A radical turning point about the attention given to children, within pedagogy, literature, and family, occurred between the 18th and nineteenth century. A new educational concern appeared thanks to the thought and work of Jean Jacques Rousseau, the father of modern pedagogy. Since then, the value of childhood shifted from an economic plan to that of feeling, regarded as affection and attention. The idea of the new Man introduced and promoted by the Enlightenment, opened to the consideration of infancy as the starting dimension of men. Therefore, doctors and pedagogists began to share a body’s philosophy, which allowed children to be protected. The techniques on the body started to join character education. Indeed, authoritative thinkers of the eighteenth century observed and controlled the “infantile bodies” of their children. They “looked with special attention at the physical life of their sons”. The “physical life of children” started to have a real attention, becoming object of hospital care, as well as of a dedicated medical (pediatric) culture, also due to a growing treatise literature [
2]. The first treatise on Pediatrics,
De Infantum Aegritudinibus et Remediis, was written by the Italian Paolo Bagellardo in 1472. However, childhood medical publishing was lacking in Italy during the seventeenth century. This was related to the political, religious, and cultural events occurred between the end of the 16th and the seventeenth century. The Counter-reform (Trento, 1545–1573) played a substantial breaking action on the scientific progress in the countries of catholic area, with the imposition of the Aristotelian orthodoxy. Consequently, cultural activities in the fields of natural sciences and medicine migrated from southern to northern Europe, especially Netherlands, England, and Scandinavian countries. Indeed, among the most important pediatric treatises of the 17th and 18th centuries stood out those of the English William Harris (
De Morbis Acutis Infantum, 1689), George Armstrong (1767) and Michael Underwood (1784), and that of the Swedish Nils Rosen von Rosenstein, published in 1765. In 1794 Christoph Girtanner, a Swiss pediatrician, wrote another relevant text, which led the way to the great pediatric treatise literature flourishing during the nineteenth century in France (Billard, 1828; Rilliet and Barthez, 1843; Bouchut, 1845; Comby, 1892), Germany (Vogel, 1860; Gerhardt, 1877; Henoch, 1881; Baginsky, 1882), Russia (Filatov, 1894) and United States of America (Smith, 1869). Italy followed at the end of the nineteenth century with its only pediatric book of that time (Biagini, 1897), also due to the cultural dependence from foreign countries, which finished only after the
Risorgimento and the process of unification [
2].
The first schools of pediatrics and children’s hospitals
The first pediatric school was founded in Italy, even if it lasted for a short time. In fact, on April 1802, a chair of pediatrics was born in Florence on initiative of the king of Etruria, Ludwig I of Bourbon, who entrusted the task to Professor Gaetano Palloni, who gave lessons at the
Ospizio degli Innocenti. The school of Palloni lasted just 3 years, until 1805, when the queen Maria Luisa of Spain suppressed the chair of children’s diseases. However, in 1807, she restored the chair of pediatrics, owing to the high number of deaths among children. Nonetheless, also this time the Florentine School of Pediatrics had no luck. Indeed, due to the upheavals caused by the Napoleonic gestures, all the old institutions were suppressed or renewed and, in the same year (1807) when Tuscany became a French province, the school was definitively closed [
1].
While the
Ospizio degli Innocenti in Florence was the first, although brief, seat of pediatric teaching, the first real pediatric hospital was born in Paris on May 1802, in the middle of the Napoleonic era. The hospital, which was called
Hôpital des enfants malades, was set up inside an old convent of nuns which was variously used in different times, until, during the Revolution, it became an orphanage (
Maison de l’Enfant Jesus). It hosted children from 2 to 15 years old. Alongside the hospital wards, an outpatient clinic was also set up for care of patients with less serious diseases and of those who did not need hospitalization. In the same location, activities for teaching and spreading childcare notions to mothers belonging to popular classes were also carried out. The
Hôpital des enfants malades soon grew as center of pediatric studies and for the spread of pediatric culture during the whole nineteenth century, becoming the cradle of French and European pediatrics [
1].
Pediatrics and society in France
The French Pediatric School foundation overlaps with that of the
Hôpital des enfats malades, between the end of 1700 and the beginning of 1800. The prestige of this school is related to great scientists as Bichat, Corvisart, Laennec, who were not pediatricians, but contributed to the advancement of pediatrics [
3]. Furthermore, there were other eminent physicians particularly interested in pediatric diseases. Charles Michel Billard (1800–1832), founder of the pediatric pathological anatomy, studied many corpses of children and babies died in the Parisian orphanages. Fréderic Rilliet (1814–1861) and Antoine-Charles-Ernest Barthez (1811–1891), both doctors at the
Sainte Eugénie Hospital in Paris, published in 1843 the
Traité clinique et pratique des maladies des enfants, which was the reference text for the pediatricians of the nineteenth century. Eugene Bouchut (1818–1891) was the first to use the laryngeal intubation in the croup (1858). Armand Trousseau (1801–1867) carried out studies on convulsions, chorea, eruptive fevers, diphtheria, and typhus. His fame is related to the first tracheotomies which performed in Paris, defining technique and postoperative treatment. His name is linked to the sign of tetany [
4]. Marie-Jules Parrot (1829–1887) was interested in the cerebrovascular lesions of childhood, and studied the nutritional disorders of early infancy, coining the term “atrepsia”. The pseudoparalysis of luetic infants bears his name [
5‐
7]. Pierre Costant Budin (1846–1917) and Adolphe Pinard (1844–1934) were obstetricians and sustained the relevance of boiling milk [
8] and breastfeeding, respectively. Thèophile Roussel (1816–1903), was a doctor and politician involved in social and occupational medicine [
9]. Jean Bernard Antoine Marfan (1858–1942) was the first professor of Early Childhood Clinic in Paris. He dealt with many fields of children’s pathology and had a great scientific production [
10]. In 1881 and 1897 were launched, respectively, the
Monthly Review of Childhood Diseases and the
Children’s Medicine Archives [
1].
Pediatrics and society in Central Europe
German pediatrics started to grow and to be notable during the eighteenth century. In 1753 Jakob Reinbold Spielmann (1722–1783) was the first to analyze the milk of women and domestic animals. In 1787, Joseph J. Mastalier founded in Vienna the first
Public Institute for Sick Children, which was, rather than a real hospital, an outpatient pediatric clinic. About 50 years later, the first Austrian pediatric hospitals (
Sainte Anne in 1837, and
Saint Joseph in 1842) were built in Vienna. Conversely, German pediatrics was officially born in 1830, with the foundation of a small ward at the
Charité Hospital in Berlin. It developed as a clinic in the following decades, under the direction of Barez. This latter had a prestigious teaching activity and founded the first pediatric journal in the world: the
Journal für Kinderkrankenheit. Other pediatric hospitals were built throughout the century in the area belonging to Germanic culture, which had in the Viennese Pediatric School its driving force, proof of an increasing interest in childhood. Carl Credé (1819–1892) was obstetrician, and proposed the prophylaxis of blenorrhagic conjunctivitis of the newborn (main cause of neonatal blindness of that time), by the instillation in the conjunctival sac of 2% silver nitrate. Eduard Heinrich Henoch (1820–1910), considered the founder of clinical pediatrics in Germany, was director of the Pediatric Clinic at the
Charité Hospital in Berlin. His name is linked to the
purpura fulminans, which from him took the name of “Henoch purpura”. Franz Soxhlet (1848–1926), chemist and physiologist, studied milk sterilization and was able to fractionate its proteins into casein, albumin, globulin and lactoproteins. Alois Epstein (1849–1918) was director of the Prague Brefotrophy, which became with him a great pediatric school. Theodor Escherich (1857–1911) linked his name to the bacteriological research on intestinal germs, and on changes of the intestinal flora in infants with nutritional disorders. He discovered the bacterium
coli, which was then called
Escherichia coli. Carl von Pirquet (1874–1929) introduced the concept of allergy. He also supported the suffering childhood, becoming organizer of social provisions for poor children, especially after the terrible famine that struck Austria after the defeat of World War I [
1].
Pediatrics and society in the United Kingdom
The first interests in childhood diseases, although not yet framed into pediatric schools, began in Great Britain as early as the seventeenth century. Daniel Whistler (1619–1684), and then Francis Glisson (1597–1677), started indeed around 1650 the first studies on rickets, while Thomas Sydenham (1647–1732) deepened various topics of pediatric interest, such as exanthematous diseases, chorea (Sydenham’s chorea), difficult dentition and scurvy [
1]. Actually, English pediatrics started with George Armstrong, and was characterized by a greatly humanitarian and sensitive care. In 1769 in London, he made the first generous experiment of pediatric care. Indeed, he opened then a pediatric clinic, where cured about 35,000 children in 12 years, sustaining alone costs and efforts. Andrew Wilson (1718–1792) was his successor, for a short time, in the direction of the London pediatric clinic, which closed in 1783 shortly after the death of its founder, due to lack of benefactors and funds [
1,
2].
Before having a real children’s hospital in Great Britain, it was necessary to wait until the second half of the nineteenth century, when the
Great Ormond Street Children’s Hospital was founded in London in 1852. It may be considered the cradle of English pediatrics, and was the first place where pediatrics was taught. Its first director was Charles West (1816–1898). In 1871, he published
Above some disorders of the nervous system in children, where he described the infantile myoclonic encephalopathy, which took from him its name (West syndrome). He also gave a significant contribution in the field of the organization of pediatric hospitals, publishing a study entitled
On hospital organization, with special reference to the organization of hospitals for children. Thomas Barlow (1845–1945) is also linked to the prestigious hospital for sick children in
Great Ormond Street, where he completed his studies. They were dedicated to infantile scurvy, to which he first gave features of autonomous disease, providing clinical and anatomical-pathological evidence. Scurvy took, then, from him the name of Barlow’s disease. George F. Still (1868–1941) followed in the direction of the
Great Ormond Street Hospital. He described chronic childhood primary polyarthritis, which was then named Still’s Disease [
1,
2].
Pediatrics and society in Italy
The first organizations for childhood appeared for the first time in Italy in the medieval age. The first institutions are the
Ospizi for foundlings or
gettatelli, which was the name attributed to abandoned or refused newborns. Including the so called “wheels” (which served to receive the abandoned newborns, guaranteeing anonymity to those who left them), they were expression of a charitable attitude, and were able to counteract infanticide [
11]. To find a new type of institutes dedicated to childhood, especially sick children, it is necessary to wait the
Ospizi Marini of the nineteenth century. They were promoted by the intelligent and passionate work of Giuseppe Giannelli, and then of Giuseppe Barellai (1813–1884) [
12]. This latter founded the first marine colony in Viareggio in 1862, which was followed by many others in marine and mountainous areas. These institutes arose thanks to the commitment of spontaneous civic committees, and to the awareness of the benefits which children affected with tuberculosis or rickets might have from thalassotherapy. The requirement was that of belonging to poor families, among which, moreover, there were most of the affected subjects [
12].In 1843, Count L. Franchi founded the
Regina Margherita Children’s Hospital in Turin, which was the first Italian pediatric hospital. Soon thereafter, in 1845, the
Ospedaletto di Santa Filomena was founded by the Marquise Falletti of Barolo in Turin, specifically intended for girls affected with tuberculosis and/or rickets, and aged 3 to 12 years. In 1869, the
Bambino Gesù Hospital was built in Rome, on the initiative of the Duchess Salviati, where children from 2 to 12 years old were accepted (Table
1) [
1,
2].
Table 1
The first Pediatric Hospitals in Italy (modified by Burgio GR, 2007 [
2])
Alessandria | Cesare Arrigo (Prof. Paolo Bosio) | 1886 |
Ancona | Children’s Hospital (Prof. Alberto Caucci) | 1900 |
Bologna | Ospedalino (Dr. Marcellino Venturoli, Dr. Gaetano Modonesi) | 1880 |
Brescia | Umberto I (Prof. Andrea Pagani-Cesa) | 1902 |
Cremona | Children’s Hospital (Dr. Felice Celli) | 1881 |
Cuneo | Regina Elena (Dr. Teresio Cattaneo) | 1912 |
Florence | Anna Meyer (Prof. Giuseppe Mya) | 1891 |
Genoa | S. Filippo (Prof. Luigi Della Valle) | 1888 |
Livorno | Santa Famiglia (Prof. Alberto Funaro) | 1888 |
Lodi | Vittorio Emanuele II (Dr. Oreste Grazia) | 1927 |
Mantova | Bulgarini | 1858a |
Milan | Children’s Hospital (Prof. Girolamo Taccone) | 1899 |
Modena | Pietro Siligardi (Prof. Riccardo Simonini) | 1911 |
Naples | Gesù e Maria (Prof. Francesco Fede) | 1881 |
Palermo | Children’s Hospital (Prof. Rosario Buccheri, Dr. Antonio Carini) | 1882 |
Parma | Children’s Hospital (Prof. Cesare Cattaneo) | 1900 |
Rome | Bambino Gesù (Prof. Francesco Valagussa) | 1869 |
San Remo | A. Nuñez Del Castillo (Dr. Vincenzo Pesante) | 1908 |
Turin | Opera Pia Barolo-Santa Filomena (Dr. Giovanni Battista Filippello) | 1845 |
Turin | Koelliker-Mensi (Prof. Enrico Mensi) | 1928 |
Trento | Maria dei Savoja (Dr. Carlo D’Anna) | 1920 |
Trieste | Spedale Infantile, Burlo Garofolo (Dr. Paolo Israeli) | 1867, 1907 |
Venice | Umberto I (Prof. Ettore Giorgi) | 1892 |
Verona | Alessandri (Prof. Giuseppe Zambelli) | 1912 |
However, in many cities, hospital care for children was also provided within large general hospitals, which dedicated special pavilions to them. A critical issue of the hospital care of that time was the exclusion of children under the age of 3, among which there was the greatest morbidity and mortality, due to the difficult management of such young patients. Although a hospital vocation of some orphanages and institutes for children with rickets, near to the twentieth century the united Italy was still widely poor of structures for hospitalization and cure of children, especially infants. Moreover, 80 years passed from the foundation of the Florentine Pediatric School, before seeing the birth, in a united Italy, of a chair of pediatrics. The credit went to Dante Cervesato (1850–1905). After gaining experiences in the pediatric field as student at the Wiederhofer of Vienna, he returned to Padua, and was able to set up a small Pediatric Clinic, where he received in 1889 the assignment of full professor of Pediatrics. From Padua, Cervesato moved to Bologna in 1900, where he created a thriving pediatric school. He there performed studies on tetany, infantile tuberculosis, neonatal hemorrhagic diseases, appendicitis, intestinal tumors, liver cirrhosis, and poliomyelitis.
Therefore, also due to a new cultural attitude towards childhood, a change in the field of pediatric care occurred between the end of the 19th and the beginning of the twentieth century. Indeed, also in Italy it became clear that childhood had the right to organized and structured places of cure, based on their specific needs. In 1876, a Children’s Hospital was built in Trieste (named in 1907
Burlo Garofolo), then followed by many others, among which Naples and Cremona (1881), Palermo (1882), Genoa and Livorno (1888), Florence (1891), Milan (1897), Bologna (1907) and Modena (1911) (Table
1). Infancy finally received from society a new attention, which never enjoyed before. However, almost all children’s hospitals were funded by private charities, and scarcely by initiative of public institutions. Often these hospitals began their activity in humble rented buildings, to become larger over time with subsequent extensions, restorations of old buildings, or even with construction of new ones [
1,
2,
13]. It is noteworthy that some hospital admissions did not have medical indications. They were healthy children “which enter healthy for various reasons … , among which the more frequent is here the concomitant admission of the sick mother in another part of the hospital, or that healed, they stay abandoned for many, painful or shameful, reasons” [
14]. This declaration of Ponticaccia (1908) is a complaint for some parental behaviors, as well as a clear proof of the social role which sometimes the hospital had to play. The patients who came to hospitals belonged to the poor classes, which were vulnerable for lacking diets and/or unhealthy environments. The scientific articles which appeared at the end of the nineteenth century and the beginning of the 20th one, provided precious information on the reasons of hospitalizations of those years, and of their length [
15‐
18]. The little patients, especially infants, were often hospitalized for severe conditions of “atrepsia”, characterized by extreme decay of the general conditions, frequently irreversible and fatal [
19]. Francesco Fede (1832–1913) first related primitive atrepsia to malnutrition, underlining that these children belonged to the poorest social classes, and calling upon an intervention from authorities aimed at improving their conditions [
19]. He was the greatest exponent of early Italian pediatrics, even if chronologically not the first. He was a founding member and president of the Italian Society of Pediatrics, and in 1893 he founded the periodical
La Pediatria [
13]. Subsequently in 1897, Luigi Concetti (1855–1920) introduced Pediatrics as a free course at the University of Rome. He promoted the first Congress of the Italian Society of Pediatrics, of which he was a founding member and then president in 1903. He founded in 1904 the
Journal of Pediatric Clinic, together with Giuseppe Mya (1857–1911) [
20]. Mya was called in 1891 in Florence to hold the chair of Pediatric Clinic. In 1901, he transferred the small rooms of his Institute at the
Maternity Hospital to the
Anna Meyer Children’s Hospital, which the Marquis of Montagliani founded in 1887 in memory of his wife (Table
1). In 1916, Vitale Tedeschi (who followed Dante Cervesato in Padua) discussed the possibility to hold the mothers within efficiently and safely organized pediatric wards [
21]. It was clear, from the beginning of the foundation of the first pediatric hospitals, that hospitalization might induce suffering in children and parents due to their separation. The time for the introduction of the mother near to her son seems however to be far, but a new attention to the physical and psychological needs of the child was starting to grow.
In more recent years, a diffuse change of point of view towards childhood finally shows the necessity of reconstructing, within hospitals, the binomial mother-child, promoting a specific and global approach to the little patient [
22,
23]. During the 1970s a process of de-hospitalization and humanization of pediatric hospitals started, also through the creation of new outpatient systems (Day-Hospital, and then Day-Surgery). In the meantime, and to respond to new and different epidemiological needs, the old sanatoriums for tuberculosis were dismantled or used for other health issues and/or diseases. Then, around the ‘80s, through many regional laws included as aims of health plans, the doors of the hospital wards started to open to the mothers of sick children. Initiatives sustained by associations of families and volunteers were carried out, allowing children to continue the normal activities within hospitals, like games and school, also through psychological support and/or that of cultural mediators. Also, the environments were humanized and tailored on the child. The habit of decorating the walls of infirmaries and hospitalization rooms progressively spread and, in neonatology units, the practice of rooming-in began [
24]. In the same years, primary care were carried out by family pediatricians in all the areas of the country.
Pediatrics and society in Palermo (Sicily)
The Pediatric Clinic was born in Palermo in 1903, when Rocco Jemma, young and brilliant doctor working in Genoa, was called to hold the role of professor of Pediatrics at the University of Palermo. Promoter of this initiative was Ignazio Florio, belonging to one of the richest and most influential European families of entrepreneurs and patrons of the time. In a few years a new and efficient structure was built, and inaugurated in 1907 [
25]. Rocco Jemma founded in those years a real school of pediatricians, who came from all Sicily. When Jemma moved to Naples in 1913, the most brilliant of his pupils, Professor Giovanni Di Cristina, succeeded him. He continued the work of his master, further expanding the scientific activities of the Clinic and starting new social and care initiatives [
16]. It is due to him, moreover, the discovery of an effective and decisive treatment for the cure of visceral leishmaniasis with antimony salts, then universally used, which allowed to overcome such infectious disease, commonly lethal until then [
17,
26]. He was active for the construction, on lands and with funds obtained from donations, of the hospitals
Casa del Sole (assigned as tuberculous sanatorium in a hilly area of the town) and
Aiuto Materno (for the hospitalization of children with high social risk). His premature and unexpected death, in 1928, left a great emptiness in pediatrics of the whole island. The city dedicated to him the Children’s Hospital in 1929, which he wanted closely related to the Pediatric Clinic, and which thereafter took his name. After Di Cristina, the direction of the Clinic and the Hospital passed to La Franca, and then Cannata, Maggiore, and Gerbasi. In 1946, the School of Specialization of Pediatrics was established, favoring the recruitment of scientifically able young doctors. Gerbasi was principal of the Faculty of Medicine and rector of the University, and gave shine to the pediatrics of Palermo, also at a national level. His school was particularly rich of prestigious pupils and personalities, first Giuseppe Roberto Burgio (who later became director of the Pediatric Clinic in Perugia, and then in Pavia). Hematology, infectious diseases, and nutrition were his areas of major scientific impact. He gave decisive contributions on deficiency diseases, as the definition of the perniciosiform anemia of infants (Gerbasi’s anemia), and on dystrophies [
26,
27]. The great social caliber of his activities was evident also during the earthquake of Belice in 1968, a dramatic time which Gerbasi faced moving on site doctors, nurses, and hospital equipments.