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Premature Care in the 1950s - An Interview with Dr. William Silverman, Father of Neonatal Intensive Care

Dr. Silverman is considered to be the "father of neonatal intensive care." Dr. Silverman wrote the major neonatal textbook for the early 1960s and his research in the 1950s on temperature control in premature infants revolutionized preemie care. He practiced and taught at Columbia and now lives in California. A major interest throughout his career has been ROP and he has written several books on the topic as well as on the need for sound neonatal research. He is the author of Where's the Evidence? Debates in Modern Medicine.

By Helen Harrison

Dr. Silverman, could you describe the premature nursery in the early 1940s at the time you were finishing your residency?

Dr. Silverman: The premature nursery then was a backwater of the hospital. Physicians weren't much interested in it because they had so little to offer. Nurses were all powerful, and it was primarily nursing techniques that sustained the infants -- gavage feedings, maintaining warmth, watching for apnea (we had no monitors). Not only were parents barred from the nursery, but physicians, too, were discouraged from coming in and handling the babies. There were a few procedures we performed -- small transfusions for anemia, and "clysis," a crude and rather ineffective way of administering fluid to the baby by injecting it in small bubbles under the skin. But essentially there was almost nothing for doctors to do.

How then did you become interested in the care of premature babies?

Dr. Silverman: During my last year of residency, I was in charge of a 600 gram baby, the smallest infant at the time to be kept alive. Although the baby died after six months, and although I was devastated by this outcome, I retained the idea that it could be done, that very tiny babies could be saved.

By the 1950s, Columbia had a 30-bed center where we cared for 350 babies a year, babies with a median birthweight of 1500 grams. We had expert nurses and the finest equipment. It was an exciting time when dramatic medical interventions were being introduced: exchange transfusions for jaundice, gastrostomies for feeding, new antibiotics. Respiratory distress syndrome had just been recognized and we began actively treating it with mist inhalations and the liberal use of oxygen. With these innovations, the physician's role became more important. I was quite enthusiastic about my work at the time.

What happened to change that?

Dr. Silverman: I began to witness a series of disasters accompanying this rapid introduction of new drugs and procedures. The liberal use of oxygen was associated with blinding of thousands of infants. Some of the drugs that appeared so promising proved in fact to be lethal; some led to brain damage or other handicaps. I was disturbed by how long it took to recognize the harmful effects of specific treatments. I began to advocate increased use of the randomized controlled clinical trial to find out if treatments were beneficial and discover any unexpected risks.......

What was the parents' role in the old premature nursery and how did you, as a physician, relate to the parents?

Dr. Silverman: Parents were allowed in the nursery corridors during visiting hours for a glimpse of their baby through the window. One of the most poignant scenes I can remember is of the young mother who would come in each day and peer at her baby through a pair of opera glasses. But many of the parents didn't come in at all: they were simply too young, poor, and overwhelmed by life.

My relationship with the parents was the usual paternalistic one that doctors have with patients or parents of patients. But there was one exception I'll never forget. A very famous singer and her husband had a 1300 gram baby in our unit. Although I repeatedly told them about all the marvelous modern techniques we were using to save their baby, they were both quite unimpressed. I later learned that years before while on tour in Portugal, the singer had given birth to another premature baby of the same birthweight. Local doctors refused to treat an infant that small, so she and her husband took the baby to their hotel room in Lisbon, wired the Air-Shields coompany in Pennsylvania to fly over an incubator, and successfully took care of the baby themselves! No wonder they were unimpressed by our efforts. For me as a physician, it was quite a humbling experience...."

More of Dr. Silverman's recollections of the 1940's - 1960's can be found in his books:

Retrolental Fibroplasia: A Modern Parable. Grune& Stratton, 1980.

Human Experimentation: A Guided Step into the Unknown. Oxford University Press, 1985.

Where's the Evidence? Debates in Modern Medicine Oxford University Press, 1998.

I also highly recommend his special article "Overtreatment of Neonates? A Personal Retrospective?" Pediatrics 1992;90:971-976.

In addition, if you have a really good library nearby, you might want to look for History of the Care and Feeding of the Premature Infant by Thomas E. Cone, Jr., M.D., Little, Brown and Company, 1985.

Helen Harrison is the well known author of The Premature Baby Book, often referred to as the "Bible of Prematurity" by older preemie parents. These observations are excerted with permission from posts to the prematurity parents support internet mailing lists on prematurity: Preemie-child and Preemie-L.

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