Sir Frederic Still (1868–1941): the father of British paediatrics

Abstract

As a pioneer of full time paediatrics, as the first professor in this new discipline, and as inaugural president of the British Paediatric Association, Still has been called with justice the father of British paediatrics.

GFS was born in Highbury, London on 27 February 1868. His father George was a customs inspector, first in Dublin and later in the Port of London. His mother Emma haled from Cornwall. There were 12 children, of whom eight survived infancy. As the eldest surviving child and only son, Still played a leading role in family life, especially after the death of his father when he was 17 years old. Money was tight. From Merchant Taylor's School, he acquired a scholarship to Gonville and Caius' College, Cambridge, where he was Winchester Prizeman. Besides Latin and Greek, he studied Hebrew and Arabic, and in 1888 obtained first class honours in the classical tripos. From Cambridge he studied medicine at Guy's Hospital in London, qualifying in 1893. Coming under the influence of Sir James Goodhart, Still studied children's diseases at Guy's and at the Hospital for Sick Children (GOS). In 1899 Kings College Hospital established a special department for the diseases of childhood (the first hospital in the United Kingdom to do so), and Still was appointed physician to take charge of it. Seven years later he was promoted honorary professor of the diseases of children, the first British chair in this new specialty. Financially life must have been difficult for him, and it has been reported that it was 14 years before he could afford to take a holiday.1,2,3,4

Always formally dressed in frock coat and top hat, Still was of slight build (fig 1). His manner was aloof, grave, modest, and reserved. He was always the gentleman, never told a funny story, and had no interest in sport. With respect to his work, he was punctilious, efficient, and an obsessive worker. Children loved him. An accurate and acute observer, he had sound judgment and unrivalled experience and knowledge of children's diseases. During a career lasting over 50 years, Still's list of publications included 108 papers and five books.5 His text book Common disorders and diseases of childhood6 published in 1909, met with immediate success and reached a fifth edition in 1927. Although covering a wide range of childhood problems including chronic infections such as tuberculosis, comparatively few of his writings related to the perinatal period. This was surprising in that he was chairman of the National Society for the Prevention of Infant Mortality between 1917 and 1937. One of his interests, however, did relate to the newborn: congenital hypertrophy of the pylorus. Although Samuel Gee (1839–1911) had redescribed this condition in 1888, it was Still who brought it fully to the attention of the medical profession with publications in 1899, 1907, and 1923.5 He described the condition as follows:

Figure 1 Sir Frederic Still, KCVO.

On congenital pyloric stenosis6

“The salient features of the disorder are briefly these: an infant under the age of four months has been vomiting his food. The vomiting began at the age of three or four weeks and for the first week or so was thought to be no more than a little indigestion might account for. But it persisted and soon began to attract notice more by its persistency than by its frequency, for it occurred perhaps only two or three times in the twenty‐four hours. Then the food was thought to be at fault and change after change was made in the feeding, each time perhaps with temporary diminution of the vomiting. But still the vomiting persisted and at times was noticed to be so sudden, copious and forcible that the vomit was shot out a foot or more from the mouth and perhaps through the nostrils as well.

Since the vomiting began the bowels have been costive, perhaps only opened with enemata. And now the infant is wasting to a marked degree and perhaps it is this wasting rather than any alarm at the vomiting which leads the parents to seek medical advice. Such is the history which leads one to examine specially for the two characteristic signs – visible and very marked peristalsis of the stomach and a palpable thickening of the pylorus – upon which the diagnosis rests … In 248 out of 250 cases I have noted the hard pylorus as palpable … during peristalsis it becomes almost as hard as a calcareous gland … it can be felt to soften and disappear under the finger, and then to appear again from time to time.”

Still noted in 1924 that 85% of his cases were male and 49% firstborn. Over the preceding 25 years, the overall mortality had been 32%, although falling to 2% over the most recent eight years. Management had been mainly by stomach washing (19% mortality), forcible dilation of the pylorus (11% mortality), or Ramstedt's operation (36% mortality). (NB Conrad Ramstedt (1867–1963), a German surgeon, had in 1912 described his operation for the relief of pyloric stenosis by simple splitting of the muscular coat of the “tumour”. It subsequently led to a dramatic fall in the mortality for the condition.)

A major advance during Still's life was the discovery of vitamins, and he wrote extensively on this subject, especially on rickets and scurvy.

On infantile scurvy6

“The antiscorbutic vitamin, sometimes called ‘Water‐soluble C', seems to have its ultimate source in the vegetable world, and its presence in animal substances such as human or cow's milk, meat, raw meat juice, is directly dependent upon the intake of the vitamin as such; the animal body, whether human or otherwise, seems to have no power of elaborating any of these vitamins for itself, it can only take them in already formed and perhaps to some extent store them.

I mention this point because it explains some otherwise perplexing clinical observations. The occurrence – almost but not quite unknown in this country – of scurvy in a breast‐fed infant seemed unintelligible so long as it was assumed that breast‐milk was per se antiscorbutic: it is now clear that any breast‐milk might produce infantile scurvy if the mother's diet were such as to supply her with little or none of the antiscorbutic vitamin – a state of things hardly ever likely to occur under ordinary conditions in this country … The antiscorbutic value of a food, e.g. milk, is more or less destroyed according to the length or degree of heating which it undergoes in cooking. It would seem, however, that this is only partially true … It has been found that vitamin‐containing substances, e.g. fruit juices, are apt to deteriorate in antiscorbutic value when kept for weeks or even for many days.”

On congenital syphilis

Syphilis was another common disease in the early 20th century, and Still wrote a number of papers on its congenital manifestations and management. He noted that 1.5% of his young patients at King's College Hospital had this condition, although the incidence in other cities such as Glasgow might be as high as 10%. He wrote:

“In (a) series of 187 pregnancies in syphilitic families 40 per cent ended in the death of the infant before or at birth and of 112 live‐born children, 33 per cent died in infancy or early childhood.”6

Treatment was with mercury and potassium iodide, continued for 1½–2 years. Alternatively a course of arsenical injections usually affected a permanent cure within a few weeks. Still reminded his readers of Colles's Law which emphasised the important fact that a mother (but not a wet nurse) might suckle the syphilitic child without risk of infection.

As the first full time consultant and professor of paediatrics in the United Kingdom, Still exerted great influence on the development of this new specialty during the first half of the 20th century. The early years of the 20th century had seen the growth of a number of societies and clubs promoting the care of children. The Society for the Study of Children's Diseases (London, 1900) was followed by the Children's Clinical Club, the Preposterous Club, and the Provincial Children's Club (1924). Meanwhile in Scotland there was both The Paediatric Club and The Edinburgh and Glasgow Paediatric Club (1922), which later in 1947 evolved into the Scottish Paediatric Club. In 1928 Donald Paterson, a paediatrician at GOS, decided to try to bring together the members of these various groups into a single association for the whole of Britain. On 2 February, 24 “paediatric” physicians were invited to attend an inaugural meeting at Still's home. Although only six came, the British Paediatric Association was founded. Still was elected to be its inaugural president, with Paterson as honorary secretary. The first full meeting of the new Association took place later that year at Windermere. Forty five of the 61 invited members were present.7

Still remained a bachelor all his life. He reserved all his love for successive cohorts of young patients, especially for little girls with long hair. With regard to mothers, he was intolerant, the one exception being his own mother who, up to her death in 1914, remained his dearest friend. He was a devout churchman and regularly took her to service on his arm each Sunday. Late in his life he wrote of her:

“Years have gone since that sweet presence.

And her ‘boy' is old and grey,

But I hear my mother calling,

I am yet a child at play,

And my mother has my heart‐love,

And it seems but yesterday.”

In 1896 Still had, with the assistance of a Murchison Scholarship of the Royal College of Physicians, acquired the Cambridge MD with a thesis on “A special form of joint disease met with in children”, a condition known ever since as “Still's disease”. Becoming a fellow of the Royal College of Physicians in 1901, he was invited to give the Goutstonion lecture in 1902, and later the Lumleian lecture (1918) and the Fitzpatrick lectures (1928 and 1929). He was Censor to the College in 1932–3. In 1927 he was also invited to give the Ingleby lectures in Birmingham. In 1933, Still was nominated President of the 3rd International Paediatric Congress in London. Awarded the Dawson Williams Prize in 1934, he was made an honorary fellow of the Royal Society of Medicine in 1937. The same year he was appointed Physician Extraordinary to King George VI and his family, and created Knight Commander of the Victorian Order. Additional honours included honorary membership of the American Pediatric Society (1903) and the LL.D of Edinburgh University.1,2,3,4

In 1931 Still published his second great work, A history of paediatrics,8 based on his Fitzpatrick lectures to the Royal College of Physicians. It took the form of a biographical approach using the great physicians of the past from Hippocrates to Jenner as stepping stones in the development of the specialty. It remains, like John Ruhräh's Pediatrics of the past (1925), a classic contribution to the subject.

Still retired from Kings College Hospital in 1933 and from most of his other medical activities in 1936. As a farewell gift he was presented by his colleagues with a portrait painted by Sir Gerald Kelly, RA. During retirement he returned to his interests in classics, music, and poetry. In 1941 he published Childhood and other poems.9 This verse, taken from it, sums up his devotion to children:

“For my garden is the garden of children

Cometh naught there but golden hours,

For children are its joys and its sunshine,

And they are its heaven sent flowers.”

During the second world war, Still's home in London was bombed, and in 1940 he moved to Salisbury. This enabled him to be close to his loved fly fishing on the Hampshire Test. In 1941, Still died at Harnham Croft on 28 June. His ashes were buried in Salisbury Cathedral churchyard. So passed a pioneer who had forged a unique position for himself as a children's consultant physician and as a founder and leader of the new specialty of paediatrics.1,2,3,4