Tuesday, July 26, 2016

Clio in the Clinic: A Book Review in Sonata Form

Exposition: I recently finished five weeks on service in the NICU. Upon discovering that I had studied the history of medicine, one of the pediatrics interns asked if I was familiar with a book called Clio in the Clinic-? She remembered reading a chapter in it about the development of the field of neonatology while in medical school. As a matter of fact, I had (finally) gotten around to finishing reading that essay collection last summer and had intended to review it on this blog, but residency interview season descended before I could get around to it.

Then, when another resident found out that the reason I am (even) older than he is is that I earned a PhD in history, he mentioned that I might want to look up the quarterly history of medicine feature in the journal Pediatrics. I took his advice, offering both to write something in the future (when I can get around to it) and to review manuscript submissions. The editor, another MD, PhD pediatrician, was encouraging.

Development: Clio in the Clinic (2005) is the brainchild of Jacalyn Duffin, a Canadian MD, PhD hematologist and a force of nature unto herself in medical history and education. She has written an engaging textbook in the history of medicine for medical and nursing students (History of Medicine: A Scandalously Short Introduction, 2010, 1999), as well as a number of scholarly articles and books. (Medical Miracles: Doctors, Saints, and Healing in the Modern World, 2008, is on my reading list.) Clio in the Clinic is an anthology that unashamedly combines physician autobiography with personal ruminations that cross the threshold between hospital and library, medicine and history, asking clinician historians (most but not all with formal graduate training) to reflect on how their historical knowledge has impacted their clinical practice. The quality of the essays is somewhat uneven, reflecting both the authors' variable comfort with the unusual genre and a light editorial hand.

Jeffrey P. Baker's chapter, "Historical Adventures in the Newborn Nursery," recounts his pathway from pediatrics resident through dissertating while a fellow to attending physician. His thesis explored the first 50 years of the field of neonatology, invented by French obstetricians in the 1880s with the help of chicken incubators turned into baby-warmers. In his Clio piece, he meditates on the temperature of an infant as a medical construct, as well as on the shifting boundary lines between obstetrics and pediatrics. Baker uses anecdotes to teach both professionalism and medical history to the pediatrics residents he precepts now. He goes on to describe a relic of early twentieth-century pediatrics, "inanition fever," an elevated temperature seen in breastfed babies who were a few days old and dehydrated because of the summer heat and/or their mother's milk not yet coming in. The concept essentially disappeared after World War II thanks to antibiotics, artificial formulas, and air conditioning. It reappeared briefly in the 1990s, perhaps due to the resurgence of breastfeeding coinciding with a new practice pattern of early discharge from Labor & Delivery (c. 2 days after birth) and an early pediatrician checkup (c. 3-4 days old). However, he and his colleagues were not able to find a medical journal interested in publishing their case report on the (now) unfamiliar phenomenon. He concludes, "the common thread uniting all the examples in this account has been to call attention to the power of historical awareness as an antidote for medical parochialism." (114)

There was little enough history of medicine in action when I was in the NICU, although the elderly physician who used to teach it in the medical school apparently gave a full impromptu lecture on Ignaz Semmelweis, Joseph Lister, and handwashing to the other team. Instead, there was a lot of managing "the numbers": corrected gestational age, weight (both absolute and daily gain/loss), milliliters of formula or breastmilk, rates of IV fluid or TPN delivery, ventilator settings, laboratory results, alarms, and of course, the temperature of both infant and incubator. There is in fact a method to this madness, which takes a little time to catch onto, and then it is a matter of adjusting variables up or down based in part on protocol, in part on the preferences of the attending physician, and in part on the clinical picture of the child itself. (Of course, the protocols are largely observational and empirical, as there are numerous ethical hurdles involved in research on children, much less such fragile ones as preemies.) Parents sometimes challenged these protocols, wanting us to feed their child more or less, or wanting to hold their baby more outside the incubator. As the French obstetricians discovered, the incubator is a life-saving technology for premature babies. But a developing infant inside its mother's body is close and accessible in an intangible way, and the incubator separates them bodily in a way that somehow seems cold. One of the most poignant comments I heard came from a father who marveled at the perverse pleasure in being able to watch his tiny daughter grow and develop in that glass womb, an experience that would have been hidden from him and her mother had she been carried to term. It reminded me that neonatology is in some ways less pediatrics--medicine for children--than it is a branch of obstetrics--medicine for pregnant mothers and their fetuses.

Recapitulation: As the community of clinician historians is relatively small, I know (of) half of the authors in Clio in the Clinic--either from reading their published work or from interacting with them at our annual conference--and was able to read their essays in their voices. So when I sat down this morning to revisit this chapter on the NICU and to write about my experiences there, I was pleasantly not very surprised to discover that the chapter author and journal editor were one and the same.

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