Neonatal Pediatrics at the Century Mark

PERSPECTIVES IN BIOLOGY AND MEDICINE Volume 32 ¦ Number 2 ¦ Winter 1989 NEONATAL PEDIATRICS AT THE CENTURY MARK WILLIAM A. SILVERMAN* Neonatal pediatrics has made stunning and completely unprecedented progress in recent years. Nonetheless, an increasing number of voices now ask, Where is this field of medicine going? Is it, dare one ask, even headed in the right direction? These are reasonable questions, but first we need to know where this subspecialty ofpediatrics has been. The current phenomenon is all the more remarkable because it differs so completely from the past. Two Epochs The 100-year saga of American interest and concerted action in neonatal medicine can be divided into two epochs. The first 70 years were, I would say, quiet and farmlike; those years might be thought ofas a "pastoral era." The calm ended about 30 years ago. It was replaced by a very active time—a "mechanistic era" that extends to the present day. At the time of the founding of the American Pediatric Society (APS) in 1888, there was surprisingly litde expressed interest in the newborn. For example, the founders voiced concern about the high mortality rates in infancy and childhood [I]. But the disproportionate loss of life in the immediate neonatal period was not singled out as a national problem deserving special attention. To some extent the situation was blurred since many of the early neonatal deaths were declared to be stillborn [2]. This paper was presented at a symposium on the newborn infant during the Centennial Meeting of the American Pediatric Society in Washington, D.C., May 3, 1988. ?Address: 90 La Cuesta Drive, Greenbrae, California 94904.© 1989 by The University of Chicago. AU rights reserved. 0031-5982/89/3202-0623101.00 Perspectives in Biology and Medicine, 32, 2 · Winter 1989 | 159 In the 1880s a little over 95 percent of American women delivered their infants at home [3]: any effort to rescue a nonbreathing or grossly malformed neonate was carried out on the family's turf where the immediate and long-term social consequences of any action by birth attendants were uppermost in the minds of all concerned. Most of the early deaths were seen by families and by doctors as the "expected" reproductive loss—similar in every way to the large number of early deaths in all species. More specifically, it seemed inhumane to prolong the lives of very small or malformed babies. Throughout all the millennia of human existence, the metamorphosis of a newborn, from biological creation to social being and family member, took place only if and when nurturing care was provided by parents. One hundred years ago, few parents were willing to place the interests of a newly born child with major biological imperfections ahead of all others in the family. There was a fairly general , but silent, understanding that the new arrival had only a tentative claim to full rights of membership in a family [4]. Welfare of the social unit also seemed to be the prime concern of the first American doctors with a special interest in the health of children. From the writings of Abraham Jacobi [5], the first president, and other founders of the APS, it appears that medical action was guided by a consideration ofthe status of the new baby as a potential family member. Organized Efforts in France In contrast to American inertia in the late 1880s, the first systematic programs organized by physicians to reduce neonatal mortality were well under way in France [6]. The planned medical action began in Paris and in Nice during the 1870s, and, interestingly, the move was not started in response to pleas from parents. The concerted effort was, in fact, motivated less by humanitarian or religious interests than by the considerations of economics and war. What was stressed was the need for more rapid growth of population to provide the country with workers and soldiers. The medical measures were taken in response to the immense loss of life in France from military action and from months of famine during the siege of Paris in the Franco-Prussian War of 1870-1871. The acute decimation of population was particularly alarming to the French because it was accompanied by a...