Although I have taken some pains to search medical literature, a comprehensive account of results obtained at the so-called show incubators was not found. Neither can I find to whom we owe this new method of entertaining and instructing the people. The London Lancet of May 29, 1897, editorially discusses the care of infants in incubators and gives an account of the first public incubators in England. After narrating a brief history of the baby incubators and discussing their success in foreign countries, it is stated that in England the question of incubators is of particular interest, for though the general death-rate of infants had decreased considerably, the death-rate due to premature births had, on the contrary, greatly increased.
Some authorities had placed this increase at 40 per cent. The London tables of mortality show that whereas the deaths registered as due to premature births amounted to 1930 in 1886, this figure rose to 2534 in 1896. "Under these circumstances any successful attempt to improve the construction of incubators and to render this life-saving apparatus available to the general public must be welcome." It is furthermore stated that they "were informed" that this had been achieved at Earl's Court, but does not give any source of the information. In these editorial notes we are informed that Messrs Samuel Schenkein and Martin Coney had opened an exhibition of baby incubators during the Victorian Era Exposition at Earl's Court.
"The main feature of this new incubator is the fact that it requires no constant and skilled care. [!!] It works automatically; both ventilation and heat are maintained without any fluctuation whatever, not only for an hour but for days." The writer evidently obtained his information from the dealers in incubators. He later admitted that the variations were no more than 2° C. The incubators used were the Altmann incubators. From the description I judge that it was a modification of the Lion incubator.
The ventilation was accomplished by a pipe conducted through the wall or window which delivered the air to a box fastened to the side of the incubators, where it was moistened and washed by passing through a layer of cotton over a saucer containing water or an antiseptic solution. We are really surprised to hear that the air passed over an antiseptic solution. This must also be some information obtained from the dealers. Medical science is not aware of any antiseptic which destroys bacteria in the air and at the same time is harmless to breathe, especially for young infants.
The description of the air and heating apparatus corresponds to the incubators used in St. Louis, except that the thermostat was different. The thermostat was in the shape of a W made of two metals, one of which expanded and contracted while the other did not. This unequal expansion turned off the gas or turned down the lamp. It was said to have been very delicate, the slightest change affecting it, etc.
Most remarkable is the assertion that as the incubators were so perfectly constructed skilled attendance was not required, as if the keeping a box up to a constant temperature is the whole difficulty in the care of premature infants.
A further description of the institute is found in the London Lancet of July 17, 1897. After announcing that the members of the press were invited to inspect the incubators at Earl's Court, it is stated that the incubators are in charge of a trained nurse from Paris who is assisted by the wet nurses who furnish food for the infants.
The institute comprises three compartments: On one side were sleeping accommodations for the two wet nurses and the trained nurse; on the opposite side was a nursery where the babies were fed, washed, etc. The public was admitted to the central room where the incubators stood. Messrs Coney and Schenkein, and two physicians attend. We can not but help smiling on reading that the babies were fed every two hours in day time and at night the watchman awakened the nurses every three hours that they might feed the infants. They were generally fed from the breast.
I have given the description of this public incubator institute somewhat at length since it is the only that can be found. That this system had great defects in construction and was defective in its nursing capacity is self-evident. How much improvement these gentlemen accomplished at other institutions of similar character (Berlin, Buffalo and New York) I can not state. That the editor of the Lancet could grow enthusiastic over it only emphasizes the general ignorance of such institutions at that time.
The financial success of the incubator shown at Earl's Court seems to have invited many other showmen to open such an exhibition, and we find Messrs Coney and Schenkein in an open letter (London Lancet, September 18, 1897) deeming it their "duty to warn members of the medical profession, also nurses, parents, and public institutions not to entrust their children to any applicant whatsoever without first taking the precaution to assure themselves that they will not be made the victims of showmen, as well of inexperienced or irresponsible persons who seek to trade upon the established reputation of an invention that has been recognized by both the medical and lay press." Is this not the voice of pure commercialism?
Indeed, in the following year (London Lancet, Feb. 5, 1898) the editor regrets that the success at Earl's Court has attracted the cupidity of public showmen. The methods used at the London World's Fair are attacked especially because the air is not obtained from the outside. The incubators at Barnum & Bailey's Circus seem to have been under better management, but the Lancet indignantly exclaims: "What connection is there between the serious matter of saving human life, and the bearded woman, the dog-faced man, the elephants, the performing horses and pigs, and the clowns and acrobats, that constitute the chief attraction of Olympia!"
Some notion of this incubator is obtained from an editorial in Pediatrics, April 1, 1898. It seems, however, that the periodical obtained most of its data from an English newspaper. I quote -- "one of the most popular of the 'side-shows' at Olympia, now the headquarters of Bailey's Greatest Show on Earth is the baby incubator department. These incubators are of English manufacture throughout, and are, moreover, far more elaborate contrivances than their German and French prototypes. All the infants treated by this method are exceedingly delicate, one of them weighing only 20 ounces, while another is barely 9 inches long, yet it is asserted that between 80 and 90 per cent are saved alive." Then follows a description of the incubator; the air is received from the outside through a metal pipe; the baby lies in a hermetically sealed glass chamber; the air is filtered by passing through cotton which has been impregnated with a powerful germicide. Infants are fed every two hours in the day time and three times at night. The greatest care is taken to prevent their inhalation of the outside air during feeding. Sterilized milk, well diluted, is the food. There is an automatic regulator of the heat, and when anything is wrong an electric bell rings.
We read that in all these incubators the results are very good. But such reports are utterly worthless, since no exact statistics have been published. In order to ascertain whether the results were very good we should have to know the number, age and weight of the babies admitted and the exact death rate. This has never been furnished by physicians in charge of these incubators. Why?
The accusation made against some of them is that babies weighing less than a certain number of ounces and under seven and a half months' gestation are not received, but I have no way of verifying this statement.
The feeling of the medical profession is against the show incubators, of this there can be no doubt. On the one hand there is a prejudice that showmen can not have the proper sentiment toward these little ones and may sacrifice proper requirements of care for show purposes; on the other hand, we feel it degrading to human sentiment to make an exhibition of human misfortunes, especially in the shape of tiny infants. It is perfectly rational, then, to inquire into the advantages that an incubator institute has to offer. In the first place, such an institution, when connected with a large Fair or Exposition is financially able to give these young infants attention which could not be procured otherwise. When it is recalled that each infant at the St. Louis Fair cost the company about $15 a day, the magnitude of the task is apparent, and if this expenditure is life-saving it would be a great boon to the poorer class. Money is necessary to save the life of premature infants. It is questionable whether any hospital or asylum could undertake this work unless the State would give a liberal support.
In the second place, such an institution has a great educational value and, no doubt, these exhibitions have contributed largely to the general feeling that an effort should be made to save premature infants and not allow them to die as a matter of course.
In the third place, such an institution serves the purpose of a hospital where premature infants may be scientifically studied, and in this way advances our knowledge and improves our methods of rearing them. Unfortunately, as far as I am aware, the material at these exhibitions in the past have not been utilized; or, at least, the scientific world has not received any increment to its knowledge from this source. It is for this reason especially that I take pleasure in giving the full particulars of the incubators at the Louisiana Purchase Exhibition, and record the details of our efforts to save life during the three months in which I had charge.
But there is one objection to these exhibitions which must be carefully considered, and this objection holds good for all infant hospitals and asylums -- namely, the death-rate of infants in such institutions is probably much higher than in private families. The danger of "hospitalism" can not be denied, but more of this later.
After all, as long as the people are interested in such exhibitions, and will pay a good admission fee, these institutions will flourish and it behooves the medical profession to see that safeguards are thrown around them, and rules of conduct must be accurately formulated. On the construction and management more will be told later.
The Imperial Concession Company, a company formed principally of St. Louis business men, with Mr. E. M. Bayliss manager, opened the incubators about June 1, 1904. While the purpose of this company was simply to make money, the character of the men governing the institution, precluded the entertainment of the notion that the infants would be neglected in any way. These business men did not claim to know anything about the care of premature infants (neither do the capitalists who build hospitals possess any special knowledge concerning the care of the sick) but they were willing to do anything that science has taught was necessary. Miss Kelly, a trained nurse, who had had considerable experience with premature and other babies was put in charge, a physician was procured who had gone East especially to study the care of these infants, and only trained nurses were employed to take care of the babies.
Everything went very well until the hot weather, when, through some error, a very virulent pathogenic micro-organism was introduced and the catastrophe of an epidemic summer diarrhea started among the babies. The losses of very young babies was increased by the death of several "graduates," and the mortality was altogether higher than was desired. On September 1st the death-rate had been about 50 per cent -- the death-rate of infantile hospitalism.
The attending physician resigned and during the month of August others were employed.
Meanwhile, certain "specialists" in incubator exhibitions, probably chagrined by the fact that they had not obtained the concession, although they had experience in many other expositions, began to assail the management in every conceivable way. Some sensational newspapers tried to make a scandal out of the baby incubators on the Pike.
But the management and the officials of the Exhibition took up the subject; a committee of the best local physicians was appointed to investigate the exhibition and a few changes in the building were ordered, one of which was that a glass partition should separate the incubators from the public. But these alterations, while helpful, had little to do with improving conditions. The catastrophe was almost over. The management spared no expense in trying to remedy every defect. Vast sums were spent in some things which really were impractical -- such as a gas pump to increase the gas pressure, electric heaters, etc. The gas pump failed to operate at times and the electric heating of water was too slow.
How to avoid these catastrophes, as Finkelstein has aptly termed them, has been clearly laid down, but occasionally, in spite of care, it may occur. What seemed especially hard was the bitter attacks of these "specialists" in incubator institutes, although the report of Major Raymond, U.S.A., showed that the death-rate in incubator babies was but 50 per cent. These figures are no higher than those of Adriance -- 60 per cent, and about the same as those of Voorhees', 50 per cent; consequently, these scandalous vituperations were uncalled for.
Still this rivalry among different individuals, who wish to conduct incubators for show purposes, can have only a healthful influence, in that rivals will watch each other and attempt to find fault with the management. This will stimulate all to do their best.
I took charge of the medical management on September 1st, and was ably assisted, first by Dr. O'Neal and later by Dr. F. N. Gordon, who were the resident physicians. I made two, but more often three, visits to the incubators daily. This study then includes our experience from September 1 to November 30, 1904. I feel it would be unjust to make a complete report on the previous experiences of the other physicians as I have incomplete data, but I shall take the liberty to refer to some phases of it, as shown by the clinical records in my possession.
The incubators and nursery were in a brick fireproof building, while the dormitories for nurses and other attendants were in a separate part of the building which was constructed, as most other exposition buildings, of a wooden frame work and staff. (Fig. 1).
The incubators, twelve in number, stood in narrow hall about three feet apart and separated from a large room, in which the public came and went, by a glass partition. This partition was built about the middle of the season on recommendation of the committee appointed by the Board of Health; previous to this the incubators were separated from the public only by an iron railing. Not only were the nurses constantly annoyed by questions from the interested visitors, but the air became surcharged at times with carbon dioxide and obnoxious effluvia from thousands of sight-seers. Hence, I deem it of the utmost importance that the room in which the incubators stand be entirely separated from the public; for the air of a room, no matter how thoroughly ventilated, in which many people congregate is unfit for young infants. Every time the door of an incubator is opened this foul air enters the baby's resting place. There is no easier way to induce the symptom complex of hospitalism. (Fig. 3)
Therefore the air in the visiting room had no connection whatever with the incubator ward, and the air supply, outlet and inlet, was entirely separate. For, to place the incubators in the public room subjects the little ones to grave dangers of intoxication and infection every time the door of the incubator is opened.
The incubator room received the air supply by a large opening in the ceiling at one end, while at the opposite end two large electric exhaust fans continually emptied the atmospheric contents. While the narrow room was, theoretically, too small, practically with this forced ventilation the air remained perfectly pure. During the cold weather the room was heated by a wood-burning stove at one end of the room, almost immediately beneath the opening for the entrance of air. An effort was made to keep the temperature of the air about 75° F., or a little higher. At this end also was a door which opened into the nursery, a corner of which was walled off for a diet kitchen and dressing room. This door remained closed most of the time so that the air from the nursery could not enter the incubator room.
The diet kitchen and dressing room was made from a corner of the nursery, walled off by a thin partition from the nursery and ventilated by an opening in the ceiling and an outlet shaft extending from a few inches from the floor upward and constantly emptied by an electric exhaust fan. The sterilization of the bottles, heating of the thermophores, warming of the milk etc., was done on a gas stove. The objectionable odor of gas was obviated by having a large hood with a flue running to the top of the building. This removed the hot air and combustion products. A trial was made with electric heaters but were found impracticable, since the heating of large quantities of water was too slow. The heat from the gas stove kept the diet kitchen at a temperature of 75 to 85° F. During the cold weather the temperature was kept up by a wood-burning stone which stood near the door of the diet kitchen.
For the purpose of dressing the babies, shelves were attached to each side of the kitchen. Pads of cotton covered with sterilized gauze were laid upon them. Underneath these pads were electrotherms which could be heated if for any reason a premature infant with feeble heating power had to remain in the dressing room for a short time.
Altogether the objectionable features of having the diet kitchen and dressing room together were minimized, but in all such institutions separate rooms should be provided.
The nursery also was separated from the public by large glass windows. It was ventilated by doors and numerous windows, and heated, during part of October and November, by two wood-burning stoves. The floor was covered with linoleum which was thoroughly cleaned every day.
The incubators used were manufactured by the Kny-Scheerer Company, of New York. It is a modification of the Lion incubator. The principal improvement consists in the use of a thermophore placed in a metal drawer in the lower part of the incubator; an improvement probably adopted from the suggestion of L. Furst and others (Berliner Klin. Woch., November 20, 1899). This thermophore is rectangular metal box which contains crystals of some salt (sodium acetate?) which when placed in boiling water liquify. The process of recrystalization going on slowly, the metal box radiates heat for several hours. The principal heating of the incubator is accomplished by means of a coil of metal tubing which contains water. The water pipe extends to the outside of the incubator where it enters a cylinder lined with fire-clay. Within this is a gas flame which heats the water. For most purposes an ordinary Bunsen burner is sufficient. In a few incubators a larger gas heater was employed. (Fig. 4).
The products of combustion from these heaters were carried off by means of a tin pipe running from the top of the heating cylinder through the ceiling of the incubator room. The incubator is made entirely of nickel plated iron, glass and tin. The two sides have large glass windows and the double doors in front are made entirely of glass except a narrow framework. The size of the incubator chamber is -- length, 56 cm., breadth, 46 cm., height, 46 cm. It might with benefit be made a little wider, for a larger chamber would be preferable on account of the greater ease in attending to the baby, and the heating capacity would be more stable. Then, again, the flow of the ventilation would need be less swift.
About 10 cm. above the water coil is a platform made of plated steel wire on which the infant lies, but separated from it by a pad of cotton covered with rubber cloth over which fresh sterilized gauze was placed daily.
The air enters the incubator below the water coil and strikes a flange within the coil which spreads the air current. It rises on all sides of the infant and where the pad is not impervious may pass through the frame. On the top of the chamber is a circular opening for the egress of air. This has a pipe attached in the upper end of which is a small metal fan (anemometer) which by the rapidity of rotation indicates the velocity of outflow. A thermometer is attached on a level of the infant to the side of the incubator walls. A hygrometer is also one of the valuable instruments in each incubator.
The air supply was received through a large tin pipe (diameter, 24 cm.) which extended from the roof of the building through the ceiling and emptied into a similar pipe which ran horizontally the whole length of the incubator room. From this horizontal pipe smaller tubes (diameter, 7 cm.) carried the air to the incubators. The air was forced through these pipes by an electric fan at the opening of the large pipe on the roof. The opening of the pipe was made vertical to preclude water entering the pipe and was covered by a double layer of gauze in order to keep out any large particles which might enter. Immediately below the fan an electric resistance coil heated the air during the cold weather.
The air was again filtered immediately on entering the incubator in a little metal box attached to the side of the incubator. In spreading out under the bedding it passed slowly over the hot water coil and was heated before rising to pass around the baby. The moisture required was obtained principally from an open vessel placed in the same drawer with the thermophore. An additional moisture was received when necessary from a beaker glass in a small side box. (Fig. 5). An opening which could be closed is found immediately below the thermophore.
As mentioned, additional heaters were provided in the shape of electrotherms. These were pads covered with rubber cloth in the center of which an electric resistance coil gave heat. During the time of dressing very young infants they were laid upon these electrotherms and thus received an additional amount of heat. Sick infants who have to be removed from the incubator can be placed on the electric heaters.
Fig. 1. The Baby Incubator Building.
Fig. 2. The Interior Court.
Fig. 3. The Incubators. Photograph taken before the Glass Partition was Erected.
Fig. 4. Showing Cylinder where Heat is Applied.
Fig. 5. Showing Metal Box attached to the side of the Incubator into which the Air enters.
(To be Continued.)