NEONATOLOGY ON THE WEB

Incubators and Milk Laboratory Feeding

That the value of the incubator is not as frequently appreciated as it should be, and I believe will be in the future, is my reason for craving the indulgence of the Association for a few moments. I should also like to intersperse the subject with a few remarks on milk laboratory feeding, with the hope only that both of these subjects will be more fully considered by the profession. L. M. Rotch, of Harvard University, in his excellent lectures on "Pediatrics," calls attention to the fact that the word incubator, as applied to the various devices for keeping up the animal heat of the infant, is a misnomer. He claims, as the object gained by such an apparatus is analogous to the work done in keeping up the heat and preserving the lives of young chickens after they are hatched, that the word brooder would be more applicable -- that is to say, he considers the incubator a hatcher, a brooder, a prolonger of life. Some authorities, among them the late Noah Webster, apply the word brooder to the hen sitting over and covering her eggs, or "hatching"; he also, with the others, defines the word brooder as a hen sitting over to cover and cherish her chickens. So that while the word incubator is defined and is strictly applicable only to the act of sitting on eggs for the purpose of hatching young or for producing young from eggs by artificial heat, and in a medical sense should not at all apply to preserving the lives of premature or puny infants, yet his term brooder, while much more sensible and accurate, may properly be applied to either eggs or chickens, and does not, in my opinion, quite meet the requirements called for by these infant life-preservers; to me his own most perfect machine, which he calls a brooder for premature infants, with the Tarnier, the Worcester, the Truax incubator, and all such appliances devised for this purpose, would be much more appropriately called premature life-preservers than either brooder or incubator. However, be their name what it may, let us with Rotch determine that the life of premature infants shall be preserved in the future more persistently than it has been in the past, whether such children be brought into the world at the twenty-fourth, twenty-eighth, or thirty-second week of intrauterine existence, or later. If they are puny, weakly, and apparently dying, a life-preserver may save them when the cotton wrapping and fancy basket now so much in vogue will utterly fail, especially with clumsy nursing. To use the life-preserver intelligently one needs only to read and apply Rotch's lectures on "Premature Infants" and "Infant Feeding and the General Principles of Examination and Treatment," delivered at Harvard. He treats the subject so thoroughly as to satisfy the most exacting student of infant preservation. I desire to reiterate in most respects, though not all, his remarks with reference to milk laboratories, whose food for premature infants, he says, when carefully prepared, is far superior to all foods, even breast-feeding. This assertion is very strong indeed, and from such an eminent authority is very conclusive. I would take exception to the latter portion of this assertion -- namely, that it is better than breast-feeding -- for while I take pleasure in lauding to the utmost the excellent results obtained from this method of artificial feeding for either premature or delicate infants, I would not give it precedence over breast-feeding by a healthy mother, and I will add that which may give strength to Rotch's assertion, that very few who give birth to premature children are themselves perfectly healthy.

I have been very favorably impressed with the excellence of the work done with the laboratory milk, every child for whom I have prescribed it seeming to do better; at the same time I deplore the fact that the cost of this almost perfect food, while very moderate considering the great amount of labor and expense involved in conducting the laboratories with their limited patronage, is as yet very much beyond the reach of the people whose babes are most likely to require such a product, and I look forward with just the least ray of hope to a time when the governments at Washington and at Ottawa shall see to it that we are represented by one of our profession, who shall be secretary or commissioner of health, having authority to establish just such laboratories, "be they milk, vaccine, antitoxin, or other laboratories," where everything necessary may be done for the preservation of the lives of premature infants and the thousands of full-term infants and puny children who die each year from starvation because of their inability to digest either unhealthy mother's milk, unhealthy cow's or even sterilized milk, or the prepared foods, while a milk especially prepared by prescription in a properly conducted milk laboratory could in very many such instances be retained, digested, and assimilated.

I also firmly believe that many lives of those prematurely born might be saved by resorting to an incubator, which can be easily obtained in cities at any of the physicians' supply houses. Or when one is unable to obtain one quickly because of its cost, or of the time and distance being too great to overcome, how easy it is to take a wooden box, 36 inches long, 24 inches wide, and 36 inches high; fasten or swing on the inside, upon a couple of narrow boards, iron rods, or straps, a shelf, 24 inches long by 15 inches wide and 3/4 inch thick, at 12 inches from the top, for the reception of a mattress or pillow upon which to lay the baby; loosen one of the side bottom boards, which should again be attached to the board above or the bottom of the box below by two leather or small brass hinges, so that it may be opened or closed at will for the reception of hot-water bottles, any number of which may be used to regulate the temperature, which should be kept at from 80° to 90° F., beginning with the latter temperature, which should usually be maintained for five or six days; then with three or four air holes, about 2 inches in diameter, at or near the bottom, for admitting fresh air, and a similar number at top for the exit of foul air; with a glass cover or old window frame hinged as a top through which the baby may be observed and cared for, and a good thermometer placed on the inside, where it may easily be seen, the apparatus is complete. With such a brooder, costing almost nothing, a careful nurse may succeed admirably in saving lives that could not possibly be saved without resorting to some such enclosure, for the amount of heat necessary to the lives of these infants cannot be maintained in an atmosphere compatible with the good health of the adult; besides, a too frequent changing of nurses will be required where a large room is used whose atmosphere is kept up to a temperature of 32.2° C. (90° F.), and these changes, with the difference in handling, are not at all to the liking or the well-being of the child.

The accompanying sketch of one of the boxes will show you better than words how cheap, simple, and quickly a useful life-preserver may be made. Such an arrangement will answer almost as well as the highest priced product; of this fact I have had an opportunity to know, for, while one of these boxes was being used, less than a mile distant the premature grandchild of a noted millionaire was rolling in the luxury of a five hundred dollar incubator. Our little tot was just as happy, and I know succeeded quite as well. A third child, whose life had almost flickered from its spare and bony receptacle, was preserved by the aid of the Truax incubator, a cut of which I show you, and by the watchful care of very efficient and attentive trained nurses.

The history of almost all delicate premature babies is similar. They become cyanosed, pulseless, unable to swallow; when an effort is made to feed them the food is regurgitated, so that feeding by rectum must be resorted to. This is accounted for in some measure by the undeveloped condition of the stomach, which at eight months may only measure 3.7 X 1.8 centimetres (1 1/2 X 11/16 inches), weigh 14 to 15 grammes, and have a capacity of 7 or 8 cubic centimetres.

The animal heat of prematures, in consequence of their early birth, is naturally deficient and is easily disturbed by an irregular or cold air, hence for this an equable and higher temperature is necessary.

The heart of each of the infants in whom I found it necessary to resort to the life-preserver showed a distinct murmur. This was especially true in Baby A. in the Truax incubator. This was observed frequently by the trained nurses and also by another physician who was called in my absence because of threatening heart failure and convulsions of the child, and who had so little hope of the child living that he informed the nurse he would not prescribe.

I will now, in closing, simply call your attention to cuts of the life-preservers used by me. Fig. 1 is a rough box made up and used as described in the paper. I keep it on hand to lend or use as occasion may require. It will answer nearly all purposes of a first-class, high-priced life-preserver. Its cost was about one dollar and a quarter. Fig. 2 is a sectional view of Fig. 1. Pipes could easily be distributed through it where the bottles show, and a piece of hose fastened to them and to any kitchen kettle, so that steam from the kettle could circulate and heat the box, at a cost of less than four dollars. Of course the kettle lid would either have to be weighted down or fastened down with a wire or cord to give a little more pressure of steam. Such a life-preserver will cost less than five dollars complete. It will be efficient and harmless. Fig. 3 shows a cut of what I consider an ideal life-preserver, the principal features of which have been described by Rotch as his brooder. It may be made either of wood or metal, preferably the latter. The preserver proper may be used upon or off its carriage, slots for the carriage axles being placed beneath. All life-preservers should, when possible, have side lights, so that the mother or nurse may see the child and the thermometer while they are in bed or resting. A bell with battery should be attached, as was in the Truax, to notify the nurse when the temperature is too high or too low. But these bells must not be depended upon; they are not yet sufficiently sensitive. Fig. 4 is a cut of the Truax, Green & Co.'s incubator used by me.

418 State Street.

	Fig. 1 -- Showing rough box, 3 x 2 x 3 feet, made up in a few minutes, at a cost not to exceed two dollars.
	Fig. 2 -- Sectional view of Fig. 1.
	Fig. 3 -- An ideal premature life-preserver.
	Fig. 4 -- The Truax, Greene & Co. incubator in section.