Abraham Jacobi, MD: The Man and His Legacy

In 1963 the American Medical Association (AMA) and the American Academy of Pediatrics (AAP) jointly established the Jacobi Award named after Dr Abraham Jacobi, acknowledged as the founder of pediatrics. He introduced pediatrics as a specialty in the opinions of medical historians. The first recipient was Dr Alexis F. Hartman, Sr, Professor of Pediatrics at Washington University in St Louis. This tribute to the efforts of Dr Abraham Jacobi reminds us of the very significant dedication that characterized Dr Jacobi's life. He was a most remarkable man of boundless energy and strong convictions. One year ago, Dr Robert Haggerty gave a very scholarly presentation of Jacobi's personal life and his professional life. Dr Haggerty referred to Jacobi as “a respectable rebel, ” in my opinion, a very appropriate description of this remarkable man. Rather than covering many facets of Jacobi's life and career as did Dr Haggerty, it is appropriate that we touch on some aspects of Dr Jacobi's character as a reminder to keep us focused on the development of our specialty, the problems it presented, and also the problems we face today. Dr Jacobi was born in Hartum, Westphalia, Germany, in 1830. His family was of very limited means; consequently, there were struggles and sacrifices to provide him with his education. His MD was obtained from the University of Bonn in 1851. 1Jacobi's professional life could have been predicted from his outspoken strong opinions and intolerance of heavy-handed rules. His life was characterized by struggles against the prejudices of new ideas, injustices, and absurdities beginning in his student years. As a “zealous democrat” he was involved in the cause of the revolutionary activities going on in the 1840s in Germany. For this he was accused of high treason and was confined in prisons in Cologne and Minden for 2 years. On his release he went to England but stayed there only a short while. On the advice of his friend Carl Schurtz, also deeply involved in revolutionary activities, he headed for America. Jacobi arrived in New York in 1853. At that time he was but one of a quarter of a million German immigrants, hundreds of thousands Irish, and other Europeans who came to America—the land of promise and opportunity. He opened an office in the Bowery of New York, 1 charging 25¢ for an office visit, 50¢ for home visits, and 5 for a confinement case if the patient could afford it. Jacobi's first official position was that of Professor of Infantile Pathology and Therapeutics at the New York Medical College. Within a few years he was at work with Emil Noeggerath, in the publication of a large volume on diseases of women and children. Physically, Jacobi was a small man. But despite his stature, he was a very impressive figure (Fig 1). He was described as picturesque, 2 appearing in cool weather wearing a large black hat with a wide brim and a long black cape that hung loosely from his shoulders. He had an idyllic place on Lake George in upper New York State and spent at least 50 summers at his home in this area. He nearly lost his life in a fire that destroyed this home when he was in his eighties. The American Pediatrics Society erected a tablet in his honor at this site in 1936. Dr Jacobi's personal life contained many sad and painful moments. His first two wives died during childbirth, but his third marriage to Dr Mary Putnam in 1873 gave him a son and a daughter. The son also died in early childhood of diphtheria. Dr Mary Putnam Jacobi3was a remarkable person in her own right—talented in amazing ways as a writer, a clinician, and a strong advocate for women in medicine. Dr Putnam Jacobi received an MD from Women's Medical College of Pennsylvania in 1864 and again in 1871 from École de Medicine, Paris. She was a most highly respected woman physician of her generation—an untiring crusader for women in medicine, and the first woman physician member of the New York Academy of Medicine. In 1870 Jacobi was established as Clinical Professor of Diseases of Children4 at Columbia University's College of Physicians and Surgeons. In 1880 he established and was President of the Section on Diseases of Children of the American Medical Association. In 1888 he was elected President of the American Pediatric Society (Fig2) —the first medical specialty society in the United States!During the second half of the 19th century almost all of the history of American pediatrics is reflected in Jacobi's work and writings. 5 He was regarded as the focal point of all pediatric thought and teaching. He influenced the care of children in almost all medical institutions in New York City. Jacobi is credited with the establishment of medical bedside teaching, a first in this country. His most outstanding contributions were the struggles against controversial and unsound medical practices of the time. He was opposed to calomel. He suggested keeping infants undressed on hot days. For pediatricians milk was a very significant community problem. It was not only contaminated, it was adulterated. Jacobi recognized that babies who were breastfed6 survived in a higher percentage than bottle-fed babies. He was a strong advocate of breastfeeding. If mother's milk was not available, raw milk should never be offered, but rather boiled cow's milk with added cereal, salt, and sugar. The statement, “Boil the milk until it bubbles, ” was attributed to his efforts. You might wonder what Jacobi faced as a pediatrician in New York City in the middle and late 1800s. The list of diseases and disorders reads like the index of a text on infectious diseases. Diarrheal diseases, smallpox, measles, scarlet fever, diphtheria, whooping cough, cholera, tuberculosis, malaria, and scurvy were some of the diseases that medicine fought. Jacobi and his contemporaries had to care for children when a relatively small percentage of homes in New York City had plumbing. In New York City, the major problems were due to the tremendous influx of immigrants, inadequate housing, poverty, and filth—and it did not get better before the 1900s; it got worse. We regard bathing and cleanliness as an absolute essential in child health, but it was looked on as a modern fetish in those times. In New York City, 62. 5% of all deaths occurred in children less than 5 years of age. One infant in five died before he/she reached his/her first birthday, and the fates of infants in Boston, Chicago, and Milwaukee were only slightly less deadly than New York City in that 50% of all deaths in these cities occurred in children less than 5 years of age. Diphtheria became an epidemic; consequently, the majority of Jacobi's writings were in this field. Ironically, he lost his 7-year-old son to diphtheria. Fortunately diphtheria antitoxin was on the way. Jacobi had performed hundreds of tracheostomies on diphtheritic children who were strangling. In 1882, a physician named O'Dwyer invented a tube for intubation that saved many infants from diphtheritic croup and obviated many tracheostomies. Jacobi noted the high mortality in foundling homes, but because of his outspoken statements on this horrifying state of affairs he was expelled from his position by the women on the board of the hospital. He stated “the younger the child, the larger the institution, the surer is death. ” But America was not alone in this dreadful state of affairs. Jacobi found the same statistics in European foundling homes. In 1887 Jacobi was appointed chairman of the State Board of Medical Examiners of New York, where he strongly advocated written examinations for licensure to practice medicine. 2 In 1895 he was offered the professorship in Berlin to succeed Henoch. He declined, stating that the ties that bound him to America were too strong to be broken. Dr Jacobi's fame does not rest alone in his greatness as a teacher and a writer. In many areas of professional endeavor he was a leader, never content to be a follower. He sought to promote the welfare of his fellow man, both as a man and a citizen. He taught the propriety of physicians taking an interest in public affairs, and an active part in matters of civic and political importance. He urged physicians to serve on public committees, address legislative bodies, and to take a stand on matters of public policy. 78Well into his seventies, Dr Jacobi did not let up. An excerpt of a speech (Fig 3) he gave in 1904 reads as follows: “It is not enough, however, to work at the individual bedside in the hospital. In the near or dim future, the pediatrician is to sit in and control school boards, health departments, and legislatures. He is a legitimate advisor to the judge and jury, and a seat for the physician in the councils of the republic is what the people have a right to demand. ”At the age of 82, in 1912, he was elected to the presidency of the AMA. The AMA had never had a foreign-born physician, let alone a Jewish physician, as its president. This brings me to the second portion of these remarks—namely, thelegacy. I view the legacy of Abraham Jacobi asadvocacy. Advocacy in pediatrics is the name of the game. Jacobi showed us the way, but others have followed suit in such an effective campaign that today we have the AAP representing nearly 60 000 pediatricians eminent in the nation as well as in the halls of Congress in the advocacy role. I want to tell you an interesting story regarding the founding of the AAP. 5 It portrays advocacy in the face of powerful opposition. The Section on Diseases of Children, or—as it is now called—the Section Council on Pediatrics, was rolling along famously up until 1922. Jacobi, its founder 42 years before, had died 3 years earlier. The AMA and the House of Delegates, including american pediatricians, met in 1922 in St Louis. At that time the Shepherd-Towner Act, which had been signed into law in 1921 and which was intended to be phased out in 1927, represented the first time that a federal grant program had been established in the field of health. This was a maternal and child health program. Despite the noble intent of this action by Congress, there was hue and cry against it by organized medicine. At that spring meeting in St Louis, the House of Delegates passed a resolution condemning the Shepherd-Towner Act. On that same day, however, in the Section of Pediatrics meeting, a resolution was introduced and passed by the pediatricians supporting the act. The following morning the St Louis papers appeared with headlines quoting the resolution supporting the Towner Act as passed by the Pediatric Section, but opposed by the House of Delegates of the AMA. “The fat was in the fire, ” wrote one reporter. A committee of wrath was sent by the House of Delegates to reprimand the Pediatric Section. The pediatricians were not only unrepentant, but they jeered at members of the House of Delegates who attempted to force them to change their stand. To put it mildly, there was a breach between the groups. Acrimony prevailed, although to my knowledge the pediatricians did not pull out of the House of Delegates. In 1929 the Illinois Medical Journal published an editorial that had this to say about the Act: “The bill is a menace and represents another piece of destructive legislation sponsored by ‘endocrine perverts, ’ ‘derailed menopausics, ’ and a lot of other men and women who have been bitten by that fatal parasite, theupliftus putrifaciens, in the guise of uplifters, all of whom are working overtime to devise means to destroy the country. ”The Shepherd-Towner Act lapsed in 1929, but subsequently Congress restored the program as Title V and VI of the Social Security Act of 1935. The dissatisfaction in the ranks of pediatrics members of the AMA persisted until finally in 1930, 35 pediatricians met in the Harper Hospital in Detroit, drew up a constitution and bylaws, and established a new society named the American Academy of Pediatrics. In the years that followed the pediatricians have attended the AMA meetings as a Section Council, with a delegate and alternate delegate, although at many times reluctantly or even dispiritedly. In earlier years, it must be admitted, the hearts of AAP delegates were not into serving this role, because of the lack of satisfaction with AMA policies. It has been my good fortune to be a member of the Section Council on Pediatrics since 1979. At that time Dr James Strain was the delegate. Subsequently, Dr Bill Montgomery became the delegate and I the alternate delegate. In the early 1980s Dr Calvin Sia was appointed the delegate. He continues to serve in this capacity at the present time. We have just been notified that the AAP will now have a total of three delegates under the new organization of the federation and the AMA House of Delegates. In the course of these nearly 20 years we of the Academy have learned how to promote issues the Academy felt were in the best interests of child health as well as the practice of pediatrics. We feel we have been effective in carrying our message to the House of Delegates obtaining not only recognition but support from the AMA in many areas. We have brought resolutions originating in the Chapter Chairman's Forum to the House. Thanks to the leadership of Dr Sia and the support of the officers of the AAP, and Jan Greene of the staff, we have learned how to introduce resolutions or speak to resolutions either in the reference committees or on the floor of the House of Delegates, been able to elicit the support of other organizations such as the American Academy of Family Practice, the Society of Child and Adolescent Psychiatry, or any one of many state delegations to help us toward our goals as advocates on behalf of children. In other words, we have learned to use the process on behalf of AAP goals and objectives. And so I would like to extend a Jacobi challenge to each of you in this advocacy role. I challenge you to take stock of your position as practitioners or as members of the AAP to do something on a personal basis as an advocate. There are many ways of serving. For example I suggest you meet the media in your city, get acquainted, and put on your pediatric advocacy hat. The AAP Division of Public Relations has a handbook that will prove very helpful to you both in learning how to meet the media as well as how to write for the media. Building a presence with the media is a gradual process. You should not be discouraged if your early attempts are turned down. You can begin by writing letters to the editor of your local paper. You may respond to an article and after you have won the respect of your media, you may be able to influence them by suggesting story ideas or a slant to an issue. The media is looking for informed and authoritative views on subjects regarding child health. The AAP Division of Public Relations can assist you. Staff can help you develop a news release, write a letter to the editor, or a guest editorial. You can also be provided with the AAP news releases to the smaller media, such as weekly newspapers. Don't overlook any opportunity to get your message out. Your city may have a cable television program devoted to health. There are many pediatricians who are sought by local newspapers to write question-and-answer columns. Your AAP state chapter would welcome your responding to my Jacobi challenge to you for the advocacy role. For some obscure reasons, I had always wanted to write a column on children's health. At the time of retirement I was fortunate enough to find a sympathetic editor of the local paper and a young journalist willing to offer me much needed advice. I launched out into a career of weekly newspaper columns entitled “Healthy Kids” that lasted (Fig4) 9 years, or about 450 columns. Although the compensation was negligible, the challenge was wonderful. Despite deadlines, it proved to be a great sense of satisfaction and accomplishment. I would urge that you give this thought. The editor afforded me the leeway to write on any topic affecting children and youth. My columns were never altered. Pediatricians spend a lot of time talking to parents, children, perhaps parent-teacher associations, and other community groups. In my experience, because writing for the newspaper is much like conversation, you should be able to do it well with a little coaching. You, too, can be an outspoken advocate on children's issues, both on behalf of the AAP, but more appropriately on behalf of our children. In conclusion, Abraham Jacobi set a fast pace, but many others have taken up the advocacy role in his fashion. Pediatrics has flourished. Our numbers have grown, to nearly 60 000. We are the authority in the nation according to our Red Book on immunizations, on child health and its culture, and out in front as primary care givers. Welcome to the advocacy role! I wish you success in this venture. When we meet a year from now, what will you have to report? Good luck!!