Incubator baby side-shows: the history and future of neonatology

Abstract

The care of infants has a somewhat sordid history, not without its side-show elements, political intrigues, and amazing success. Abandonment of infants and outright infanticide was not uncommon in ancient times. The Roman Church, however, was instrumental in beginning to rescue abandoned infants. Over time, greater recognition was afforded newborns and young children with the advent of dispensaries and hospitals created for the purpose of administering to this population. France was a focal point for the evolution of the modern care of newborns, with development of incubators at the end of the 19th century. Incubator baby side shows as entertainment and evidence of scientific advancement shepherded in the concept of evolving technology in the care of particularly preterm (weakling) infants. However, it is not until the latter half of the 20th century that the technological revolution in the care of newborns took off with the advent of neonatal intensive care units. The limits of viability have now been pushed to as low as 22 weeks’ gestation, with anticipation of further technological innovations that may further impact those limits.

The history of infant care has a rather checkered past, not without its side-show elements, political intrigues, and amazing success. Abandonment of infants and outright infanticide was not uncommon in ancient times. Estimates of the incidence of exposure vary widely, but consensus suggests that it was not rare. Harris suggests that ancient Greek and Roman culture accepted the practice for reasons that ranged from limiting family size, to securing male gender preference, to economic necessity, and the elimination of defective infants.¹ Christianized Roman emperors including Constantine passed edicts in 312 CE allowing for the selling of infants and offering aid to the poor to diminish exposures and abandonment of infants. Valentinian in 374 CE passed an edict penalizing infant exposure.¹ Judaism promoted the preservation of all viable and legitimate infants and passed on this sentiment to Christianity.¹ Further preservation of life occurred as the Roman Church at the Council of Vaison (442 CE) began offering protection of foundlings in churches.² The Milan Foundling Hospital was established in 787 CE.² Later in the 13th century Pope Innocent III decreed the establishment of Holy Spirit Hospitals and foundling wheels to be installed so women could leave their infants in secret and avoid exposing them.²

In the 17th century, St. Vincent de Paul and the Daughters of Charity set up a number of homes and hospitals for foundlings in Paris.² And, in 1670, Louis XIII issued a royal edict that created the l’Hopital des Enfants-Trouves in Paris to care for foundlings. Despite these efforts, mortality among these infants remained high, with only 10% of the occupants reaching the age of 5 years.²

In 1739, The Foundling Hospital of London was established by Thomas Coram. To bring in donations for running the hospital, Coram solicited artists to donate pictures in hope the wealthy would visit what became the first public art gallery in London. Handel, in fact, composed a special anthem for the hospital and donated a copy of the Messiah for display.³ In 1769, George Armstrong opened the Dispensary for the Infant Poor in London, supposedly the first dispensary exclusively for children in the world.⁴

Further advances occurred at the beginning of the 19th century with the opening of the Hopital des Enfants-Malades in Paris, which was the first true hospital for infants and children. In 1814, the opening of the Paris Maternite provided midwifery delivery services and care of abandoned infants.^5,6 Elizabeth Blackwell, the first woman to graduate with a medical degree in the United States, spent 4 months studying midwifery there, contracting gonococcal ophthalmia from an inadvertent splashing of fluid out of an infant’s eye. She lost her left eye as a result. Unfortunately for Blackwell, Carl Siegmund Franz Credé, a German physician, did not discover the prophylactic effect of silver nitrate until 1879. He also was one of the first to use a warming tub to attempt to warm particularly preterm or weakling infants at the time of birth.⁷

INCUBATOR BABY SIDE SHOWS

Although reports exist of other incubator innovators, French physicians Auvard and Tarnier appear to receive the most credit for developing a number of different incubators to warm infants at birth.^8–11 The idea appeared to arise from the observations of farmers warming eggs to hatch. In addition, Tarnier developed a technique of gavage feeding preterm infants. Pierre Budin, a student of Tarnier’s, furthered work on developing incubators and became an authority on the care of preterm infants.

The main purveyor of the infamous Incubator Baby Sideshows was Martin Couney.⁸ He was born in 1870 in Breslau, Germany, and supposedly earned a medical degree in Leipzig; however, this is somewhat disputed. He made his way to Paris in the 1890s and studied with Pierre Budin. For the 1896 World Exposition in Berlin, Budin sent Couney to display a newly developed version of the incubator. Couney suggested that live premature infants be placed in the incubators to attract attention. The Berlin Charity Hospital was consulted and agreed to provide six preterm infants for the six incubators on display. Budin sent along nurses to care for the infants, and thus was born the first incubator baby side show. The exhibition was an overwhelming success, and a visitor from London asked Couney to exhibit the following year at the Victorian Era Exhibition in London. Because London physicians would not allow local babies to appear in the exhibit, Budin supplied Couney three wicker baskets full of Parisian premature infants to take across the English Channel for the exhibit. Again, the exhibition was a smashing success and the Lancet noted that in one day no less than 3600 visitors attended the exhibit. Because of Couney’s success, imitators soon followed, establishing incubator side shows throughout London and Europe. A Lancet editorial critiqued the idea, asking the question, “Is it in the keeping with the dignity of science that incubators and living babies should be exhibited amidst the merry-go-rounds, 5 legged mules, clowns, penny peep-shows, and amidst the glare and noise of a vulgar fair?”¹² The critique did not dissuade Couney, and in 1898 he emerged in Omaha, Nebraska, at the Trans-Mississippi Exhibition. The usual charge for the exhibition was 25¢. Couney continued his exhibitions across Europe and the United States over the next 40 years and established permanent exhibits at Laguna Park in Chicago and Coney Island, New York.

At the end of his career, Martin Couney was condemned by some physicians and appreciated by others. In particular, Julius Hess at Michael Reese Hospital in Chicago appreciated Couney’s innovative incubators and established an incubator unit in the hospital. Couney lived to see the first premature infant station complete with incubators established in 1943 at Cornell Hospital in New York. That was the year his Coney Island show closed and his wife died. He was broke and disheartened because he never billed parents for taking care of the infants, depending on the nickels, dimes, and quarters brought in for admission. He died in 1950.¹³

THE MODERN ERA OF NEONATAL INTENSIVE CARE

It has been since the 1960s that the greatest advances in neonatal care have occurred.^14,15 The development of the specialty of neonatology and the proliferation of neonatal intensive care units (NICUs) have contributed to the dropping of the limits of viability of preterm infants to now dramatic lows. At the beginning of the 20th century, infant mortality was at a minimum 100 per 1000 live births, or 10%. By the 1990s, that had dropped almost 10-fold to less than 10 per 1000 live births.¹⁶

In the late 1970s the limit of viability was about 28 weeks’ gestation.¹⁷ That has now been pushed down to 23 to 24 weeks’ gestation, with controversy about whether to pursue resuscitation for infants ≤22 weeks’ gestation.^18–20 To examine the success or lack thereof in pushing the limits down this far, US vital statistics data were examined.^21–23 For the last 30 years, there has been little change in the absolute number of births at 24 and 23 weeks’ gestation, with about 3000 24-week births and 2500 23-week gestation births per year (Figure 1). The absolute number of 22-week or less gestation births have decreased slightly.

Figure 1.

Absolute number of births of infants born in the United States from 1990 to 2024 by gestational ages 20 to 24 weeks.

The percentage of those births that have been admitted to a NICU from 2017 to 2023, the last year for which final mortality data are available, demonstrate important changes in the thinking for how these periviable fetuses are cared (Figure 2). NICU admission rates are available only beginning in 2017 because that is the first year that the extended birth certificate data became available, which contains information on infant admissions to a NICU. These statistics demonstrate that there has not been a great deal of change for 24- and 23-week gestation infants since 2017, with about 90% of 24-week gestation infants admitted and a slight increase over time for the 23-week gestation infants, from 75% to 83%. The most apparent change has occurred amongst the 22-week gestation infants, with an increase in NICU admissions from 30% in 2017 to 56% in 2023. This speaks to the increased dialogue in the literature about whether or not efforts should be made to resuscitate these infants. For those infants at 21 and 20 weeks’ gestation, little change has occurred, and for the most part <10% are admitted to NICUs.

Figure 2.

Percentage of births by gestational age admitted to neonatal intensive care units in the United States for 2017 to 2023. Data examined only from 2017 since that is the first year the expanded birth certificate form with NICU admission data was available; 2023 is the last year for which final mortality data are available.

The percentage survival of these very immature fetuses further defines the utility or futility in attempting to intervene to save them (Figure 3). At 24 and 23 weeks’ gestation, survival has remained about the same at 70% for the 24-week gestation infants and 55% to 57% for the 23-week gestation infants. The obvious change has been among the 22-week gestation infants, increasing from 32% survival in 2017 to 41% survival in 2023. A speculative guess as to the underlying mechanism for this change would be that it is a function of greater efforts in attempting to resuscitate these infants rather than any advance in technology. “If you don’t try, they die.” Survival data at 20 and 21 weeks’ gestation is extremely unreliable, with less than 20 survivors for the years examined.

Figure 3.

Percentage survival by gestational age for infants admitted to a neonatal intensive care unit in the United States, 2017 to 2023.

DILEMMAS IN PUSHING THE LIMITS OF VIABILITY

The question is: Should we be trying? Despite a survival rate approaching 40% among these 22-week gestation infants, recent data suggest that <10% of the survivors of this group are normal or have only mild developmental delay.²⁴

Ultimately, the parents will, in conjunction with the physicians, make the value judgment of whether to pursue attempts to intervene and support the life of the infant.²⁵ Some families will say a 10% chance is enough; others will require a greater probability of survival and survival without significant impairment before making the commitment to enter into the drama of trying to keep one of these small infants alive. And, the efforts required to do so are dramatic and require a commitment to endure the ups and downs associated with usually at least a 4-month hospital stay.

Despite how well physicians may attempt to prepare families for the issues associated with caring for these small infants, how well parents truly hear and understand the implications as they begin this journey is quite questionable, let alone understanding the potential financial costs of care.²⁶ Recent reports in the lay press (“Doctors Can Now Save Very Premature Babies. Most Hospitals Don’t Try”) demonstrate the confusion surrounding whether parents as well as the press understand the implications of birthing these very premature infants.²⁷

On the horizon are the beginning of attempts to maintain these periviable fetuses in the ultimate incubator, an artificial womb or placenta. Work on this technology began over 60 years ago and has now progressed to the point where after successful attempts to maintain lamb fetuses for periods of time in these environments, human trials are now being considered.^28–31 The ethics of how informed consent is obtained from vulnerable women desperate to save their periviable fetuses is challenging at best.³² How physicians explain these trials as experiments or as life-saving technology will certainly bias the decisions of the women involved.³³ Can physicians be truthful as they move to introduce this technology? This is a relevant point. The beginning of cardiac transplantation brought the issue to the fore as to the ethics of how the introduction of the procedure was presented. According to Paul Ramsey in his book The Patient as Person:

Donor and recipient alike must consent to heart transplant as a scientific exploration from which may come new knowledge of benefit to others in the future, and not primarily as a present form of therapy, even a heroic one. It is this canon of loyalty between physician-investigator and patient-subject—which may have been violated in some or many, if not all, of the heart transplants to date.³⁴

Consideration must be given to the “human” issues of implementing technology for supporting younger and more immature fetuses. The impact of supporting fetuses in an artificial environment may well have significant psychological and cultural effects that we cannot predict. The vision of raising in vitro–conceived embryos in an artificial environment to harvesting at gestational extra-environmental viable ages may be far-fetched at this time. Nevertheless, it is a much more tenable idea today than when it was first proposed by Aldous Huxley in his dystopian novel Brave New World, published in 1934. In this prescient novel, Huxley envisioned reproduction occurring from conception to birth in an artificial environment.

As a society, we must intentionally confront the ethical implications of developing technologies capable of sustaining nascent human life in artificial environments rather than allowing these issues to simply normalize to the technology available. According to Daniel Callahan, a philosopher and prominent figure in the biomedical ethics movement in the late 1960s and early 1970s, “to be human must take into account the interaction of biological, psychological (read consciousness), and cultural factors.”³⁵ Merely defining human life as a biological phenomenon independent of the state of consciousness of the biologic life and cultural milieu in which it occurs as moral justification for the promotion of nascent biologic life seems problematic. Thus, the implementation of technology merely to support biological life is morally problematic. How to morally justify the technology to promote the biologic phenomenon of nascent life with appropriate attention to the state of the biologic life’s state of consciousness and the cultural milieu within which it occurs remains the challenge.

Disclosure statement/Funding

The author reports no funding or conflicts of interest.