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Retrolental Fibroplasia: A Modern Parable
by William A. Silverman, M.D.

Chapter 2

The Evolvement of Care for
Feeble and Prematurely Born Infants

Humankind is not exempt from the general biologic rule of reproductive extravagance. In all species of living creatures, the number of individuals who survive the fetal period, birth, and early infancy has been, throughout millenia, only a small fraction of the total number of beings launched at conception. Humanity's place within the balance of competing species was maintained by high rates of reproduction and by attentive nurturing of newborn infants who are immature and dependent as compared with the precocious status of the newborn of many other mammals. Without elaborate techniques of hygiene and supportive care, relatively few human infants can survive the immediate newborn period or the first months of infancy. The toll of life has always been disproportionately high among the smallest, most enfeebled offspring, i.e., those born prematurely or those who are small and weak because of retarded growth or maldevelopment.

However, the concept that these "expected losses" should be prevented is a relatively new idea in human history. Harris presents evidence which suggests that our stone-age ancestors experienced reproductive pressures and consequent environmental depletions which led to the practice of infanticide. He concludes that this strategy (especially the killing of female infants to reduce reproductive potential) was used regularly by prehistoric cultures in order to keep their populations low in relation to the means of subsistence. Infanticide was also practiced by many civilizations; for example, in Roman Law the father of the family was bidden to destroy deformed children. the stabilization of population in Japan between 1726 and 1852 has been attributed to widespread infanticide (the practice was called "mabiki", literally "thinning out"). McKeown has adduced that the modern rise of population is due, in no small part, to the decrease of infanticide in most areas of the world.

Even when rescue of less-than-robust infants was seen as a desirable social goal, the first life-support efforts were halting and crude. In some ancient societies, weak newborn infants were wrapped in wadding or sheep skin, with the wool adhering, to protect them from excessive heat loss. The peasants of Silesia and Westphalia placed feeble infants in a jar full of feathers. In England, the cot or cradle was put close to the hearth, and the fire tended night and day to provide constant heat. Directions for the control of heat exchange between the delicate neonate and his environment are contained in an old quatrain:

Thou, Nurse in swaddling Bands the Babe enfold,
And carefully defend its Limbs from Cold:
If Winter by the Chimney place thy Chair
If Summer, then admit the cooling Air . . .

In 1780, Chaussier experimented with the use of the newly discovered gas, oxygen, in newborn infants who failed to establish normal respirations. Meissner advised, in 1838, that premature and debilitated neonates be given enemas of human milk and two milk baths each day, in addition to oral feedings of mothers' milk. The first specially designed incubator, a double-walled heated tub for human infants, is attributed to von Rühl of St. Petersburg, Russia, in 1835; an identical device was described by Denucé of Bordeaux, France in 1857 (Fig. 2-1), and by Credé at the University of Leipzig in the early 1860s.

Concerted efforts to save infants began following the immense loss of life in France from military action and the months of famine during the seige of Paris in the Franco-Prussian War (1870-1871). In England, the steady fall of the birthrate, beginning in 1871, was cited as evidence for the need to conserve the lives of all infants, ". . . even the prematurely born . . ," for "economic as well as sentimental" reasons.

In 1878, E. S. Tarnier, a leading Parisian obstetrician, visited an exhibition, the Jardin d'Acclimation, and came across a warming chamber for the rearing of poultry, devised by M. Odile Martin of the Paris Zoo. He asked Martin to build a similar box, sufficiently ventilated and large enough to hold one or two premature infants (Fig. 2-2). This was done and the first warm-air incubators were used at the Paris Maternité Hospital in 1880. In a report presented to the Academy of Medicine of France in 1895, the following note appeared:

The minute and delicate care which these weakly [prematurely born ] infants require, especially in winter, to protect them from the cold is so great that till now most of them have died ... since Doctor Tarnier introduced ... the ingenious contrivance, called a "couveuse," a large number of these infants have been saved.

In 1884, Tarnier began to use intragastric tube feedings of human milk (gavage) in the care of premature infants, a technique which was successful in supporting the nutrition of the smallest and most feeble infants who were unable to suck.

Winckel, in 1882, attempted to rear small infants in a womblike warm bath (Fig. 2-3), but the device was impractical and was not widely copied. On the other hand, a giant walk-in incubator (3.6 x 1.8 meters) for infants and their attendants, designed by Colerat in 1886, was imitated. Glassed-in, hot-air rooms were used for many years in a number of large hospitals in Europe and in the United States.

In 1888, Pierre Budin of Paris began to publish articles describing his experience at the Maternité Hospital with the care of premature infants. Through the influence of Madame Henry, formerly chief midwife at this hospital, he established a special department for "weaklings" at the end of 1893. Budin also was appointed to the Clinique Tarnier in 1898 and, under his tutelage, these two hospitals in Paris became the first centers in the world for specialized studies of premature infant care. In ten lectures to his students, published in 1900, Budin enunciated three basic problems in care of the prematurely born:

"1. Their temperature and their chilling;
2. Their feeding;
3. The diseases to which they are prone. "

The Tarnier incubator (improved with a "Regnard regulator," a monitoring device which activated an electric bell to warn against over-warming) was used at Charit´ by Budin to solve the thermal problem. He advocated human milk feedings to solve the second problem by nursing at the breast of mother, or wet nurses when possible. If the infant was unable to suckle, milk was hand-expressed in a trickle into his mouth, fed by spoon into the mouth (or into the nose by means of a special "nasal spoon"), or introduced directly into the stomach by intermittent gavage. Budin began the practice of weighing the infant before and after feeding to calculate the amount of milk taken in 24 hours by infants of different birth size. From this, he concluded that a premature infant should ". . . take, in general, a quantity of milk equal to or a little more than one-fifth of its body-weight" each day.

Proneness to infection was the risk stressed in the third of Budin's considerations. Following a severe epidemic of respiratory infections among premature infants at the Maternite Hospital in 1896, Budin became convinced of the importance of special precautions. In the same year, he proposed the following plan for a special unit:

  1. Grouping together the healthy premature infants;
  2. Isolating the sick and suspect infants;
  3. Separating wet nurses' babies from contact with the premature infants;
  4. Establishing a milk room where "sterilized" milk could be heated;
  5. Keeping the bottles of sterilized milk cool in summer in an ice chamber;
  6. Providing a toilet and dressing room for wet nurses where they were to ". . . wash their hands and face and don an overall" before ministering to their premature infant charges.

These guidelines for the care and feeding of premature infants were adopted slowly and with very little modification throughout the Western world.

The spread of Budin's ideas was spurred on under very curious circumstances. He asked a young associate, Martin Couney, to exhibit the newly modified Tarnier incubator at the World Exposition in Berlin in 1896, and armed him with a letter of introduction to Professor Czerny, an illustrious obstetrician. Couney hit upon the idea of placing live premature infants in the exhibit incubators and asked Czerny's help to obtain the babies. Czerny sent him to Empress Augusta Victoria, the protectress of Berlin's Charity Hospital, who agreed readily, since the premature infants were considered to have very little chance of survival. Couney brought six incubators and an entourage of Budin's nurses to the exposition and named the exhibit "Kinderbrutanstalt". The notion of a "child hatchery" caught the imagination of the Berlin public. Soon there were ribald songs about the exhibit in the beer halls and night clubs, and Couney's infant exhibit, located in the amusement section next to the Congo Village and the Tyrolean Yodelers, became a huge success. Several "batches" of infants were reared at the show and, according to Couney, "there were no deaths".

The following year Couney organized a similar exhibit of the Paris methods of care in Earl's Court, London, at the Victorian Era Exhibition. This exhibit received favorable reports in a number of editorials in the respected medical journal, The Lancet, which commented on the need to adopt these new French techniques to reduce the large number of infant deaths in England due to premature births.

Following these two successful experiences, Martin Couney was launched on a colorful and life-long career. With Madame Louise Recht, a Budin-trained nurse, Couney traveled throughout the United States and the world organizing live premature infant shows at virtually every large exposition. These exhibits grew so in size, that in 1901 at the Pan-American Exposition in Buffalo, New York an imposing building was erected specially for Couney's show of the Budin techniques (Fig. 2-4). (The first incubators purchased by the Children's Hospital of Buffalo were those used in the Pan-American Exposition.) Two years later, in 1903, Couney settled in the United States and his exhibit, for which he charged a 25¢ admission fee, became a fixture at Coney Island every summer for the next four decades. Despite the bizarre side-show setting, he enjoyed a good reputation among obstetricians who referred babies to him for free care. His last "Incubator Baby Exhibit" was in New York at the 1939 World's Fair.

Julius Hess organized the first conventional premature infant station in the United States at the Sarah Morris Hospital, Chicago, in 1922. The methods of care used by Hess and his chief nurse, Evelyn Lundeen, were those developed by the French obstetricians and further popularized by English and German physicians. Hess affirmed the influence of the showman Couney in the preface to his first textbook.

During the first four to five decades after the turn of this century, the care of prematurely born and feeble newborn infants became fairly routine. The results were judged satisfactory on the basis of hospital reports of a slow but steady rise in the survival rate of small neonates, although reliable national and international data were not collected until the late 1940s. The empirical techniques developed in Paris were rigidly applied by the expert nurses who ruled in premature units. Strict isolation measures discouraged traffic in the glass-enclosed rooms and parents had to observe their offspring from a distance; even physicians were discouraged from touching their charges too frequently.

This quiet, cloister-like atmosphere was shattered beyond recognition by the RLF epidemic. Soon after the widespread extent of the disorder was appreciated in the 1940s, it was noted with alarm that the complication seemed to occur most frequently in infants reared in premature infant nurseries with the most highly organized and advanced programs for care!


Fig. 2-1. Warm tub with double-wall jacket first used by Denucé in 1857. Hot water was installed into the top petcock (right) and removed from the bottom spigot.

Fig. 2-2. The Tarnier-Martin couveuse. A double-wall chamber (K) with a glass top (d) and a door (P) opening into the infant compartment. Warming was accomplished by heating water with an oil flame in an external "thermo-syphon" (Th) connected to a large water chamber (W) beneath the infant section. The closed incubator was ventilated by a rising current of warm air (L). Arrows indicate the flow of air from entry ports at the base of the unit, around the water chamber, to exit ports at the top of the baby compartment. Z indicates the opening for water fill; (a) was the emptying pet-cock.

Fig. 2-3. Winckel's warming bath for premature infants, 1882.

Fig. 2-4. The building and interior room with infant incubators for the demonstration-rearing of live premature infants at the Pan-American Exposition, Buffalo, New York, 1901.

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