Growth Of Neonatal-Perinatal Medicine: A Historical Perspective

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Growth Of Neonatal-Perinatal Medicine


A Historical Perspective


Tonse N.K. Raju



The terms neonatology and neonatologist were not in general use 50 years ago. In the preface to the first edition of his monograph Diseases of the Newborn, Dr. Alexander Schaffer christened the new specialty and its practitioners, asking our “forgiveness” for doing so. An apology was not needed because time has proved him to be immensely prophetic. In 1975, the first Neonatal-Perinatal Medicine subspecialty examination was offered by the American Board of Pediatrics, and 355 were certified as the country’s first neonatologists. After the 2012 certifying examination, 5552 individuals have been certified by the Board as neonatologists. This phenomenal growth has been matched by an increasing fund of knowledge. Today a cursory search using the subject heading “newborn” in the National Library of Medicine’s PubMed database yields nearly 60,000 citations.59 Thus, at the beginning of the twenty-first century, neonatology stands tall and strong as a specialty, carving a unique niche, bridging obstetrics with pediatrics and intensive care with primary care.


Although the formal naming of our specialty appears to be recent, its roots extend into the nineteenth century, when systematic and organized care for premature infants began in earnest. This chapter traces the origins and growth of modern perinatal and neonatal medicine, with a brief perspective on its promises and failures. The reader may consult scholarly monographs and review articles on specific topics for in-depth analyses.6,7,24,31,78,79



Perinatal Pioneers


Many scientists played strategic roles in developing the basic concepts in neonatal-perinatal medicine that helped to formalize the scientific basis for neonatal clinical care. Their work and teachings inspired generations of further researchers advancing the field. For brevity’s sake, only a few are shown in Figure 1-1.



Medicinal chemistry (later called biochemistry) and classic physiology gained popularity and acceptance toward the end of the nineteenth century, inaugurating studies on biochemical and physiologic problems in the fetus and newborn. Some leading scientists in the early twentieth century making fundamental contributions and training scores of scientists from around world included Barcroft8,34 and his mentee Dawes in England (gas exchange and nutritional transfer across the placenta and oxygen carrying in fetal and adult hemoglobin); Ylppö in Finland (neonatal nutrition, jaundice, and thermoregulation); Lind in Sweden (circulatory physiology); Smith in Boston81 (fetal and neonatal respiratory physiology); DeLee in Chicago26,27 (leading researcher on incubators and in high-risk obstetric topics, he also founded the first US “incubator station” at the Chicago Lying-in Hospital); Day in New York (temperature regulation, retinopathy of prematurity, and jaundice); and Gordon38 in Denver (nutrition). Although no formal curriculum existed, all these centers offered rigorous training in perinatal physiology and clinical medicine Smith once said, “If you were interested in babies and liked Boston, I was the only wheel in town!”60 Table 1-1 highlights some milestones in perinatal medicine.



TABLE 1-1


Selected Milestones in Perinatal Medicine

























































































Category Year(s) Description
Antenatal aspects 1752 Queen Charlotte’s Hospital, the world’s first maternity hospital, is founded in London57
1915-1924 Campbell introduces outlines of regular prenatal visits, which become a standard
1923-1925 Estrogen and progesterone are discovered
1928 First pregnancy test is described, in which women’s urine is shown to cause changes in mouse ovaries
Fetal assessment 1543 Vesalius observes fetal breathing movements in pigs
1634 Paré teaches that absence of movement suggests a dead fetus
1819, 1821 Laënnec introduces the stethoscope in 1819, and his friend Kergaradec shows that fetal heart sounds can be heard using it
1866 Forceps are recommended when there is “weakening of the fetal heart rate”
1903 Einthoven publishes his work on the ECG
1906 The first recording of fetal heart ECG is made
1908 The term fetal distress is introduced
1948-1953 There are developments in the external tocodynamometer
1953 Apgar describes her scoring system3
  1957-1963 Systematic studies are conducted on fetal heart rate monitoring
1970 Dawes reports studies on breathing movement in fetal lambs
1980 Fetal Doppler studies begin
1981 Nelson and Ellenberg report that Apgar scores are poor predictors of neurologic outcome
Labor and delivery ca. 1000–500 bc In Ayurveda, the ancient Hindu medical system, physicians describe obstetric instruments
98-138 Soranus develops the birthing stool and other instruments
1500s There are isolated reports of cesarean sections on living women
1610 The first intentional cesarean section is documented
1700s The Chamberlen forceps are kept as a family secret for three generations
1921 Lower uterine segment cesarean section is reported
1953 The modern vacuum extractor is introduced
Fetal physiology 1900-1950 Barcroft, Dawes, Lind, Liley, and others study physiologic principles of placental gas exchange and fetal circulation


image


ECG, Electrocardiogram.


See references 2, 41, 43, 61, 82 for primary citations.



The High-Risk Fetus and Perinatal Obstetrics


Because so many deaths occurred in early infancy in times past, many cultures adopted remarkably innovative methods to deal with such tragedies. According to a Jewish tradition, full, year-long mourning is not required for infants who die before 30 days of age.40 In some Asian ethnic groups, infant-naming ceremonies are held only after several months, until which time the infant is simply called “it.” In India, an odd or coarse-sounding name is given to the first surviving infant after the death of a previous sibling; this is aimed at deflecting evil spirits. In her book on the history of the Middle Ages, Tuchman notes that infants were seldom depicted in medieval artworks.89 When they were drawn (e.g., the infant Jesus), women in the pictures looked away from the infant, ostensibly conveying respect, but perhaps because of fearful aloofness.


Since antiquity, the care of pregnant women has been the purview of midwives, grandmothers, and experienced female elders in the community. Wet nurses helped when mothers were unavailable or unwilling to nurse their infants. Little or no assistance was needed for normal or uncomplicated labor and delivery. For complicated deliveries, male physicians had to be summoned, but they could do little because many of them lacked expertise or interest in treating women. Disasters during labor and delivery were common, rendering this phase in their lives the most dreaded for women.43 In the early 1900s, unexpected intrapartum complications accounted for 50% to 70% of all maternal deaths in England and Wales.17,56 Because the immediate concern during most high-risk deliveries was to save the mother, sick newborns were not given substantial attention; their death rates remained very high.


Occasionally, happy outcomes of high-risk deliveries did occur. In one of the oldest works of art depicting labor and delivery (Figure 1-2, A), a bearded man and his assistant are standing behind a woman in labor, holding devices remarkably similar to the modern obstetric forceps. The midwife has delivered an evidently live infant. In Figure 1-2, B, three infants from a set of quadruplets, nicely swaddled, have been placed on the mother, as the unwrapped fourth infant is being handed to her for nursing. A divine figure in the background is blessing the newcomers.



Cesarean sections were seldom performed on living women before the thirteenth century. Even subsequently, the procedure was performed only as a final act of desperation. Contrary to popular belief, Julius Caesar’s birth was not likely by cesarean section. Because Caesar’s mother was alive during his reign, historians believe that she probably delivered him vaginally. The term cesarean probably originated from lex caesarea, in turn from lex regia, the “royal law” prohibiting burial of corpses of pregnant women without removal of their fetuses.11,94 The procedure allowed for baptism (or a similar blessing) if the child was alive or burial otherwise. Infants surviving the ordeal of cesarean birth were assumed to possess special powers, as supposedly did Shakespeare’s Macduff—“not of a woman born,” but of a corpse, and able to slay Macbeth.54


Soranus of Ephesus (circa 38-138 ad) influenced obstetric practice for 1400 years. His Gynecology can be regarded as the first formal “textbook” of perinatal medicine. Initially extant, it was rediscovered in 1870 and translated into English for the first time in 1956.88 Soranus wrote superbly about podalic version, obstructed labor, multiple gestations, fetal malformations, and numerous other maternal and fetal disorders. In an age of belief in magic and the occult, he insisted that midwives should be educated and free from superstitions. He forbade wet nurses from drinking alcohol lest it render the infant “excessively sleepy.” His chapter, “How to Recognize the Newborn That Is Worth Rearing,” remains one of the earliest accounts on assessing viability of sick newborns—a topic of great concern even today.



Midwives and Perinatal Care


Although occasionally caricatured (Figure 1-3), midwives were responsible for delivering obstetric care for thousands of years. Men disliked obstetrics, and women were shy to let male physicians handle them. Good midwives were always in great demand, and many of them held important social and political positions in European courts.43,61,91



The emergence of man-midwives (Figure 1-4) in England had a major effect on high-risk obstetric practice. Chamberlen the Elder (1575-1628) is usually credited for inventing the modern obstetric forceps.43,61,63 For 150 years, through three generations of Chamberlens, the instrument remained a trade secret. By then, others had developed similar devices, and patients began associating good obstetric outcomes with male physicians—a strategic factor in transforming midwifery to a male-dominated craft.43 The shift from women-midwifery to men-midwifery might also have been caused by changing social values and gender relationships in which women voluntarily began making choices about their bodies.91 Today’s increasing roles for female midwives and the higher proportion of women choosing specific birth practices (e.g., home versus hospital delivery, “underwater births,” cesarean delivery on request) offer interesting contrasts and perspectives to eighteenth century obstetrics.




Neonatal Resuscitation: Tales of Heroism and Desperation


Popular artworks and ancient medical writings provide accounts of miraculous revivals of apparently dead adults and children.66 These are tales of successes only, for the failures were buried and rarely reported. Attempts to “stimulate” and revive apparently dead newborns included beating, shaking, yelling, fumigating, dipping in ice-cold water, and dilating and blowing smoke into the rectum.25,30,66 Oxygen administration through an orogastric tube to revive asphyxiated infants persisted well into the mid-1950s, when James and Apgar showed conclusively that the therapy was useless.1,52



Apgar and the Language of Asphyxia


Few scientists in the twentieth century influenced the practice of neonatal resuscitation as profoundly as Apgar (1909-1974). A surgeon, she chose obstetric anesthesia for her career. Her simple scoring system inaugurated the modern era of assessing infants at birth on the basis of simple clinical examination.3 Right or wrong, the Apgar score became the language of asphyxia. It is often said that the first words heard by a newborn infant are “What’s the Apgar score?” Although “giving an Apgar” has become a ritual, its profound effect has been on formalizing the process of observing, assessing, and communicating the infant status at birth in a consistent and uniform manner. This process eventually led to the formal steps of resuscitation at birth using the score. Few people know that it was also Apgar who was the first to catheterize the umbilical artery in a newborn.16 A woman of enormous energy, talent, and compassion, Apgar was honored with her depiction on a 1994 US postage stamp (Figure 1-5).




Foundling Asylums and Infant Care


In its early days, the Roman Empire experienced decreasing population growth. The emperors taxed bachelors and rewarded married couples to encourage procreation.82 In 315 ad, Emperor Constantine, hoping to curb infanticide and encourage the adoption of orphans, decreed that all “foundlings” would become slaves of those who adopted them. Similar humanitarian efforts by kings and the Council of the Roman Church led to the institutionalization of infant care by establishing foundling asylums for abandoned infants,82 also called “Hospitals for the Innocent”—the first children’s hospitals. Parents of unwanted infants “dropped off” their infants in a revolving receptacle at the door of such asylums, rang the doorbells, and disappeared into the night (Figure 1-6). Such accounts are poignant reminders of the contemporary problem of child abandonment, because of which many states have programs to save such “dumpster babies” or abandoned infants.72



Foundling asylums adopted pragmatic techniques for fundraising. In eighteenth century France, lotteries were held, and souvenirs were sold. In May 1749, Handel gave a concert to support London’s “Hospital for the Maintenance and Education of Exposed and Deserted Young Children.” The final item of the program was the playing of “The Foundling Hymn.”82



Saving Infants to Man the Army


During the French Revolution, France faced appalling rates of infant mortality. With rates greater than 50%, the Revolutionary Council in 1789 enacted a decree proclaiming that working-class parents “have a right to the nation’s succors at all times.”82 The postrevolutionary euphoria about equality and fraternity among men stimulated reforms, heralding an idealistic welfare state, leading to collecting and maintaining valid statistics about children. The world’s first national databases began in France in the late eighteenth century.82


Over the next century, France faced a population problem similar to that of ancient Rome—a negative population growth. The birth rate had declined, and infant mortality remained high. Fearing future shortages of troops, the military leaders, deeply engaged in battles with Prussia, were naturally alarmed. Commissions were set up to study the depopulation problem and develop remedial actions. A series of measures began to improve maternal and neonatal care.6,7,22,24,82 Young parents were encouraged to uphold their patriotism and bear more children to “man the future armies.” It is the irony of our times that such noble intentions as saving infants were motivated by brutal needs for enhancing military might.



An Ingenious Contrivance, the Couveuse, and Premature Baby Stations


A popular story of the origin of modern incubator technology is that upon seeing the poultry section during a casual visit to the Paris Zoo in 1878, Tarnier (1828-1897), a renowned obstetrician, conceived the idea of “incubators” similar to the “brooding hen” or couveuse.6,7,22,24 He asked an instrument maker, Martin, to construct similar equipment for infants. With a “thermo-syphon” method to heat the outside with an alcohol lamp, Martin devised a sufficiently ventilated, 1 m3 double-walled metal cage, spacious enough to hold two premature infants. The first couveuses were installed at the Paris Maternity Hospital in 1880. Tarnier’s efforts led to dramatic improvements in survival rates for preterm infants.


Although a few others had developed incubators before Tarnier,7 it was he and his students, Budin (1846-1907) and Auvard, who are largely responsible for institutionalizing preterm infant care. They placed several incubators side by side, promoting the concept of caring for groups of sick preterm infants in geographically separate regions within their hospital.6,7,86 Budin and Auvard improved the original couveuse by replacing its walls with glass and using simpler methods for heating. Their efforts greatly influenced incubator technology during the first half of the twentieth century in Europe and the United States (Figure 1-7 and Table 1-2).



TABLE 1-2


Evolution of Incubators
























































Year(s) Developer/Product Comments
1835, ca. 1850 von Ruehl (1769-1846) A physician to Czarina Feodorovna, wife of Czar Paul I, von Ruehl develops the first known incubator for the Imperial Foundling Hospital in St. Petersburg. About 40 of these “warming tubs” are installed in the Moscow Foundling Hospital in 1850
1857 Denucé (1824-1889) The first published account of introducing an incubator is a 400-word report by Denucé. This is a “double-walled” cradle
1880-1883 Tarnier (1828-1897) Tarnier incubator is developed by Martin and installed in 1880 at the Port-Royal Maternité
1884 Credé (1819-1892) Credé reports the results of 647 infants treated over 20 years using an incubator similar to that of Denucé
1887 Bartlett Bartlett reads a paper on a “warming-crib” based on Tarnier’s concept, but uses a “thermo-syphon”
1893 Budin (1846-1907) Budin popularizes the Tarnier incubator and establishes the world’s first “special care unit for premature infants” at Maternité and Clinique Tarnier in Paris
1893 Rotch (1849-1914) The first American incubator with a built-in scale, wheels, and fresh-air delivery system is developed; the equipment is very expensive and elaborate
1897 Holt incubator A simplified version of the Rotch incubator is developed. In this double-walled wooden box, hot water circulates between the walls
1897-1920s Brown, Lyons, DeLee, Allin Many modifications are made to the early American and European incubators by physicians. These are called baby-tents, baby boxes, warming beds, and other names
1922 Hess Hess introduces his famous incubator with an electric heating system. For transportation, he develops special boxes that can be plugged into the cigarette lighters in Chicago’s taxicabs
1930-1950s Large-scale commercial incubators There is worldwide distribution of Air-Shields and other commercial ventilators
1970-1980 Modern incubators Transport incubators with built-in ventilators and monitoring equipment are developed—mobile intensive care units

See references 6, 7, 2224, 7779 for primary citations.

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