Book Review

The Machine in the Nursery: Incubator technology and the origins of newborn intensive care

N Engl J Med 1997; 336:230-231January 16, 1997

Article

The Machine in the Nursery: Incubator technology and the origins of newborn intensive care
By Jeffrey P. Baker. 247 pp., illustrated. Baltimore, Johns Hopkins University Press, 1996. $45. ISBN: 0-8018-5173-4

Every medical device has a history that is usually thought of as technological — the story of successive refinements in machines and tools. But instruments of diagnosis and healing also reflect an understanding of the pathophysiologic states they are designed to address. The history of devices is thus also a history of diseases and of patients.

There is yet a third facet to the history of medical devices: the history of the forces that shape how and when an approach is introduced and adopted. This aspect contains many puzzles. Why did Thomas Latta's use of intravenous-fluid therapy for vascular collapse in cholera disappear for almost a century after its introduction in 1832? Why was artificial ventilation used for decades in the operating suite before it became a standard approach to ventilatory failure not induced by anesthesia? Why did coronary care units and neonatal intensive care units arise within just a few years of each other?

Jeffrey Baker, a self-described physician-historian, has given us an intriguing view of the social forces that shaped the rise, fall, and resurrection of the incubator as a device for the treatment of premature infants. Baker skillfully shows the interactions of this medical device with a variety of social forces and cultural constructs, from its humble origins as a simplified copy of machines used in the poultry industry through its varied incarnations in France and the United States between 1880 and 1920.

In the aftermath of the Franco–Prussian war of 1870–1871, the statesman Jules Simon proclaimed that infant mortality robbed France of a battalion of soldiers each year, and Emile Zola expressed his demographic fears in a novel unsubtly titled Fécondité. Thus, the first incubators for infants, developed and used in Paris, reflected the Third Republic's passionate concern with the depopulation of France. The government provided support, both moral and financial, for the obstetricians Budin and Tarnier and the midwife Madame Henry in their use of the device to treat the infants they referred to as “débiles.”

In the United States, fairs and exhibitions, great promoters and diffusers of 19th-century technological innovation, included sideshows in which tiny premature infants were displayed in incubators to paying customers. This unique form of third-party payment continued as late as the New York World's Fair of 1939 and, despite the condemnation of various civic groups, was a Coney Island and Atlantic City staple for decades in the 20th century. Baker notes further that at the birth of this century, the fight over who “owned” the newborn — obstetrician, pediatrician, or mother — led to a variety of ways of taking care of premature infants, each with its own philosophy and set of statistics to justify its approach, and to sharply varied opinions as to the value of the new artificial environment for babies presented by incubators.

Baker pays special attention to the important role of educated women on all sides of this debate. In the arena of public health, Julia Lathrop directed the Children's Bureau in Washington, D.C., and S. Josephine Baker did likewise at the Bureau of Child Hygiene in New York. In the arena of public advocacy, Hortense Joseph created the Infants' Aid Society and funded America's first permanent incubator station at Michael Reese Hospital in Chicago. Nurses in the United States and midwives in France were central figures in all early efforts in premature care, and the names of the most prominent — Henry, Koch, and Lundeen — are as important as those of the pioneering physicians, if not more so. Although he was speaking of the division between obstetricians and pediatricians, Dr. Ballantyne of Edinburgh aptly referred to the newborn as occupying a “No-Man's Land.”

Using scholarship meticulously but unobtrusively and drawing on a rich variety of sources, Baker emphasizes that the invention of the incubator first required recognition of prematurity as a medical problem in need of a solution. And that recognition itself waxed and waned as other problems of infant health, such as congenital syphilis and gastroenteritis, were viewed as separate issues or as intertwined with the problem of prematurity. Not just today, but throughout this century, prematurity has been viewed alternately as a community failure in maternal hygiene and public health or as a technological failure in the delivery of heat and calories.

This small and concisely written book covers only a short period of the history of premature care and ends just as neonatology, under the leadership of the Chicago pediatrician Julius Hess, begins to emerge as a discipline and pediatrics begins to assert its primacy in the care of the premature. Thus, the links suggested in the book's title to the origins of newborn intensive care, an entity whose central machine is not the incubator but the respirator, do not emerge.

Modern care of newborns is as fraught with contradictions as its predecessors. Taxpayers fund billions of dollars in medical care for premature infants annually, but a relative pittance for prevention, subsequent care, or research. The long-term value of intensive care for newborns at the threshold of viability is uncertain. I hope that this thoughtful author will continue his explorations into the history of the care of premature babies and trace the origins of current practice to provide insights into some of our pressing dilemmas.

Nigel Paneth, M.D.
Michigan State University, East Lansing, MI 48824-1316