 today's lecture started since I think we have a quorum. Okay, so it is my great pleasure to welcome Dr. Jeffrey Baker, MDPH professor of Pediatrics history director of the Trent Center for Bioethics, Humanity, and the History of Medicine at the Duke University School of Medicine. Today's title why American neonatology began in Chicago the story of professional territory eugenics and ethics. Dr. Jeffrey Baker is director of the Trent Center for Bioethics and Humanities and History of Medicine a professor of pediatrics and practice of history. He has served for over 25 years as a general pediatrician in Duke's children's primary care with the focus on children with autism and special needs. Dr. Baker's historical work is also centered on child health. As the author of the book the machine in the nursery incubator technology in the origins of the neonatal intensive care, he is the leading authority on the history of neonatal medicine. Dr. Baker co-edited a 75th anniversary history of the American Academy of Pediatrics and has written numerous historical articles related to pediatrics, vaccination controversies, and autism. He directed the Academy's Pediatric History Center from 2009 to 2018 and continues to serve as the pediatric history monthly feature editor of the journal Pediatrics. He is also an active member of the American Association for the History of Medicine for which he co-chaired the program committee for its 2017 meeting. Dr. Baker has lectured widely on historical topics to many academic audiences in North America. Most recently his research interests have been centered on the history of racism in medical centers and their communities. He has co-led an interdisciplinary Bass Connections project in 2018 to 2019 documenting Durham's health history understanding the roots of health disparities. He continues active work situating Duke University's own institutional history within the context of his community and has spoken to many local audiences on this topic. As the director of the Trent Center's History of Medicine program since 2006, Dr. Baker has taught history to undergraduates, residents, and medical students in all four years. In 2021 he co-developed a new interprofessional humanities elective moral movements in medicine. He has held many other leadership positions at Duke including director of the Duke Autism Clinic, Duke Health Center at South Point, and the AB Duke Scholarship Program. In 2019, Dr. Baker was awarded the Excellence in Professionalism Aware by Duke School of Medicine. His book Machine and the Nursery Incubator Technology and the Origins of Newborn Intensive Care was published in 1996 and as we did learn in the pre-session chit-chat that this was the fruit of his PhD thesis. But I want to end this introduction by saying that Jeff is a colleague, friend, and most importantly a kindred spirit. As a pediatrician with extensive experience, he deals with some of the most challenging patients, those with autism. As this lecture series has explored, there's a really wonderful cross-fertilization between history and clinical medicine and to be able to do historical research and scholarship at the highest level and to be an active clinician is really what I personally aspire to. Finally, I always appreciate any lecture that shows the convoluted nature of medical progress at the same time highlighting an important Chicago historical connection. So without further ado, it's my pleasure to welcome today's speaker, Dr. Jeff Baker. Thank you very much, Mindy. You're too kind. And it's thank you for inviting me. My only sadness on this, I wish I could see you in person. I see a lot of names here that are really recognizable to me on the, just your various names on boxes and probably a lot of others that will someday be recognizable to me. So just sorry, I can't meet with you in person. Yeah, I really think highly of the Claim Program and at the University of Chicago, which is I did travel to do some of my research for this project there. I'm going to share my screen and the regulatory, there we go. And, Alina, if you just give me a thumbs up, if you can see the title slide. And yes, I shamelessly pitched to Chicago for this talk. Knowing that a lot of the Claim Fellows come from all over effects, there's Chicago comes off pretty well in this talk, but we're going to hope to make some bigger points about what the complexities around the story of the history of American Neatology. I have only nothing to disclose besides a minor project I've done with autism with Apple with an iPhone. So the formal objectives of this talk are we're going to talk about how DNA medicine, you got a lot earlier than most people think, in France in the late 1800s. Now it came to the United States and how there's this strange story involving incubator baby shows and eugenics. We're going to talk about a bigger theme, which is how did responsibility for these babies pass from mothers to doctors? And how did nurses play into that story? And we're going to try to, I'm hoping the discussion in particular, we'll be able to look at the implications of this earliest story for medicine today. So I wanted to say a little bit autobiographically about my story. So I was a resident in the 1980s. And honestly, my rotation as a medical student as a PEADS resident in the intensive care nursery was very traumatic. I really was. I just remembered as a place of noise and alarms all the time. These tiny fragile babies that seem to be overwhelmed by technology. At that point, we hardly ever saw parents in the nursery. It was a completely technologized space. It was a disturbing hard place to work. And you wondered what was happening to these babies? What were we doing to them? Often inflicting painful procedures on them. And I'm sorry to say without analgesia. It was a time of controversy. And I was only partly, partly aware of all of this going on. But it was a time when there were national controversies over questions of what was called the baby dough controversy. I'm gonna say a little more about that toward the end of the talk, but a national controversy regarding parents who declined surgery to save the life of a baby with Down syndrome. Lots of controversy over whether we're going too far with this technology, with small premies, who should make those decisions on and on. I was very affected by that. And I did toy with thinking about ethics as a career. But I had done a lot of work in history. And that led me to ask questions I didn't see being asked by all the episodes who are so involved who are writing so many articles and books at this time. It was kind of assumed that all of this controversy was new. You know, it's sort of the, as the history of bioethics is often told is in a framework of new technologies create new dilemmas that have never happened before. And so now we need a new ethics. Well, yes and no. Intensive care technology was obviously pretty new. But I at the end of my chief was chief year, I attended a talk by a senior neonatologist. And that talk shared something I'd never heard before. There was in fact, a long history of neonatal medicine. And it was a pretty bizarre history. There were long before mechanical ventilators for babies. There were incubators. An incubator, which to me was kind of a boring technology, really. When incubators were first invented, they created a huge wave of interest in saving premies in the late 1800s. And some strange things happen such as incubator baby shows being set up in world fairs and side shows, including where you are in Chicago. These were brought centered around a figure named Dr. Martin Cooney. We're going to mention him again, who ran one of these shows at Coney Island until 1943. Strange figure. Cooney. So most neonatologists know nothing else about the history, especially will have heard of these side shows where one neonatologist said, all I know about our history is we started as a side show. So this has some, there's always a cottage industry of books written about this. It seemed like an interesting story to explore. As I learned more about it, I learned that this technology came from France. So therefore, there was a promise that maybe I could get a trip to France out of all this. That's always good when you do a dissertation. This story I also learned at early point connects to Chicago, because it turns out Chicago is really where the first permanent premature infant nursery gets established in the United States. And the person established that Dr. Julius Hess dedicated his book to Dr. Martin Cooney, who set up incubator baby shows in Chicago, including this is the century of progress exposition of 1933. And here's Dr. Hess. Dr. Hess is not a flamboyant figure. He's he's a mainstream figure of the University of Chicago. Yet he dedicates his book to Dr. Cooney, which is pretty wild to think about. So I decided I hadn't within the first week of my district of my graduate school, which I did after residency, I had my dissertation topic already staked out, which is a good idea. So I'm going to talk about how I really started off my dissertation. Really thank you about the bioethical questions of the nursery. I'm kind of hoping to kind of look at this older story, and kind of ask, you know, what questions can we learn? What I'm sorry, what what lessons can we learn from this only story? The story took me on down so many twists and turns, it took me to this very different world. And it wasn't, it wasn't so simple as just saying here are the lessons. I, I kind of came back, looking at our own world in a very different way. And that's what I want to try to convey in this talk. And to sort of make some connections with, with ethics, although maybe a little differently than not simply just lessons of history, if you will. So I'm going to try to punch you in a journey that took me years to understand. And I want to begin by just giving you a sense of, let's imagine, you know, the babies who are an intensive care nursery or a special care nursery today, what would have happened to them if they're born in the 1800s? Well, they would have been born at home. And typically, we, I think we can, from reading a lot of literature, this is the first chapter of my book. Babies were born at home, almost always the 19th century, when a premature baby is born, they'll be left at home with the mother, and would be in the mother's care. A baby born more than two or three months early would probably have died within hours, maybe a couple of days, the most, maybe early enough, or an early enough, they would have had immature lungs. But there's a very big population of babies born just one to two months early. These are sort of 32 to 36 weekers today, who do really well today. We don't worry much about them anymore. But in this time period, these babies, 32 weeks and above, even though they had decent lungs, they were very precarious. And then a very high mortality rate of about 50 to 70% in the first weeks of life. It wasn't from highly memory disease in the premature lungs. It was because they're such bad feeders, they got cold really easily, they're prone to infection, but high mortality. And yet doctors didn't have any responsibility here, the baby would just be turned over to the mothers. And it was up to the mother to try to rear the baby as best she could, maybe the baby would put into a laundry basket and wrapped up well and breastfed as best she could, but many of them would die. So one of the questions that I was exploring is how does response, how does premature baby become a responsibility of medical establishment instead of mothers? And that is the story that's triggered by the invention of a medical intervention, which is the incubator. And we're going to trace this in three acts, how it was invented in France. And there's a reason it was in France, not here, how it gets from France, the United States. And then what happens to the United States, essentially, my book, I explore how you can take the same technology in two different contexts to illuminate those contexts and understand the values that shape each of them. So that's what I want to try to outline to you in fairly fast form. So the first act, the invention story, let's get started. And I told you there's a reason that starts in France. And it has to do not so much with science, but with really with war with nationalism. In 1870 to 71, France loses a war to Germany, the Franco-Prussian War. It happens really fast. It's an enormous embarrassment to France. You know, this is, you know, 60 years after Napoleon, what's gone wrong, politicians afterwards, what happened to us? And they find a reason to explain their country's deterioration, what they called the population. French mothers were having babies at only half the rate of the Germans. They were starting to do early kinds of birth control. And the implications French politicians are very clear. They didn't start producing more babies, they weren't going to have enough soldiers or workers to fight the next war against the Germans. So in this context, the infant mortality is very high everywhere in the 19th century. But in many countries, it was sort of written off as kind of a fact of life. You just expect babies to die at high rates. In France, it becomes a problem, because it's not just a fact of life. It's like it's robbing the country of future soldiers and workers. So in that context, doctors have the incentive to start putting energy into what's killing babies. Here's a cartoon image from the time showing a French doctor who is feeding pasteurized milk to babies who are climbing over a hill, headed toward a cannon that again is presumably headed aimed toward Berlin. So doctors are tracking this and not only pediatricians, pediatricians would have been part of the story with pasteurization to address diarrhea. But obstetricians also are attracted by really the new prestige attached to reducing infant mortality. So in this context, there's an obstetrician who becomes a kind of pediatrician, his name is Stefan Tarnier. And he was the head obstetrician at France's maternity hospital, Paris's largest maternity hospital. France has a running start on most countries in that in Paris in particular, there was some large maternity hospitals. This goes from a tradition when back to the French Revolution. So whereas around the world, in many places, very few babies are born in the hospital in Paris. That's not the case. You got about 20% of babies born in the hospital here. They're still usually born into a fairly poor woman. So Tarnier sees is not had to be there. And in this context of worries about depopulation depopulation, he sees all these premature babies born one, two months early, and they're, you know, they're having failure to thrive. They don't grow and they die within days. He sees this now as a problem, not a fact of life. He looks for a way to warm them more effectively. And by the way, picture the maternity hospital, this is great big stone edifice, it gets pretty cold in the winter, okay. So he finds an answer to one of these babies actually had a visit to the Paris Zoo, where he sees the chicken incubator display. And he has that said, well, this is actually a machine to heat up eggs. Can we do this for babies? He has the zoo's instrument maker, make a similar device for the hospital. And this will become the incubator. And he has two models. The first one is a big machine. There's a, there's a Bunsen burner that heats water that circulates through a big reservoir at the bottom. And the top container can hold four babies. Again, think about the connection to egg incubators. You can just stack them in there. This was not real good for infection control. But it did warm the babies. It was also kind of complicated. So within three years, he develops a smaller model that's just a one infant, one incubator model heated by hot water bottles. This bigger one is the more technologically advanced. Wonderful image. I love this image of showing this being used in the maternity hospital. And this is an English magazine. So it shows this is getting some press around the world is a remarkable thing. These are generally nurse nurses and wet nurses supervised by a midwife who are doing this. That's Dr. Tarnier. The second big French figure in the story is a successor, a person named Pierre Boudin. And Boudin will continue to carry on Tarnier's work with incubator. I think I should have a skip to one thing. Tarnier not only developed this machine, but he showed and made an impact. And this really needs to be highlighted. He showed that just the act of warming these premature infants were born through an incubator, reduced the mortality of premature babies who are in the 1200 to 2000 gram range from 66 to 38%. That's a pretty big impact. And this is 1880. There are many things where you can have an impact like that. So I think a lot of what Tarnier did that is important is not just the machine, but showing that it makes a difference. Those numbers are so good, we might want to talk a little more about them. Are they totally believable? But that's what he's shown. And now the successor has a different kind of contribution. Pierre Boudin will continue to care premature babies. He's got to write the first. He's another obstetrician who becomes even more of a pediatrician. It turns out in France, in this period, obstetricians are the are become sort of the group of doctors who supervise babies until they're about six months old. So a very different line that is going to happen in other countries like the United States. So there's sort of an OB pediatric suit especially that's forming here, which is I think part of the actually backstory to this. So Boudin is very much in this tradition, he published a book called The Nursing on the Care of Premature Babies and describes the story I've told you about. Actually, Boudin's contribution to the story is not really improving the technology. In fact, he embraces those that second generation really simplified incubator, the one that just says it's basically a box with triangular hot water bottles. Do we even call this technology? It seems so simple, right? But he found it was very effective. But let me show you why he made a big deal of these small incubators. As this shows you where he used them. The idea was these incubators were set up, whereas Tarnier had incubators a separate nursery area, Dan moves them back with the mother's beds. And here are the mothers around the room. And the babies are at the foot of their bed. Boudin wanted the incubators to be made of glass. He wanted the mother to be able to see the baby and connect to the baby. He wanted the mother to be the nurse. He wanted the mother to be breast feeding the baby and to care for them and do the dressing changes because because he made a big point, he said, it's not just enough to save the baby. You must save a baby whose mother is capable of he said suckling it of nursing it. And indeed, Dan will continue to follow the graduates of this. I think what you could say is a mother baby unit, you continue to follow them afterwards in regular clinics, you would see them give advice about breastfeeding, weigh them. In fact, this is the beginning of well childcare. Petitions are not doing this yet. Boudin is against this. He's an obstetrician. So are you getting a sense of this French? There's a style of technology that's happening in France that we can't summarize it by just saying they had incubators. It's a style of medicine that focuses on supporting the mother and technology in some ways is an extension of her. So to kind of summarize that this this Act one of the incubator in France is led by obstetricians. I want to emphasize that. It points to a different possible professional pathway than we eventually had an obstetrics of outlining with pediatrics rather than gyn. The settings in maternity hospitals, cultural contacts of nationalism and this pro natalism that comes out of that. And it centers on supervising the mother promoting breastfeeding, less focus on the technology. These people are not making technology more and more complicated. That's the move in the next part of the story. Doctors like Boudin and Tarnier became heroes in their context for saving all these babies. It was said that Pierre Boudin was eulogized in his death for having saved a battalion of babies for France. And it was later commented that had he lived until 1914, he would have seen the battalion go to their deaths. Unfortunately, you can still go to to Paris and there is a monument to Dr. Tarnier and a mother and a baby. And there's the incubator again. I don't know of any monuments to doctors who took care of premature care for premature babies in the United States shows the enormous cultural weight to this. And yes, although I took this picture much more recently, I did get my trip to Paris as part of my dissertation. So really, that's the French story. And now what I want to do is talk about, how does this technology get from there to the United States? And what, how does it, how is it going to change? And let's say a little bit, talk a bit about what obstacles there were to the incubator spreading. So this French incubator campaign is mainly in cities and maternity, which you have maternity hospitals, which is still only where about 20% of French babies are born, which is still better than other countries. It became hard to apply this to other communities that didn't have babies were born at home. They did try and won't go into that, but it didn't work out very well. How if you want to get impact on future soldiers and workers, you needed to get technology out more broadly, and to babies born at home. And that was hard. To some it felt we needed a different kind of approach or different kind of institution. We can imagine a lot of ways to imagine this. But the interesting thing is that the approach that really takes off is one that focus on better incubators for a different place in the hospital. And here a figure comes in called named Dr. Alexander Leon, who is a he's an inventor. He actually was a chicken incubator, dude, he made lots of fancy chicken incubators. He's watching what's happening here with the babies in Paris. He says, I can make a better incubator. I can because of my chicken incubator work, I got good thermostats, I can put in a ventilation system, so I can keep baby free of infection. I can make something that's stronger, better, and it can compensate for these challenges of bringing baby, taking care of babies. Oh, yeah, mothers may not want to take the babies to the hospital. Hospitals are kind of scary places to take your baby. So Leon said, I'm going to develop a different kind of place that's more hopeful than the hospital. And he developed what are called works for babies translated, charitable works we might translate it as storefront. In the English literature, they're called incubator charities storefront little charities where Leon would set up little incubators wards, okay? And babies can be cared for here. They were supported by spectators, spectators come and watch standing behind the guardrail, watch babies, and that provided a staff of nurses. You can see we're on the slide, the slope now towards the incubator baby show, right? It seems a little crazy to us. But again, parents at the time are very ambivalent to take babies to hospitals. Because very high rate death rate for infants there. So a new setting is more helpful to them. Leon does a lot of promotion. He never publishes a single article in the professional literature as Tonya Boudin did. But he puts out, he does interviews, he does popper magazine articles. Here's a picture of his graduates and these friends, all these were raised in one of his incubator charities. He's put out a message here, right? That these babies can be saved and they can be healthy and strong. And from there, it's a short step as he looks to influence people beyond France to reach out to other countries. World fairs were the big way you promoted technology in those days. If you've been to Smithsonian World's Fair exhibit, it's all about technology. Leon's brilliant insight was we can do this with babies in the exhibit. We'll get a lot more people watching. And he was right. At his first exhibit, which is actually the Berlin exposition of 1896. It was a phenomenally successful, became most popular exhibit at the World's Fair. And this is an image from an English magazine depicting it. And this is a really fascinating image. And it gets us to think about the relationship against the mother and the machine and the baby. Remember in the mainstream French of Cetric tradition, the incubators kind of being downplayed and simplified and the focus on helping the mother breastfeed supporting her. Now we've got incubators that are every bit as big as the mother. Okay, look at the mother looking over incubators like her. That the caption of this magazine article was an artificial foster mother infants at the I apologize the Berlin exposition 1896. I was doing I typed this too late. But their rivals to each other. It's like the machine is coming arrival to the mother. And then on the left of her, there's I don't know if that's a father or a man, but he's looking the whole thing, presumably much more scientific curiosity and attachment, rather than feeling the challenge. Interesting image to me of what's happening here to the incubator. And so these shows come to the United States. And this is the Buffalo Pan American Exposition 1901. And big deal. A whole set of incubators, nurses taken care of the infants. Look at these images and ask yourself are these really side shows. This is I'm not the viewer from St. Louis. This is the St. Louis had had an incubator baby exhibit for the Louisiana Purchase Exposition 1904. And it's quite a remarkable place. Again, full battery of incubators and trained nurses, they had trained doctors covering it. They had a transport service. They even had a doctor who did studies in it. And those of you are actually pediatrics will probably be used to the idea that due to the custom to providing premature babies 120 kilocalories per kilogram per day to get them to grow. Guess where that study was done? The St. Louis World's Fair. That is the John Donahorsky did the first study show coming up with that number. So really, interesting stuff. And amidst all this is Dr. Martin Cooney. Oh, he said he was a doctor. He wasn't really a doctor. That's just what he told the New Yorker. Cooney fabricated a lot of his own story. He somehow he came from Europe, he became interested in the incubator baby show phenomena in Berlin. And he came to the United States and decided that Cooney Island will be a great place for which he could launch incubator baby shows every year. Cooney is an ambiguous figure, I think. And as his main base is in Cooney Island. He toward the end of his life in 1939, he was interviewed by the New Yorker. And he said all my life, I have been making propaganda for the proper care of premature infants. In other words, he presented himself as a propaganda somebody who's trying to get people to take seriously the idea that premature babies can be saved. Is that the message people took for who paid to see us exhibit? This is an infinite incubator exhibit at Cooney Island. It lasted it said to have been the longest lasting exhibit at Cooney Island in 1943. And you can see there's a barker in front somebody who's saying, come on in, you're gonna see these tiny babies. You know, that's definitely a midway or sideshow phenomenon. I think these are somewhat ambivalent exhibits. It's fascinating to think about, are they side shows? Or are they really about promoting technology? I think they're a bit of both quite honestly. Sometimes in the World Bears, they would be put into the sideshow part of the World's Bear, rather than the technology section. One of the big arguments I made in my work was that, whereas most doctors have focused, most writers on this have focused on the sideshow aspect. And, you know, that's there clearly. And it's, it's a pretty weird story and to talk about. I do think that we need to also emphasize the message of technological optimism, that in some ways, we need a picture. This is a time when modern medicine, as we think of it, is just starting to take off. The germ theory is coming about. That's what I'm glad that you called me because when I was And it's a time when this is sort of like, there's a sense, especially in the World Bears, that this is a hopeful technology pointing to the future. I think that's a big element of this. I think it's also sending a message that premature infants could be normal. And that's where I want to kind of shift to the context in the United States, why it would not be so rarely assumed these babies were normal as in France. That carries us into the third of the actor, which is how do we, how do we get from these, the story of age-mater baby shows to the actual beginnings of neon etology as really a legit specialty within the United States? How does that happen? And it faces a lot of obstacles in the United States. It's not that doctors were unaware of it. I mean, you could find medical reports of Tarnier's invention that are appearing in the 1880s, 1890s. And the World Fair Exposition certainly did impart a lot of awareness of what the French doctors were doing. Although they would usually focus on the technology, not the bigger aspects of what they were doing with the mother. So many doctors take note of that and they try to make their own incubators, set them up in hospitals. But the United States, almost all babies are born at home. So the doctors that do this, they're three babies have been brought by a mother into the hospital. Usually the baby gets there, the baby's on the verge of dying, and they don't make it. So the earlier years, to talk about the resistance of why it doesn't work, a lot has to do with the simple, the challenges of trying to use this in a time when hospital birth is very unusual. But the bigger social context in the United States is very important. United States does not have, people in the United States, especially leaders, people who have in shape and are not worried about the population. United States has lots of babies being born. Now, they're being born mainly in the immigrant classes, right? United States, there is some concern from the Anglo-Saxon elites that their group isn't having babies fast enough. They talked about, they didn't talk about the population, they talked about race suicide. They're not having babies the same rate, say, as the Irish and Southern Europeans and Eastern Europeans. So this is a real different context. The prospect of saving a baby is going to feel different in this context. And that doesn't mean that we don't have a crusade to lower infant mortality. 15 to 20% of babies in America, in American cities die before their first birthday as in France. We do launch a crusade to deal with this, but it has a different flavor than what happened in France. The main focus of American infant mortality crusaders in the early 1900s was reduced deaths of older babies from diarrhea, from contaminated milk. And a lot of effort was put into that, with pasteurized milk and the like. The second leading cause of death of infants, which was neonatal mortality, which is mainly premature babies, got a much more ambivalent response among infant mortality crusaders. They weren't so sure they wanted to put a lot of energy into that one. And now I think we get into, this took me a while to my work before I started to realize this. But why was there an ambivalence that could take care of saving a, you know, a 36 weaker, you know, like me, it's like a no brainer. 36 weaker should be the straightforward thing in the world. We should be saying those babies, right? They're not that sick. But in this age, babies are born one to two months early. They weren't just called, first of all, they weren't called preterm. Preterm is our word for early. They were called premature. When you do history, it's not hard when you encounter a word you don't recognize. You know, to look that up. Besides, you see a word and you think you know what it means. But in fact, you don't premature did not mean preterm. It meant not fully mature. And that could be because something is wrong with a baby. And they would use this anonymously with weak, or so they call these babies just weaklings. That's the word used in textbooks at this time, signature weak babies. And here's the thing. It's widely believed that premature birth was according in the words of one writer, nature's way of expelling a defective fetus. So even a baby is just born one to two months early, there is ambivalence about saving that baby. Not because we say we're not worried about immature lungs, because it felt something could be wrong with them selling hereditary. And here's a quotation from one of the leading members of the Children's Bureau, who is giving a big talk in 1915, you know, that the whole folk at a conference that's all about reason for mortality. But when she starts to talk about preemie, she changes her language, says these puny old conditioned babies crowd out her welfare stations and hospitals, many of them die in later infancy, still others live on dragging out in the feeble existences, possibly finally becoming the progenitors of weaklings like themselves. So it's not a quality of life like what was are we just keeping the baby alive for a year or so, the actual fears they will grow up and create more weaklings. Now I think you can start to see why saving even just mildly premature babies is seen with skepticism. And that's just as I'm actually increase this as we go from 1990, 10, 1920, because the United States, my sense is you've talked about this some but the great eugenic movement, a great eugenic movement is sweeping America, reaching its peak in the night around the time of the First World War in 1917 to 20, creating a lot of concern that basically the quality or national stock, if you will, that of the American race is deteriorating. And a fear that we are sliding into a kind of degeneracy. And your locale in Chicago, you may have heard about this story. One of those remarkable one manifestation of eugenics movement was a doctor named Harry Haseldon, who began a campaign where he said, I'm not going to operate on babies with significant birth defects. His name was Harry Haseldon. He got a lot of created a controversy newspaper about that, but he stuck to his guns and became kind of a Dr. Jack Kovorkin, if you recognize that name for the early for the 1910s. And to try to reach out to people, promote his ideas that you shouldn't try to say baby spirit defects. He's a big eugenicist. He produced a silent movie called The Black Stork. And it becomes a big success. And I just show this image that this could be a whole another talk that I've been said by historian Martin Pernin, if you may have heard from, but it's part of the background of again, why premies get lumped together with a variety of other quote unfit people. So now we're at our question. What happened? Let's talk about American leading American doctors. So some of you are probably from Johns Hopkins. I hope you won't be offended by my question by what I'm about to say, but Johns Hopkins likes to think of itself as the beginning of everything great in American medicine, right? It's the Johns Hopkins hospital and it really was the great innovator of American medicine in the 1890s, 1900s. By all, we would expect neonatology to have been born at Johns Hopkins, okay? That's what should be expected. But it wasn't. It wasn't. This is a picture of the Dr. J. Whitridge Williams. The head obstetrician at Hopkins wrote Williams obstetrics, the textbook that I grew up with, a very influential figure, probably most influential obstetrician in America. He ran the OB service. He's a national authority. But with the nursery, he has really very much a hands-off attitude toward the newborn nursery. And I found records of what happened there. When babies were born, after babies were born, they're pretty much left to the care of the mothers and nurses, mainly the mothers. Premature babies is the same thing. It was kind of left to the mother. And if a premature baby died within as late as two weeks, it would just be called a stillborn. And that remarkable stillborn, that label lasts until two weeks. Williams believed that a lot of these deaths of these mild premature babies were actually from congenital syphilis. And yet he did studies where he lumped together fetal deaths and his quote, stillbirths and came up with stats to pass that, to substantiate that. So Williams, and Williams comes from this very genteel upper crust background. I think you can see how some of these eugenic fears of the unfit propagated cells would resonate with him. So this doesn't take off in Johns Hopkins. This is a bigger story than just Johns Hopkins. I've mentioned that in France, OB and pediatrics were kind of coming together. Okay. And it seemed to be starting to form their own specialty. In the United States, this climate of eugenics and ambivalence by taking care of small babies, obstetrics don't really see much to gain about alliance with pediatrics. They see much more to gain about alliance with surgery. So in America, obstetrics joins the surgery and comes OB-GYN. And yes, it'll do that eventually in France as well. But that's what happens this time period. This was really tragic for newborns. A lot of what happened in France was because you had these OB-Peds people. They were true peridatologists. In America, that doesn't happen. And it's even more tragic because as you get to 1915, 1920, now finally, most childbirths are moving into the hospital. So it really was plausible that we could provide incubator care. And yet this happened as the OBs are losing interest. So the literature of the time uses this, begins to, many doctors writing the medical literature of the time, begin to describe the newborn nursery as a no man's land. This of course being a phrase borrowed from the First World War. No man's land, though, in this case, it's not between the Germans and the French, but between the two specialties. Obstetricians control the nurseries, but that really do little for the infants. And premature babies who die are basically left alone and called stillbirths. Pediatricians do have more interest, but they don't have much access. They can't access a lot of these nurseries. And honestly, I'm not sure much they could have done because they don't really appreciate breastfeeding. They would have probably given babies their formula, which would have its own issues. This distinction between OB and Peds and the no man's land phenomenon is most striking in the East Coast cities, the most established hospitals, the most famous hospitals, if you will, also have these most entrenched boundary lines. And now at last, we get to Chicago, because it turns out, I think what I was trying to say, these boundaries get less strict in the Midwest and the West. I mean, I think about how when I did my residency in Colorado, I learned to do circumcision, and we did them, not OB. It's a more fluid boundary. So Chicago turns out, things are more fluid between OB and Peds. And so Chicago is beautiful. Obstetrician, Joseph Delis actually goes about the only Obstetrician America who really follows up on that French OB Peds tradition at first. He is a great inter, he remembers the interventionist in childbirth. Actually, I think I've got a bigger picture here, sorry about that. Delis will eventually become Williams's great rival and become very important OB here. He's utterly different than Williams at Hopkins, though. Williams is Eastern European Jewish background. He represents the kind of people that the upper crust despised, if you will. And it kind of makes sense that I don't think the themes of eugenics resonated with Delis, the way they might have had with some of the East Coast Gentry. Delis, there's a lot of interesting things promoting midwifery among the poor, but also routine forceps among the wealthy. He sets up an incubator baby station and it's the first one in the United States. He sets up something that's lying hotly on incubators, trained nurses, and he sees you on the right track, but he runs out of money. It is expensive. He can't support the nurses. And philanthropy, he couldn't raise the money through philanthropy. So his story is not long-lasting, but it begins to bring, and by the way, we can think about why philanthropy didn't come to the rescue right. This is a questionable cause he's promoting probably to plan for us. Anyway, he leaves this, but plants a seed where Chicago is going to move forward. It turns out before Delis closed the nursery, he moves this station, the incubator station, to a pediatrician named Isaac Apt. You know, anything about pediatric history, he's one of the most famous pediatricians in the United States. Apt leaves it, but then another pediatrician who was an associate of Apt takes his own interest in the premature baby, and he won't work with Delis because he mentioned himself. This is Julius Hess who he mentioned before. It does seem that one spark for Julius Hess was he was aware of Martin Cooney's work, who Martin Cooney apparently came to Chicago's white city one time, but I think Hess's interest goes as deep in that. I think it connects to Delis and Apt and these people in Chicago before. So look at the Hess bet and Hess's incubator. It's basically a metal shield and that's heated. It has made a big deal. You don't want to over-stimulate the baby. You want to handle them as little as possible, shield them and stimulate. Really, the heart of Hess's nursery is to emphasize the role of the neonatal nurse. And in Hess's nursery, nurses, not doctors, do almost all the work. The doctors like Hess would just round once in the morning and then nurse everything else. They develop protocols to care for these babies. And the doctors would get reprimanded if they tried to do too much with the babies. The nurses besides protocols, again, develop this philosophy of handle the baby as little as possible. Don't deplete them of energy. Sort of think of problem prematurity as a lack of energy. And they raise with these protocols and really protocols that historians at this time write about what they call scientific motherhood. How to raise a baby by the protocols of science. These nurses are really much doing that. Hess's own work isn't to care for these babies day to day, but is to try to counter the charges of eugenesis. And his research is all outcome research. And he uses IQ tests. IQ tests, of course, were again, at least not states, they were developed by eugenesis. They weren't invented by them, but they were developed by them. He uses IQ tests to study the long-term outcomes of his graduates. And in a big book, he publishes, he shows that they actually grow up into children with comfortable IQ to those of other children. And it's a wonderful thing. This will eventually start to make the care of premature babies respectable. Actually, to think about what's happening here with this nursery. Why did I call this eugenic nursery? You know, you kind of wonder what was this philosophy of minimal handling basically selecting for babies who were just kind of hearty survivors who just got a tough protoblast more meant to live. So therefore, they did okay. And the babies who were delicate just wouldn't have made it. I don't know. But there's a sense it's the kind of nursery that's compatible with eugenics. That's why I mean this is so different than what we saw in France. Hexper makes this textbook. Here's the title, premature and congenitally disease infants. He's drawing a firm line here between the early baby and the baby whose comes him as hereditary disease. And that, I think, is a very firm moral line that he's created. So this is a key, this is sort of the climax of this 3x story, you know, that now the incubators adapted to the United States. That's really changed the process and fitted the context of eugenics. Well, this all seems like a long, let's take a deep breath, stand up. This takes feels like a long time ago, right? It feels like a story that seems utterly different than the story of the modern intensive care nursery. And I don't there's a whole other story about the rise of the intensive care nursery. We can talk about it in the questions. I don't think I want to go into it too much here. But it's a story that involves the rise of high oxygen therapy and then the retro-linal fibroplasia, but not the maturity epidemic that leads to a backlash against the hands-off method and the incorporation of precise control of the babies in the 1960s and finally the rise of lots of technology. I'm going to just skip these slides because I'm running out of time. I'm playing this on the introduction, I'm saying too much about me. But by the 1970s, you have the rise, in the 60s and 70s, the rise of what we think was the intensive care nursery. Now some ventilators, monitors, IVs, all this stuff, it's so traumatizing. It's not developed through RCTs, but through this very messy process of just trying things and seeing what works. Before the 70s, there's very little public debate about any of it, and whether limits are being transcended. It's kind of remarkable, it's just all happening behind the scenes. But an ethical backlash does happen, not too long before I started to be exposed to it. And the interesting thing about this ethical debate in the 70s is that it's said not in the care of the premature babies who are being saved, but rather the world called the congenital handicapped infants. So when you talk to ethicists about the milestones of this time period, one of the milestones was that film produced, it's called about the Hopkins, about a baby at Johns Hopkins who had Down syndrome and was allowed to die without intervention. And this was shown in ethics conferences around the country. Again, think about how it's really a story of, it's a focus on a quote, congenally a baby who would have been recognizable as the kind of baby the genesis would have had concerns about. A famous milestone in the rise of neonatal bioethics was an article by two people who read that, two doctors running the Yale special care nursery who wrote an article about how babies with things like Down syndrome, congenital anomalies, or spina bifida were pretty much allowed to not get any intervention. We're just kind of kept apart. Let's get a lot of controversy when it came out. Again, I see continuity here in some of what's happened in the early 20th century. When I was in the nursery, the big controversy was the baby dough controversy. An infant born with Down syndrome and a salvageal atresia, something that is prepared, there was difficulty. The parents felt the surgery was not in the interest of the child, they declined it. But the baby un-morphine, the baby, the possible went to court but the baby did die. And this was the controversy that then caused the Reagan administration to respond in a sort of a pro-life kind of way saying that these babies with handicaps who are not being given expected therapy, at least set up a hotline for anybody who's psyched a baby is being under-treated to call and report the infection. A lot going on here and to be fair, there really was a lot of disturbing thinking and not treating some of these infants. But it was a big controversy that was happening while I was being trained and led to the debates we have today about how do you define things like futility in infant care and quality of life. And those were the buzz words of this time period to lead your way out of these difficult issues. And both those words turned out to be very problematic. Let's think you guys know, you know, futility decisions kind of highlighted how hard it was to make judgments about that without better data. The data was often lacking. And quality of life was just showing to be a very problematic concept that doctors tended to rate quality of life of preemie, of preemie's futures. Doctors tended to rate quality of life much lower than their parents did. So it was all really quite a mess. And I really just wanted to kind of give you a flavor of that later period because I know that's a whole another talk. I just wanted to give you an exposure, probably to see you know that I'm aware of it. But I want to just end up by just making a couple of comments about, you know, really, is there any relevance of this earlier story? You know, it's pretty obvious that that last story has relevance to the day. But what about this early story? You know, story from 1880 to 1920. And in closing, I'm going to argue that this story was important. And a way to think about it is to think that it's, it was in these years that doctors staked out the territory of neonatal medicine for themselves that pediatricians in particular did. So here's a dreadful American painting, although a pretty famous one called American Progress by John Gast, depicting the taming of the American frontier. And it's a picture that shows technology having a pretty important role. Just like when we tell the story of neonatal technology, it's often told the story of technology expanding frontiers of viability. Here's the railway, the telegraph steamships all moving forward to tame this empty wilderness in the painting. But just as in the painting, it wasn't really an empty wilderness, right? This was a, there were Native Americans living that wilderness. Okay. They are, they're marginalized this image. The image also doesn't make you forget that, yeah, there's other groups that were contesting for this territory, even besides Native Americans. There was Mexico, there was Canada, all of these for contesting. And especially this reminds us that, you know, we take for granted the borders of the United States, but there's nothing for granted, nothing inevitable about the United States having borders it has. It's a part of history. Similar, I think history is not just about showing us how we got to the present. It, to me, history is more about, I always think that history might have gone a different direction. That our present is not the inevitable product of history. It spurs us to think about other possibilities that might have happened in development, in this case of neonatal medicine. And some of the things I think I hope they've come through in this talk are this made, this made me return to the present thanking about how really the boundary between OB and pediatrics is just really an unnatural thing. It's really bad when I work in the nursery and I see the babies, but I don't know what's going on with the mothers. And pediatricians do have sort of a, you know, both of us, Obies and Peas, we take care of both mothers and babies. But we both, you know, we were sort of led to focus on one to the exclusion of the other. That's the way that our specialization is focused, shape our moral formation. This theme of the ICU nurses substitute mother. Mothers were not replaced by machines in this story. They were actually, it was only when nurses came that they were the ones who made it palatable to think of a baby being cared for in a hospital. And I, I find that a powerful idea. Quite frankly, when I was a resident, I was kind of resentful of the nurses because they're always telling me what to do and reprimanding me. But now I can really see there this great wisdom as representatives of the mother. And they stand in this long tradition, a space, the no man space created a space for women where nurses became very powerful. And the last thing we may want to think about is how is this older, you know, this powerful cultural tradition of eugenics, how is that still shaped us today? I did not think of myself as having connections to that when I was feeling like I was overtreating premature babies. I do think a lot of that, my moral distress came from just being in a closed space and doing painful procedures to infants. But I do wonder if I was too quick to underestimate the quality of life these babies can have. Okay. And certainly later on in my career, I realized I definitely had, once I became a general nutrition, because they are these babies long term. So that is it for what I wanted to share. And I did not see any questions because I've been on the screen on our, what do we call it, the slideshow mode that would be happy to take any comments or questions or Okay, well, I'm going to start about right. I'm just going to start, not outrage, but thank you. And we always, the people just have to get to their computers. I just want to comment a couple of things. First of all, I thought that was an absolutely superb lecture. I love how you made the narrative understandable. I love the way you brought in these other things that people would not anticipate. And really, as I said beforehand, show the fact that you're exactly right. These are not a fate of complete. I mean, I remember the first Chicago hospital was a hospital built by a woman named Mary Harris Thompson. And it was for the widows and orphans of the Civil War. And so in some ways, there's a natural correlation diseases of women and children, right? But it's interesting how those things, you know, come apart, go together the way we think about it. Just a personal Chicago connection. I'm sure you know this because I'm sure you did this for your book is, you know, Hess's papers are in the special collections archives. And I bet you there's a lot more treasures. Now, one of the things we're going to do, I'm going to let Peggy talk in a minute and see if Luke wants to say something. But one of the things we're going to do after this lecture series is put together a list of resources for people who are interested to continue learning about these areas that you've highlighted, you know, the whole Cooney and, you know, Isaac apt. And we didn't even talk about Chicago lying in hospital and Dali who's a fascinating character. And you know, I'm actually sitting right now as we speak in what they call the old CLI Chicago lying in hospital. But let me let some of the people who are in the audience, especially Peggy start. Thanks. I loved your talk. And I have lots of questions for you that I'll I'll wait for in our after session. But I wondered whether you could just give the the spiel on Virginia after that you skipped. Yeah, sorry. I do try to respect the deadlines. So, so when I try to tell the story of the rise of the shift from the hands-off nursery to the interventionist nursery, I try to do it just like five slides. And I didn't even have time for that today. I do think that was Virginia Abgar's score was one of the critical moments when she dealt with score to rate, you know, the condition of the baby has been resuscitated. The idea that every baby gets rated and resuscitated if possible, that ends the fiction of the late stillborn baby. OK, this old idea that you call babies stillborn even if they died a few days later, that goes away. And it leads to a more aggressive approach. So I think that really is an important turning point of that sense. Thanks for that question. Answering Deb Warner. The leaves papers are now in Kansas. When I was did my research, I have looked at Hess's paper. The leaves papers were Northwest Memorial. I think had papers that stored them in this place in South Chicago. And it was such a dangerous archive that when I went there, the cab driver would not pick me up again. And the archivist had to drive me out. So yeah, medical history is actually more dangerous than you might expect. And actually before Luke talks, I just want to say one thing in public is that Deli was courted heavily by U of C and he was very much afraid that his maternity hospital would get taken over by the University of Chicago, the big academic place. And he was only chairman of OB for two years. He actually was very afraid of exactly the thing that happened to him. So, you know, just as you said, learning the history, you know, on one hand, we, you know, venerate Deli, but Deli was a very complicated person and did great things and complicated things. And today, I don't think he would have been loved the same way he was in his time, but Luke, you're on. I'm a little bit off topic here, but relating to the very last thing you said is that over time, you think you underestimated the quality of life in these premature infants. What I'm curious if you can talk more about that and what caused you in your experience, general pediatricians to kind of make that a sense. So thanks, Luke. Why did I, what do I mean? Why say I underestimated the quality of life for a lot of babies I was caring for? Well, I am speaking about me when I was a resident, okay? And gosh, I, we had a, in the U.S. of Colorado, there was a ICN, but we had, there was a little award called the chronic care unit for the ex-premies because you're in Colorado, there's no oxygen, so we couldn't get them home. And they would say they're months and months. And when every night I'd be on call every third or fourth night, I would get paged up invariably to one of them to code them, essentially. And it was really emotionally traumatic for me as it was for all of us. It was hard to imagine a good future for a full pre-me when you were experiencing something like that kind of thing over and over. And I think, I don't want to go to tell about how I reacted, but I think I was kind of known for a lot of dark humor about how premature babies and things like that, and that's how I survived that. No one would ever who knew me as a resident would ever suspect that 10, 15 years down the road I would become one of the main doctors carrying free children with special needs. It was a utter shift and I got out into a different world once I started seeing children, seeing the graduates and seeing them regularly and seeing them not in the pathological world of the hospital, but the world of seeing them with their families, seeing them coming from the home. I had a really different view of them. And that's what I'm trying to describe. I feel like I was mainly shaped by immediate context. I still wonder if there's some indirect role that just sort of cultural language that's floating in the air was still shaping me to be less be more pessimistic about these babies. But surely the big factor was I just never saw the mothers or parents very much in the hospital. Later on I really did. I saw how these babies had meaningful lives with them. I didn't know that. Yeah. And we both trained in the 80s which was a really different era. But let me let our friend Chris Krenner from Kansas. Dr. Krenner. Hello. Thank you and great talk. I really enjoyed it and I wanted to say we've got a few of our medical students, our top medical students from the University of Kansas are also sitting in here. So thank you so much. I wanted to ask about the divide between hospital and home and a lot of the story early is about what would have been a minor part of medical care in hospitals. When did babies start being brought in from homebirth to come into the hospital? And a little bit you might. I wondered about how eugenics plays out in a different setting hospitals at this time where you know the resource of the of urban immigrant populations which would have been sort of a tar natural target. But is there a eugenics that plays out outside the hospital in these kind of birth stories? Or is it or how does it shift curious? Well, lots of questions here. But thanks again. And you could hear your insights. Thank you. Thank you, Chris. The first one, I think I understand better than the second one because it's better documented. But see, here's the thing that's really important to understand about infant hospital, about children's hospitals in the late 1800s and very early 19. They evolved out of what were previously known as family hospitals. Places, institutions where one would take a baby who's being abandoned. Okay. And this was a huge issue. New York had a giant family hospital. It had to close its doors within four months after 1,200 babies have been left there. And those kind of institutions which were initially were just death traps. All these babies were brought in and they couldn't possibly take care of them. They gradually get taken over by doctors and get turned into the early infant and children's hospitals. Okay. But parents aren't so quick to be sure that they, these institutions say they still have a lot of connotations of death from standpoint of parents. The mortality rate what I understand infants under one year who put into an infant hospital say around 1900 in New York. It's about 50% death rate. They just didn't do well at all. I think people are aware of that. So imagine now you have a baby born at home. It's really delicate. And yeah, the hospital is an option but you know that very high chance your baby is going to die there. You're probably not going to rush your infant down there. You're going to do what you can before you do that. Before you take the baby there. And indeed that's what I found when I studied the records. I initially assumed that the problem for the infant hospitals in this context was that mothers try to get the babies really quickly to the hospital. But even of course a few hours they deteriorated. That wasn't it. Most mothers brought the babies to the hospital after several days not after a few hours. They clearly were trying what they could at home and only the ones who they couldn't save where they bring in the hospital. And then at that point it was too late. And the doctors who tried to save those baby incubators they literally would have a 90% plus death rate. So that helped a little bit. I'm really glad you asked that question because I didn't it has a chapter in the book who didn't make it into the talk. I need to restate you the other question if you want to try that again. I didn't tell them again. Sorry. But there might be other things to talk about. I was thinking about eugenics and it obviously is easier to picture in the hospital setting where it is a vulnerable population. But I wondered if in a period when not so many newborn children are coming into the hospital it's still it's a factor somehow and how that if there's a different place different advice outside the hospital than inside the hospital. Okay. Thank you. Now I got it. Now I got it. So I was kind of surprised when I the first group of sources I looked at and doing this project so long ago were the pediatricians and they never wrote about eugenics. They just talked about the technology trying to save the babies. It reminded me of modern neonatologists who I've interviewed in the 70s and I said did race influence what you do? And they said no we were colorblind they all looked the same. They never talk about it. And I I didn't see I only saw the eugenics stuff coming up explicitly when I shifted focus from the doctors to the people working for health departments the woman who are doing the visiting home nurses who after 1910-1920 you get health departments are being to send mothers to do a home visit they're sitting I'm sorry nurses to do home visits and they visit all newborns that they say New York and that's when you start to see these comments about that slide for example I showed you about these puny you'll condition influence are going to crowd our institutions that comes from one of those people they're the ones to express the ambivalence and they often use that word weakly rather than premature too that side does that help that that's that's where I saw it. That's the question those are good helpful clarifying questions I think because things I didn't talk about Peggy you want to continue the conversation yeah I'm curious the Who Shall Survive movie is a great movie and and the version that's available through Indiana University has a post-movie conversation between Bob Cook and Bill Curran Cindy Callahan and a couple other people which and it's super super interesting to to listen to and it and it seems as though it was primed to make an impact but it didn't in my opinion it didn't make an impact on the public I think it might have made an impact a lot of impact on physicians but public awareness of this didn't of the non-treatment issue didn't really come about until the baby doh cases of the early 80s and then in the mid 80s there was a reporter named Carlton Sherwood from CNN that did a three-part series that's amazing amazingly hard hitting it's available through the Minnesota's disabilities site and he goes through the Spina Bifida cases from Oklahoma that the non-treatment of the non-treatment algorithm of I think it was Richard Gross and then he includes the whole Who Shall Survive movie which is only nine minutes long in the final piece of it and I'm curious if I can't I don't actually know how to do research on media so if that had any effect on the public's perception of the treatment of disabled children or if it just fell on deaf ears I don't know CNN was I guess somewhat new in them at the time did it make any impact did it have any effect and more generally if you have any comments on the Oklahoma Spina Bifida situation I'd be interested in those really good questions Dougie I really am more of a historian of this early period and I have an amateur's knowledge of the later period but I would not I moved to other areas after this okay so I you're raising some really interesting questions that I would like to know more about it does I share your opinion that the movies of the 70s really didn't seem to have much broader cultural impact at that point maybe do had more CNN that's really fascinating I don't I don't know are you are you going to study this yourself yeah I'm I'm working on a book where this is the context and sort of the 71 to the the 71 case to the baby does of the 80s and the Danville twins and the Spina Bifida so that's the context in which I'd like to situate my story I have to tell can you write me offline I would love I would love to yeah and you know yeah yeah yes thanks Deb for that the reference yeah I came close to doing part to you but I didn't happens that's the dang thing I've been a doctor you just do all this I understand anyway those are really great questions I think they really point to where this is the study Lordus Rodriguez you want to take the floor I thank you so much so I'm sorry about the background so I'm actually currently a student at UChicago and I'm really I don't know I found your talk really interesting thank you so much for presenting if I may ask a quick question about I understand that part of like the early French developments did also include follow-up with some of the graduates have been with some of the graduates of neonatal and perinatal care what I'm wondering is that did that also follow through when when hospitals within the U.S. or just like different institutions within the U.S. started to adopt the practice of taking care of those infants yeah really really great question Lordus really good question did it was it picked up on the practice of following up the babies with that picked up in the United States and not it was picked up by a different group of people so I really so I told you so the obstrations first of all don't do it so much okay because they and I say it's focused I've mentioned much more on the mother and intervention with the mother so they they really don't do it as far as I can see at this period pediatricians addressing infant mortality were all about giving the baby clean milk and it's called milk stations early 1900s and they didn't work because you could give the baby a nice bottle of pasteurized milk they take them to their house and they spoil and the baby still gets E. coli okay so by about 1910 there's a pushback push for a different approach to reduce an infant mortality and it's realized it's not enough to give the baby a bottle of milk you need to educate the mother and so the person who actually introduces this approach supervising the mother to United States is not an obstetrician it's not a pediatrician it's Sarah Josephine Baker the first woman physician who directed New York's Bureau of Child Infant Hygiene she's a woman who couldn't she went and led into the pediatric club she creates a different kind of career focused on infant welfare I'm sorry infant public health I'm sorry and she discovers Boudin's work okay in France and says we can do this and she takes the city's nurses and doctors to supervise the babies so that's what happens here so a little bit of a complicated story so it influences us but not among the obstetricians we could maybe see Julius Hess's studies of the IQ of babies long term as being kind of echoing that but I think Sarah Josephine Baker would really be my vote for who picks up on this so before we let you go Jeff I just wanted to say one thing is I love the fact that your traumatic experience in the NICU kind of propelled you into this work and in some ways it's a good example of how our clinical lives can really move us forward whether it's in positive or in anxiety-provoking ways that make us really want to come to terms with things and I just want to thank you on behalf of the McLean Center and give you at least a few minutes to get up and stretch your legs before you're on the afternoon session and thank you on behalf of all of us I thought that talk was outstanding and thanks Deb for all the typing there where you're helping us find all these resources I promise to share them over time with this entire group