more important than how m u c h knowledge one has. T h e real significance of Dr. Howland's career was that he was the h i n g e - - t h e chief hinge the turning point of American pediatrics from that of the nineteenth century to the pediatrics of the twentieth century, to academic pediatrics as we know it today. It is only fitting that we should commemorate him in the form of our annual medal. REFERENCES
1. Davison, W. C.: J. PEDIAT.46: 473, 1955. 2. Edsall, D. L.: Medicine 5: 195, 1926. 3. Lusk, G., Welch, W. H., and Flexner, S.: Howland memorial meeting, Bull. Johns Hopkins Hosp. 41: 311, 1927. 4. Gamble, J. L.: Remarks at presentation of portrait of John Howland, Pediatrics 21" 655, 1958. 5. Park, E. A.: Howland Award address, Pediatrics 10" 82, 1952.
865
John HowlanJ: Turning point of American pediatrics H o w l a n d A w a r d Address
L. Emmett Holt, Jr., M.D. NEW
YORK~
NEW
YORK
I D O N ' T H A V E to tell you how touched I am to be given this award today. Of all the organizations I have belonged to, the American Pediatric Society comes closest to m y heart. I owe it a debt that I wish I could repay. I owe Dr. W a r d a debt also--for his kind mention of my assets with a most tactful omission of m y deficiencies, but more particularly for the help and support he has given me through the years we were together at New York University. T h a n k you, Bob, for your kind words, your good deeds, your, lasting friendship ! I am going to depart a little from the tradition of talking about some aspect of one's own work. Instead, I shall talk about one of the three men who have played a dominant part in m y life. The three were my father, John Howland, and Ned Park. It is fitting on this occasion that I talk about Dr. Howland. T h e number of those who knew him is steadily shrinking, and for the sake of the m a n y who did not know him, it seems worthwhile to tell a little something about his life, why we have a medal named for him, and what his legacy is to American pediatrics today. I know in advance that I shall fail in this task. Others have written about Dr. Howland: Wilburt Davison, 1 David Edsall, 2 G r a h a m Lusk, 3 James Gamble, 4 and none better than Dr. Park 5 in
the first H o w l a n d lecture where, in his inimitable style, he really brought Dr. Howland to life, touching upon his foibles as well as his greatnesses. Nevertheless, I shall try. I knew Dr. H o w l a n d from my earliest childhood. I n the early 1900's he was my father's office assistant, and was in our house every day. In the summer, when he visited our camp in the Adirondacks, he was to us children our most glamorous visitor. It is hard to say what it was that made h i m so. Perhaps it was because he liked us and paid some attention to us. As Gamble pointed out, he always remained a boy at heart. Then, he was a star athlete. He had been an oarsman in college, and rowing was important in our lives--that was before the days of motorboats. He had also been intercollegiate tennis champion. O n one of these visits, Dr. Howland reached the conclusion that he would give up tennis, t h a t championship tennis and medicine were incompatible, and that golf was more suitable for a busy doctor, and he formally presented my teen-age sister with the racquet that had won the intercollegiate championship. It was a specially built racquet, made from designs by the Doherty brothers, who w e r e English champions of that day, and it was much too heavy for m y sister, but would she ever play tennis with anything else? Figs. 1 and 2 are pic-
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Fig. 1. John Howland at camp in the Adirondacks, some time in the early 1900's.
Fig. 2. John Howland at the time of his association with the Johns Hopkins School of Medicine.
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tures of Dr. Howland taken at about that time. Perhaps you can get some idea of his personality from them. For many years I did not see Dr. Howland, but when I went to medical school in Baltimore, I spent, a great deal of time at his house; most of my Sunday evenings were spent there. They were wonderful evenings. Dr. Howland was a great raconteur, interested in everything under the sun, and full of interesting experiences. A young medical student sitting at his feet could not help but imbibe some of his philosoptfy--his enthusiasm for adding to medical knowledge, not just applying it. I have to thank Ren6 Dubos for pointing out the derivation of the word enthusiasm: "a god within." I was just one of many who came under Dr. Howland's spell. One wanted to be like him, to do the kind of things that he was doing. I had always intended to be a practitioner like my father. I went back to New York for two years of hospital training--they were good years, too, but I had been inoculated, and I went back to Baltimore to work with Dr. Howland and try my hand at academic pediatrics in the only place where it existed in this country. I can't say that I have regretted it. Dr. Howland came from a rugged New England background. He was born in New Hampshire, but brought up in New York City, where his father was an eminent judge and his mother a talented musician. At Yale his career was not marked by academic distinction, although his standing was good. He was interested in sports and in social life, and was editor of the Yale News. The decision to study medicine came late in his college career, the result apparently of a warm contact with Dr. Sanford, the leading practitioner in New Haven. It may have been that feminine influence was responsible for this contact, for Dr. Sanford eventually became Dr. Howland's father-in-law. But when college was over, he lost no time in getting to work. From New York University you could get a degree in three years, as contrasted with Columbia, and New York University he chose. In those days medicine was
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learned not so much in medical school as from a private "quiz." A famous one was that of Dr. Ellsworth Eliot, whose graduates never failed to get good hospital appointments. Dr. Howland was no exception, and obtained a much sought-after appointment in medicine at the Presbyterian Hospital. This was followed by two years as resident physician at the New York Foundling Hospital under my father. There was a brief interlude during the Spanish-American War when he served as ship's surgeon in charge of typhoid patients returning from Cuba. He then went to study in Germany--the mecca at that time for all ambitious American doctors. The year, spent partly in Berlin and partly in Vienna, was an eye-opener. Here in the university clinics were doctors adding to knowledge, not just acquiring accepted knowledge. Heubner was a leading figure in Berlin pediatrics, and he and the famous Max Rubner were trying to put infant feeding on a firm scientific basis. Energy metabolism studies, undertaken by indirect calorimetry, promised to tell what infants really needed to be fed. The young visiting American was inspired to do likewise. He was, as Lusk put it later, possessed of a demon which gave him no peace unless he could conduct scientific research--which was difficult in New York. There was then no living for a pediatrician except practice. It was a busy life. Howland had a teaching appointment at Columbia and appointments as attending pediatrician at several hospitals. It was at Bellevue, however, that he found the opportunity and the stimulus to undertake metabolic work. Graham Lusk , the professor of physiology at Cornell, had been a pupil of Carl Voit and of Rubner, and had collected about him an enthusiastic group of students of metabolism : Murlin, Hoobler, Eugene Dubois, and others. C. A. Herter and his assistant, A. N. Richards, were actively engaged in neighboring facilities under the aegis of Columbia, and biochemistry was beginning to bud. Richards told me that one day in the early 1900's he found Dr. Howland 'in the laboratory testing the urine of an infant with
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recurrent vomiting. Richards was a trained chemist, which Howland was not. The prevalent idea at that time was that most diseases were due to unidentified toxins which affected body oxidations. Howland was sure that such a toxin could be found, and they agreed to work together, studying the chemical effects of known poisons which might affect oxidations. The resulting collaboration involved studies of indote, of chloroform, and of cyanide poisoning in animals with a variety of chemical techniques. The results were not startling, and did not go far to solve the problem of recurrent vomiting, but it was careful, painstaking work; in the course of it, Howland learned a great deal of the chemistry which stood him in good stead later. It was in Lusk's laboratory, however, that the start was made of his work on calorimetry. One of Lusk's younger staff' members was constructing a calorimeter for use with small animals, and plans were made that Howland should use it for babies from the children's medical service at Bellevue to clear up some of the imperfections in the work of the early German investigators. The calorimeter was duly constructed and put to use, and is shown in Fig. 3. It provided for both direct and indirect calorimetry. Direct heat production was measured with an accuracy of approximately 2 per cent, indirect calorimetry was carried out by measurements of the expired gas mixture, and the nonprotein respiratory quotient was calculated in many of the studies from urinary nitrogen. A number of significant observations came out of this work: 1. They were the first observations by direct calorimetry ever made in infants and they showed that the correlation between tile direct and indirect method was excellent, making it unnecessary in the future to employ the more cumbersome direct method. 2. They provided the first observations of "basal" metabolism during sleep, which German investigators had not successfully a c complished. The technique adopted was to stimulate the :infants during the morning hours, making Si~re that they got no sleep;
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Fig. 3. Calorimeter used by John Howland in the early 1900's.
they were then fed and put in the chamber, in which they slept happily for hours. 3. The effect of mild exercise (casual movements while awake) in contrast to crying was measured and found to be much larger than had been supposed. 4. The specific dynamic action of a high protein meal was studied and found to be of the order of magnitude of 10 to 26 per cent, and it was shown that only a part of this increased heat production resulted from the combustion of pro.tein; fat and carbohydrate contributed a substantial part of it. 5. A number of observations were made on greatly undernourished infants, who were found to have a surprisingly low metabolic rate. The rigid Heubner standards for feeding normal infants (100 calories per kilogram) it now appeared were not universally applicable, for this work demonstrated the great variability among individual infants, depending on how much they slept or cried. The observations were relatively few in
number, but they were pioneer observations, the prelude to the more extensive ones of Talbot and Benedict and the definitive ones of Levine and his collaborators (notably Gordon) that came with the succeeding decades. It was appreciated as early as the 1870's by Rubner that energy requirements were proportional to surface area. This was known as Rubner's law, and Meeh developed the formula relating surface area to body weight, a' Direct observations of surface area had up until then been confined to measurements made in Germany on three infants. Howland felt that the Meeh formula was not sufficiently well established for infants and he and Richard Dana undertook a series of direct measurements of surface area. They made observations of 14 infants, including premature infants. The bodies were covered "~Ru}~ncr's law: caloric requirements oo surface area Meeh: S.A. : K Wt.2/~ • Ht. ~ Dubois: S.A. ~ K ( W t . ~
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John H o w l a n d
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largely from d a t a on adults. I t m a y well be t h a t the H o w l a n d a n d D a n a g r a p h is the m o r e accurate for infants. Dr. H o w l a n d ' s interest during these years was not confined to energT requirements. H e was interested in the m a j o r calorigenic foods t u f f s - - t h e i r tolerances a n d their requirements. T o g e t h e r with Dr. R o b e r t A. Cooke, w h o later became a well-known allergist, he designed a metabolism bed for infants in which balance studies of fats a t different levels of intake were carried out. T h e y showed that in a n u m b e r of n o r m a l infants
with pieces of p a p e r fitted to patterns inked on the body surface a n d the papers were then weighed. I t was f o u n d t h a t the constant employed in the M e e h f o r m u l a was indeed not applicable to infants, a smaller constant fitting the d a t a better. A simple g r a p h was presented, showing the relation of surface a r e a to body weight which would relieve the n o n m a t h e m a t i c a l l y m i n d e d physician from the necessity of working with exp o n e n t i a l functions (see Fig. 4 ) . I t was app r e c i a t e d by Dr. H o w l a n d t h a t height as well as weight influenced surface area, but he felt t h a t the influence of height in infants was a small one a n d m a d e no effort to evaluate it. I t was somewhat later that Dubois developed the f o r m u l a which is employed in current nomograms, in which both weight a n d height are taken into consideration. I have m a d e comparisons from Dr. Howland's d a t a on surface area as d e t e r m i n e d from his g r a p h a n d from the Dubois f o r m u l a (see T a b l e I ) . T h e r e is a discrepancy, as you can see, b u t it does not follow t h a t the Dubois f o r m u l a gives the m o r e nearly correct answer. T h a t f o r m u l a was derived
T a b l e I. C o m p a r i s o n of d a t a on surface area
Average height (cm.) 50.4 52.4 56.0 59.2 62.8 66.0 69.6 73.0
Weight &g.)
3.4 4.0 5.0 6.0 7.0 8.0 9.0 10.0
Weight in grams.
0)
f
,N
Fig. 4. Relation of surface area to body weight
Surface area (M e) Crawford and asso- Howland ciates graph (1950) (1912) 0.208 0.218 0.225 0.248 0.28 0.30 0.30 0.35 0.32 0.40 0.37 0.45 0.40 0.50 0.43 0.54
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high-fat intakes were well tolerated, and led to no disaster, but he never quite freed himself from the view that certain other infants might be harmed by such intakes and might develop fat intolerance. ' Dr. Howland's metabolic studies brought him prompt recognition. Before they were completed, he had been appointed the head of the Children's Medical Service at Bellevue. He was elected to the American Pediatric Society at this time, one of the youngest members ever elected, being only 10 years out of medical school. H e was invited to give a Harvey Lecture, on the Scientific Basis of Infant Feeding, which makes good reading today. The first decade of this century must have been a very exciting time to be in medicine. Work in pathology there had been Dr. Howland's first two publications represented pathological observations--but research in this country on live patients with the tools of biochemistry and immunology was something new. The early 1900's saw the formation of the Rockefeller Institute (my father had played a part in that), of the Society of Experimental Biology and Medicine (the "Meltzer Verein"), and of the "Young Turks" (the American Society for Clinical Investigation). Dr. Howland was a charter member of that and a moving spirit. The ferment was going on all over the country. But it was difficult for a clinician who had to make a living by practice to devote tile necessary time to do first-class scientific work, and there began to be talk of the need for full-time posts. Washington University in St. Louis was the first to put this into practice. In 1910, three full-time clinical chairs were created, in medicine, surgery, and pediatrics, and Howland was an obvious choice for this last one. In preparation, he was given a year of study abroad, which he spent at Strassburg. Czerny and Keller were then at the height of their productive period, and it must have been a most stimulating atmosphere. Dr. Howland worked with Stolte, carrying out prolonged balance studies of infants at different levels of nitrogen intake and showing the adjustments that took place
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with time. The observations included measurements not only of nitrogen, but also of sulfur, phosphorus, and various minerals. It was a first-class piece of work. The data were left with Stolte, who was to arrange for their publication. But years went by and they were not published. Howland could get no answer from letters to Stolte. Whether Stoke had lost the data or had turned antiAmerican, no one knew. Seven years later, toward the end of World War I, when the German pediatric journals were running short of material, the paper by Stolte and Howland appeared in the Jahrbuch. Dr. Howland was so disgusted by the delay that he told me he couldn't bear to read the paper. I n the fall of 1911, he went to St. Louis, but the new era there proved to be a false dawn. It was a period of continuous disappointments and frustrations. Promised research facilities did not materialize. The Children's Hospital was run by a group of women who were continually interfering in matters medical, and the final straw was added when he was severely reprimanded for admitting two Negro infants to the wards. Within six months he called it quits, returned the money that had been given him for the year abroad, and returned to New York--without a job, without a practice (for in two years it had e v a p o r a t e d ) - - b u t to a place where he felt he had friends and was appreciated. He did not have long to wait. Dr. Welch had been negotiating with the Rockefeller Foundation to set up full-time clinical medicine at Johns Hopkins, and within a few months Howland was installed as the new full-time professor, a post he held until his death in 1926. The last phase of Dr. Howland's c a r e e r - I think it could be called the crowning phase--was the 14 years he spent in B a l t i more. It was marked by two major scientific achievements: the demonstration of acidosis in infantile diarrhea, and the joint study with MeCollum's department of experimental rickets which culminated in the discovery of vitamin D. Acidosis had been suspected by German
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pediatricians as an accompaniment of diarrhea, but had not been demonstrated. The Kussmaul type of breathing was known to be associated with experimental acidosis in animals. But, as knowledge began to unfold about acid-base equilibrium, Dr. Howland became intrigued with the idea that acidosis was perhaps the underlying chemical basis for what the European pediatricians had called "alimentary intoxication." Perhaps this was the toxic factor, and he was going to find it. The convenient tools of today were not at hand; there was no Van Slyke apparatus, no p H meter. But with the aid of Marriott, whom Howland had brought to Baltimore, acidosis was diligently searched for and in time was effectively demonstrated by four different techniques: (1) by the increased tolerance to alkali, as judged by the amount needed to make the urine alkaline, (2) by the decreased CO2 tension of the alveolar air, (3) by the characteristic alteration of the hemoglobin dissociation curve, and (4) by a colorimetric procedure applied to blood serum. The proof was conclusive. While the work was in progress in Baltimore, a distinguished investigator in New York was also at work on the problem. Oscar Schloss was in touch with Van Slyke and the apparatus he was developing to measure the CO2 content and capacity of the serum, and, with the new Van Slyke apparatus, he too had independently demonstrated t h e existence of acidosis in diarrhea. When he learned of the work of Howland and Marriott, he generously withheld his own paper until after the publication of their work, in order to give them the priority which he felt they deserved. It was a disappointment that the correction of acidosis failed to correct the "alimentary intoxication," as had been hoped. The role of dehydration in bringing out that symptom complex remained to be clarified and in that Marriott, Gamble, and Schloss played leading roles--the first two after they had left Baltimore. The Work on experimental rickets was a remarkable demonstration of what can be accomplished by a mass attack on a prob-
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lem. It is hard for us today to realize how important a problem rickets was in those days. Clinical rickets was evident in at least one-third of all pediatric hospital admissions and autopsies showed the incidence in infants to be over 90 per cent. From time to time severe chest deformities were encountered that threatened life. There were numerous bone deformities that we now still see occasionally in the metabolic forms of rickets, and dystocia resulting from early rickets was an important obstetrical problem. In magnitude, though not in mortality, rickets was certainly the number one pediatric problem. The arrival of Dr. McCollum in Baltimore was a godsend to Dr. Howland, and they soon joined forces. McCollum had pioneered in studies of dietary diseases, using rats. An experimental approach to the study of a bone disease, however, needed expert knowledge of bone pathology and microchemical methods for the study of the minerals concerned in bone metabolism. These last, the pediatric department was in a position to supply. Shipley and Park supplied the pathological talent and K r a m e r the micromethods. (See Fig. 5 for a picture of Drs. Park and Howland at about this time.) They must all have worked together in the planning of the studies, and no doubt Dr. McCollum's fertile brain was an important ingredient of their success, but an outstanding success they were. Rickets was produced in rats, the dietary conditions which gave rise to it were well defined, the potency of cod-liver oil and o f ultraviolet radiation were established beyond a doubt, and the findings were beginning to be applied clinically. The chemical diagnosis of rickets had been added to the roentgenological diagnosis, and therapy was being worked out quantitatively. I think that Dr. Kramer's contribution to this study is one that has not been generally appreciated; without the microchemical methods Which he supplied the work would not have b e e n so fruitful. When I arrived in Ba!timore , in the fall o f 1922, the Harriet Lane H o m e was 10 years old. The firgt crop o f its graduates had moved on: Marriott to St. Louis, taking
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Fig. 5. Drs. Park and Howland at the Harriet Lane Home in 1916.
Clausen with him; Park and Powers to New H a v e n ; Blackfan to Cincinnati; Gamble to Boston; G r a h a m Ross and Tisdall to C a n a d a ; Rivers to New York; Sisson to Boston. The existing members of the permanent staff, besides Dr. Howland, were four: Kramer, Shipley, Davison, and Josephs; to this group were added six neophytes, of which I was one. T h e investigative effort was still heavily oriented toward the problems of rickets and bone calcification. Dr. H o w l a n d asked me what I wanted to work on. M y interests were chemical, and he suggested that I work on fats. But fats for some reason had little appeal for me then, although I became interested in them later. The rickets work was glamorous; I wanted to have some part in it, and a place was found for me. We six neophytes were assigned to the chemical laboratory with Ben K r a m e r as our boss. We were organized into two teams: Bill Orr, Frank Boone, Lawson Wilkins, and myself were one team, whose job it was to do bal-
November 1966
ance studies and blood studies on rachitic babies to see if ultraviolet light would effect the same chemical changes as cod-liver oil. Joe Pincus and Gittleman were to do the same in rats. Before we did anything experimental, though,, we were given an exceedingly thorough ctrilling in routine methods, including all the recently devised Kramer-Tisdall methods of microanalysis for blood. We all worked in the cellar of" the Harriet Lane H o m e ; the six of us in one room, Dr. Howland and Dr. K r a m e r in another. T h e laboratory floor was built onto the Harriet Lane several years later in order to induce Dr. Howland to remain in Baltimore instead of accepting a call to Hapeard. Dr. Howland always insisted in doing some laboratory work himself (Fig. 6). I think he and K r a m e r were then analyzing rat bones for their carbonate-phosphate ratio. Dr. Howland wanted all his research team to be mathematically oriented, and a professor from the university campus was induced to come over once a week to give us a course in calculus. It was an interesting pastime, but I doubt if it did us very much good. I never used it, and I think about all it accomplished for me and perhaps for some of the others, too, was to dispel the inferiority complex some of us felt when we encountered a paper with an integral sign in it. Dr. K r a m e r used to give us talks on physical chemistry, which were very stimulating. W e discussed the solubility product principle, and how it had been applied by Howland and K r a m e r to ascertain whether or not bone would be deposited from a given concentration of calcium and inorganic phosphate in the blood: if the Ca x P product was 40 or more, rickets could not occur; if the product was below 30, rickets was inevitable. It occurred to me that this formulation was not a correct expression of the solubility product principle: If, as was then believed, the bone phosphate was tertiary calcium phosphate, the true ion product controlling its deposition should be not Ca x P but (Ca++) ~ • PO4~) 2, a relationship which needed to be evaluated. I think Dr. H o w l a n d v~as a little upset by this. I was treading a sacred ground, and I was still a
Volume 69 Number 5 part 2
Fig. 6. John Howland in the laboratory at the Harriet Lane Home. neophyte, but when I told him I wanted to knock off for a year and study the solubility of the calcium phosphates and work out the equilibria responsible for their deposition, he was wonderful to me. He arranged for a special laboratory and equipment for me to carry out that work and relieved me for a whole year of clinical responsibilities so that I could pursue the laboratory work without interruption. For several years, Dr. Kramer and I used to have polite differences of opinion about the ion product in the serum which was concerned in calcification of bone (this was after he had moved to New York), I maintaining that the first salt deposited was the tertiary phosphate and that the proper product was (Ca++) a x (PO(--) 2, and he that the first salt was the secondary phosphate and that the simple product Ca x P was the valid one. Later it turned out that we were both wrong. When x-ray analysis of crystal structure came along, it was clearly established that bone salt was neither secondary nor tertiary calcium phosphate; it was ap-
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atite, a double salt. The process was furthermore complicated by adsorption phenomena which neither of us had taken into consideration. Forty-four years ago these things seemed very important. They seem much less so today. Working all by myself apart from clinical duties was probably not good for me. I became interested in thermodynamics, and wanted to apply its laws to the phenomena of bone calcification, but Dr. Howland thought I was getting too far away from pediatrics. He made the point that, as far as he knew, the important advances in medicine had been made by observations, not by calculations. I think the advice is worth repeating. Under Dr. Howland, the Harriet Lane Home was a success from the start. Its graduates were sought after, and the list of those who occupied positions of distinction in other institutions is an impressive one (Table I I ) . Full-time medicine was a success, full-time pediatrics was a particular success, and the idea spread. I had not, however, realized it until Dr. Park pointed it out to me that of the three departments at Johns Hopkins in which full-time was started, it was the result in pediatrics rather than in medicine and surgery that persuaded the Rockefeller Foundation that full-time was a success, and that they should institute it elsewhere. The department of surgery was very little affected by full-time; there were peculiar difficulties faced by Theodore Janeway in the Department of Medicine, and he lived only a few years after his appointment there, but pediatrics flourished. What were tile ingredients that made it such a success? Dr. Howland combined in an extraordinary degree the attributes that are sought after today in department heads: He was a superb clinician (there was none better), a talented teacher, and an outstanding scientist. He was not burdened with having to raise money for research grants. He was perhaps the last of the great clinicians who could cover the field of pediatrics as a whole. The age of specialization in pediatrics had not yet arrived. His 90 publications
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Table II. Graduates of the Harriet Lane Home trained by Dr. Howland (1912-1926) Department heads
Biackfan Casparis Chown Clausen Davison Dodd Gamble Holt Marriott Park Powers Sato Weech Wilkins
(Cincinnati, Harvard) (Vanderbilt) (Winnipeg) (Rochester) (Duke) (Arkansas) (Harvard) (New York Univ.) (Washington Univ.) (Yale, Johns Hopkins) (Yale) (Sendal) (Cincinnati) (Johns Hopkins)
cover the whole range of pediatrics: nutrition, infectious disease, respiratory disease, heart disease (he wrote an outstanding paper on idiopathic hypertrophy of the heart which had not then been differentiated into several different entities), and surgical pediatrics (these are two excellent papers on the diagnosis of appendicitis in children). Dr. Howland's clinics were memorable. They made the students think, and they were often dramatic. He loved to open a retropharyngeal abscess with his fingernail, hoidding the child by the feet to prevent aspiration. Eventually the E N T department prevailed upon him to let them open the abscesses with more modern surgical tools. They were not as successful as Dr. Howland, and they lost their first four cases before they learned the danger of opening the mouth too wide with a mouth gag and of hyperextending the neck. The day of the pedagogic questionnaire did not come in Dr. Howland's time---the urge on the part of educators to increase the number of pediatric hours in the medical curriculum. When it did come, some time after Dr. Howland's death, it turned out that the man who had trained more pediatric teachers than anyone else had done so with a smaller number of hours reserved for pediatrics than was provided by any medical school in the United States--96 hours in all as contrasted with over 200 in the national
Some pediatricians who achieved academic distinction
H. W. Josephs B. Kramer W. B. McClure J. B. Pincus T. M. Rivers A. J. Schaffer A. T. Shohl W. R. S i s s o n
(Johns Hopkins) (State Univ., N. Y.) (Univ. of Chicago) (State Univ., N. Y.) (Rockefeller) (Johns Hopkins) (Yale) (Harvard)
average. Elective students, about a fourth of the class, got more than this; pediatrics was far and away the most sought-after elective. It was Dr. Howland's belief that one should concentrate on the few. There were other outstanding teachers and clinicians besides Dr. Howland, and I do not think that the success of the department and the demand for its graduates stemmed from this. It came from Dr. Howland's personal qualities, his ability to inspire others with his own enthusiasm, and his unerring judgment as to who would be creative and who would not. And his men were creative. They were not necessarily highly trained, but they had picked up techniques. Marriott, for example, was not a highly trained chemist, but Dr. Howland told me that Marriott was the most facile man he had ever worked with; he could put every bit of his knowledge to use. Dr. Howland was inclined to take a dim view of women in medicine. He appreciated the talents of a number of outstanding women, such as Katherine Dodd and Margaret Handy, whom he had on his staff, but he had little sympathy for what he liked to call "aggressive feminism." On one occasion the superintendent of nurses at Johns Hopkins made an impassioned plea to the executive medical faculty that nurses be given academic status and be granted a B.N. (bachelor of nursing) degree. Dr. Howland spoke up and said that by all means they should have a
Volume 69 Number 5 part 2
degree, but it should be not a B.N. but an S.N--"spinster of nursing." T h e project was not pursued. I n Dr. Howland's day, nutritional problems occupied the center of the pediatric stage; the era which was then called the "newer knowledge of nutrition" was just beginning. Some of his pupils, a m o n g them myself, have stayed with that field and have watched the multiplication of the essential nutrients and of their interrelationships. I a m tempted to digress for a m o m e n t to raise the question that comes home to me and to others who have taken this road: what lies ahead for nutrition? Is the end of the road in sight, and should we steer our successors into paths more rewarding in terms of child health? As I see it, despite the abuses of nutrition that beset u s - - t h e exploitation of unnecessary nutrients, the dietary f a d s - - n u trition has a real future. There would seem little of importance to be learned about the nutrition of the healthy person. A few more vitamins and trace minerals will doubtless be discovered and be exploited in their turn, but the real problem of the future is that of nutrition in disease. T h e more we learn about intermediary metabolism and its derangements, the greater are the opportunities for circumventing them by dietary means as well as by pharmacological agents. Congenital metabolism anomalies are responding one after another to a dietary approach, and the congenital anomalies, one after another, are being aped by temporary disturbances. There would seem to be no end to the possibilities here. I n the past, nutrition concerned us only in regard to the disturbances of the alimentary tract, but we
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now know that metabolic anomalies may affect any system in the body. Those of the nervous system are particularly enticing at the m o m e n t as subjects for investigation. The metabolic defects associated with prematurity would also seem to offer a wide field for research and correction. Nutrition should grow parallel to advances in intermediary metabolism. To return to Dr. Howland, I have given you a ve~3r cursory sketch of him. You can learn a lot more from Dr. Park's beautiful essay. There are m a n y lessons to be learned from his career. H e was one of the "slow maturers," who are seldom appreciated by admitting officers of medical schools because they have diversified their interests in college. There is the point which Dr. Howland himself made, that the ability to use what knowledge one has is more important than how m u c h knowledge one has. T h e real significance of Dr. Howland's career was that he was the h i n g e - - t h e chief hinge the turning point of American pediatrics from that of the nineteenth century to the pediatrics of the twentieth century, to academic pediatrics as we know it today. It is only fitting that we should commemorate him in the form of our annual medal. REFERENCES
1. Davison, W. C.: J. PEDIAT.46: 473, 1955. 2. Edsall, D. L.: Medicine 5: 195, 1926. 3. Lusk, G., Welch, W. H., and Flexner, S.: Howland memorial meeting, Bull. Johns Hopkins Hosp. 41: 311, 1927. 4. Gamble, J. L.: Remarks at presentation of portrait of John Howland, Pediatrics 21" 655, 1958. 5. Park, E. A.: Howland Award address, Pediatrics 10" 82, 1952.