Historical Perspectives

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“The experimental hypothesis, in short, must always be based on prior observation.”—Claude Bernard (1) Modern adult intensive care started in Denmark in 1952 in response to the high mortality from the respiratory complications seen with a devastating epidemic of poliomyelitis. Anesthetists and physiologists created a new discipline when they collaborated to make sequential measurements of cardiorespiratory variables, then aggressively corrected abnormal conditions. (2) When modern neonatal intensive care emerged a decade later, it followed the same philosophy. The start of modern neonatology was stimulated in large part by an expanding understanding of: 1) the circulatory and respiratory physiology of adaptation to extrauterine life, 2) how those adjustments could fail, and 3) the pathophysiology of hyaline membrane disease. (3)(4)(5)(6)(7)(8)(9)(10) (The monograph by Dawes (3) gives an excellent overview of the relevant animal research). This research had reached a point where it could be applied to clinical care if the necessary physiologic measurements could be made in newborns. To this end, investigators began to catheterize the umbilical arteries of newborns to measure blood gas tensions and pH, with several investigators also measuring aortic pressures. (9)(11)(12)(13) Such invasive techniques were highly controversial initially, but they gradually became the accepted methodology for monitoring the sick neonate. (12) The use of oxygen in preterm infants who had cardiorespiratory distress was an important component of this change in approach to the sick infant. The standard had been to use no more than 40% oxygen to prevent retrolental fibroplasia (retinopathy of prematurity). However, it was obvious that this approach would be insufficient to relieve hypoxia in some infants and would produce hyperoxia in others. Avery and Oppenheimer (13) observed an increase in deaths due to …