Incubator-Baby Side Shows William A. Silverman, M.D.

Greenbrae, California Pediatrics 64(2):127-141, August 1979

Reproduced by permission of Pediatrics .

On the morning of Thursday, March 2, 1950, I read the following obituary in the New York Times:

MARTIN A. COUNEY, "INCUBATOR DOCTOR" Dr. Martin A. Couney, a specialist in the care of prematurely born infants, who had shown such babies to the public for an admission price at fairs and other exhibitions throughout the United States and in Europe for more than fifty years, died last night at his home, 3728 Surf Avenue, Sea Gate, Coney Island. He was 80 years old. "The Incubator Doctor" as Dr. Couney was informally known, was born in Germany, studied medicine in Breslau, Berlin and Leipzig, receiving an M.D., and later in Paris under Dr. Pierre C. Budin, noted pediatrician, who developed a method of saving the prematurely born. At the Berlin Exposition in 1896, Dr. Couney operated an exhibit of prematurely born babies to show the Budin technique. The exhibit was a financial success, as was a second one at Earl's Court in London. In 1898 Dr. Couney paid his first visit to the United States and staged an exhibit at the Omaha Trans-Mississipi Exposition. He returned to Paris for the exposition of 1900, but was back in this country for the Buffalo Exposition the next year, and then decided to remain here for good. For years he had shows at both Dreamland and Luna Park, and the night Dreamland was destroyed by fire the babies were saved by a quick transfer to the Luna Park incubators, some of the lodgers doubling up. Dr. Couney had one of his Baby Incubators attractions at the New York World's Fair [1939-40]. He leaves a daughter, Hildegarde Couney, long associated with her father's affairs. His wife, Annabelle May Couney, died in 1938.

This biographic sketch triggered a faint memory: I remember being puzzled about the "incubator-baby exhibit" when I walked by what I thought was one of many ordinary side shows in the amusement area of Chicago's Century of Progress Exposition in 1933. Now, 17 years later, my curiosity was rekindled. I decided to pursue the facts about this colorful (and bizarre!) chapter in medical history. I have had a delightful time; the search has taken 28 years (so far), and some loose ends remain. For instance, I have been unable to reconcile some of Couney's accounts (given to various reporters over the years) with the recorded evidence or with statements obtained when I interviewed his nephew, some of his fellow workers, and a number of physicians who knew him. [1]

Martin A. Couney (Fig. 1) was born on either the 31st of Dec. 1860 or the 30th of Dec. 1870 in either Alsace or Breslau. His father died when he was young. He had three older siblings: Alphonse Coney (sic), who was a jockey, lived for many years in France (according to a vague account he later moved to San Francisco, but I have been unable to confirm this); Marx Coney died in his 60s (I know no other details); and he had a sister named Betty (again, there are no further details). Martin was educated in Breslau and Berlin, he received a medical degree in Leipzig, and in the 1890s he went to study under the tutelage of Pierre Constant Budin of Paris.

Budin had been a pupil of E. S. Tarnier, a leading Parisian obstetrician who pioneered in efforts to improve the survival of prematurely born infants. The early attempts begin following the immense loss of life in France from military action and months of famine during the siege of Paris in the Franco-Prussian War (1870-1871). [2] In 1878, Tarnier 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 the zoo keeper to build a similar box, sufficiently ventilated and large enough to hold one or two premature infants (Fig. 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 [4]:

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 1888, Pierre Budin 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 studied of premature infant care. In ten lectures to his students, published in 1900 (as the book titled Le Nourisson) [5], Budin enunciated three basic problems in care of the prematurely born:

Their temperature and their chilling. Their feeding. The diseases to which they are prone.

The Tarnier incubator (improved with a "Reynard regulator," a monitoring device which activated an electric bell to warn against overwarming) was used by Budin to solve the thermal problem. He advocated human milk feedings to solve the second problem by nursing at the breast of the mother or wet nurses when possible. If the infant was unable to suckle, milk was hand-expressed in a trickle into the 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 Maternité 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:

Grouping together the healthy premature infants; Isolating the sick and suspect infants; Separating the web nurses' babies from contact with the premature infants; Establishing a milk room where "sterilized" milk could be heated; Keeping the bottles of sterilized milk cool in summer in an ice chamber; 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 of feeding of premature infants were adopted slowly, and with very little modification, throughout the Western world.

The spread of these ideas was spurred on through the curious circumstances which grew out of Budin's request that his young associate, Martin Couney, exhibit the newly-modified Tarnier incubator at the World Exposition in Berlin in 1896. [6] Budin armed the young man with a letter of introduction to Professor Czerny, an illustrious obstetrician. Couney hit upon the idea of placing live premature infants in the infant 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: the premature infants were considered to have 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 and soon there were ribald songs about the exhibit in the beer halls and night clubs. Couney's exhibit was located in the amusement section next to the Congo Village and the Tyrolean Yodlers; it was a huge success, always jammed with people. Several batches of infants were reared at the show and, according to Couney, "there were no deaths." During the exhibit, a London promoter by the name of Samuel Schenkein visited Couney and invited him to repeat the show in London the following year at the Victorian Era Exhibition to be held in Earl's Court. Couney agreed.

I have been able to track down an account of the London exhibit which appeared in a commentary in Lancet, May 29, 1897, entitled "The Use of Incubators for Infants" [4]. The editors reviewed the history of infant incubators, noted 2,534 infant deaths in London for one year attributed to premature birth, and they welcomed any attempt to improve the construction of incubators:

That this has been achieved will, we are informed, shortly be rendered evident by a remarkable exhibit at Earl's Court. A structure is now in the course of erection just opposite the Welcome Club, where infants prematurely born will be nursed and kept in new and model couveuses. 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 fluctuations whatsoever, not only for hours, but even for days. The incubator need not be touched for these purposes, and the only attendance necessary is that needed for feeding and washing the infant... Only air taken outside the building is supplied to the infant within the incubator. When we consider how often private houses, and even hospital wards, are inefficiently ventilated, it is not necessary to insist on the advantage of deriving the air-supply direct from the street or garden...

I have been unable to find out how Couney obtained these incubators; they were definitely not the Tarnier-Martin couveuses ventilated by convective currents of air, but German devices made by Paul Altmann of Berlin. [7]

On July 17, 1897, another piece appeared in Lancet. [8] It described the exhibition in some detail:

On Monday members of the press were invited to a private view of the incubators for infants at the Victorian Era Exhibition, Earl's-court. These are exhibited in a building facing the Welcome Club, and divided into three compartments. On one side there is sleeping accommodation for two wet nurses and for Mdlle. Louise Recht, who has been specially trained at the Paris Maternity Hospital to look after debilitated and prematurely born infants reared in incubators. A special service for this purpose was established at the Maternité in 1893 [sic], and here some 400 children, born under most unfavourable circumstances, are received annually. On the other side of the building there is a nursery, where the infants are taken to be fed and washed. The public are admitted to the central room, and here they can view the infants lying within the incubators, and are shown how the apparatus is ventilated and warmed and the temperature automatically maintained. The mechanism employed for this purpose has already been fully explained in these columns. Its efficiency is now put to a practical test. Messrs. Coney [sic] and Schenkein, who are the representatives in England of this the "Altmann Incubator," invite the criticism of the medical profession, and will supply every possible facility for the fullest investigation. They are ready to take in their charge any prematurely born child, and, apart from the trained nurse and the wet nurses, they have retained the services of two physicians, who attend three or four times a day to watch over the health of the infants. At night the watchman awakes the nurses every three hours so that they may feed the infants, and in the day time the babies are fed, generally from the breast, every two hours. In the nursery there is a small pharmacy, contrivances for sterilising milk, ingenious feeding bottles, and scales so that the infants may be weighed and their progress daily observed. A very large number of persons have already visited this exhibit, including many trained nurses. Much interest is manifested by the visitors. The incubators and the ventilating tubes are silvered, which gives them a bright and cheerful appearance, while the infants within look clean and comfortable, so that altogether it is a pleasant as well as an interesting sight...

It is interesting that Lancet made no mention of the fact that Couney was a physician (note that his name was given as "Coney," the spelling used by his siblings). And a crucial detail was left out of this account: English physicians had refused to allow local babies to appear in the exhibit. Couney and his backer Schenkein were desperate. Couney appealed to Budin for help and the response was generous. Couney loaded three wicker baskets full of Parisian premature babies, crossed the Channel with them and saved the exhibit! The show was a smashing success.

By the end of the summer of 1897 a note of disenchantment crept in, and on Sept. 18, 1897, the following letter appeared in Lancet: [9]

Sirs, -- In the interest of the general public we desire to call your attention to the fact that the success of our Infant Incubator Exhibition at Earl's Court has attracted the notice of unscrupulous imitators. We are informed, for example, that various persons are calling upon, and writing to, members of the medical profession, hospitals, infirmaries, etc., asking for their support, and falsely representing that they are opening branch institutions in connection with us, and asking for the loan of children to experiment with. We consider, under these circumstances, that it is our duty to warn members of the medical profession, also nurses, parents, and all public institutions, not to entrust their children to any applicants whatsoever without first taking every precaution to assure themselves that they will not be made the victims of showmen, as well as of inexperienced and irresponsible persons who seek to trade upon the established reputation of an invention that has been recognized by both the medical and lay press. The institution at Earl's Court is the first of its kind in England, and we have not made any arrangements, nor have we given anyone authority to further exhibit, at any exhibition or place of public resort in the United Kingdom, so that all persons, no matter what their credentials may seem to be, making application for space and intimating that they have the power to exhibit Mr. Paul Altmann's invention should be classed as imposters. We are, Sirs, yours obediently, Samuel Schenkein

Martin Coney

On Feb. 5, 1898, an editorial noted: [10]

The introduction of incubators for babies into this country has been favourably noticed in The Lancet . The incubators which we described were exhibited at Earl's-court. [See The Lancet , May 29th, 1897.] They were manufactured by scientific instrument makers of high reputation who provide many of the apparatus used in Professor Koch's laboratory. Skilled attendants were employed who had been specially trained not merely in the care of babies and the management of incubators but more particularly in the nursing of prematurely born or especially debilitated infants. Again, though the Victorian Era Exhibition was looked upon as a mere pleasure resort by many it was also a serious exhibition where objects of art of great value were collected side by side with scientific inventions bearing on medical and public health questions. Thus surraounded there was nothing derogatory to the dignity of the healing art in the exhibition of incubators at Earl's-court. Also a healthy site was chosen in the broadest part of the gardens where there was plenty of fresh air. The incubators were scientifically ventilated and only received the air taken from the outside. This exhibition had an extraordinary success. On one occasion there were no less than 3600 visitors in a single day. This success, however, has not proved an unmixed blessing. It attracted the attention and cupidity of public showmen, and all sorts of persons, who had no knowledge of the intricate scientific problem involved, started to organise baby incubator shows just as they might have exhibited marionettes, fat women, or any sort of catch-penny monstrosity. It is therefore necessary that we should at once protest that human infirmities do not constitute a fit subject for the public showman to exploit. Incubators are only useful for prematurely-born children, and especially for infants whose lives cannot possibly be saved any other way. Therefore constant medical supervision and the presence day and night of nurses trained in the use of incubators and of wet-nurses is indispensable. To organise all this in a satisfactory manner necessitates a considerable outlay and cannot be lightly undertaken by inexperienced persons. An incubator show, if such there must be, should correspond in every respect to a hospital ward. Now, at the World's Fair held at the Agricultural Hall, Islington, there is an incubator show where the charge for admittance is only 2d. We fail to see how this small sum can cover the cost of properly trained attendants and of wet-nurses. On visiting this exhibition we were informed that the infants were fed by their mothers -- but how can the mothers attend during the whole of the night at the Agricultural Hall and where is their sleeping accommodation? Then, again, the incubators do not derive their air supply from without. The infants breathe the atmosphere of the interior of the Agricultural Hall, where, apart from the numerous visitors, the whole of Wombwell's menagerie is kept. Just opposite the incubators there are some leopards and everyone is familiar with the obnoxious odor that arises from cages in which such animals are incarcerated. There is a similar exhibit at the Royal Aquarium, and we cannot think that the dust of bicycle racing, the smoking of the men, and the exhalations from the crowd of people who visit that resort are likely to constitute an atmosphere suitable for prematurely born infants. Of the thousands who daily flock to these two buildings, how many convey pathogenic germs which may enter the incubators since they are not ventilated from without? Is it in keeping with the dignity of science that incubators and living babies should be exhibited amidst the aunt-sallies, the merry-go-rounds, the five-legged mule, the wild animals, the clowns, penny peep-shows, and amidst the glare and noise of a vulgar fair? At Barnum and Bailey's Show also there is an incubator show where, however, the air is brought in from without; but, again, what connexion is there between this 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 to Olympia? ...

I have wondered how Couney reacted to this editorial; certainly it had no influence on his activities because in the summer of 1898 he showed up in Omaha, Neb., at the Trans-Mississippi Exposition. (And the caution did not inhibit his imitators: "incubators with living children" were shown at an Italian exhibition in Turin in the same year.) I have obtained a photograph of the Omaha exhibit (Fig. 3) which shows the incubator maker's ad prominently displayed on a wall behind the neat row of cabinets:

Paul Altmann

Berlin Germany

State Rights on Application

But I have been unable to obtain any more details about this show. In 1939, Couney told an interviewer that he had to bring the infants from Chicago but I have not been able to verify this. And I cannot even imagine how he succeeded in transporting a covey of small babies from Chicago by train in the summer of 1898!

In 1900, Couney was in Paris exhibiting at the World Exposition. The following year he came to New York for the 1901 Pan-American Exposition in Buffalo. I have collected some descriptions of this show. [12] The incubator exhibit was housed in an imposing building built specially for this purpose (Fig. 4). Again the show was located in the amusement area -- this rankled Couney who yearned to be in the scientific section. Two articles about the exhibit appeared in 1901 (both are notable for their hyperbole). One observer wrote:

It is a curious fact to be noted in the character of people who are attracted to this peculiarly located show, that they are mostly women... and only... the doorkeeper knows how many ignorant, poor women surrender their only quarter they spend on the midway for a visit to this place...

and the article went on:

...to call the highly polished metal machines, elaborately fitted with ventilating devices, and holding beribboned infants on dainty pillows, "incubator" is a misnomer. The babies are not incubated, like the chicken from the egg in one of the varieties of the poultry farm machine. They are taken from mothers of low vitality, when the conditions of food and air make their survival quite impossible, placed safe behind plate glass and swathed in delicate flannels and in that way reared into normal babyhood...

The article rambled on and on, defending the exhibit as a scientific institution. As I read this piece, it occurred to me that Martin Couney himself prepared the copy, but I have no proof for this uncharitable thought.

A second article was written by Arthur Brisbane (he later achieved fame as the featured columnist for Hearst's newspapers). The essay was entitled "The Incubator Baby and Niagara Falls" [13], it began:

...men go to the exhbition at Buffalo to see and to think. Two features well worth seeing and thinking about are chosen for discussion here. Two vast extremes. The falls of Niagara with the great system of lakes and rivers behind them; the diminutive baby in its hot-air chamber, sightless, deaf, feeble -- but with the great human race, the vast sea of organized thought back of it...

In similar style, Brisbane went on:

... What is the power of the falls beside the force that may originate in the tiny brain of an incubator baby? The brain is smaller now than half an apple. But that brain may start a work that will persist and affect man's destiny when the falls shall have dwindled down to an even placid stream...

He then described the exhibit and world-shaking lessons to be drawn from "... our small tiny-faced friends in the rows of incubators..."

A series of "snap shots on the midway" were reproduced in a guidebook for the fair; these show the interior of the infant-incubator building (Fig. 5) and a picture of "the smallest infant ever born who lived" (Fig. 6). I recently received another photograph of the 1901 exhibit (Fig. 7) and I suspect that it shows Martin Couney as a young man (but I have been unable to verify the suspicion). The Buffalo exhibit received some serious attention; for example, Scientific American extolled the "model nursery at the Pan-American Exposition" and reproduced the interior photograph (Fig. 5) in the Aug. 3, 1901, issue. The Children's Hospital of Buffalo purchased Altmann's infant incubators shortly following the exposition.

The commercial prospects of an infant-incubator extravaganza did not escape the notice of American entrepeneurs. A group of St. Louis businessmen formed "The Imperial Concession Company" for the purpose of exhibiting infants at the Louisiana Purchase Exposition of 1904. A palatial building was erected (Fig. 8), Mr. E.M. Bayliss was engaged as manager, Miss Kelley ("a trained nurse who had considerable experience with premature and other babies") was put in charge, and an unnamed local physician was hired as a consultant. The ambitious project opened in June 1904 (Fig. 9). Everything went well until the onset of hot summer weather when a catastrophe occurred; an epidemic of summer diarrhea started among the babies. The losses of very young babies was increased by the death of several graduates. By September, the death rate reached about 50%. The attending physician resigned and a committee of local physicians was appointed to investigate the exhibit. A few changes in the building were ordered: one requirement was that a glass partition should separate the incubators from the public. On Sept. 1, 1901, Dr. John Zahorsky, the eminent St. Louis pediatrician, took charge of the medical management of the exhibit. He visited his charges two to three times a day and carefully supervised every detail of their care. Zahorsky described this experience in considerable detail in a series of articles which appeared in the St. Louis Courier of Medicine, beginning with the December 1904 issue (Fig. 10). [16] The shaky experience in St. Louis seemed to put off further imitators. One discouraging feature was the expense of the venture: Zahorsky reported that each infant cost the company about $15 a day; "the magnitude of the task is apparent," he wrote. No other competitors surfaced on the American scene until 1939.

Couney emigrated to America in 1903 and settled in Coney Island. He exhibited there every summer for the next 40 years. He married an Irish nurse (Annabelle May) who was an expert in premature infant care. His daughter, Hildegarde, was born prematurely and she spent the first three months of her life in an exhibit incubator. [17] (As noted in the New York Times obituary, she became a nurse and worked with her father.) Madame Louise Recht, the Budin-trained nurse, who was with Couney from the very outset of his "show" career, remained as the central figure on his staff. The incubator-show became a fixture of the amusement area. A sign at the entrance read "All the World Loves a Baby." Della Robbia bambino symbols (later adopted as the insignia of the American Academy of Pediatrics) were used liberally in the decor. The barkers were interesting "characters" (their spiel ended with the cry, "Don't pass the babies by!"). George Stewart later became a career diplomat who, at one time, was the American consul in Venice, Italy; "Van" earned his living as a department store Santa Claus in the Christmas season. An actor named Archibald Leach worked as a barker at the Luna Park exhibit while waiting for a part in an upcoming Broadway musical. Following this stint he went on to become a famous movie idol under the name given to him by Paramount Pictures -- Cary Grant.

In addition to the annual shows in Coney Island, Couney exhibited in other parts of the world from time to time (e.g. Portland, Ore. in 1906; Mexico City in 1908; Rio de Janiero in 1910; Lakeside Amusement Park, Denver, Colo., in 1913; and sporadically in Atlantic City and in Chicago -- vide infra). In all of these shows Couney was proud of the fact that he "never took a cent from the parents." But he was puzzled (and hurt) by what he felt was an unappreciative attitude of parents. They visited their babies relatively infrequently; when it came time to send the infants home, Couney had difficulty in persuading them to assume their parental responsibilities. Zahorsky had much less experience than Couney, but the St. Louis pediatrician quickly grasped the implications for both parent and infant when neonates are reared away from their parents; Zahorsky discussed the phenomenon of "hospitalism" among babies "on the Pike" at some length. [16]

In 1915, Couney organized an impressive exhibit at the Panama Pacific International Exposition in San Francisco (Fig. 11). [18] Here "the tiny tots that had tried to begin life too soon and had to be kept in warm glass chambers awhile so they could get a better start, excited the sympathy of thousands." A constant stream of visitors of every age and condition visited the show. (The concession took in over $72,000 during the ten-month run of the exhibition.) The guidebook of the fair noted:

The appeal of the helplessness of the unconscious mites of humanity rescued and thriving in spite of adverse fate reaches alike the specialist and the careless sightseer who may learn here the particulars of nourishment, nurture and care given these incubator babies. The concession may be described as educational and, in these days of awakening to social service and duty to humanity some study of the methods pursued in working out late discoveries and theories, is well worth while.

A very short strip of movie film of the interior of the building has survived; it shows a typical Couney set-up: a row of Lion-type incubators and a railed corridor to guide the visitors through the room. A white-jacketed man appeared in several frames of this film strip, but the images are too fuzzy to make me confident about a guess that this was the young Martin Couney. One of the few pictures of a parent of an incubator baby came to light a few years ago when I received a photograph (Fig. 12) from one of the graduates of the San Francisco exhibit of 1915. [19]

I mentioned earlier that Couney exhibited in Chicago occasionally (e.g., White City and Laguna Park, both amusement enterprises). Somehow he met the young Julius H. Hess, of Chicago, who later became the leading American expert on the subject of prematurity. I have collected several stories of how the paths of these two men crossed, but the accounts are conflicting. It is clear, however, that they were good friends. Hess paid tribute to Couney in the preface to his textbook, Premature and Congenitally Diseased Infants (1922):

I desire to acknowledge my indebtedness to Dr. Martin Couney for his many helpful suggestions in the preparation of the material for this book.

A similar tribute appears in the 1928 text on infant feeding written by Hess:

To Dr. Martin Couney I affectionately inscribe this effort to put into practice the experiences of a quarter of a century. The thoughts on premature infants were largely stimulated by his devotion to the welfare of these small infants.

In 1933-1934 at the Chicago's Century of Progress Exposition, Couney's exhibit (Fig. 13) was located on the midway next to Sally Rand's show (the famous fan dancer told arresting policemen that Couney's babies wore fewer clothes than her dancers and she couldn't understand what all the fuss was about). Hess loaned his chief nurse, Miss Evelyn Lundeen, to Couney for the two-season exhibit. I interviewed Miss Lundeen before she died [21] and she discussed the exhibit with some disdain. She was not happy about the "showmanship" which was part of the daily routine. For example, Miss Lundeen related that the nurses were instructed to add more clothes as the babies grew larger to heighten the illusion of smallness of each of the infants on display, and Madame Recht wore an oversized diamond ring on her finger; she slipped this huge "sparkler" over the babies' wrists periodically to demonstrate how tiny the hands were (Fig. 14). Nonetheless, Miss Lundeen was convinced that the babies were receiving excellent care and she was lavish in her praise for the skill of Madame Recht's team of nurses.

Couney was a tremendous success in Chicago. In the midst of the exposition (May 28, 1934) the Dionne quintuplets were born in Callander, Ontario. The newspaper publisher, William Randolph Hearst, wishing to capitalize on the sensational event, offered to charter a plane to send Couney to the Canadian town with a reporter, a photographer, and an exclusive contract for reports of the infants in exchange for the expert's services. Couney declined explaining that his first responsibility was to the 30 babies under his care. He also told Hearst that he feared there would be no gas to heat his incubators in the backwoods of Canada. He confessed to Miss Lundeed, privately, that he was sure the quintuplets would die and he was less than enthusiastic about the prospect of a highly publicized failure. When Couney left Chicago, he donated his equipment to Hess and gave his ambulance to the city of Chicago. It became the first premature infant transport vehicle in the United States.

Couney returned to Coney Island for the routine summer shows. He enjoyed a fine reputation among the obstetricians in the New York area; they sent infants to his exhibit confident that the babies would receive skilled care. In 1937 he was honored by New York's Medical Society and he was presented with a platinum watch.

For the 1939-1940 New York World's Fair, Couney planned a major exhibit. The quarters were designed by Skidmore and Owings, architects for eight of the largest exhibits at the fair. A U-shaped structure was erected at considerable expense (the cost exceeded the original estimate because of trouble with pilings at the site -- a huge ash heap, known as the "Corona dump," in a tidal marsh near Flushing). There was a suite for Madame Recht and for Hildegarde, rooms for others on the staff -- including 15 trained nurses (Fig. 15), 5 wet nurses and their own nursing infants, as well as a cook and a chauffeur -- and a sumptuous apartment for the incubator-doctor himself (e.g., bedroom, living room, bath and a private garden). The bright-pink colored building was decorated with a huge Della Robbia bambino plaque; long lists of the sites and calendar years of previous exhibits were displayed on the walls adjoining the entrance. [23] One sign proclaimed that the exhibits had been seen by 1,500,000 visitors throughout the world, and in large letters, fairgoers were told, "Once Seen Never Forgotten." Physicians who visited the exhibit were treated royally; hospitality often included a lavish lunch or dinner with Couney at Henri Soulé's restaurant in the French Pavilion, the forerunner of the world famous Le Pavillon on East 57th Street in New York City. (Couney was a gourmet; he liked his gigot rare, accompanied by the finest wines.) On June 14, 1940, there was a reunion of the babies cared for during the previous season; 43 graduates were brought back to the exhibit. Each set of parents was presented with a silver cup inscribed with the name of their baby, and a certificate signed by Couney and by Grover Whelan, the president of the fair; it declared that the baby gained a start on life at the incubator station. The "vital statistics" of the two-year show were published in the Medical News columns of the Journal of the American Medical Association on Nov. 9, 1940:

Mortality Experienced at Exhibit during New York World's Fair 1939-1940 [24]* Gestational Age (mo.) Admitted Died 6 9 0 6 1/2 18 4 7 37 6 7 1/2 9 0 8 20 0 8 1/2 1 0 Unknown 2 0 Total 96 10 *These "statistics" gave no indication of the classic "transferred-in" sampling distortion: the babies came to the exhibit some days after birth and they were, therefore, a select group of hearty survivors (weaker coevals succumbed elsewhere in the early hours and days after birth -- the period of highest mortality risk after premature birth).

In 1939, Arnold Gasell of Yale was interested in the "beginnings of the human mind;" it occurred to him that serial motion picture records of "fetal infants" (prematurely born babies) might provide some clues to the prenatal phase of behavioral development. He learned that the largest collection of premature infants on the eastern seaboard was in the exhibit at the World's Fair. He went to the exhibit with his cameraman, Mr. Paul Hartmann, and they photographed Couney's charges at some length in 1939 and again in 1940. I reviewed a short bit of this extensive record in 1959, [25] and the entire record in 1970. [26] I made a copy of the segment of the film showing the methods of feeding and care provided by the legendary Madame Recht (Fig. 16). In one scene she demonstrated the hair-raising technique of nasal-spoon feeding (Fig. 17). When I showed this film to nurses during the "no touch" era in the early 1960s they could not believe their eyes. And the next sequence was met with nervous laughter; it showed a 17-day-old infant (weight 945 gm) receiving a bath in a basin of water followed by a vigorous massage and rub down with a coarse towel.

Gesell wrote The Embryology of Behavior in 1945, [27] and he acknowledged the help provided by Couney and his staff:

The arrangements for observation and for cinematography (at Flushing, New York) were ideal, and we are profoundly indebted to Dr. Couney for his personal cooperation and his interest in medical science which made this particular phsae of our study possible.

Notice that he avoided any mention of the sideshow setting in which the serious studies took place.

The 1939-1940 venture was a financial disaster for Couney. The overhead expenses were tremendous and 25% of the gross receipts had to be turned back to the authorities of the fair. The admission charge of 25 cents meant that he needed 700 customers a day to break even, and the incubator babies were now "old hat" to the public. Couney's difficulties were not helped by the health department; there were frequent inspections and criticisms, and the inspectors projected a condemning attitude. This experience was a far cry from his past glories.

After the fair closed, Couney returned to his routine at Coney Island, but the attendance dwindled each year. When the first premature infant station opened at Cornell's New York Hospital, Couney closed his show for good. He told his nephew, "I made propaganda for the preemie. My work is done." Twenty years after his death a bronze tablet was placed on the wall next to the entrance of the Holiday Inn on the boardwalk in Atlantic City to mark the site of his old shows. It noted that "Dr. Couney was the first person in the United States to offer specialized care for premature infants." [29]

It would be fatuous to attach deep significance to this odd chapter in medical history, especially since the incubator-show phenomenon was largely the result of the activities of one man. But I find it hard to ignore the resemblance between the theatrics of the side-show exhibits and the dramatic actions in present-day neonatal intensive care units. In both cases, I find a disturbing detachment from reality. Premature termination of pregnancy is so often a signal of serious social disfunction in the family and in the community [30]. The narrowly focused response to this complex problem is quite unreal when viewed from a perspective which goes beyond the confines of the special care facility. The feeble infant is plucked up and deposited in a theatre-like setting in which superb technical experts make all-out efforts to support life. And when this has been accomplished successfully, the infant graduates. But no comparable effort is mounted to deal with the enormous problems which face the graduate at home and in the community. Future historians may look back with some fascination at the tunnel vision in the incubator-show era and in the present day. I can almost hear the comment (in French, of course, since the movement did begin in France): Plus ça change, plus c'est la même chose. [31]

Figures

Fig. 1. "Incubator-doctor" at the time of the New York World's Fair, 1939-1940. Fig. 2. Tarnier-Martin Couveuse. [3] 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, the opening for water fill, and a, the emptying pet-cock. Fig. 3. Infant incubators in operation at the Trans-Mississippi Exposition, Omaha, Ne., 1898. [11] The Lion incubator manufactured by Paul Altmann was warmed by a cylindrical "water-boiler" (a) mounted on the outer wall of the unit and the infant's cabinet was ventilated by fresh air blown through a large pipe by an electric fan on the outside of the building; the air entered the incubator through a metal box (b) attached to the side of each cabinet. here the air was moistened by being passed through a layer of absorbent wool suspended over a saucer containing water. From this filtering box the air passed into the bottom and center of the incubator where it was diffused and passed over the surface of hot-water coils from the external heater, and then flowed into the infant's compartment in the upper part of the incubator. On the top of the incubator an outlet "chimney" (c) was fitted with fan-blades which allowed only one-way passage of an upward current of exhaust air. Fig. 4. Infant incubator building at the Pan-American Exposition in Buffalo, NY, 1901. This "scientific institution for the rearing of prematurely born infants" was located at the corner of the midway and the mall at the exposition. Fig. 5. Interior of the infant incubator building in Buffalo, 1901, showing eight incubators, each containing a "live babe." Fig. 6. Baby Qbata, an "echo-nym" for the "smallest infant ever born who lived"; the baby, who weighed 2 lb 9 oz at birth, was cared for in the Buffalo exhibit. Fig. 7. Baby Qbata in the infant incubator. The unidentified looker-on may be the young Martin Couney. [14] Fig. 8. Spired facade (top) and interior court (bottom) of the Baby Incubator Building at the Louisiana Purchase Exposition, St. Louis, Mo., 1904. Fig. 9. Scene at the 1904 fair in St. Louis. The incubators were manufactured by Kny-Scheerer Company of New York; the design was a modification of the Lion device. [7] Heat was applied from two sources: (1) by a thermophore placed in a metal drawer in the lower part of the incubator (a rectangular metal box containing crystals of some salt [sodium acetate?] which liquirifed in boiling water; heat was radiated to the incubator during the slow process of recrystallization [15]), and (2) by means of a coil of metal tubing which contained water; the water-filled tube extended to the outside of the incubator where it entered a cylinder lined with fire-clay; within this was a gas flame from a Bunsen burner which heated the water; the products of combustion from the heater were carried off through a tin pipe from the top of the cylinder through the ceiling of the incubator room. Air entered the incubator below the water coil and encountered a baffle which spread the current so that it rose on all sides of the infant. On the top of each compartment was a circular opening for the egress of air; this had a pipe attached, and in the upper end was a small metal fan (anemometer) which indicated the velocity of outflow. Fig. 10. Report of the experience at the Louisiana Purchase Exposition. Nine babies were admitted during the three-month period (Sept. 1 through Nov. 30, 1904) when Dr. Zahorsky was in charge of infant care (six of the infants weighed less than 1.5 kg at birth, one survived; three infants, all weighing 1.7 kg, survived). He encountered considerable difficulty with thermal problems and he concluded that "... the thermoregulatory apparatus of the infant, however feeble it might be, is severely strained when temperature is too high. Better results follow lower temperatures." Fig. 11. Exhibit building at the Panama Pacific International Exposition, San Francisco, 1915. It was located just beyond the lane leading northward to the Laguna Street gate. The exhibit was advertised by the presence of some tall Hungarian storks in the little garden in front of the building (one is seen here nesting, indicated by the arrow). The guidebook of the fair quipped, "... storks that perhaps made mistakes, or flown too fast." Fig. 12. Father holding infant on the day the "graduate" was sent home from the San Francisco exhibit at age 3 months. The baby was born on march 15, 1915, weighing 1 1/2 lb. [19] Fig. 13. Couney's exhibit at the Century of Progress Exposition, Chicago, 1933-1934. Note the oxygen tank standing beside each incubator. It is interesting to recall that the use of oxygen in the management of premature infants at the Sara Morris Premature Infant Station in Chiago was introduced in 1931. Over a three-year period (1931-1933), 346 of 792 infants admitted to Sara Morris unit were placed in the newly developed Hess infant oxygen bed (oxygen was administered for more than 24 hours, occasionally as long as six weeks, in concentrations of 40%-55%). The new oxygen policies were credited, in part, for improved survival over the previous period from 1922 to 1929. [20] Fig. 14. Exhibit baby with Madame Louise Recht's diamond ring encircling the wrist. Fig. 15. Nurses with arms full of infants at the World's Fair, Flushing, NY, 1939-1940. The nurse in the center is Couney's daughter, Hildegarde (she died in 1956). [22] Fig. 16. Madame Louise Recht with an exhibit baby at the New York World's Fair, 1939-1940. Fig. 17. Nasal-spoon feeding of "Ann" (born Oct. 4, 1939, gestational age 28 weeks, birthweight 880 gm). On Oct. 21, 1939 (weight 945 gm) the infant was fed by Madame Recht and Gesell recorded the following notes: The infant is taken out of the Hess bed, diaper changed. Is snugly reclothed. Napkin bib placed under chin. Nurse holds child in palm of right hand, rests head in palm of left hand. The sagittal axis of the head makes an angle of about 30° with the table top. An assistant nurse takes the rubber cap from a small bottle containing 3 cc of warm and diluted mother's milk. Pours portion in the spoon, filling about three quarters of the bowl. Nurse gently places the point of the spoon beaker at the left nostril, slightly tilting when necessary. The milk is not actually poured but is held in a position where the imperceptible aspirations of the infant's breathing apparently by gentle suction withdraw the fluid. The rate of withdrawal is variable, although the infant in this case remained relatively quiescent throughout the whole period of feeding, which may require some 10 minutes, introducing the several spoonfuls totaling 3 cc. [sic] Sometimes the rate of withdrawal is rapid and one can see the lowering of the level of fluid with the aspirations. Other times it lingers longer at one stage. Sometimes there is slight spilling over the upper lip but even this excess fluid with a little help from the beaker is rapidly regathered into the outgoing tide so there is almost no waste. Occasionally an expiration interferes and there is a tiny bubble which bursts. The infant does not fuss. At some feedings not even this variation occurs and the whole undertaking is smoothly accomplished almost without exertion on the part of the infant. It would seem as though this method of feeding may require less expenditure of energy on the part of the infant than does gavage. Some infants, however, resist nasal feeding and in those cases gavage is resorted to. If an infant resists gavage nasal feeding is substituted. It is interesting that this method of feeding (which dated back to Budin) was disparaged by Hess because "of dangers due to decomposition of milk in the nose and nasopharynx with secondary development of rhinitis and pharyngitis," and not because of the hazard of aspiration!

Footnotes

[1] Dr. Alfred J. Ephraim (Couney's nephew), Dr. Moe Goldstein (consultant to the 1939-1940 exhibit at the New York World's Fair), Miss Evelyn Lundeed (the famed nurse who was in charge of Sara Morris premature infant station in Chicago for many years), and Paul Hartmann (Dr. Arnold Gesell's camera technician) provided me with first hand accounts of Martin Couney, as well as photographs and movie film of the various exhibits. Dr. Lawrence M. Gartner obtained reminiscences, photographs and movie film from others who knew the "incubator-doctor": these included Dr. E. Harrison Nickman, Dr. Thurman B. Givan, and Jerome Champion.

[2] Dunham EC: Evolution of premature infant care. Ann Paediat Fenniae 3:170, 1957.

[3] Fürst L: Über Wärmevorrichtungen für zu früh geborene oder lebensschwache. Kinderaerztl Dtsch Med Wochenschr 13:750, 1887.

[4] Commentary: The use of incubators for infants. Lancet 1:1490, 1897.

[5] Budin P: Le Nourisson, Paris, Octave Doin, 1900 (English translation by Maloney WJ: The Nursling, London, The Caxton Publishing Co., 1907).

[6] Liebling AJ: Patron of the preemies. New Yorker Magazine, June 3, 1939, p. 20.

[7] Although Lancet [4] and a Letter to the Editor [9] referred to this device as an "Altmann incubator," Zahorsky [16] described the design as a "Lion" incubator. Hess also referred to this type of infant bed as a "Lion incubator (Couney model)." Paul Altmann of Berlin may have manufactured the incubator based on Lion's directions; I have been unable to learn anything about the man named Lion.

[8] Commentary: The Victorian Era Exhibition at Earl's Court. Lancet 2:161, 1897.

[9] Schenkein S, Coney M: Infant incubators (letter-to-the-editor). Lancet 2:744, 1897.

[10] Editorial: The danger of making a public show of incubators for babies. Lancet 1:390, 1898.

[11] This rare picture was found by Dr. Warren Bosley in a book of photographs of the Trans-Mississippi Exposition.

[12] Herman Sass, senior librarian of the Buffalo and Erie County Historical Society, and Edna L. Habicht, administrative assistant, The Children's Hospital of Buffalo, provided the material concerning the 1901 Pan-American Exposition in Buffalo.

[13] Brisbane A: The incubator and Niagara Falls. Cosmopolitan 31 (No. 5), September, 1901.

[14] Dr. Eva K. Ray found this photograph in an antique store in Philadelphia in 1978. Dr. Gartner examined Figures 6 and 7 and he suggests that the man in the first photograph (with the straw hat) is Couney, pointing out the similarities of eye and mouth expression in Figures 1 and 6. Gartner thinks it more likely that the well-dressed gentleman in Figure 7 is an outsider, "while the person in Figure 6 is clearly dressed in working clothes."

[15] The suggestion for the thermophore came from remarks made by L. Fürst at a meeting reported in Berlin Klin. Wochenschr 36:1044, 1899.

[16] The series of articles were reprinted in a small book entitled "Baby Incubators" by John Zahorsky, St. Louis, Mo., Courier of Medicine Co., 1905. Dr. Marshall Klaus found reference to the show babies in a book by L. Frank Baum (author of the "Oz" books) entitled John Dough and the Cherub published in 1906. The cherub in this story is named "Chick" and he says at one point, "I'm the Incubator Baby you know." And a character in the book asks, "Were you, by any chance at the Pan-American Exposition? Or the Louisiana Purchase Exposition? ... there were a good many Incubator Babies at both these expositions."

[17] Dr. Gartner has attempted to pin down rumors that Hildegarde was an exhibit baby adopted by Couney. The hearsay evidence collected over a period of years has been difficult to interpret.

[18] Gladys Hansen, of the San Francisco Public Library, supplied photographs of the exhibit building. The details of the fair were described in The Blue Book -- A Comprehensive Official Souvenir Book Illustrating the Panama Pacific International Exposition at San Francisco, San Francisco, The Independent Pressroom Printers, 1915.

[19] This photograph was given to me by man on the staff of television station KPIX in San Francisco. He heard that I was interested in the 1915 exhibit and contacted me to ask whether I had ever met any of the graduates. When I said, "No," he replied, "You're looking at one."

[20] Hess JH: Oxygen unit for premature and very young infants. Am J Dis Child 47:916, 1934.

[21] The interview with Miss Lundeen was arranged through the good offices of Dr. Marvin Cornblath.

[22] This photograph was given to Dr. Gartner by Dr. Moe Goldstein.

[23] These details appear in a movie film taken by Dr. Nickman. [1]

[24] Medical News: New York City. JAMA 115:1648, 1940.

[25] Mrs. Louise Bates Ames allowed me to view and copy a short length of the film record taken by Dr. Gesell.

[26] Dr. Albert J. Solnit obtained permission to allow me to review Dr. Gesell's extensive film record at Yale; Mr. Paul Hartmann told me of the experience in photographing the exhibit in 1939 and in 1940.

[27] Gesell A: The Embryology of Behavior, New York, harper & Bros., 1945.

[28] A "$75,000 incubator palace" was erected at the 1939-1940 Golden Gate International Exposition in San Francisco by Mr. Ed Breckenridge, an amusement park promoter. This show cared for 85 babies during the two-year run of the fair. Breckenridge announce, "Business is great!" Dr. Martha James, the medical consultant to this show, was not impressed with the attendance.

[29] The bronze tablet was placed through the efforts of Dr. Gartner in 1970 when he was the chairman of the annual Newborn Dinner held at the time of the spring meeting of the pediatric research societies in Atlantic City.

[30] Sterky G, Mellander L: Birthweight Distribution -- An Indicator of Social Development. SAREC Report No. 4:2, Uppsala, Swedish Agency for Research Cooperation with Developing Countries, 1978.

[31] "The more things change, the more they are the same," attributed to Alphonse Karr, Les Guêpes, Jan., 1849.

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