iBHi 
 
 
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 82«6 
 
 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY
 
 5"Ml- t:
 
 8!?.f)f> 
 
 Premature and Congenital^ 
 Diseased Infants 
 
 BY 
 
 JULIUS H. HESS, M.D. 
 
 PROFESSOR AND HEAD OF THE DIVISION OF PEDIATRICS, UNIVERSITY OF ILLINOIS 
 
 COLLEGE OF MEDICINE; CHIEF OF PEDIATRIC STAFF, COOK COUNTY HOSPITAL; 
 
 ATTENDING PEDIATRICIAN TO COOK COUNTY, MICHAEL REESE AND ENGLE- 
 
 WOOD HOSPITALS; CONSULTING PEDIATRICIAN, MUNICIPAL CONTAGIOUS 
 
 HOSPITAL AND WINFIELD TUBERCULOSIS SANITARIUM, CHICAGO; 
 
 MEMBER OF ADVISORY BOARD CHILDREN'S BUREAU, 
 
 DEPARTMENT OF LABOR, WASHINGTON, D. C. 
 
 ILLUSTRATED WITH 189 ENGRAVINGS 
 
 LEA & FEBIGER 
 
 PHILADELPHIA AXD NEW Y O R K 
 192 2
 
 S<H £ 
 
 Copyright 
 
 LEA & FEBIGER 
 
 1922 
 
 Printed in u. s. a.
 
 
 
 lAlS 
 
 /f/0 
 
 If A3. 
 
 In the name of 
 
 CLARA MERRIFIELD HESS 
 
 This book is affectionately dedicated to the 
 most helpless of the human race 
 
 THE INFANT BORN PREMATURELY 
 
 particularly needful of aid in its 
 struggle for existence 
 
 624297
 
 PREFACE. 
 
 In the absence of any definite collection of material on the care 
 of prematurely born human infants, I have attempted to compile 
 information taken from many sources. The foundation of this 
 work with premature infants was laid in the researches of the 
 French obstetricians and was adopted and further popularized by 
 English and German physicians. 
 
 The growing importance of the subject is indicated by the increase 
 in premature births during recent years revealed by vital statistics. 
 Of 2806 deaths of infants occurring in Chicago during one year, 
 739 deaths in the first month of life were due to prematurity. Of 
 860 who died during the first twenty-four hours, 399 deaths were 
 due to premature birth, while of 1700 who died during the first week 
 of life, 588 deaths were due to premature birth. 
 
 A study of the etiological factors predisposing to premature 
 birth emphasizes the necessity for proper prenatal care of the 
 mother, thus eliminating a large group of premature births pre- 
 cipitated by her overwork and her anxiety, or by trauma, as well as 
 by improper hygiene and insufficient and improperly balanced diet. 
 The general experience of workers who have interested themselves 
 in prenatal care of the mother in its larger aspect proves that 
 careful following of scientific instructions inevitably decreases the 
 number of premature births coming under observation. 
 
 Many diseases, such as syphilis and nephritis, which are direct 
 causes of premature birth, are amenable to treatment which will 
 prolong the intra-uterine life to the natural period, or at least to the 
 point where prenatal development is compatible with post-natal 
 existence. Proper preparation for the care of these infants will 
 justify the induction of labor prior to full-term when pathologic 
 conditions exist; moreover this procedure may be undertaken at a 
 much earlier time than when proper facilities are not available. 
 
 In the United States the care of premature infants has not received 
 the general attention of the medical profession which it merits. 
 Facilities for the care of such infants are lacking. first, because 
 special obstetrical hospitals in most instances decline outside cases, 
 and, second, because comparatively few general hospitals are 
 properly organized to undertake the special care required. Proper
 
 VI PREFACE 
 
 handling of these infants demands a thorough knowledge of their 
 immediate needs. The first intimation of coming labor must be 
 met by preparation for the infant's reception in order to avoid the 
 dangerous period of exposure immediately after birth which is a 
 primary cause of the high mortality. If a sudden lowering of 
 temperature produces fatality in some cases in full-term infants, 
 how much more likely it is to produce fatality in an immature 
 infant, whose organs are not completely developed, who is lacking 
 in the protective covering of body fat possessed by the mature 
 infant, whose vitality is low and whose resistance is at a minimum. 
 Coming from an equalized temperature of unvarying degree it is 
 precipitated into alien surroundings, deprived of its usual nutrition 
 and subjected to handling which, however tender, is still a shock to 
 its delicate external and internal structures. 
 
 As a part of the great movement toward conserving and develop- 
 ing the individual to his highest point of health efficiency, as an 
 important factor in national health, and as an effort directed toward 
 the source of a considerable morbidity, the care of premature infants 
 and the conservation of their flickering lives has a prominent place. 
 
 I desire to acknowledge my indebtedness to Dr. Martin Couney 
 for his many helpful suggestions in the preparation of the material 
 for this book. 
 
 J. H. H. 
 
 Chicago, 1922.
 
 CONTENTS. 
 
 PART I. 
 
 ETIOLOGY, PHYSIOLOGY, PATHOLOGY. 
 CHAPTER I. 
 
 What Constitutes Prematurity in the Infant 17 
 
 CHAPTER II. 
 
 Classification of Prematures 19 
 
 CHAPTER III. 
 Physiology 27 
 
 CHAPTER IV. 
 
 Pathological Findings in Prematures 103 
 
 PART II. 
 
 NURSING AND FEEDING CARE. 
 
 CHAPTER V. 
 
 Maternal Nursing 107 
 
 CHAPTER VI. 
 Wet Nursing 114 
 
 CHAPTER VII. 
 Carf. and Nursing of Premature Infants 131 
 
 CHAPTER VIII. 
 Methods of Feeding 171 
 
 CHAPTER IX. 
 Incubators -05
 
 vm CONTENTS 
 
 PART III. 
 
 GENERAL DISEASES. 
 
 CHAPTER X. 
 
 Diseases of the Respiratory Tract 235 
 
 CHAPTER XI. 
 Diseases of the Gastro-intestinal Tract 266 
 
 CHAPTER XII. 
 Diseases of the Urinary Tract 299 
 
 CHAPTER XIII. 
 Diseases of the Nervous System 301 
 
 CHAPTER XIV. 
 Sepsis 311 
 
 CHAPTER XV. 
 
 Syphilis 320 
 
 CHAPTER XVI. 
 Tuberculosis in Prematures 336 
 
 CHAPTER XVII. 
 Edema and Scleredema ix Premature Infants 342 
 
 CHAPTER XVIII. 
 Diseases Peculiar to Premature Infants 346 
 
 PART IT. 
 
 THE OUTLOOK FOR THE PREMATURE. 
 
 CHAPTER XIX. 
 Prognosis 361 
 
 CHAPTER XX. 
 
 The Future of the Premature Infant 377
 
 LIST OF ILLUSTRATIONS. 
 
 PAGE 
 
 Fig. 1. — Case of Congenital Goiter 20 
 
 Fig. 2.— Case of Congenital Thymus 20 
 
 Fig. 3.— Mongolian Idiot 21 
 
 Fig. 4. — Chondrodystrophia 21 
 
 Fig. 5. — Chondrodystrophia 22 
 
 Fig. 6.— Cretinism 23 
 
 Fig. 7.— Dyspituitarism ... 23 
 
 Fig. S. — Case of Siamese Twins .24 
 
 Fig. 9.— Triplets 25 
 
 Fig. 10.— Chart Showing Growth in Late Fetal Weeks ... 33 
 
 Fig. 11.— Changes in Body Proportions in Fetal Life . . 36 
 Fig. 12. — Chart of Weight and Surface Area .... .48 
 
 Fig. 13.— Dermatograph 49 
 
 Fig. 11.— Position of Stomach in Sixteen Weeks' Fetus 53 
 
 Fig. 15. — Position of Stomach in Full-term Infant . . .... 54 
 
 Fig. 16.— Roentgenogram of Stomach Immediately After Feeding 55 
 
 Fig. 17.— Section Through Esophagus (Thirty-two Weeks) . . 56 
 
 Fig. 18.— Section Through Middle of Fundus of Stomach (Twenty-two 
 
 Weeks) 56 
 
 Fig. 19.— Section Through Pyloric End of Stomach (Twenty-four Weeks) 57 
 
 Fig. 20.— Section Through Pyloric End of Stomach (Twenty-eight Weeks) 57 
 
 Fig. 21. — Stomach of Twenty-four Weeks' Fetus 59 
 
 Fig. 22.— Stomach of Twenty-six Weeks' Fetus 59 
 
 Fig. 23.— Stomach of Twenty-eight Weeks' Fetus 59 
 
 Fig. 24.— Stomach of Thirty-two Weeks' Fetus 60 
 
 Fig. 25.— Stomach of Thirty-six Weeks' Fetus 60 
 
 Fig. 26.— Stomach of Forty Weeks' Fetus 61 
 
 Fig. 27.— Embryologic Eye Section 75 
 
 Fig. 28. — Embryologies! Section of Temporal Bone 76 
 
 Fig. 29. — Development of Centers in Weeks 78 
 
 Figs. 30 and 31.— Fetus at Seven Weeks 79 
 
 Figs. 32 and 33.— Fetus at Eight Weeks 80 
 
 Figs. 34 and 35.— Fetus at Ten Weeks 84 
 
 Fig. 36. — Photograph (a) and roentgenogram (b) of transparent speci- 
 mens of fetus at ten weeks. One-half actual size .... 85 
 
 Figs. 37 and 38.— Fetus at Eleven to Twelve Weeks 86 
 
 Figs. 39 and 40.— Fetus at Thirteen to Sixteen Weeks 87 
 
 Fig. 41. — Ossification Centers, Eleven to Twelve, and Thirteen to Sixteen 
 
 Weeks 88 
 
 Fig. 42. — Cross-section, Arm of Fetus, Twenty-two Weeks .... 89 
 
 Fig. 43. — Cross-section, Forearm of Fetus, Twenty-two Weeks ... 90 
 
 Figs. 44 and 45.— Fetus at Seventeen to Twenty Weeks ... 91 
 
 Figs. 46 and 47.— Fetus at Twenty-five to Twenty-eight Weeks . 92 
 Fig. 48. — Skull of Fetuses, Seventeen to Twenty Weeks, and Twenty-five 
 
 to Twenty-eight Weeks 93 
 
 Figs. 49 and 50. — Fetus at Twenty-nine to Thirty-two Weeks. . . 94 
 Figs. 51 and 52.— Fetus at Thirty-three to Thirty-six Weeks . 95 
 FlG. 53. — Skull of Fetuses, Twenty-nine to Thirty-two Weeks, and Thirty- 
 three to Thirty-six Weeks 97
 
 X LIST OF ILLUSTRATIONS 
 
 PAGE 
 
 Fig. 54.— Good Secreting Breast 115 
 
 Fig. 55. — Type of Breast to be Avoided in Selecting Wet-nurse . . . 115 
 
 Figs. 56 and 57. — Uniform of Wet-nurse 120 
 
 Fig. 58.— Proper Method of Holding Baby During Nursing . . 125 
 
 Fig. 59.— Premature Infant, Nursing 126 
 
 Fig. 60.— Breast Pump 127 
 
 Figs. 61 and 62.— Direct Expression of Breast Milk .... . 128 
 
 Fig. 63.— Floor Plan of Infant Ward 136 
 
 Fig. 64.— Hospital Bath Room 138 
 
 Fig. 65.— Divan Bath . . 138 
 
 Fig. 66. — Electrically Warmed Dressing Table 139 
 
 Fig. 67. — Unhealed Dressing Table 139 
 
 Fig. 68. — Scale for Weighing Infant 140 
 
 Fig. 69. — Thermometer (Adjustable) 140 
 
 Fig. 70.— Hygrometer 140 
 
 Fig. 71.— Table of Relative Humidity 141 
 
 Fig. 72.— Milk Station 141 
 
 Fig. 73.— Portable Bath Basin . . 142 
 
 Fig. 74. — Individual Bed for Infected Cases 142 
 
 Fig. 75. — Emergency Robe 144 
 
 Fig. 76. — Emergency Robe on Infant 145 
 
 Fig. 77.— Woolen Bag with Hood 154 
 
 Figs. 78 and 79.— Undershirt and Overshirt 155 
 
 Fig. 80.— Pinning Skirt 156 
 
 Fig. 81.— Bib 156 
 
 Fig. 82.— Pattern for Shirts '. 157 
 
 Figs. 83 and 84.— Dressing the Babv 158 
 
 Figs. 85 to 91.— Hospital Records 160 to 165 
 
 Fig. 92. — Special Bath Room for Private Home 166 
 
 Fig. 93. — Plan for Stations in Private Home 167 
 
 Fig. 94. — Feeding Premature Infant 172 
 
 Fig. 95.— Fruit Spoon for Mouth Feeding 173 
 
 Fig. 96. — Medicine Dropper for Use in Feeding 173 
 
 Fig. 97.— Nursing Bottles 173 
 
 Fig. 98.— Breck Feeder 174 
 
 Fig. 99. — Utensils for^Catheter Feeding 175 
 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 Fig. 
 
 00. — Catheter Feeding (Roentgenograph) 176 
 
 01.— Catheter Feeding 177 
 
 02. — Baby Juanita, Weight 1070 grams 185 
 
 03. — Baby Juanita, Weight and Food Curves 185 
 
 04.— Baby Silvis B 186 
 
 05.— Baby Silvis B., Weight and Food Curves 186 
 
 06.— Baby Allen B., 1135 grams 187 
 
 07.— Baby Allen B., Weight and Food Curves 187 
 
 08.— Baby Peggy, 1185 Grams 188 
 
 09.— Baby Peggy, 2155 Grams 188 
 
 10. — Babv Peggv, Weight and Food Curves 189 
 
 11.— Baby Grace A., 1180 Grams 189 
 
 12.— Baby Grace A., 1875 Grams 190 
 
 13.— Baby Grace A., Weight and Food Curves 190 
 
 14.— Baby Peter P., 1220 Grams 191 
 
 15.— Baby Peter P., Weight and Food Curves 191 
 
 16.— Babv Ethna H 192 
 
 17.— Baby Ethna H., Weight and Food Curves 193 
 
 18.— Joseph and Edward R., Twins, 1360 and 1190 Grams ... 193 
 
 19.— Joseph and Edward R., Weight and Food Curves .... 194 
 
 20.— Babv Grace B., 1395 Grams 195 
 
 21.— Baby Grace B., Weight and Food Curves 195 
 
 22.— Baby Glenn 196 
 
 23.— Baby Glenn, One Hundred and Eight Days Old .... 196 
 
 24.— Baby Glenn, Aged Five Years 197
 
 LIST OF ILLUSTRATIONS xi 
 
 PAGE 
 
 25.— Baby Glenn, Weight and Food Curves 197 
 
 26.— 'Baby Ann C, Aged Eighteen Days 198 
 
 27.— Baby Ann C, Aged One Hundred and Thirty-six Days . . 198 
 28.— Baby Ann C, Weight and Food Curves . . . . . . .199 
 
 29. — Utensils for Artificial Feeding 200 
 
 30.— Warm Tub Incubator ... 206 
 
 31. — Modified Warm Incubator 207 
 
 32.— Tarnier Incubator . 207 
 
 33.— Finkelstein's Incubator 209 
 
 34.— Reinaeh Heated Bed 210 
 
 35.— Rommel Incubator L'll 
 
 36. — Lyon-type Incubator. Couney Model 212 
 
 27. — Lyon-type Incubator. De Lee Model 213 
 
 38.— Moll Heated Bed 214 
 
 39.— Hess Water-jacketed Infant Bed 214 
 
 40. — Cross-section Hess Bed (Diagram) 215 
 
 41. — Cross-section Hess Bed (Direction Air Currents) .... 216 
 42. — Variation in Weight Curyes of Infant While In and Out of 
 
 Heated Bed 220 
 
 43. — Copper Receptacle Containing Pads 224 
 
 44. — Incubator Room, Escherich-Pfaundler System 227 
 
 45. — Heated Room, University of California 228 
 
 46. — Sloan Hospital Incubator 229 
 
 47. — Obstetrical Bag Designed for Transportation 230 
 
 48. — De Lee Transportation Incubator 231 
 
 149 and 150. — De Lee Incubator, Outer and Inner Case . . 232 
 
 51. — Thymus Gland Causing Death 248 
 
 52. — Congenital Atelectasis -!•">_' 
 
 53. — Diffuse Congenital Atelectasis •. 255 
 
 54. — Incomplete Diaphragmatic Hernia 256 
 
 55. — Incomplete Diaphragmatic Hernia 257 
 
 56. — Application in Inguinal Hernia 295 
 
 57. — Inguinal Herm'a Bandage 296 
 
 58. — Pad for L'se in Hernia Bandage 296 
 
 59. — Umbilical Hernia Bandage 297 
 
 60. — Umbilical Hernia Bandage, Cotton Cigarette in Place . . . 298 
 
 61. — Umbilical Hernia Bandage, Adhesive Strap in Place . . . 298 
 
 162 and 163.— Pabv P. H., Megacephalus 304 
 
 64.— Baby P. H., Weight and Food Curves 305 
 
 65. — Hydrocephalus 306 
 
 66. — Oxvcephalus 307 
 
 167 and 168.— Congenita] Syphilis 322 
 
 69. — Congenital Syphilis 323 
 
 70.— Osteochondritis Syphilitica 324 
 
 171 to 175.— Bone Development in Syphilis 326 and 327 
 
 76. — Erythroblastosis : 344 
 
 177 and' 178.— Rickets 347 and 348 
 
 79. — Spasmophilia 354 
 
 80. — Fracture of Both Forearms in Spasmophilia 359 
 
 81.— Two Greek Triplets. 690 and 740 Grams 365 
 
 182 and 183.— Two Greek Triplets, Weight and Food Curves . . 365 
 
 84.— Infant Born at Thirty-six Weeks 383 
 
 85.— Same Child Aged Two and a Half Years 384 
 
 86.— Same Child, Aged Four and a Half Years 384 
 
 87.— Infant Born at Thirty-four Weeks, Complication 5 
 
 Paraplegia 
 
 88— Same Child, Standing Posture . . 385 
 
 89. — Same Child, Showing Results Following Tendon Transplanta- 
 tion 386
 
 INDEX OF TABLES. 
 
 PAGE 
 
 Brain Weight 37 
 
 Causes of Premature Births 371 
 
 Death, Fetal Ages Factor in 362 
 
 Decreased Mortality with Increased Birth Weight 363 
 
 Food Requirements in Calories, 1000 and 1500 Grams in Weight . . . 181 
 
 Humidity Readings 141 
 
 Infants with Birth Weights to 2500 Grams in First Eight Years . 381 
 
 Kidneys, Weight 39 
 
 Liver, Weight 38 
 
 Measurements of Assistance in Estimating Viability 369 
 
 Mortality Statistics in Prematures 375 
 
 Ossification Centers, Body 81 
 
 Head 80 
 
 Pelvic Girdle and Lower Extremities 83 
 
 Vertebrae 82 
 
 Outcome in Prematures, as Regards Development 37 ^ 
 
 Percentage Saved After Induced Labor 370 
 
 Relation Between Birth Weight and Length Measurement .... 30 
 
 Mortality and Subnormal Temperature 368 
 
 Of Body Weight to Megacephalus 307 
 
 Spleen, Weight 39 
 
 Temperature on Admission and Mortality of Premature Infants . . 230 
 
 Time of Occurrence of Megacephalus 308 
 
 Umbilical and Inguinal Hernia, Occurrence of 294 
 
 Walking and Talking Time in Prematures 382
 
 PREMATURE AND CONGENITALLY 
 DISEASED INFANTS. 
 
 PART I. 
 ETIOLOGY-PHYSIOLOGY-PATHOLOGY. 
 
 CHAPTER I. 
 DEFINITION. 
 
 The term premature, in the precise meaning of the word, refers 
 to those infants born before the end of the fortieth week of preg- 
 nancy, but in common usage it refers only to those infants who 
 have undergone a gestation period of two hundred and sixty days 
 or less, and so it may be understood that when the designation 
 premature is used, it refers to those infants born three weeks or 
 more before the usual termination of pregnancy. 
 
 There is another class of infants who may be considered in 
 practically the same category as the prematures. These are the 
 weaklings, infants born possibly at term, or nearly so, yet who 
 have suffered more or less severely during their intra-uterine 
 existence through factors which interfered with their nutrition and 
 consequently their development. They are classed as congenitally 
 diseased or debilitated. 
 
 In contrast to the prematures there are the full-term and mature 
 infants. The full-term must be considered that one who is born 
 at the completion of the normal period of two hundred eighty days 
 of pregnancy. The mature infant is one possessed of all the facul- 
 ties for extra-uterine existence and may be born before or at the 
 expiration of normal gestation. Thus it may be seen that the 
 functional and not the anatomical characteristics should decide 
 maturity. While prematurity pertains to time and congenital 
 disease or debility to function, the prematures do not need to be 
 weaklings, whereas the full-terms may show evidence of congenital 
 disease or debility. 
 
 The congenitally diseased are usually pale in appearance, thin, 
 underweight, show a lack of cutaneous turgor, and have a low 
 2
 
 18 INTRODUCTION 
 
 reactive capacity, suckle and drink poorly and have a tendency 
 to restlessness, abnormal abdominal distention and dyspeptic- 
 stools. Not infrequently this class of infants fails to gain weight 
 in a normal manner and, therefore, often require several weeks to 
 regain their birth weight. This indicates functional incapacity 
 even in the absence of demonstrable organic disease. This lack of 
 functional development varies greatly with the individuals. 
 
 With reference to this class Jaschke 1 remarks that we should admit 
 that vital debility must be designated as a congenital functional 
 deformity which manifests itself chiefly in a deficient resistance or 
 very low tolerance to the conditions and variations of the extra- 
 uterine life. The debilitated infants react on one hand with 
 symptoms of disease toward physiological stimulus, and on the 
 other hand their well-being is unfavorably influenced by the slight- 
 est degree of over- or understimulation. 
 
 Many premature infants, not only have been born before full- 
 term, but also have their physical development retarded by intra- 
 uterine disease and are below the average physical development 
 for fetuses of a similar age. . 
 
 It must be remembered that all infants born before the end 
 of a normal term are born before the end of a full intra-uterine 
 pregnancy, and consequently their organs are not fully developed. 
 As a result they show certain definite body weaknesses, and a lack 
 of resistance to the traumas of extra-uterine life. These are imma- 
 ture even though fully developed for their fetal age. 
 
 This, however, is only a relative body iveakness in the absence of 
 inherited constitutional debility and malformations. 
 
 It is also a fact that the younger the fetus when leaving the 
 uterus, the greater are the difficulties to be overcome in the carry- 
 ing out of the required body functions necessary to life and, 
 therefore, the lower its vitality. 
 
 In a study of premature and congenitally debilitated infants at 
 least two factors in the life history of the fetus must be considered: 
 
 1. The term of its intra-uterine life. 
 
 2. The state of its functional development at birth as evidenced 
 by the presence or absence of inherited disease. 
 
 Congenital debility is dependent upon constitutional influences 
 in the parents, and intercurrent disease during the term of preg- 
 nancy. 
 
 Notwithstanding the fact that both of the above factors must 
 be given the most careful consideration, practically, in most 
 instances, the influence of either factor on the extra-uterine life 
 of the fetus in its early days cannot be definitely determined. 
 
 1 Physiologie, Pflege unci Ernahrung des Neugeborenen. J. F. Bergman, 1917.
 
 CHAPTER II. 
 
 CLASSIFICATION. 
 
 For practical clinical purposes the group of infants comprising 
 the premature and congenitally debilitated may be classified as 
 follows : 
 
 1. Premature infants, with no pathological changes. 
 
 2. Premature infants, with pathological changes, due to: 
 
 (a) Constitutional disease and chronic infections in the parents. 
 
 (b) Maternal factors influencing the fetal nutrition, such as 
 o\ erwork, undernourishment and acute illnesses during pregnancy. 
 
 (c) Local conditions in the mother. 
 
 (d) Multiple pregnancies. 
 
 (e) Constitutional defects and congenital malformations in the 
 fetus. 
 
 (/) Infants born to parents late in life. 
 
 3. Full-term infants with pathological changes due to the same 
 causes as those enumerated under 2. 
 
 ETIOLOGY. 
 
 The occurrence of premature birth depends upon many causes, 
 which may be divided into those resulting in the expulsion of a 
 healthy premature, and those which have a damaging effect upon 
 the product of conception. In the first class may be included 
 various injuries, falls, heavy lifting, overwork or other physical 
 exhaustion, sudden emotional disturbances and premature rupture 
 of the membranes, either accidental or intentional, occurring in 
 those conditions whose existence does not affect the nutrition of 
 the ovum, as in pelvic and spinal deformity in the mother, placenta 
 previa, etc. 
 
 Conditions in the mother requiring operative procedure not 
 involving the uterine cavity frequently result in premature labor 
 either through shock and trauma, resulting from operations, as for 
 ovarian conditions and uterine fibroids, or infection may be an 
 added danger in cholecystitis, cholelithiasis, appendicitis, ileus and 
 renal operations. 
 
 The cases which fall within the second category all react to a
 
 20 
 
 CLASSIFICATION 
 
 greater or lesser degree upon the fetus, some producing only momen- 
 tary weakness, as the milder acute infections, others causing a 
 weakened physical condition as a result of their long-continued 
 action upon the nutrition and development of the fetus. 
 
 Fig. 1. — Case of congenital goiter. 
 
 Fig. 2. — Case of congenital thymus (atrophy of gland following two exposures to 
 
 roentgen ray).
 
 ETIOLOGY 
 
 1\ 
 
 
 <^ 
 
 Mi 
 
 
 "^ -%»• 
 
 
 w 
 
 - 
 
 
 i 
 
 
 « 
 
 
 
 
 i 
 
 flH^ 
 
 i 
 
 Fig. 3. — Mongolian idiot. 
 
 Fig. 4. — Chondrodystrophia.
 
 22 
 
 CLASSIFICATION 
 
 The most frequent causes are the chronic infections. Syphilis 
 plays the leading role, and is estimated as being a factor in from 
 50 to 80 per cent of all cases of repeated premature expulsion of the 
 fetus, while Lesage and Kouriansky 1 state that syphilis is a factor 
 in the causation of congenital debility of the full-term in 25 to 35 per 
 cent. If the luetic infection is recent, abortion is the rule; but as 
 the infection becomes older, the succeeding pregnancies terminate 
 
 Fig. 5. — Chondrodystrophia. 
 
 later and later until a living child with or without manifestations 
 of the disease is born, usually prematurely. 
 
 Chronic nephritis is one of the most frequent causes of spon- 
 taneous premature labor, and the offspring of these mothers are 
 often puny, due, either to the systemic effect on the mother, or 
 resulting from impaired nutrition of the fetus due to placental 
 
 1 Congenital Debility and Atrophy, Nourrisson, Paris, July, 1919, No. 4, 7, 193.
 
 ETIOLOGY 
 
 23 
 
 hemorrhages and infarcts. Nephritis in the mother is also one 
 of the most frequent indications for the induction of premature 
 labor. 
 
 Fig. 6. — Cretinism. 
 
 Pulmonary tuberculosis is less frequently the cause of premature 
 labor, but the children, even at full-term, are often small and 
 weak. Tuberculosis of other organs and tissues influences the fetus 
 in proportion to the nutritional effect upon the mother or, again 
 when involving the vertebral column or hip-joints may by their 
 
 Fig. 7. — Dyspituitarism. 
 
 resulting deformities require premature induction of labor. Con- 
 genital tuberculosis is very rare, but does occur. In the majority of 
 cases, not the disease per se, but the predisposition is inherited.
 
 24 
 
 CLASSIFICATION 
 
 Premature birth occurs in .30 or 35 per cent of the cases of broken 
 compensation in heart disease. The premature infants are, in 
 these cases, often imperfectly nourished as a result of the poor 
 aeration of the mother's blood. Exophthalmic goiter is occasion- 
 ally the cause of premature emptying of the uterus. If chronic 
 dyspnea exists, as a result of laryngeal or tracheal stenosis from 
 pressure, the development of the fetus will necessarily be retarded. 
 
 Fig. 8. — Case of Siamese twins. Thoracopagus tetrabrachius tetrapus. (From the 
 service of Dr. Ludwig Simon, Michael Reese Hospital, Chicago.) 
 
 Any of the acute infectious diseases may be responsible for the 
 termination of pregnancy before the end of term. Pneumonia, 
 influenza, typhoid fever, malaria, diphtheria, scarlet fever, measles, 
 small-pox, Asiatic cholera and bubonic plague— all have a dele- 
 terious effect on the continuance of pregnancy. Premature labor 
 is very common in pneumonia and influenza, being more frequent 
 in late pregnancy. 
 
 Of local conditions, diseases of the decidua or endometrium, 
 gonorrheal infection and malpositions of the uterus frequently 
 result in premature labor, but usually before the fetus is viable. 
 Anomalous positions of the fetus in the uterus may be responsible 
 for the premature expulsion of the uterine contents.
 
 ETIOLOGY 
 
 The occurrence of multiple pregnanqj is a fruitful source of 
 premature labor. About 70 per cent of twin pregnancies termi- 
 nate prematurely and the length of practically all triplet and 
 quadruplet gestations is considerably shortened in most instances 
 due to lack of room in the uterine cavity. Miller's 1 figures are 
 slightly smaller. He states that of 3380 plural births, 2040, or 
 00 per cent, were premature, and had a body weight of less than 
 2500 gm., and a length under 45 cm. Even when mature, twins 
 are usually small and of low body weight. This, of course, is even 
 more true of triple pregnancies, the reserve strength possessed by 
 the mother not being sufficient to allow three fetuses to reach their 
 normal development. Again in the presence of several fetuses the 
 growth may proceed unequally so that one may be born with 
 unimpaired vitality, and the others with greatly diminished strength 
 (Fig. 9). 
 
 Fig. 9. — Triplets. 
 
 Faulty nutrition of the fetus, such as is found in maternal over- 
 work or from lack of sufficient food, as well as that due to wasting 
 diseases, the blood dyscrasias (pernicious anemia and leukemia) 
 and intoxication from alcohol (acute and chronic), phosphorus, 
 arsenic, mercury or lead may— any one of them— cause either an 
 early termination of pregnancy or so serious a lowering of nutrition 
 of the fetus that the vitality at birth may be greatly impaired. 
 In addition, congenital malformations in the fetus sometimes bring 
 on premature birth. In diabetes prematurity is not infrequent, 
 and the infants may show glycosuria. 
 
 Infants born to parents late in life are often born prematurely, 
 perhaps because of the factor of undernourishment. This is also 
 
 1 Peculiarities of the Disease of the Premature Infant, Jahrb. f. Khlk., lssc>,25, 120.
 
 2G CLASSIFICATION 
 
 the case in prematures born of women who have had numerous 
 pregnancies, at short intervals. 
 
 Finally, habitual miscarriage, without evident cause, resulting in 
 the interruption of successive pregnancies, not infrequently at about 
 the same stage, is not rare. The author has records of several such 
 women without a history of syphilis or other constitutional disease, 
 and in whom uterine deformity is not demonstrable. 
 
 The frequency of premature labors varies greatly in different 
 clinics. Rommel 1 quotes the following figures from various clinics, 
 noting the number of infants under 2500 gm. in weight and below 
 4o cm. in length. 
 
 Miller . . . . 5.0 per cent 
 
 Von Winckel 
 Fehling 
 Budin . 
 Pinard 
 
 13.3 
 
 25.0 
 10.7 
 15.4 
 
 Orphan Asylum . 
 
 Moscow 
 
 Maternity . . . 
 
 Munich 
 
 Maternity 
 
 Halle 
 
 ( 'Unique Tarnier 
 
 Paris 
 
 " Baudelocque 
 
 Paris 
 
 It is stated that the percentage of premature births is greater 
 during the colder months of the year. 
 
 1 Quoted from Pfaundler and Sehlossman Handb. f. Kinderh., Leipzig, 1901.
 
 CHAPTER I I 1 
 PHYSIOLOGY. 
 
 CLINICAL FEATURES. 
 
 The appearance and characteristics of the healthy premature 
 child vary with the fetal age at the time of birth. With a lengthen- 
 ing of the period of gestation, the distinctive characteristics of 
 the fetus become less and less marked until it becomes impossible 
 to differentiate the slightly premature from the full-term infant. 
 All the distinguishing features of the premature may also be found 
 in the congenitally diseased full-term infants, and as there may be 
 all degrees of prematurity, so we also find all stages of development 
 between the extremes of functional and anatomical inferiority 
 on the one hand and the normal constitution on the other. Both 
 the premature and the debilitated infant may exhibit the following 
 features in varying degrees. 
 
 The body is usually small and puny, though in some instances 
 the infant may be of a considerable size, yet with a very imperfect 
 development of its internal organs. 
 
 The weight is low, varying from amounts approximating 700 gm. 
 (1£ lbs.) to 2500 gm. (5| lbs.) in the viable. The latter figure 
 may be exceeded in infants nearing maturity, and by some of 
 the full-term weaklings, but will serve as a fair maximum. 
 
 The skin is soft and usually of a vivid red color. The epidermis 
 is thin and the bloodvessels are easily seen. 
 
 The skin frequently hangs in folds. The adipose tissue is scant, 
 the features are angular and the face looks old. 
 
 Lanugo is plentiful, especially upon the extensor surfaces of the 
 extremities. 
 
 The skull is round or ovoid in contradistinction to the usually 
 markedly dolichocephalic skull of the full-term new-born. The 
 fontanelles are large and the sutures prominent. 
 
 The nose exhibits many small comedones. The ears are soft and 
 small and hug the skull. 
 
 The nails have scarcely reached the ends of the fingers even in 
 the larger infants, while in the smaller they may be very poorly 
 developed. 
 
 The cry is feeble, monotonous and whining. 
 
 The infant lies in a deep sleep, and must be aroused for its feed-
 
 28 PHYSIOLOGY 
 
 rags. Efforts at suction are weak or absent. All movements afe 
 slow, functions are sluggish and the child shows a remarkable degree 
 of muscular inertia. 
 
 The temperature has a very decided tendency to remain below 
 normal and is inclined to be irregular in character. 
 
 The urine is usually scanty. 
 
 The bowels are sluggish and constipation is the rule. 
 
 Early and intense jaundice is common. 
 
 These are the principal findings which are to be seen on super- 
 ficial examination. A more critical review of these various char- 
 acteristics follows. It must be remembered that any of these 
 symptoms may vary in different individuals of the same age, 
 depending upon the cause of prematurity, and upon the condition 
 of health present in both the mother and the child. With increas- 
 ing age, the characteristics become less marked, until the picture 
 eventually merges into that of the full-term infant. 
 
 The determination of the exact age of the infant prematurely born 
 is a matter of considerable difficulty. The information furnished 
 by the mother as to the time of her last menstrual period, or as 
 to the time when life was first felt, gives an entirely insufficient 
 approximation of the probable date of confinement, and errors of 
 a month or even more are not rare. In institutions for found- 
 lings all data is, as a rule, absent, and other methods for deter- 
 mining the infant's fetal age must be relied upon. The weight 
 of the infant is of uncertain value also, as an infant of 1500 gm. 
 weight may be the product of a pregnancy of seven months in a 
 healthy woman, while one of the same or less weight may be the 
 eighth-month offspring of an albuminuric or syphilitic mother. 
 The body measurements also vary materially with the individual. 
 The degree of development of the osseous system is of great value 
 in determining the anatomical development, and indirectly the 
 condition of the bones acts as a guide to physiological development, 
 even though they do not give absolute data as to age. Body 
 measurements and osseous development are fully discussed later 
 under their respective headings. 
 
 More important than a determination of the approximate term 
 of pregnancy or a consideration of the size of the infant, at least 
 in those infants born but a few weeks before the natural termination 
 of the period, is a history of syphilis, tuberculosis, traumata, or 
 other causes, operating in the mother and responsible for the early 
 emptying of the uterus. 
 
 His 1 gives the following description of the developmental features 
 of the fetus at varying ages: 
 
 1 Anatomie menschlicher Embryonen, 11, Leipzig, 1882.
 
 BODY WEIGHT AND OTHER MEASUREMENTS 29 
 
 Fifth Lunar Month (112 to 140 days).— Head about the size of 
 hen's egg; the skin is red and shows some fat deposit. The scalp 
 shows indications of hair, the body is covered with lanugo, (lie 
 nails can be distinguished, the eyelids remain closed. The fetus 
 rarely lives over five to ten minutes, making feeble attempts at 
 respiration. The heart-beats may be strong. 
 
 Sixth Lunar Month (140 to 1G8 days).— The body shows increased 
 fat deposits, though still lean, the skin being wrinkled. The eye- 
 lids are separated and eyebrows and -lashes may be seen. The 
 infant may live for several hours. The respiratory and digestive 
 organs are underdeveloped, respirations being superficial and 
 digestion practically impossible. 
 
 Seventh Lunar Month (168 to 196 days).— The infant has an 
 aged appearance but the wrinkles are filling out. The eyes arc 
 open. The cry is a weak whine or grunt. Few of these infants 
 born during the twenty-fifth and twenty-sixth weeks survive, and 
 when they do are usually hydrocephalic, paralytic and dwarfed. 
 Those of the twenty-seventh and twenty-eighth weeks are far 
 more promising. 
 
 Eighth Lunar Month (196 to 224 days).— The infant is beginning 
 to fill out, many of the wrinkles having disappeared. The bones 
 of the head are soft and flexible. Ossification begins in the lower 
 epiphysis of the femur. The testicles are often in the scrotum. 
 The cry is stronger, though it may still be very weak. Under 
 proper conditions many of these infants survive. 
 
 Ninth Lunar Month (224 to 252 days).— Panniculus adiposus 
 develops. The wrinkles smooth out and the limbs become rounded. 
 The lanugo begins to disappear, and the nails are at the tips of 
 the fingers. Respiratory, circulatory and digestive organs are 
 capable of carrying on the body functions. 
 
 Tenth Lunar Month (252 to 280 days).— The general body func- 
 tions improve during this month and at the end of this period 
 development is complete. 
 
 BODY WEIGHT AND OTHER MEASUREMENTS. 
 
 Infants born at full-term weigh on the average from ;!()()() to 
 3500 gm. The dividing line between the premature and full-term 
 infant has been generally placed at 2500 gm. If under that figure 
 they may be considered below par as far as concerns the strength 
 and ability to overcome the forces which assail them on every 
 hand. The weight of the premature varies even within greater 
 limits than that of the full-term infant, and as one may sec a child 
 below 2500 gm., so also there are prematures with a weight above 
 this limit.
 
 30 
 
 PHYSIOLOGY 
 
 The weight depends upon the cause of the premature birth and 
 upon the age of the child. Those born of mothers afflicted with 
 nephritis, tuberculosis, or other wasting diseases, and infants 
 showing active syphilis, are usually considerably smaller than the 
 same aged infants of healthy parents. Diseases and abnormal 
 location of the placenta also restrict the growth of the fetus. The 
 infant in placenta previa is often undersized, even when born at 
 term. Multiparity may predispose to undersize. 
 
 His, in a comparison of the fetal weight and length with the 
 age, made the following table: 
 
 Weight. 
 16 to 20 weeks 250 to 280 gms. 
 
 20 
 
 ' 24 ' 
 
 24 
 
 ' 28 ' 
 
 28 
 
 ' 32 ' 
 
 32 
 
 ' 36 ' 
 
 36 
 
 ' 40 ' 
 
 645 
 
 ' 1000 " 
 
 1000 
 
 ' 1220 " 
 
 1220 
 
 ' 1600 " 
 
 1600 
 
 ' 2500 " 
 
 2500 
 
 ' 3100 " 
 
 length 
 
 wi 
 
 ill 
 
 Length. 
 
 
 17 to 26 
 
 cm 
 
 28 " 
 
 34 
 
 " 
 
 35 " 
 
 38 
 
 " 
 
 39 " 
 
 43 
 
 " 
 
 46 " 
 
 48 
 
 n 
 
 48 " 
 
 50 
 
 " 
 
 THE AVERAGE LENGTHS IN CENTIMETERS OF NORMAL FETUSES 
 AS GIVEN BY DIFFERENT OBSERVERS. 
 
 Lunar 
 
 
 
 
 
 
 Schroe- 
 
 months. 
 
 Mall. 2 
 
 Von Winckel. 3 
 
 De Lee. 1 
 
 Lambert z. 5 
 
 Ahlfeld.* 
 
 der. 7 
 
 1st 1 
 
 0.25 
 
 
 0.75-0.9 
 
 
 
 
 2d 
 
 0.55- 3.0 
 
 0.9-2.5 
 
 2.5 
 
 
 
 
 3d 
 
 4.1 - 9.8 
 
 7-9 
 
 7-9 
 
 " 6-11 
 
 
 
 4th 
 
 11.7 -18.0 
 
 10-17 
 
 10-17 
 
 11-17 
 
 
 
 5th 
 
 19.8 -25.0 
 
 18-27 
 
 17-26 
 
 17-28 
 
 
 
 6th 
 
 26.8 -31.5 
 
 28.34 
 
 28-34 
 
 26-37 
 
 
 
 7th 
 
 33.1 -37.1 
 
 35-38 
 
 38-35 
 
 35-38 
 
 36-40 
 
 
 8th 
 
 38.4 -42.5 
 
 40-43 
 
 43 
 
 38-42 
 
 40-43 
 
 41.3 
 
 9th 
 
 43.6 -47.0 
 
 46-48 
 
 46-48 
 
 42-45 
 
 46-48 
 
 44.6 
 
 10th 
 
 48.4 -50 
 
 48-50 
 
 48-50 
 
 45-52 
 
 48-50 
 
 46.0 
 
 The weight and length as compared to the fetal age is shown 
 in the following table from Oberwarth, 8 which gives the average 
 length also: 
 
 Fetal 
 
 age. 
 
 Weight. 
 
 Length. 
 
 26 weeks 
 
 330 to 1041 gms. 
 
 28.0 to 37.0 cm 
 
 28 " 
 
 
 995 " 1408 " 
 
 36.3 " 37.5 " 
 
 30 " 
 
 
 797 " 1700 " 
 
 33.1 " 41.3 " 
 
 32 " 
 
 
 1868 " 1964 " 
 
 42.0 " 42.7 " 
 
 34 " 
 
 
 1286 " 2213 " 
 
 39.0 " 47.0 " 
 
 36 " 
 
 
 2424 " 2700 " 
 
 46.1 " 48.0 " 
 
 1 The length for the first two months represents the measurement from the vertex 
 to the buttocks; all the other measurements are from vertex to sole. 
 
 2 Manual of Human Embryology, 1, 196. 
 
 3 Handbuch der Geburtshiilfe, 1903, Bergman, Wiesbaden. 
 
 4 The Principles and Practice of Obstetrics, Philadelphia: W. B. Saunders Co., 2d 
 Ed., 1915. 
 
 6 Development of the Human Skeleton during Fetal Life, Fortschr. a. d. Geb. d. 
 Rontgenstrahlen, Suppl. I. 
 
 6 Von Winckel's Handbuch der Geburtshiilfe, I, No. 1, p. 290. 
 
 7 Quoted from von Winckel's Handbuch der Geburtshiilfe. 
 
 8 Ergeb. d. inn. Med. u. Kinderh., 1911, 7, 191.
 
 BODY WEIGHT AND OTHER MEASlfh'EM EXTS 
 
 31 
 
 These compare favorably with those given by Ahlfeld and 
 Hecker. 1 
 
 Fetal age. 
 27 weeks 
 29 " 
 31 " 
 33 " 
 35 " 
 37 " 
 
 Weight. 
 
 1140 gms. 
 
 1575 " 
 
 1975 " 
 
 2100 " 
 
 2750 " 
 
 2875 " 
 
 I, cunt h. 
 36.3 cm. 
 39 6 
 42.7 
 43.9 
 47.3 
 
 l.s.ij 
 
 Potel and Halm's 2 figures do not include the length. 
 
 Fetal age. 
 
 Weight. 
 
 27 weeks 
 
 995 to 1146 gms. 
 
 29 " 
 
 1540 " 1700 " 
 
 31 " 
 
 1881 " 1964 " 
 
 33 " 
 
 2150 " 2213 " 
 
 35 " 
 
 2400 " 2700 " 
 
 The following small group taken from my cases give the age of the 
 fetus as computed from the date of the last menstruation. That 
 this is an unreliable method may be recognized by noting the 
 variation in figures. in Cases 2, 3, 11, 13, 14 and 15. We therefore, 
 place little reliance on the mother's estimate as to the date of 
 conception. 
 
 
 Fetal age, 
 weeks. 
 
 Weight, 
 gni. 
 
 Length, 
 cm. 
 
 Diameters of head. 
 
 
 O. F. 
 
 Bi. P. 
 
 Bi. T. 
 
 Oc. M. 
 
 S. O. B. 
 
 1 
 
 21 
 
 700 
 
 30.0 
 
 7.5 
 
 5.5 
 
 4.5 
 
 9.0 
 
 7.5 
 
 2 
 
 22 
 
 1015 
 
 37.0 
 
 7.5 
 
 6.5 
 
 6.0 
 
 9.0 
 
 7.5 
 
 3 
 
 27 
 
 1690 
 
 40.0 
 
 9.0 
 
 8.0 
 
 6.5 
 
 11.0 
 
 7.5 
 
 4 
 
 29 
 
 1449 
 
 
 8.0 
 
 7.0 
 
 7.0 
 
 8.0 
 
 7.0 
 
 5 
 
 31 
 
 1175 
 
 37.5 
 
 9.0 
 
 7.0 
 
 6.0 
 
 11.0 
 
 8.0 
 
 6 
 
 32 
 
 1380 
 
 34.0 
 
 9.0 
 
 8.0 
 
 7.0 
 
 11.0 
 
 7.0 
 
 7 
 
 32 
 
 2040 
 
 45.0 
 
 11.5 
 
 8.5 
 
 7.5 
 
 13.0 
 
 9.5 
 
 S 
 
 33 
 
 1175 
 
 44.0 
 
 9.0 
 
 7.0 
 
 6.0 
 
 li.o 
 
 8.0 
 
 9 
 
 33 
 
 2110 
 
 45.0 
 
 10.0 
 
 8.0 
 
 6.0 
 
 12.0 
 
 8.0 
 
 10 
 
 38 
 
 3625 
 
 50.0 
 
 11.0 
 
 9.5 
 
 8.0 
 
 13.25 
 
 9.5 
 
 11 
 
 39 
 
 1610 
 
 41.5 
 
 10.0 
 
 7.75 
 
 6.25 
 
 11.75 
 
 8 - :> 
 
 12 
 
 39 
 
 3260 
 
 49.0 
 
 11.5 
 
 9 . 5 
 
 8.5 
 
 13.5 
 
 9.75 
 
 13 
 
 40 
 
 1370 
 
 38.0 
 
 9.0 
 
 7.0 
 
 6.0 
 
 10.0 
 
 8.0 
 
 14 
 
 41 
 
 1570 
 
 35.0 
 
 11.0 
 
 8.0 
 
 7.5 
 
 11.5 
 
 7.0 
 
 15 
 
 41 
 
 1810 
 
 38.5 
 
 10.0 
 
 8.0 
 
 7.5 
 
 12.5 
 
 8.5 
 
 In contrast with these measurements of the diameters of the 
 head in prematures, the average measurements of the skull in a 
 mature new born are noted as follows by Schauta. 3 
 
 1 Arch. f. Gynak., 1872, 2. Quoted from Pfaundler and Schlossman, Leipsig, 1901. 
 
 2 Do l'accroissement en poids des enfants nes avant termc. These, Paris, 1895. 
 
 3 F. Lehr. d. ges. Gyn., 2. AufL, Leipzig u. Wien, 1897.
 
 32 PHYSIOLOGY 
 
 1. Diameter suboccipito-bregmaticus (from the posterior edge of 
 the great occipital foramen to the anterior angle of the great fon- 
 tanelle), 9 cm. 
 
 2. Diameter fronto-occipitalis (from glabella to the occipital 
 protuberance), 11 cm. 
 
 3. Diameter mento-occipitalis (from the point of the chin to the 
 farthest point of the occiput), 13 cm. 
 
 4. Diameter verticalis (from the vertex to the base of the skull), 
 9.5 cm. 
 
 5. Diameter biparietalis (between the parietal tuberosities), 9 cm. 
 
 6. Diameter bitemporalis (between the farthest point of both 
 coronary sutures), 8 cm. 
 
 Parents short in stature or small in build may have children 
 who do not weigh over 2000 gm. or measure over 45 cm. in length, 
 and yet who are neither premature nor congenitally weak. 
 
 It does not do to estimate the vitality of these infants from a 
 consideration of their birth weight. Many of them born at or 
 near term have a normal weight, yet they do not survive. On 
 the other hand, infants of considerably less weight may present 
 evidence of great vitality, a lusty cry and take nourishment with 
 avidity. According to our experience the condition of the turgor 
 of the prematurely born infants is of much more importance than 
 all these. Flabby prematures with a poor turgor and a poor tonus 
 are usually not viable. Prematures with a good turgor and a good 
 tonus even with a low weight commonly survive. 
 
 In addition to the variations in weight and length, the premature 
 shows variations in other measurements. 
 
 Other Measurements of the Fetus. — Yon Winckel 1 regards the 
 circumference of the head as of importance for the diagnosis of the 
 age of the fetus and gives the following figures: 
 
 4th month . 
 
 . . 10-14 cm. 
 
 Sth month 
 
 . . 25-30 cm. 
 
 5th month . 
 
 . . 13-18 cm. 
 
 9th month 
 
 . . 29-33 cm. 
 
 6th month . 
 
 19-24 cm. 
 
 10th month 
 
 . . 32-37 cm. 
 
 7th month . 
 
 . . 23-28 cm. 
 
 
 
 Ileiche 2 reports the following comparative body measurements: 
 
 
 TABLE 
 
 I. 
 
 
 
 12 Children. 
 
 Weight 800-1200 gm 
 
 Group. 1. 
 
 Min. 
 
 Max. 
 
 Average. 
 
 Length of the body 
 
 . 34 cm. 
 
 41.0 cm. 
 
 37.4 cm. 
 
 Circumference of chest 
 
 . 21 " 
 
 24.5 " 
 
 22.5 " 
 
 Circumference of head 
 
 . 24 " 
 
 29.5 " 
 
 26.8 " 
 
 i Lehrb. d. Geb., Leipsig, 1889. 
 
 2 The Growth of the Prematurely Born in the First Months of Life, Ztschr. f. 
 Kinderh., December, 1915, 13, 332.
 
 BODY WEIGHT AND OTHER MEASUREMENTS 
 
 33 
 
 
 table i (Continued) 
 
 
 Group 2, 
 
 26 Children. 
 Mill. M:ix. 
 
 Weight 1200-1500 gm 
 Average. 
 
 Length of the body 
 Circumference of chest 
 Circumference of head 
 
 37.0 cm. 45.0 cm. 
 . 22.5 " 27.5 " 
 . 26.0 " 31.0 " 
 
 41.6 cm. 
 
 24.8 " 
 28.4 " 
 
 Group 3. 
 
 28 Children. 
 
 Weight 1500-2000 gm 
 
 Length of the body 
 Circumference of chest 
 Circumference of head 
 
 . 41 cm. 48.5 cm. 
 . 25 " 32.5 " 
 . 27 " 32.0 " 
 
 44.2 cm. 
 
 27.2 " 
 
 30.3 " 
 
 Group 4. 
 
 22 Children. 
 
 Weight 2000-2500 gm 
 
 Length of the body 
 Circumference of chest 
 Circumference of head 
 
 . 41.5 cm. 49.0 cm. 
 . 26.0 " 30.0 " 
 . 29.0 " 33.5 " 
 
 46.5 cm. 
 28.4 " 
 32.2 " 
 
 GR. 
 
 4000 
 
 3800 
 
 80 
 3000 
 
 3400 75 
 
 3200 7() 
 
 CM. 
 
 3000 54 
 
 05 
 2800 52 
 
 CO 
 
 2600 50 
 
 2400 55 48 
 
 2200 - n 46 
 aO 
 
 2000 44 
 
 45 
 1800 42 
 
 40 
 1600 40 
 
 1400 35 38 
 
 1200 3Q 36 
 
 1000 34 
 25 
 
 800 32 
 20 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 38 
 36 
 34 
 32 
 30 
 28 
 20 
 24 
 22 
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 7 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 600 30 
 
 25 26 27 28 29 30 31 
 WEEKS 
 
 32 33 31 35 
 
 30 37 38 39 40 41 42 43 14 45 
 
 
 
 
 
 
 
 
 
 3 — o 
 
 -RC 
 
 >M 
 
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 -IT 
 
 ER 
 
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 Fig. 10. — Curves showing growth in weight, length, head and chest measurements 
 in the late fetal weeks and first weeks after maturity. (Reiche.) 
 
 3
 
 34 
 
 PHYSIOLOGY 
 
 These figures show a gradual and steady increase of the weight 
 and the chest and head measurements, up to the time of maturity, 
 when they should average 3200 gm. in weight, 50.5 cm. in length, 
 with a chest circumference of 32.9 to 33.8 cm. and a head circum- 
 ference of 34.5 cm. 
 
 We see in the eighth to the tenth month an abrupt rise of the 
 curve of chest circumference, the curve flattening somewhat soon 
 after birth. This increase in the circumference of the chest in 
 the last fetal months is considerably higher than that of a mature 
 child during the first months after birth. In the latter the cir- 
 cumference of the chest increases from 32.5 to 37.2 at the end 
 of the third month to 41 at the end of the sixth month, there- 
 fore in the first six months of life approximately about as much as 
 in the last three fetal months. 
 
 In the curve of the growth of the skull the flattening appears 
 even somewhat earlier. The ratio, however, between the growth 
 of the skull in the last three fetal months and that in the first 
 six months of life is the same as in the circumference of the chest. 
 Also the circumference of the head grows absolutely and relatively 
 considerably more in the last fetal months than in the first six 
 months of life. 
 
 A proof for the correctness of these figures Reiche 1 finds in 
 the fact that the corresponding figures are considerably lower in 
 children who die shortly after birth. They are premature weak- 
 lings whose intra-uterine development in spite of sufficient body 
 weight did not attain such a degree that it might be completed in 
 the extra-uterine life. 
 
 The corresponding figures are, as follows: 
 
 Group 1. 
 
 7 Children. 
 Min. Max. 
 
 Weight 800-1200 gm. 
 Average. 
 
 Length of the body 
 Circumference of chest 
 Circumference of head 
 
 . 34.0 cm. 38.5 cm. 
 . 18.0 " 23.5 " 
 . 21.0 " 27.5 " 
 
 37.0 cm. 
 20.6 " 
 25.0 " 
 
 Group 2. 
 
 9 Children. 
 
 Weight 1200-1500 gin. 
 
 Length of the body 
 Circumference of chest 
 Circumference of head 
 
 . 39.0 cm. 42.0 cm. 
 . 21.0 " 27.0 " 
 . 26.0 " 31.0 " 
 
 40.1 cm. 
 23.8 " 
 28.8 " 
 
 Group 3. 
 
 5 Children. 
 
 Weight 1500-2000 gm. 
 
 Length of the body 
 Circumference of chest 
 Circumference of head 
 
 41 .5 cm. 47.0 cm. 
 . 25.0 " 27.5 " 
 . 28.0 " 31.0 " 
 
 43.6 cm. 
 25.9 " 
 29.6 " 
 
 From these figures Reiche 2 concludes that in premature weak- 
 lings the length of the body does not vary greatly from that of 
 
 1 The Growth of the Prematurely Born in the First Months of life, Zeitschr. f. 
 Kinderh., December, 1915, 13, 332. 
 
 2 Ztschr. f. Kinderh., 1915, 13, 349.
 
 BODY WEIGHT AND OTHER MEASUREMENTS 
 
 35 
 
 healthy children, but on the other hand the measurements of the 
 circumference of the chest and of the circumference of the head 
 
 are considerably smaller. 
 
 Ylppo 1 recently studied the relation of the chest circumference 
 to that of the head in prematures and full-term infants. He found 
 that at birth the circumference of the head is greater than that of 
 the chest, and the greater the prematurity the more marked is the 
 relative disproportion between the head and chest circumferences. 
 These facts are borne out by his table: 
 
 
 
 
 
 Hreast 
 
 Weight of infants, 
 Grams. 
 
 Number. 
 
 Circumference 
 of head. 
 
 Circumference 
 of chest. 
 
 cumference, 
 per cent of 
 bead circum- 
 ference. 
 
 Under 1000 .... 
 
 16 
 
 25.0 
 
 20.8 
 
 83.2 
 
 1001-1500 .... 
 
 78 
 
 31.8 
 
 24.5 
 
 77.0 
 
 1501-2000 .... 
 
 75 
 
 30.0 
 
 26.3 
 
 87.7 
 
 2001-2500 .... 
 
 74 
 
 32.3 
 
 29.5 
 
 91.3 
 
 New born 
 
 
 
 
 
 3000-3500 .... 
 
 100 
 
 33.5 
 
 31.0 
 
 92.5 
 
 In comparison with the 
 the conclusions drawn by 
 tabulations compiled by 
 infant. 
 
 preceding tables on prematures we note 
 von Reuss 2 from his own work and the 
 Weissenberg 3 on the mature new-born 
 
 
 
 Boys. 
 
 
 
 Girls. 
 
 
 Body measurement. 
 
 Min. 
 
 Max. 
 
 Average. 
 
 Min. 
 
 Max. 
 
 Average 
 
 Body length . 
 
 47.5 
 
 54.0 
 
 50.8 
 
 43.5 
 
 53.0 
 
 50.0 
 
 Span of arms 
 
 45.0 
 
 52.0 
 
 48.6 
 
 42.0 
 
 52.0 
 
 48.0 
 
 Vertex-shoulder . 
 
 11.5 
 
 13.5 
 
 12.4 
 
 10.5 
 
 13.5 
 
 12.1 
 
 Sitting-height 
 
 31.2 
 
 36.5 
 
 33.8 
 
 30.0 
 
 36.4 
 
 33.3 
 
 Breadth of shoulders 
 
 9.0 
 
 12.2 
 
 10.7 
 
 9.0 
 
 12.0 
 
 10.4 
 
 Breadth of hips . 
 
 7.0 
 
 8.7 
 
 . 7.8 
 
 6.8 
 
 8.3 
 
 7.7 
 
 Circumference of head 
 
 30.5 
 
 35.5 
 
 32.7 
 
 29.0 
 
 35.0 
 
 32 6 
 
 Girth of chest 
 
 25.5 
 
 32.0 
 
 28.2 
 
 25.0 
 
 32.0 
 
 28 5 
 
 Length of trunk 
 
 19.5 
 
 24.0 
 
 21.4 
 
 19.0 
 
 24.0 
 
 _' 1 'J 
 
 Length of arni 
 
 19.5 
 
 23.5 
 
 21.4 
 
 18.5 
 
 22.5 
 
 21.0 
 
 Length of leg 
 
 18.0 
 
 22.2 
 
 20.5 
 
 17.0 
 
 21.8 
 
 20.3 
 
 Length of hand . 
 
 5.8 
 
 7.0 
 
 6.4 
 
 5.8 
 
 7.5 
 
 6.4 
 
 Length of foot 
 
 7.3 
 
 8.3 
 
 7.8 
 
 6.5 
 
 8.3 
 
 7.8 
 
 The peculiarities of the proportions of the body characteristic 
 of the full-term new born consist therefore of the following: Not 
 only the sitting height, but also the height of the trunk proper is 
 greater than the leg. The length of the trunk proper is greater 
 
 1 Pathologisch-anatomische Studien bei Friihgcburten, Ztschr. f. Kinderh., March 
 25, 1919, Orig. Bd. 20. 
 
 2 Die Krankheiten des Neugeborenen, Julius Springer, 1914. 
 
 3 Die Korperproportionen des Neugeborenen, Jahr. f. Kinderh., 1906, 64, S39.
 
 36 
 
 PHYSIOLOGY 
 
 than that of the arm. The arm is longer than the leg. The cir- 
 cumference of the head is usually greater than that of the chest. 
 Occasionally the circumference of the head and chest are equal; in 
 strongly built infants the circumference of the chest often exceeds 
 that of the head. The body length approximates 47 to 54 cm. and 
 errors in statements of length result because of the lack of considera- 
 tion for the deformity of the skull and caput succedaneum (von 
 Reuss 1 )- 
 
 Jaschke, 2 in a recent study of the premature and debilitated 
 child, came to the conclusion that there was less variability in 
 
 n.H. 
 
 B.H. 
 
 B.H. 
 
 ML. 
 
 Second Month Fifth Month Tenth Month 
 
 Fig. 11. — Changes in body proportions in fetal life. B.H., Body height; M.L., 
 
 Midline. 
 
 certain relations between measurements of the body than was com- 
 monly thought. "In immature infants the fronto-occipital cir- 
 cumference of the head always is greater than the circumference 
 of the shoulders (Frank and others), while in mature infants the 
 opposite is true; also the proportion between the height of the 
 head and the height of the body (Stratz) is disturbed since the 
 height of the head is greater than one-fourth of the length of the 
 body; this is due especially to relatively shorter legs" (Fig. 11). 
 
 1 Die Krankheiten des Neugeborenen, Julius Springer, 1914. 
 
 2 Physiologie, Pflege und Ernahrung des Neugeborenen, Wiesbaden, 1917.
 
 INTERNAL ORGANS 
 
 37 
 
 INTERNAL ORGANS. 
 
 Gundobin 1 , studying the average weight of the inner organs of 
 the mature new born in grams, noted the following: 
 
 Brain 389-354.5 
 
 Heart 17.24-16.5 
 
 Lungs 57 (Lt. 25; Rt. 32) 
 
 Liver 120-130 
 
 Pancreas 2.63 
 
 Spleen 7.2 
 
 Kidneys 11-12 
 
 Suprarenals 2.5 
 
 Testicles 0.2 
 
 Epididymes 0.12 
 
 Ovaries 0.2 
 
 Thyroid 1.6 (Max. 2.8; Min. 1.3) 
 
 Thymus 11.7 
 
 In contrast with these figures, we may quote from the anatomical 
 studies of Ylppo on premature infants. 
 
 BRAIN WEIGHT OF INFANTS (YLPPO). 2 
 
 
 Number of 
 cases. 
 
 Boys. 
 
 Age. 
 
 Average weight in 
 
 grams. 
 
 
 Of body. 
 
 Of entire brain. 
 
 Ratio of brain to 
 body weight. 
 
 Fetus of eight months 
 
 3 
 
 2440 
 
 248 
 
 1 toJlO 
 
 Newly born 
 
 3 
 
 2785 
 
 389 
 
 1 to.7.2 
 
 1 month 
 
 3 
 
 3860 
 
 517 
 
 1 to.7.5 
 
 
 5 
 
 4400 
 
 533 
 
 1 to 8.2 
 
 3 
 
 5 
 
 4480 
 
 555 
 
 1 to 8.1 
 
 4 " 
 
 5 
 
 4890 
 
 568 
 
 1 to 8.6 
 
 5 
 
 5 
 
 5614 
 
 632 
 
 1 to 8.9 
 
 6 " 
 
 5 
 
 6035 
 
 668 
 
 1 to 9.0 
 
 7 " 
 
 3 
 
 6560 
 
 702 
 
 1 to 9.3 
 
 8 " 
 
 3 
 
 6460 
 
 768 
 
 1 to 8.4 
 
 Ylppo found several instances in which the large brain weight 
 seemed to be out of proportion to the figures of other observers. 
 His studies led him to believe that the brain of the premature 
 (even the smallest) grows at the same rate as if the fetus were in 
 utero and that it develops in extra-uterine life after certain given 
 laws of Nature; thus, the small body weight having relatively 
 little to do with the brain. In these cases of marked disproportion 
 he found that when one compares the absolute age of the prema- 
 
 1 Quoted from von Reuss: Krankheiten der Neugeborenen, Julius Springer, Berlin, 
 1914. 
 
 2 Pathologisch-anatomische Studien bei Fruhgeburten, Ztschr. f. Kinderh., .March 
 25, 1919, Orig. Bd. 20, 212.
 
 3& PHYSIOLOGY 
 
 ture, from the time of conception, with that of a normal infant, 
 it is seen that the brain weight of the two compare favorably. 
 His conclusions were that the size of the brain has nothing to do 
 with a hydrocephalic process, since it is not explained by an abnor- 
 mal water content, and that the " megacephaly " of prematures is 
 a physiological process. 
 
 Tonsils.— In prematures there appears at the site of the palatine 
 tonsils only one or two small cavities. Only after four to five 
 months does a glandular structure appear. 
 
 Thyroid Gland. — This is very small, but it has a very rich blood 
 supply. In one case of a seven-months premature Ylppo observed 
 an enlargement of the thyroid (1.5 gm.): weight of infant, 1270 
 gm.; length, 44 cm. Microscopically there were large quantities 
 of colloid in the center of the follicles, but no hemorrhages or 
 evidence of degenerative changes. 
 
 Thymus Gland.— In prematures of 1000 to 2000 gm. it is between 
 1 and 3 gm., while in full-terms it may be as much as 20 gm. 
 Gundobin 1 estimated it in prematures of similar weight as on the 
 average of 2.5 gm. 
 
 Heart.— The heart on the average is from 0.5 to 0.75 per cent 
 of the body weight of prematures. In those from 900 to 1200 gm. 
 Ylppo found that the weight ranged from 4.5 to 7 gm. In full- 
 term infants and those with a longer intra-uterine growth (of the 
 prematures), the relation between heart and body weight was 
 found to remain about the same by Lomer, thus : 
 
 4000 gm. infant — 27.6 gm. heart = 0.7 per cent body weight. 
 2-3000 gm. " -20.7 gin. " 
 1-2000 gm. " - 11.4 gm. " 
 
 The ductus Botalli closes more slowly and later in prematures. 
 On the average blood ceases to pass through after the end of the 
 first or second week of life. 
 
 Liver.— The liver is the largest of the internal organs of the 
 premature body. The smaller the premature, the greater is the 
 relative size of the liver. 
 
 WEIGHT OF THE LIVER IN PREMATURES (YLPPO). 
 
 Weight of infant, 
 Grams. 
 
 Number of 
 cases. 
 
 Average weight 
 of liver. 
 Grams. 
 
 Liver weight, 
 percentage of 
 body weight. 
 
 Under 1000 
 1001-1500 
 1501-2000 
 2001-2500 
 
 11 
 
 12 
 
 4 
 
 3 
 
 43.73 
 
 53.17 
 
 56.75 
 
 102.33 
 
 4.8 
 4.3 
 3.3 
 4.5 
 
 1 Die Besonderheiten des Kindesalters, Berlin, 1912.
 
 BODY TEMPERATURE 
 
 39 
 
 With the increase of body weight the liver weight slowly increases. 
 The figures for the group of 1501 to 2000 gin. are too small, and 
 are based only on four observations. The weight of the liver in 
 prematures has to do with the richness of its blood supply. 
 
 Spleen.— The spleen, as the liver, is very rich in blood. 
 
 WEIGHT OF THE SPLEEN (yLPPo). 
 
 Weight of infant. 
 Grams. 
 
 Number of 
 
 cases. 
 
 Average weight 
 
 nl spleen. 
 
 Grams. 
 
 Spleen weight 
 
 percentage of 
 body weight. 
 
 Under 1000 
 
 1001-1500 
 
 1501-2000 
 
 2001-2500 
 
 14 
 
 12 
 
 4 
 8 
 
 1.5 
 2.8 
 
 4.4 
 7.2 
 
 0.17 
 0.21 
 0.22 
 
 0.28 
 
 As with the liver, the spleen increases in size with increase in the 
 body weight. 
 
 Kidneys.— The ratio between the weight of both kidneys and the 
 body weight is greater in prematures than in full-terms and older 
 infants: 
 
 WEIGHT OF KIDNEYS (YLPPO). 
 
 Weight of child. 
 Grams. 
 
 Number of 
 cases. 
 
 Average weight 
 
 of kidneys. 
 
 Grams, i 
 
 Kidney weight 
 percentage of 
 body weight. 
 
 Under 1000 
 
 1000-1500 
 
 15 
 17 
 
 5.2 
 8.9 
 
 0.59 
 0.76 
 
 Gundobin showed that in full-terms the percentage was 0.38 per 
 cent. 
 
 Vierordt 1 showed that in men between nineteen and twenty-five 
 years of age the percentage was 0.48 per cent. 
 
 The embryonic features of the kidneys are very marked. The 
 fetal markings disappear fairly rapidly. In one case of a sixth to 
 seventh embryonic month premature of 1000 gm. birth weight, 
 the fetal markings were gone after five to seven weeks of life 
 (Ylppo). 
 
 BODY TEMPERATURE. 
 
 During the intra-uterine life the child receives gratis the material 
 necessary for its maintenance, for the development and regenera- 
 tion of its cells. The maternal blood stream brings to the level 
 of the placenta the oxygen and other substances needful for its 
 
 1 Gerhardts Handbuch d. Kinderh., 1881, 1, 1, part 2, p. 386.
 
 40 PHYSIOLOGY 
 
 nutrition, and the passing of these foods into the antenatal circu- 
 lation requires no effort on the part of the fetus other than the 
 cardiac contractions. From birth on, however, the child is an 
 independent being and it must fight that it may live. 
 
 The upkeep of the somatic tissues is dependent upon the func- 
 tions of the respiratory system and the digestive tract, and these 
 activities require of the new-born infant an expenditure of energy 
 of which it has had no previous experience. Before birth the 
 energy resulting from intracellular combustion was transformed 
 into that amount of heat necessary to the performance of the 
 new cellulo-chemical reactions occurring in the fetus. After birth 
 a much greater amount of energy is necessary because of the more 
 extensive reactions taking place within the tissues and because of 
 the appearance of motion. Increased metabolism is, therefore, 
 necessary to the accomplishment of the digestive and respiratory 
 functions and to enable the infant to fight against external physical 
 agents, principally cold. 
 
 Cause and Nature of Hypothermia.— Heat regulation is one of the 
 least developed functions of the premature infants, their body 
 temperature showing marked fluctuation with a tendency to hypo- 
 thermia. This is due to several factors: 
 
 1. Faulty Heat Regulation Due to Lack of Development on the 
 Part of the Nervous System.— It is possible to imagine that in a 
 premature infant where the development of the brain is still going 
 on, and the separation into the white and gray matter has not been 
 completed, that the nervous system is not sufficiently matured to 
 function normally. 
 
 2. Loss of Heat Through Radiation.— The extent of the heat 
 loss from the body of an animal by conduction, radiation, evapora- 
 tion from the skin and the surface of the lungs is determined by 
 the extent of the surface and by the thickness of the ill-conducting 
 subcutaneous fatty layer; the heat loss, therefore, is in greater 
 part proportional to the extent of the surface of the body. In a 
 premature infant the body surface is relatively greater than in a 
 full-weight new born, since the size of the body is absolutely smaller. 
 Wrinkled skin and absence of the fat deposits in the skin are respon- 
 sible for the greater loss of heat. It is these physical conditions 
 which make it difficult for the premature to retain its own heat and 
 predispose to the readiness with which the subnormal temperature 
 can occur. 
 
 3. Insufficient Oxygen Combustion.— Due to a poorly developed 
 respiratory center causing asphyxia. 
 
 Babak 1 found that the lower the temperature in the respiratory 
 
 1 Ueber die Wiirmeregulation der Neugeborenen, Pflugers Arch., 1902, 89, 154.
 
 THE GROWTH OF THE PREMATURE 41 
 
 chamber, the greater the consumption of oxygen, this correspond- 
 ing to the irradiation of heat. The average values in one hour per 
 gram of body weight amounted to: 
 
 Temperature in chamber. Consumption of Oi. 
 
 Deg. C. cc. 
 
 24.0 378 
 
 23.2 562 
 
 20.0 581 
 19.9 632 
 
 17.1 636 
 12.9 739 
 12.1 874 
 
 From the results of this experiment it is clear that the infant's 
 organism attempted to equalize the physical minus with the chemical 
 plus. But in spite of the more intensive exchange of gases, the 
 body temperature was sinking with a low external temperature and 
 also when the infant was insufficiently covered. The increase in 
 oxidation processes, therefore, was not sufficient to compensate 
 for the increased heat radiation. 
 
 4. The Circulation.— The circulation as affected by its nervous 
 mechanism and weak cardiac action is another important factor. 
 
 5. Insufficient Heat Production Due to Lack of Food or Improper 
 Metabolism.— This cause of hypothermia is of minor importance in 
 the premature infant which is fed a sufficient quantity of breast 
 milk and shows ability to assimilate the same. As the sucking- 
 centers are too poorly developed to enable the infant to obtain 
 sufficient nourishment, most of these infants cannot be trusted 
 to their own resources in obtaining their food. 
 
 A careful consideration of all of the factors tending to hypo- 
 thermia make it evident that we cannot depend on an equalization 
 of the heat loss from the body surface by the internal production 
 of heat, and therefore in order to maintain a uniform temperature 
 it becomes necessary to assist the infant by giving it an artificial 
 environment of good air sufficiently heated to maintain a normal 
 body temperature. 
 
 THE GROWTH OF THE PREMATURE. 
 
 Initial Weight Losses.— Loss of body weight during the first days 
 of life occurs so constantly in full-term infants that moderate 
 losses must be considered physiological. This is also true of 
 premature infants although in most instances it is relatively greater. 
 Premature infants lose relatively more and regain their birth 
 weight more slowly, often requiring a month (De Lee 1 ) and also, as a 
 
 i See page 30, Ref. 4.
 
 42 PHYSIOLOGY 
 
 general rule, the nearer the prematures are to full term, the lower 
 is the relative loss of weight as expressed in percentages. 
 
 The average loss in weight in the premature and in other infants 
 of relatively low birth weight during the first days of life is shown 
 in the following table adapted from Reiche: 
 
 Weight. 
 
 Length. 
 
 Average decrease. 
 
 800-1200 gm. 
 
 32.0-40 cm. 
 
 71 gm. 
 
 1200-1500 " 
 
 37.0-44 " 
 
 97 " 
 
 1500-2000 " 
 
 40.0-48 " 
 
 137 " 
 
 2000-3500 " 
 
 41.5-50 " 
 
 177 " 
 
 Gundobin's figures are considerably higher, as he came to the 
 conclusion that the initial loss of weight in infants with a birth 
 weight under 2000 gm. gm. amounted on the average to 148 gm. 
 
 The artificially-fed infants lose more weight than the breast fed, 
 but no differences were noticeable between those infants nursing 
 at the mother's breast and those fed by a wet-nurse (Reiche) . 
 
 In children of muciparous women both the absolute and also the 
 relative percentage value of the weight loss is smaller than in those 
 of primiparous, which is undoubtedly due to better nursing condi- 
 tions, milk appearing sooner in multipara? and being usually more 
 abundant. 
 
 The loss of weight is also relatively larger the less the birth 
 weight of the infant, as the following table taken from Pies 1 will 
 show : 
 
 Primiparse. Multipara. 
 
 Initial weight. Average decrease. Average decrease. 
 
 2500 gm. 240 gm. = 11.2 percent 195 gm. =8.2 percent 
 
 2510-3000 " 235 " =8.3 " 180 " =6.2 
 
 3010-3500 " 295 "= 9.0 " 265 " = 8.1 
 
 3510-4000 " 360 " =9.7 " 325 " =8.7 
 
 4010-4500 " 245 " =8.4 " 366 " =8.3 
 
 Average 275 gm. = 9.3 per cent 266 gm. = 7.9 percent 
 
 Initial loss in weight rests upon the fact that the new-born 
 infant gives off more than it takes in. The meconium is account- 
 able for a considerable part of the loss. This averages in weight 
 according to Camerer 2 from 70 to 90 gm.; according to Hirsch 3 
 from 150 to 200 gm. In addition to that, the urine voided before 
 the child receives much fluid must be considered, though this is 
 probably small. The water lost through the lungs and skin, the 
 loss of the stump of the umbilical cord, and, in some cases, the 
 vomiting of swallowed liquor amnii during the first twenty-four 
 
 1 Ueber die Dauer, die Grosse und den Verlauf der physiologischen Abnahme der 
 Neugeborenen, Monatschr. f. Kinderh., 1911, 9, 51. 
 
 2 Beitrag zur Physiologie des Sauglingsalters, Ztschr. f. Biol, 1900, 39, 37. 
 
 3 Die physiologische Gewichtsabnahme der Neugeborenen, Berl. klin. Wchnschr., 
 1910, 2.
 
 THE GROWTH OF Till-: PREMATURE 43 
 
 hours, are all factors in reducing the weight of the new horn. Fur- 
 thermore, it has been shown that there is a loss of the body tissues, 
 of the fat, glycogen and albumin, as evidenced by the loose and 
 wrinkled condition of the infant's skin, and lost turgor of the tissues 
 in general. Landois 1 found that the loss of weight in infants in 
 whom the cord was tied late was 5.9 to 7. 1 per cent less than those 
 in whom the cord was tied and cut early. 
 
 Gundobin 2 found that the lowest weight was usually reached 
 sometimes between the fourth and sixth (lays in the full-term infant 
 and that the birth weight was regained on the eleventh to the 
 sixteenth day. Very frequently, however, and especially in weak- 
 lings and prematures, the birth weight was not regained as early 
 as the sixteenth day, twenty or thirty days being required to 
 make up the initial loss. The artificially-fed regained the loss 
 later than the breast-fed infants. 
 
 Pfaundler, 3 in his observations on 1000 new-born infants came 
 to the conclusion that the physiological weight loss occurred in 42 
 per cent by the fourth day. The loss in the infants of from l.iOO to 
 4000 gm. birth weight averaged 7.8 per cent of the latter, and was 
 about the same for the heavy as for the light, although it was 
 relatively slightly greater in the former. 
 
 Birth weight. Loss in weight. 
 
 Over 4000 gm. 325 gm. = 7.6 per cent of the birth weight 
 
 3500-4000 " 300 " = 8.0 " 
 
 3000-3500 " 250 " = 7.7 " . " " 
 
 2500-3000 " 210 " =7.6 " " 
 
 2000-2500 " 190 " =8.4 
 
 1500-2000 " 130 " =7.4 " " " 
 
 Average 7 . 8 per cent 
 
 Ramsey and Alley 1 noted in 300 cases that the average loss of 
 weight continued for three days and was regained by the tenth 
 day by only one-fourth of the infants. 
 
 Shick, 5 believing that the initial loss of weight was avoidable, 
 gave each infant 10 per cent of its body weight of breast milk 
 the first twenty-four hours, increasing the amount until 15 per 
 cent was given at the end of the third twenty-four hours. He 
 employed the milk of mothers having infants less than a week old 
 and was able to prevent the initial loss in all of his twelve cases. 
 
 The increase in weight of the prematures is noted in the table on 
 p. 44 in a group of the author's cases. 
 
 1 Zur Physiologie der Neugeborenen, Monatsschr. f. Geb. u. Gyn., 1905, 32, 194. 
 
 2 Besondeiheiten des Kindesalters, Berlin. 1912. 
 
 3 Korpermass-Studien an Kindern, Ztschr. f. Kinderh., .March 2S, 1916, 151-152. 
 
 4 Observations on the Nutrition and Growth of New-born Infants; an Analysis of 
 300 ( ilinical Charts, Am. Jour. Dis. Child., June, 1918, 15, 408. 
 
 6 Zur Frage der physiologischen Korpergewichtsabnahme der Neugeborenen, 
 Ztschr. f. Kinderh., 1916, 13, 257.
 
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 THE GROWTH OF THE PREMATURE 15 
 
 The growth of the premature infant has been well shown by the 
 tables of Camerer, 1 who figures out the daily average increase in 
 ten infants who had a birth weight ranging from 1330 to 1!)7() gm. 
 
 Week of life ... 2 4 8 12 16 20 24 28 32 30 
 
 Weight in grams 1630 1830 2090 2636 3272 3906 4430 4068 5367 5717 6217 
 Average daily gains 
 
 in grams 9 19 23 22 20 14 12 10 10 
 
 Camerer compared the increase in weight in breast-fed and bottle- 
 fed premature infants with an initial weight of from 1590 to 1740 
 gm. 
 
 Doubled weight. Trebled weight. Quadrupled weight. 
 
 Breast fed . . 10th week 22d week 33d week 
 
 Bottle fed . . 11th " 24th " 40th " 
 
 Camerer's further figures also show that the artificially-fed full- 
 term infant is much slower in its weight increase than the breast-fed 
 child. 
 
 Average Doubled Trebled Quadrupled 
 
 birth Number of weight, weight, weight, 
 
 weight. infants. weeks. weeks. weeks. 
 
 Breastfed . . 1680 8 12 24 52 
 
 Artificially fed . 2420 18 18 44-48 
 
 The average daily increase in weight of the premature of different 
 periods as well as for the premature child is shown by Friedenthal: 1 
 
 Fetal months. Average daily increase in weight. 
 
 6th to 7th 19.5 gm. 
 
 7th to 8th 29.3 " 
 
 8th to 9th 23.3 " 
 
 9th to 10th 13.3 " 
 
 1st month of mature child 25.0 " 
 
 The growth in length proceeds slowly from month to month, 
 diminishing in rate (Friedenthal). 
 
 Age. Growth in length per month. 
 
 6th to 7th fetal month 6.0 cm. 
 
 7th " " 5.0 " 
 
 8th " " 4.5 " 
 
 9th " " 4.0 " 
 
 If these figures of Friedenthal's are plotted into a curve it is seen 
 that the curve of the body weight and that of the body length run 
 parallel up to the seventh or eighth month, at which time the 
 length curve rises less abruptly than the weight curve. 
 
 Pfaundler 2 found that the rate of growth in an infant born three 
 months prematurely became the same as that of a maturely born 
 child when the premature had reached the age of three months. 
 
 1 Med. Wchnschr., 1909, No. 34. 2 See p. 43, Hef. 3.
 
 46 PHYSIOLOGY 
 
 These figures apply, of course, to the healthy prematures only and 
 not to those debilitated from disease or by unfavorable environment 
 or food. 
 
 Reiche's 1 investigations have shown that the growth of the 
 prematures follows the same rules of growth that hold good for 
 the corresponding months after impregnation. In healthy prema- 
 tures there is no difference between the intra-uterine and extra- 
 uterine growth in the same months, so that the birth in itself causes 
 no disturbance of growth provided that the infant has reached a 
 certain stage of development, compatible with the exercise of certain 
 indispensable functions, e. g., respiration, circulation and digestion. 
 This stage of development is seldom reached before the twenty- 
 eighth week of life, when the infants are about 34 cm. long and 
 weight approximately 1 kg. It has, therefore, been proposed to 
 designate the age of the infant from the time of conception rather 
 than from the time of birth. Serious chronic diseases of the mother 
 (especially lues and tuberculosis) exert a growth-inhibiting influence 
 upon the infant. Their progress is not governed by the same laws 
 that hold good for healthy premature infants. 
 
 Reiche has also studied the relation between the growth in 
 weight and the growth in length and has introduced the term 
 length-weight coefficient, by which is understood the weight of a 
 unit of length. The following table shows the birth-weight coeffi- 
 cient for different groups of prematurely born infants: 
 
 Birth-weight. 
 
 Length of body. 
 
 Length 
 
 -weight coefficient. 
 
 800-1200 gm. 
 
 32.0-40 cm. 
 
 
 28.0 gm. 
 
 1200-1500 " 
 
 37.0-44 " 
 
 
 33.8 " 
 
 1500-2000 " 
 
 40.0-48 " 
 
 
 43.2 " 
 
 2000-2500 " 
 
 41.5-50 " 
 
 
 48.7 " 
 
 Langstein 2 formulated the following law from the observations 
 of Reiche and others: Both the growth in mass and the growth in 
 length of these organisms in whom the transition from intra-uterine 
 to extra-uterine life had to occur prematurely, proceeds according 
 to the same laws that correspond to the period of time after 
 impregnation. 
 
 The majority of multiple pregnancies terminate prematurely and 
 therefore the percentage of twins among the prematurely born is 
 considerably higher among mature children. By the development 
 of more than one child in the mother's womb the growth may be 
 impaired, and this consists, as a rule, in impairment of growth in 
 mass, only in exceptional cases in impairment of growth in length. 
 
 1 Ztschr. f. Khk., Dec, 1915. 
 
 2 Ernahrung und Wachstum Friihgeborener, Bcrl. klin. Wclmschr., 1915, 24.
 
 THE GROWTH OF THE PREMATURE 47 
 
 But even in these prematurely horn, twins have a tendency in their 
 first months of life to make up this loss. The curves of growth of 
 twins run, as long as no intercurrent diseases interfere, parallel to 
 each other and also to the curve of those children in whom a larger 
 difference in growth was present at birth. The proportions of 
 growth between the circumference of the thorax and the circum- 
 ference of the head are scarcely influenced by multiple pregnancy. 
 In individual twins even these curves run parallel to each other. 
 
 Weight in Relation to the Body Surface.— Ssytcheff 1 gives the 
 following table comparing the surface area and the weight in the 
 premature and in older children. 
 
 Surface area per 
 W T eight. Surface area, kg. of weight. 
 
 Age. gm. sq. cm. sq. cm. 
 
 Premature four days old . 1505 1266.4 841.4 
 
 Newborn 2097 1476.0 704.0 
 
 3 months old .... 3520 2279.0 647.0 
 
 6 " 5138 2961.0 576.2 
 
 1 year old 9095 4800 .0 527 . 
 
 Thus it is seen that the larger the volume (weight) of the infant 
 the smaller the surface area relative to that weight. 
 
 In estimating or comparing heat loss or other metabolic processes 
 relating to or dependent upon surface area, it is evident that one 
 should have an exact method of determining that area. Meeh, 2 
 in 1879, w T as the first to construct a formula for this purpose, the 
 basis for which was the observation of Molischott that the volume 
 of bodies of similar composition and form varies in the ratio of the 
 cube root of their weight and their surface areas in the ratio of 
 the square root of their volume. 
 
 Recent investigations have given us two reliable formulae for 
 the rapid estimation of the body surface of the infant, those of Dubois 
 and DuBois 3 and of Howland and Dana. 4 
 
 The formula of Dubois and DuBois, which is entirely independent 
 of the body weight, predicates the division of the body into several 
 regions, the various measures of length of these regions being 
 multiplied by the sums of the various measurements of the width, 
 and the figure thus obtained multiplied by the constant for the 
 given region. These constants have been worked out by the 
 investigators and represent the reciprocal of the average factor for 
 that particular combination of length and breadth measurements 
 which showed the smallest variations. 
 
 1 Quoted from Gundobin, Die Besonderheiten des Kindesalters, Allg. mediz. 
 Verlagsanstalt, Berlin, 1912. 
 
 2 Oberflachen Messungen des menschlichen Korpers, Ztschr. f. Biol., 1879, vol. 15, 
 
 3 Arch. Int. Med., 1916, 863. 
 
 * A Formula for the Determination of the Surface Area of Infants, Am. Jour. Di*. 
 Child.. 1913, 6, 33.
 
 48 
 
 PHYSIOLOGY 
 
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 Fig. 12. — Chart showing weight and surface area of infants. (Howland and Dana.) 
 
 f » See p. 47, Ref. 4. 
 2 See p. 47, Ref. g.
 
 THE GROWTH OF THE PREMATURE 
 
 49 
 
 infants among his observations and Lissauer had measured the 
 area of 11, making 14 in all. Howland and Dana first plotted on 
 a chart the weight and surface area of these 14 cases and then 
 drew a curve as nearly as possible to all these points so that the 
 distance from any point would be as small as possible. 
 
 This curve (Fig. 12), by its distance from the axes ox and oy, 
 represents an average of the observed data, so that when drawn 
 
 Fig. 13. — Dcrmatograph. Apparatus for measuring body surface. (Pfaundler.) 
 
 to the proper scale, the point on the curve representing any known 
 weight of the child may be marked on the chart and the surface 
 area read off directly. Thus, if one has an infant weighing 7000 
 gm. and it is desired to know its surface area, one finds where the 
 7000 gm. line intersects the curve. Carrying this point horizontally 
 to the left, it is seen to intersect the oy axis at a point corresponding 
 to 4100 sq. cm. 
 This formula, u equals mx plus b, is the algebraic representation 
 4
 
 50 PHYSIOLOGY 
 
 of this form of curve, and in it x and y represent the abscissas and 
 ordinates of the curve, b represents the distance along the y axis, and 
 m represents the tangent of the angle that the curve marked with 
 the x axis. 
 
 In this formula: 
 
 y = surface area of child in square centimeters. 
 
 x = weight of child in grams, 
 
 m = 0.483. 
 
 b = 750. 
 
 The factor b was read directly from the chart and m was obtained 
 by dividing 5560 minus 730 by 10,000. Having these last three 
 quantities, it becomes possible to obtain the y or surface area by 
 simple computation— the weight times 0.483 plus 730. 
 
 Pfaundler, 1 in 1916, reviewed the previous methods of measuring 
 body surface and elaborated a new method based on the principle 
 that the body surfaces are usually in the form of a cylinder or 
 obtuse cone. The body was divided into sixteen regions by use 
 of an instrument— dermatograph, and the areas added to give the 
 total surface. This instrument is illustrated in Fig. 13. 
 
 CHARACTERISTICS OF VARIOUS ORGANS. 
 
 Respiratory Tract.— One of the most marked features of the 
 premature and of the congenitally weak are the poor respiratory 
 efforts, indeed, Billiard 2 has defined congenital weakness as "the 
 incomplete establishment of respiration." The premature in 
 response to the need of air, inspires at birth, but its muscular power 
 is weak and its efforts are insufficient to raise the thoracic wall 
 and thus dilate the pulmonic cavity. As a result, though the 
 large bronchi are rilled with air, many of the small bronchioles 
 are not dilated and a large portion of the lung continues to remain 
 in a fetal stage, and may require several weeks for its complete 
 expansion. The reason for this poor functioning of the organs of 
 respiration lies in the lack of development of the respiratory centers 
 in the medulla. 
 
 Most observers state that the chest wall of the premature infant 
 is more or less immobile, moving but slightly with each respiration, 
 but it has been our experience that quite constant evidence of 
 prematurity is shown in the flexibility of the thorax and its tendency 
 to retraction with each inspiration, the seeming immobility being 
 the result of the poor effort on the part of the muscles of respiration, 
 
 1 Korpermass-Studion an Kindern, Ztschr. f. Kinderh., March 28, 1916, Bd. 14, 
 1-148. 
 
 2 Traite des maladies des enfants nouveau nes, 1833, 73.
 
 CHARACTERISTICS OF VARIOUS ORGANS 51 
 
 due to their weakness. The chest walls can expand but the mus< u- 
 lar power is insufficient to make them do so. This muscular inertia, 
 which is so well evidenced in these infants, is therefore partly the 
 result of poorly developed muscles and partly the result of deficient 
 innervation due to a similar lack of development of the cerebral 
 centers. 
 
 Accompanying the deficient oxygenation of the blood are attacks 
 of cyanosis, during which respiration ceases entirely. This apneic 
 interval lasts for one or two minutes and then breathing is resumed. 
 These attacks are not at all infrequent during the first fortnight 
 and often appear without warning. In those cases in which recov- 
 ery occurs the attacks become less frequent and less severe, but 
 when unrelieved they are of grave significance and not uncommonly 
 result fatally. 
 
 Clinically the weakened respirations are manifested by the 
 monotonous, feeble, whining cry and grunting expirations with 
 comparative immobility of the thorax, and the superficial and often 
 irregular character of the respirations, which become abdominal in 
 type. While a child born at the sixth month may breathe for 
 hours or days, previous to that time respiration is not fully estab- 
 lished. Even though respiratory exchange does not occur, the 
 heart may be found beating several hours after birth . 
 
 The frequency of respiration in the sleeping premature immedi- 
 ately after birth is frequently as high as 40 to 50 per minute. When 
 awake the rate is about 50 or more unless the infant is crying, when 
 it is much less than in ordinary breathing. The type of respiration 
 in the premature is essentially diaphragmatic, superficial and 
 irregular, showing interruptions particularly during crying when 
 these pauses may be quite long. The soft and yielding character 
 of the thoracic wall in the premature permits of slight degrees of 
 retraction of the lower intercostal spaces during the deeper inspi- 
 rations. 
 
 The physical findings over the lungs of premature infants are 
 uncertain. On inspection and palpation the thorax shows deficient 
 mobility, on percussion the sounds over the bases are lower than 
 over the balance of the chest, and on auscultation the vesicular 
 murmur is hardly perceptible. At autopsy these signs are con- 
 firmed and the lower parts of the lungs particularly are seen to be 
 atelectatic, at times the major portion of the organ being involved, 
 making gaseous interchange very difficult. 
 
 The complete establishment of respiration may be prevented not 
 only by the weakness of the respiratory movements but by the 
 aspiration of liquor amnii or mucus during the last moments of 
 delivery, which mechanically prevents the entrance of air into 
 the pulmonary alveoli. (See Atelectasis.)
 
 52 PHYSIOLOGY 
 
 Parrot, 1 Billiard 2 and others have noted a condition which is 
 spoken of as life without respiration, of which the characteristic 
 manifestations are the absence of thoracic movements, the presence 
 of a pulse and of movements of the extremities, and the absence 
 of asphyxia immediately after birth. The persistence of the 
 ductus arteriosus renders this condition supportable, as it allows the 
 blood to pass directly into the aortic current without passing 
 through the lungs. Such infants remain in their intra-uterine 
 state of apnea until the respiratory centers become sufficiently 
 irritated by the increasing venous blood to evoke respiratory 
 action. This life without respiration should not be confounded 
 with the apparent death of children born at or before term. Appa- 
 rent death has two forms: The syncopal form, which is characterized 
 by pallor of the skin and absence of pulse, and the asphyxiated 
 form, distinguished by cyanosis of the skin and the presence of a 
 pulse beat. (See Apparent Death.) 
 
 The nasal passages of the new-born prematures are particularly 
 narrow, favoring the easy occurrence of stenosis in inflammatory 
 conditions involving the nasal mucosa. 
 
 Interference with respiration also results from the aspiration of 
 food or vomited matter into the larynx or trachea, the lack of 
 development of the pharyngeal and laryngeal reflexes being respon- 
 sible for the not infrequent occurrence of this accident. Attempts 
 at drinking sometimes result in mechanical hindrance of obstruction 
 to inspiration during the act of swallowing. Aspiration of food is 
 often followed by a pulmonary infection and thus atelactasis of the 
 lung may be said to predispose to a pneumonia which not infre- 
 quently leads to death. (See Infections of the Lungs.) 
 
 Jaschke 3 considers the deficient function of the respiratory 
 apparatus as being due to the fact that the irritability of the respi- 
 ratory center is so low that a large accumulation of carbonic acid 
 in the blood is necessary to make it act. With the sinking of the 
 carbonic-acid tension with stronger respirations, the depth of 
 respiration decreases again, because of lowered stimulation of the 
 respiratory center and finally a point is reached in which the blood 
 is arterialized, when the respiratory center no longer responds. 
 A pause in respiration sets in and lasts until excess of carbonic acid 
 stimulates new respiratory movements. 
 
 A further point is brought out by Jaschke. There appears to 
 be a disturbance of the gaseous interchange, which is probably 
 explained by the peculiarity of the blood serum of debilitated 
 premature infants. This was first noted by Pfaundler. 4 The 
 blood serum shows a diminution of the OH ions, and a correspond- 
 
 i L'athrepsie, Paris, 1877. 2 See p. 50, Ref. 2. 
 
 3 See p. 18, Ref. 1. 4 Quoted from Jaschke.
 
 CHARACTERISTICS OF V ARK) IS ROANS 
 
 53 
 
 ingly greater concentration of the II ions, which condition makes 
 the draining of carbonic acid from the tissues more difficult. 
 Jaschke believes that this agrees with Finkelstein's 1 theory that 
 the attacks of cyanosis are to be regarded as an expression of a 
 chronic carbonic-acid intoxication. 
 
 Fig. 14. — Roentgenogram showing position of stomach in a sixteen weeks' fetus. 
 
 The Digestive Tract. — I. Anatomy. — The muscles of the buccal 
 region, of the tongue and of the soft palate are weak. 
 
 The stomach of the premature infant before its first feeding, as 
 seen in autopsy, is in an almost vertical position and tubular in 
 its form. In the premature infant which has been fed the fundus 
 is fairly well developed and causes the stomach to assume a more 
 oblique position. This is corroborated by a roentgen-ray examina- 
 tion (Figs. 14 and 15). 
 
 1 Quoted from Jaschke.
 
 54 
 
 PHYSIOLOGY 
 
 A. F. Hess 1 was able to demonstrate that the gastric canal of the 
 infant is more nearly vertical than horizontal, and that therefore 
 from a functional standpoint the infant's food traverses the gastric 
 canal in a vertical rather than a horizontal path, even though the 
 stomach lies more or less horizontally. This fact is even more 
 true of the physiological path of the food in the premature (Fig. 1(>). 
 
 Fig. 15. — Roentgenogram showing position of stomach in a still-born, full-term 
 
 infant. 
 
 The cardiac end of the stomach, is found well to the left and 
 usually about the level of the tenth dorsal vertebra. The cardiac 
 sphincter is usually poorly developed (Fig. 17). This in part 
 accounts for the ease with which the premature infant regurgitates 
 its food. The pylorus lies somewhat higher than that of the full- 
 
 1 Am. Jour. Dis. Child., 1912, 3, 133.
 
 CHARACTERISTICS OF VARIOUS ORCAXS 
 
 .).) 
 
 term new-born, in whom it is found about midway between the 
 ensiform cartilage and the umbilicus. Before feeding it is almost 
 always found to the left of the median line. The pyloric muscula- 
 ture is usually quite well developed, even in the new-born premature 
 (Figs. IS, 19 and 20). 
 
 
 ' 
 
 
 
 
 ^ ■ 
 
 
 
 
 
 .... 
 
 * 
 
 
 Fig. 16. — Roentgenogram of stomach immediately after feeding showing oblique 
 position and early passage of food through the pylorus. 
 
 The musculature of the stomach at autopsy in the new-born pre- 
 mature is in a state of contraction, giving the stomach a tubular 
 appearance. In the living, however, this tubular appearance 
 quickly disappears with the administration of food, the fundus 
 enlarging much more rapidly than the balance of the stomach in 
 order to meet the physiological* demands. 
 
 Gastric Ca pacify.— Although many authors have measured the 
 full-term infant's stomach as to its capacity, both at autopsy and 
 in the living, their figures vary considerably. 
 
 Mosenthal, 1 after a careful study of full-term infants measured 
 
 > Arch. Pediat., 1009, 26, 761.
 
 Fig. 17.— Section through the esophagus near its junction with the stomach of a 
 fetus, aged thirty-two weeks. Normal size and enlarged 10 diameters. Section 
 taken from stomach shown in Fig. 24. 
 
 Fig. 18. — Transverse section through the middle of the fundus of the stomach of a 
 fetus of twenty-two weeks. The glands have shallow crypts, in this case filled with 
 coagulated mucin. The glandular portion of the section is not so thick as in the 
 adult. There are a few parietal cells at the base of the fundus glands. Normal size 
 and enlarged 10 diameters.
 
 Fig. 19. — Transverse section through the pyloric end of the stomach of a fetus of 
 twenty-four weeks. The long pyloric glands have deep crypts between them, repre- 
 senting a close approach to the adult type. The absence of Brunner's glands removes 
 it from the immediate vicinity of the pyloric sphincter. Normal size and enlarged 
 10 diameters. Taken from stomach in Fig. 23. 
 
 
 5^3 
 
 
 
 v^s 
 
 
 «Hff 
 
 
 
 mSsfip ' } M 
 
 
 
 KEM 
 
 
 jBttQSI^B 1 
 
 &? 
 
 
 
 
 
 
 WpHQ 
 
 
 
 
 
 iB^m'' it 
 
 Fig. 20. — Transverse section through the pyloric end of the stomach of a fetus 
 of twenty-eight weeks. Normal size and enlarged 10 diameters, taken from stomach 
 in Fig. 23.
 
 5§ physiology 
 
 during life and post mortem, states that the physiological capacity 
 of the stomach exceeds the anatomical gastric capacity during life 
 because of the rapid passage through the pylorus of the individual 
 feedings during the act of nursing. This fact is corroborated by 
 the roentgen ray (Fig. 16) in several of our cases. Therefore, the 
 gastric capacity, as measured post mortem by filling the stomach 
 with water under pressure of 15 cm. of water with the pyloric end 
 of the stomach ligated, must also fall short of giving the exact 
 functional capacity. 
 
 Pfaundler's 1 figures for the stomach capacity during the first 
 three months of life for the full-term infant are 90,100 and 110 cc. 
 
 Holt 2 gives the following averages for stomach capacity in a 
 series of studies made on infants dying during the first four weeks 
 of life and examined post mortem. 
 
 Age. No. of cases. Capacity. 
 
 Birth 5 36 cc. 
 
 Two weeks 7 45 " 
 
 Four weeks 4 60 " 
 
 Notwithstanding the fact that distention of the stomach accord- 
 ing to the method of Pfaundler at autopsy is far from an ideal 
 method of estimating the physiological capacity of the stomach, 
 the author has undertaken to measure the stomach capacity for 
 the various fetal ages after the sixth month by this method, and 
 to illustrate the same graphically by photographs which represent 
 the actual size of these stomachs at various fetal ages. This has 
 been done more especially ' to illustrate the dangers of individual 
 overfeedings which are so disastrous to the life of the premature. 
 
 Figs. 21 to 26 are photographs taken with specimens immersed 
 in oil and represent the exact size of the stomach under 15 cm. 
 of water pressure at different ages. 
 
 The stomach of the premature infant on a diet of breast milk 
 is usually found empty at the end of one and one-half to two hours. 
 That of the artificially fed requires a considerably longer period of 
 time, depending upon the nature of the food administered, even 
 in the case of feeding with predigested milk. 
 
 2. Physiology.— The digestive functions of the healthy premature 
 infant are proportionate to the age at the time of birth. At the 
 sixth or seventh month most of the functions and secretions are 
 rudimentary and insufficient, while in the older infants the lessening 
 of digestive ability is not so great. 
 
 The sucking ability in the prematures and weaklings is feeble 
 as a result of the lack of muscular strength necessary to operate 
 
 1 Magenkapazitat in Kindersalter, Wien. klin. Wchnschr, 1897, 44. 
 
 2 Diseases of Infancy and Childhood, New York and London, 1911, p. 309.
 
 CHARACTERISTICS OF VARIOUS ORGANS 59 
 
 Fig. 21. — Stomach estimated fetal age twenty-four weeks capacity, 5 cc 
 
 Fig. 22. — Stomach estimated fetal age twenty-six weeks capacity, 8 cc. 
 
 Fig. 23. — Stomach estimated fetal age twenty-eight weeks, capacity 10 cc.
 
 60 PHYSIOLOGY 
 
 the suction, the muscles of the buccal region, of the tongue and 
 of the soft palate being weak. Accompanying this muscular 
 asthenia is an inactivity of the salivary glands, as a result of which 
 the mouth is dry. The lack of sucking movements tends also to 
 retard the development of these glands. 
 
 Fig. 24. — Stomach estimated fetal age thirty-two weeks, capacity 18 cc. 
 
 The strength to swallow is also diminished in the premature. 
 In the weakest a few drops of milk placed in the mouth remain 
 
 Fig. 25. — Stomach estimated fetal age thirty-six weeks, capacity 25 cc. 
 
 there; in the stronger, though at first they nurse, they soon tire 
 and their efforts to swallow cease.
 
 CHARACTERISTICS OF VARIOUS ORGANS 61 
 
 "Hunger contractions" were studied by Taylor 1 in 5 premature 
 and 40 full-term new-born infants. A comparison of the con- 
 tractions in the new born with several older children showed that 
 the hunger contractions in the former were greater than in the 
 latter. Reflex inhibition from the presence of food in the stomach 
 was present in infants of all ages. The time of appearance of 
 hunger after feeding in healthy infants gaining in weight and 
 receiving a sufficient amount of food was: For premature infants 
 under one month, one hour and forty minutes; in full-term infants 
 under two weeks, two hours and fifty minutes; in infants from 
 two weeks to four months, three hours and forty minutes. 
 
 Fig. 26. — Stomach estimated fetal age forty weeks, capacity 45 cc. 
 
 The ferments of the gastro-intestinal canal are most conveniently 
 discussed from the standpoint of action. The first group arc 
 those that aid in the splitting up of protein substances. 
 
 Pepsin is present in the gastric mucosa as early as the fourth 
 fetal month, though not in such quantities as in the older children. 
 It increases in amounts up to about the third month of life and 
 then remains at about that level. Hydrochloric acid and rennin 
 are also present in fetal life. Hess 2 was able to demonstrate free 
 hydrochloric acid in 54 out of 55 cases immediately after birth. 
 
 1 Hunger in the Infant, Am. Jour. Dis. Child., October, 1917, 14, 233. 
 
 2 Gastric Secretion of Infants at Birth, Am. Jour. Dis. Child., 1913, 6, 264.
 
 62 PHYSIOLOGY 
 
 Lipase was found to be present in small quantities by Ibrahim 1 
 in a fetus of 800 gm. and plainly present in those from 1100 gm. 
 upward. Sedgwick 2 had previously demonstrated it in 1905. 
 
 Trypsin is present in the pancreatic extract of the new born. 
 Ibrahim found trypsinogen as early as the sixth fetal month and 
 enterokinase was also found by him in an extract of intestinal 
 mucosa from premature infants. The lower third of the small 
 intestine is most active in the production of enterokinase. 
 
 Secretin, the ferment which activates the pancreas, was found 
 in the small intestine of the full -term hew born by Ibrahim and 
 Gross, 3 but its activity was slight. In the premature it is probably 
 even more deficient. 
 
 Erepsin splits albumoses and peptones and originates from the 
 mucosa of the small intestine. It has been demonstrated in the 
 premature by Langstein, 4 Jseggis, 5 Cohnheim 6 and others. 
 
 The next group consists of the carbohydrate ferments, of which 
 the milk-sugar ferment lactase is found in the intestinal contents, 
 the stools and the intestinal mucosa. It is frequently absent from 
 the intestinal tract of the premature, as it makes its appearance 
 rather late in fetal life. Nothmann 7 was able to demonstrate it 
 in the stools of the mature new born in only a few cases. The 
 presence of relatively large amounts of milk sugar in the infant's 
 food probably increases the amount and activity of the lactase. 
 The deficiency of lactase at birth is indicated further by the finding 
 of lactose in the urine of new-born infants (Nothmann). This 
 would seem to point to a lack of milk-sugar fermentation (von 
 Reuss) . 
 
 The cane-sugar splitting ferments, invertin and saccharose, are 
 present at an early date in embryonal life, although there is no 
 use for them in those fed on human milk or where lactose is used 
 artificially, for a long period of time. They are found in the 
 intestinal walls and in the meconium. 
 
 Maltose is present, according to Ibrahim, 8 in all parts of the 
 small intestines and in the intestinal contents of prematures. 
 Diastase, the amylolytic ferment, is present in the salivary glands 
 and in the pancreas of the new born. Ptyalin is found in the 
 parotid and in the submaxillary secretions, although it is not 
 required until the beginning of the starch feeding. Ibrahim believes 
 
 1 Verhandl. d. deutsch., Gesellsch. f. Kinderh., Koln, 1908, p. 36. 
 
 2 Arch. Pediat., 1906, 23, 414. 
 
 s Jahrb. f. Kinderh., 1908, 68, 232. 
 4 Jahrb. f. Kinderh., 1908, 68, 9. 
 6 Zentralb. f. Gyn., 1907, 1060. 
 
 6 Ztschr. f. Physiol. Chem., 1903, 37, 467. 
 
 7 Monatsschr. f. Kinderh., 1909, 8, 377. 
 
 8 Ztschr. f. Physiol. Chem., 1910, 64, 95.
 
 CHARACTERISTICS OF VARIOUS ORGANS 63 
 
 that the pancreatic function of the new born and espei ially of the 
 
 premature new horn is somewhat below that of the older infant, 
 and, therefore, the instructions of the older clinicians not to feed 
 these infants mixtures containing much starch were correct from 
 a physiological point of view (von Reussj. 
 
 The third and last group of ferments are those which act upon 
 the fats. Steapsin was found in the pancreatic secretion by Zweifel, 1 
 and Ibrahim 2 showed that it was also present in the premature. 
 The meconium contains this ferment. Lipase is very active in 
 the gastric mucosa of prematures. 
 
 In general the premature may be said to possess nearly all the 
 ferments necessary for the breaking-down of its food. Some of 
 them, such as diastase and ptyalin, which are not present during 
 fetal life or only in the most insignificant quantities, are called 
 forth even in the premature, by the administration of food, and 
 though they may be deficient both in amount and in activity at 
 this time, the continued stimulation offered by food soon results 
 in a material increase in both qualities, at least in the case of pre- 
 matures who possess a sufficient degree of vitality. All necessary 
 ferments being present, it is of little advantage to feed the prema- 
 ture infant predigested human milk. 
 
 Ferment therapy also is of little value in premature infants as is 
 also true in older children. If the required ferments are present 
 they will increase with the giving -of food. It is not the absence 
 of ferments that is responsible for the peculiarities of action of the 
 digestion of the prematures, but rather the way the food is broken 
 down and absorbed; and a clear realization of these differences is 
 necessary to an understanding of the peculiarities of the digestion 
 of the new born, both premature and at term. 
 
 The normal gastric mucosa provides only for the absorption of 
 salts and carbohydrates. 
 
 Ganghofer and Langer 3 found that up to the fourth day of life 
 the intestinal tract is permeable to foreign proteins and the import- 
 ance of this is great. The permeation of these through the intesti- 
 nal wall results in the formation of antibodies in the tissues, and 
 the danger of sensitization of the organism to that particular 
 protein. Herein lies one of our most important indications for 
 feeding with human milk. 
 
 The intestinal canal is more frail than in the full-term infants 
 and the intestinal musculature is weak and easily distended and 
 often times unable to expel the contained meconium. 
 
 The meconium- begins to he formed at the fourth fetal month. 
 
 1 Untersuchungen iiber das Verdauungsapparat der Neugeborenen, Berlin, 1874. 
 
 2 See p. 62, Ref. 1. 
 
 3 Miinchen. med. Wchnschr., 1904, 1497.
 
 64 
 
 PHYSIOLOGY 
 
 It is made up of the secretions of the gastro-intestinal tract, vernix 
 caseosa, threads of mucus, desquamated epithelium, biliary acids 
 and salts, cholesterol, fat droplets, fatty-acid crystals and liquor 
 amnii which has been swallowed. That which is passed on the 
 first day is dark green, thick, sticky, homogeneous and odorless. 
 Its excretion lasts from twenty-four to ninety-six hours. During 
 the first few hours it is free from bacteria and even later the number 
 of organisms present is small. The characteristic yellow color of 
 the breast milk stool is scarcely established before the fifth and 
 sixth day and then only when the milk taken is rich. The sour odor 
 of the breast-milk stool may also be recognized at this time. 
 
 Hymanson and Kahn, 1 investigating the properties of meconium 
 found that there were traces of ammonia and amylase, but no 
 uric acid, trypsin, erepsin, lactase or lipase. Their analysis of the 
 inorganic constituents is given in the table which follows: 
 
 
 1. 
 
 2. 
 
 3. 
 
 4. 
 
 5. 
 
 Parts per thousand: 
 
 
 
 
 
 
 
 732.3 
 
 801.7 
 
 784.5 
 
 697.7 
 
 718.6 
 
 
 267.7 
 
 198.3 
 
 215.5 
 
 302.3 
 
 281.4 
 
 Organic matter 
 
 245.2 
 
 180.1 
 
 197.7 
 
 280.5 
 
 257.9 
 
 Ash 
 
 22.5 
 
 18.2 
 
 17.8 
 
 21.8 
 
 23.5 
 
 Ash percentage of: 
 
 
 
 
 
 
 Total meconium 
 
 2.25 
 
 1.82 
 
 1.78 
 
 2.18 
 
 2.35 
 
 
 • 8.3 
 
 9.1 
 
 8.2 
 
 7.2 
 
 8.3 
 
 Analysis of meconium ash (per cent) : 
 
 
 
 
 
 
 Fe 2 3 
 
 3.17 
 
 1.17 
 
 2.24 
 
 0.92 
 
 1.44 
 
 CaO 
 
 18.24 
 
 
 17.55 
 
 21.18 
 
 16.34 
 
 MgO 
 
 4.21 
 
 8.05 
 
 6.17 
 
 6.18 
 
 4.75 
 
 P2O5 
 
 12.62 
 
 8.62 
 
 
 
 11.70 
 
 SOs 
 
 23.14 
 
 25.63 
 
 18.47 
 
 28.30 
 
 24.32 
 
 CI 
 
 5.86 
 
 7.12 
 
 6.89 
 
 5.34 
 
 
 
 24.19 
 
 
 33 . 72 
 
 
 
 3. Bacteriology of the Gastro-intestinal Tract.— The gastro- 
 intestinal tract of a healthy premature is sterile at birth and 
 remains so for a short time afterward, the meconium remaining 
 sterile for about twelve hours. This is followed by invasion of 
 bacteria, most probably with the first feeding, and during the 
 next two days the gastro-intestinal flora is very variable, depending 
 chiefly on the surroundings of the infants. After the third day, 
 however, a typical intestinal flora develops, the type depending 
 chiefly upon the diet of the infant. 
 
 In an infant fed with human milk saccharolytic bacteria pre- 
 dominate, the chief one being Bacillus bifidus, which is especially 
 
 1 Study of the Intestinal Contents of Newly Born Infants, Am. Jour. Dis. Child., 
 February, 1919, 17, 112.
 
 CHARACTERISTICS OF VARIOUS ORGANS 65 
 
 numerous in the large intestine up to the sigmoid flexure. This 
 portion of intestine also contains the largest number of bacteria. 
 Bacillus coli is also present, especially in the region of the ileocecal 
 valve and cecum, but still Bacillus bifidus predominates. The 
 flora of an infant on human milk are much more homogeneous than 
 that of an infant artificially fed. 
 
 In artificially-fed infants there is a relative increase of Bacillus 
 coli and of proteolytic bacteria and a diminution of Bacillus bifidus. 
 However, the flora of artificially-fed infants arc much more variable 
 and depend chiefly on the chemical composition of the food. 
 
 Human milk low in protein and high in sugar leads to the flora 
 of fermentation, while cows' milk which is high in protein and low 
 in sugar leads to flora of putrefaction. 
 
 Carbohydrates favor the development of fermentative organisms, 
 lactose favoring especially Bacillus bifidus and maltose and dextrin 
 compounds favoring Bacillus acidophilus. 
 
 Proteins favor the development of organisms of putrefaction, 
 especially when given in excess. 
 
 Fat seems to have no distinctive action on the intestinal flora. 
 
 Metabolism of Premature Infants. — The following facts are 
 quoted from Jaschke, 1 who states that there is not sufficient material 
 on hand at the present time for comparing the metabolism of 
 prematures both healthy and debilitated with the metabolism of 
 mature normal infants. 
 
 "The expenditure of energy as related to the unit of body surface 
 is in the premature much greater than in the mature new born 
 (Camerer), when the age is calculated from birth; on the other 
 hand, however, they are almost the same, if age is calculated from 
 the time of conception (Pfaundler) which very well agrees with the 
 curve of the potential of life. The nitrogen under balance in the 
 premature lasts longer than in the mature new born, which is 
 probably dependent in the first place upon the small food intake. 
 There are not sufficient experiments on the gaseous exchange and 
 on the insensible perspiration to enable one to draw conclusions 
 that would be of general value. There is nothing known of mineral 
 metabolism." 
 
 Nervous System.— The lack of development of the cerebrospinal 
 nervous system is greater than that of the sympathetic system. It 
 is most markedly evidenced by the muscular inertia shown by the 
 infant. Many of them lie in a state of stupor or somnolence from 
 which they must be aroused to be fed. Others can be aroused by 
 external stimulation which calls forth only a weak cry and slight 
 movements of the body. These movements are slower than those 
 
 i Sec p. 18, Ref. 1.
 
 66 PHYSIOLOGY 
 
 of the full-term infant and the child tends to relapse into a deep 
 sleep as soon as the stimulus is removed. Also depending to some 
 extent upon the incomplete development of the nervous centers 
 are the weak respiratory functions and the feeble efforts at sucking. 
 At this time the development of the brain is still going on and the 
 separation of the white and gray matter is not yet completed. 
 
 The nasal and pharyngeal reflexes are particularly weak in 
 children born before term. Abdominal reflexes are almost never 
 present in the premature; in fact they are rarely seen in the new- 
 born infant. 
 
 Among many neurologists the opinion is prevalent that prema- 
 turity predisposes to idiocy, imbecility and epilepsy. However, it 
 appears in these instances it is not so much the premature birth 
 that is responsible, but rather there seems to be a common cause lead- 
 ing to retarded development and premature expulsion of the fetus. 
 
 Cardiovascular System.— As compared with other organs the heart 
 is relatively well developed. That the heart should be strong is 
 not surprising, as from the first months of pregnancy the precocious 
 development of this organ is found to be in complete accord with 
 the importance of its function. The high position of the dia- 
 phragm and the equality of the diameters of the thorax causes 
 the long axis of the heart to lie in a more nearly transverse position. 
 Because of this position the apex beat is found in the fourth inter- 
 space, 0.5 to 1 cm. outside the mammillary line. 
 
 The variability of the pulse-rate, which is quite marked in the 
 premature new born, ranges from 90 to 200 per minute, with an 
 average of about 120. This variability is the result of the lack 
 of development of the cardiac inhibitory centers. 
 
 At birth the thoracic respirations determine a considerable flow 
 of blood through the pulmonary artery to the lungs. The function 
 of the ductus arteriosus ceases at this time and the blood current is 
 diverted from the foramen ovale through the tricuspid orifice into 
 the right ventricle. Within twenty-four to forty-eight hours after 
 birth the ductus arteriosus is almost completely closed normally, 
 while the foramen ovale is soon completely occluded by the rapid 
 growth of its valvule. If, however, the ductus arteriosus is not 
 closed, as is frequently the case in the premature infants, due to 
 non-expansion of the lungs with a resulting increased resistance in 
 the lesser circulation, cyanosis may result. 
 
 The heart is usually only secondarily involved in asphyxial 
 attacks, the tones becoming weak and slow during the spells of 
 cyanosis. The heart action often persists for hours after the respi- 
 ration ceases. Myocardial asthenia in the premature may also 
 result in cyanosis and is frequently accompanied by edema. (See 
 Cyanosis.) General circulatory difficulties may also be the cause 
 of subnormal temperature in these infants.
 
 CHARACTERISTICS OF VARIOUS ORGANS 67 
 
 Blood-pressure in the mature at birth and for the first few days 
 of life is low and in the prematures and weaklings it is still lower. 
 In the new born the pressure ranges around 80, while the figures 
 for the premature and the weaklings will vary from 60 to 70 mm. 
 of mercury (Trumpp). 1 
 
 The vascular walls in the premature are weaker than in the infant 
 at term and because of this these children arc subject to hemorrhage 
 following relatively slight traumata. This is particularly true of 
 the intracranial vessels and thus we see that hemorrhages in this 
 region are relatively more frequent in the premature. 
 
 The intracranial hemorrhages are usually followed by early 
 death and in many instances undoubtedly these are interpreted as 
 respiratory deaths because of the influence of pressure on the 
 respiratory center. 
 
 This tendency to hemorrhage in the premature in some cases is 
 due to deficient coagulability of the blood. 
 
 In a study of the new-born Rodda 2 found by his method that the 
 average coagulation time was seven minutes, with a normal range 
 between five and nine minutes. 
 
 There is a prolongation of coagulation and bleeding times from 
 the first day to the maximum on the fifth day of life, with a return to 
 the average first-day determination time before the tenth day. It 
 is significant that this coincides with the age incidence of hemor- 
 rhagic disease and cerebral hemorrhage. 
 
 In icterus neonatorum normal coagulation and bleeding times 
 were found. 
 
 Several cases of melena neonatorum gave markedly prolonged 
 coagulation times— up to ninety minutes— and bleeding times of 
 hours, days or until the condition was controlled. 
 
 Suspected and mild cases of congenital syphilis gave normal 
 findings. Severe and progressive cases gave prolonged times. 
 
 Pfaundler 3 found a low alkali reserve in debilitated prematures 
 and believed this to be an important factor in the low immunity to 
 infection. The blood also shows an increased viscosity due in all 
 probability to the increase of water loss over intake during the first 
 days. Rusz 4 has also suggested, as a second factor, the delayed 
 tying of the cord, with a resulting flow of blood from the placenta, 
 causing a relative overloading of the fetal circulation. 
 
 The cell content of the blood of the premature does not differ 
 greatly from that of the new-born infant, though it does possess 
 certain special characteristics (Kunckel). 5 
 
 1 Jahrb. f. Kinderh., 1906, 63, 43. 
 
 2 Am. Jour. Dis. Child., April, 1920, 19, 269. 
 
 3 Verhandl. d. Ges. f. Kinderh., Brcslau, 1904, 21, 24. 
 * Monatsschr. f. Kinderh., 1911, 10, 360. 
 
 6 The Changes in the Blood of the Prematurely Born and Weaklings, Ztschr. f. 
 Kinderh., July 26, 1915, 13, 101.
 
 68 PHYSIOLOGY 
 
 The erythrocytes are slightly less in number and diminish readily 
 under the influence of infections, jaundice and edema. Maero- 
 cytes and microcytes are very numerous and poikilocytosis is also 
 often observed . Nucleated erythrocytes are characteristic of the blood 
 of the premature infant and the farther the child is from term the 
 more numerous are these nucleated cells. In the mature infant 
 nucleated cells are only found during the first few days of life, while 
 in the premature they are found as late as ten days after birth. 
 A large number of these cells is incompatible with life. They re- 
 appear quickly with the onset of any infection and are slower to 
 disappear when the temperature is subnormal. With redevelopment 
 of a subnormal body temperature during the first weeks of life, the 
 nucleated reds tend to reappear. 
 
 The leucocytes are less numerous or only slightly increased. 
 Instead of 12,000 to 13,000 leucocytes, as found in the normal full- 
 term new-born infant, there are on the average 8000 in one cubic 
 millimeter in the premature. 
 
 The differential count shows a high percentage of mononuclears 
 and abnormal elements, such as mast cells (basophiles) and myelo- 
 cytes. These cells possess little activity, which is an important 
 factor in the low resistance of these infants to disease. What 
 bearing the lowered alkalinity has on the feeble reaction of the 
 white cells is still an open question. The reaction to infection is, 
 as a rule, very feebly polynuclear and may even be replaced by 
 one of transitional forms and abnormal elements, myelocytes and 
 mast cells, as if the hematopoietic organs were only capable, in 
 their deficiently developed states, of putting into the circulation 
 immature elements. The polynuclear eosinophiles are fewer in 
 number in the premature and disappear when an infection occurs. 
 In congenital syphilis they are usually increased. 
 
 While in the normal full-term infants the hemoglobin content 
 gradually sinks and at the end of the fourth week amounts to about 
 85 per cent (by Sahli's hemoglobinometer), in the prematurely born 
 infants its value at this time is 50 to 60 per cent; therefore, in 
 prematurely born infants there is a distinct and very early hemoglo- 
 bin impoverishment of the blood, which reaches its maximum in 
 about the third to the fourth month. While the hemoglobin con- 
 tent shows a marked deviation from the normal, the number of 
 erythrocytes is only little below the normal and therefore the 
 hemoglobin content of the individual blood corpuscle is considerably 
 less than normal. This accounts for the constant and early devel- 
 opment of anemia in prematures during the first three months of 
 life. The cause of this hemoglobin deficiency seems to be an 
 insufficient iron content of the premature's blood, which is easily
 
 :d blood cells. 
 
 WL 
 
 te blood cells. 
 
 6,135,000 
 
 
 7.512 
 
 5,799,000 
 
 
 5 . 755 
 
 5,376,000 
 
 
 8.572 
 
 CHARACTERISTICS OF VARIOUS ORGANS 69 
 
 understood when we recall that Hugouneng 1 has proven that the 
 quantity of iron stored up by the fetus in the last third of pregnancy 
 is twice as large as that during the first two-thirds. 
 
 Liechtenstein's 2 studies on a large number of premature infants 
 showed a considerable degree of anemia in a large percentage of 
 his cases. 
 
 In a study of the blood findings in 90 prematurely born infants 
 (those of known syphilitic and tuberculous parentage were excluded ) 
 in greater part born one or two months before term, Lichtenstein 
 recorded the following findings: 
 
 In 10 cases he found: 
 
 Age. Hemoglobin. 
 
 First day of life . . . 96 . 7 
 Third day of life . . . 90 . 7 
 Tenth to twelfth day of life 85.8 
 
 The hemoglobin and red cell counts were relatively those of the 
 full term, showing an absence of congenital anemia. The white 
 blood cells were below the averages given for full-term infants 
 and presented an absolute leukopenia. 
 
 There was also a more marked anisocytosis, polychromatosis and 
 erythroblastosis than is seen in the blood picture of the full-term 
 new-born. 
 
 Subsequent examinations of the blood in 19 premature infants 
 breast fed over two weeks by healthy mothers gave the following 
 averages : 
 
 Age. 
 3 to 4 weeks 
 2 months 
 3 
 4 
 5 
 6 
 
 These results, when compared with examinations of wet-nurses' 
 infants, showed a decided oligochromemia (controls never under 
 55); and oligocythemia (controls rarely under 4,000,000). The red 
 cells increased toward the end of the first half year of life. The 
 white cell counts for full-term infants usually averaged between 
 10,000 and 12,000, those of the prematures after the fourth week 
 between 7000 and 9000. 
 
 There is also a constant anisocytosis and anisochromemia which 
 changes run parallel with the oligochromemia. Erythroblasts were 
 found in some cases as late as the fourth month. 
 
 1 Compt. Rend, de L'Acad. des Sc, April, 1899, 128. 
 
 2 Svenska Lakaresa As Kapets Handlinger, Stockholm, December 31, 1 ( J17, No. 4, 
 43. 
 
 Hemoglobin. 
 
 Red blood cells. 
 
 White blood cells 
 
 . 76.0 
 
 4,023,000 
 
 7,560 
 
 . 50.5 
 
 3,616,000 
 
 8,720 
 
 . 40.2 
 
 2,945,000 
 
 7,(14.' 
 
 . 40.5 
 
 3,065,000 
 
 7,969 
 
 . 44.0 
 
 3,733,000 
 
 7,969 
 
 . 40.0 
 
 3,740,000 
 
 7,969
 
 70 
 
 PHYSIOLOGY 
 
 The percentages of the various white cells do not vary greatly 
 from the picture of the full-term infant. Metamyelocytes were 
 occasionally seen as late as the second month. The figures are 
 tabulated in the following tables: 
 
 WHITE BLOOD CELL PERCENTAGES (LICHTENSTEIN} 
 
 . 
 
 t-, r Neutrophile 
 
 Day ° f leucocytes, 
 
 examination. perc ^ nt .' 
 
 Eosinophile 
 
 leucocytes, 
 
 per cent. 
 
 Small 
 
 lymphocytes 
 
 per cent. 
 
 Other Large mono- 
 lymphocytes nuclears, 
 per cent. J per cent. 
 
 .Metamye- 
 locytes, 
 per cent. 
 
 1st day . 
 3d day . . 
 10 to 12 days 
 
 45.8 
 31.0 
 27.9 
 
 1.8 
 3.1 
 3.2 
 
 11.6 
 
 23.5 
 20.3 
 
 18.5 
 27.5 
 33.2 
 
 8.2 
 
 8.7 
 
 11.2 
 
 13.4 
 5.9 
 3.8 
 
 white blood cell percentages in the later months 
 (lichtenstein). 
 
 
 Leucocytes. 
 
 Lymphocytes. 
 
 Large mononuclears. 
 
 Eosin- 
 ophile. 
 
 Age of 
 infants. 
 
 Max. Min. 
 per 1 per 
 cent . cent. 
 
 No. 
 cases. 
 
 Max. 
 per 
 cent. 
 
 Min. 
 per 
 cent. 
 
 No. 
 cases. 
 
 Max. 
 per 
 cent. 
 
 Min. 
 per 
 cent. 
 
 No. 
 cases. 
 
 Per 
 cent. 
 
 0.5-1 month 
 2 
 3 
 4-G " 
 
 33.5 
 20.3 
 41.5 
 35.0 
 
 5.8 
 
 7.3 
 
 9.5 
 
 29.8 
 
 5 
 
 8 
 6 
 4 
 
 76.5 
 82.8 
 79.8 
 60.8 
 
 51.5 
 56.5 
 44.0 
 48.0 
 
 5 
 8 
 6 
 4 
 
 14.5 
 17.3 
 12.0 
 14.3 
 
 1.0 
 6.3 
 3.5 
 
 4.8 
 
 5 
 
 8 
 6 
 4 
 
 2-3 
 2-3 
 2-3 
 2-3 
 
 Lande 1 examined a group of 70 prematures born from the sixth 
 to the eighth month of pregnancy, with weight from 830 to 2500 
 gm. The majority were fed on human milk, made an average 
 monthly gain of 450 gm., and were relatively free from infection 
 and congenital lues. The results of examination of the hemoglobin 
 content and the percentage of the red and white blood cell elements 
 in the newly born prematures during the first weeks of life are 
 shown in the following table: 
 
 
 No. 
 
 cases. 
 
 Hemoglobin. 
 
 Erythrocytes. 
 
 Erythro- 
 blasts. 
 
 White blood cells. 
 
 Age of 
 infants. 
 
 Max. 
 per 
 
 cent. 
 
 Min. 
 
 per 
 
 cent. 
 
 Com- 
 monest 
 
 value, 
 per cent. 
 
 Max. 
 cc. 
 
 Min. 
 cc. 
 
 Com- 
 monest 
 value. 
 
 Max. 
 
 Min. 
 
 Max. 
 
 Min. 
 
 Com- 
 monest 
 value. 
 
 1 day 
 
 2-4 " 
 0-8 " 
 
 12 
 
 15 
 
 
 
 140 
 
 135 
 
 105 
 
 100 
 
 100 
 100 
 
 110-120 
 
 125 
 
 5.8 
 
 6.7 
 5.6 
 
 3.8 
 
 4.1 
 
 4.0 
 
 4.3-5.0 
 4.6-5.4 
 
 7000 
 
 6700 
 100 
 
 400 
 
 
 
 
 20,000 
 
 16,000 
 11,400 
 
 3800 
 
 3600 
 6600 
 
 10,000 
 
 to 
 15,000 
 8,000 
 
 to 
 12,000 
 
 i Ztschr. f. Kinderh., 1919, 22, 299.
 
 CHARACTERISTICS OF VARIOUS ORGANS 
 
 71 
 
 
 
 Leukocytes. 
 
 Lymphocytes. 
 
 Large 
 mononuclears. 
 
 
 
 Myelo- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Age of 
 
 IB 
 
 
 
 "S 55 
 
 
 
 *B 
 
 
 
 § t 
 
 O i) . 
 
 Eosino- 
 
 M..-i 
 
 blasts 
 
 and) J 
 
 myelo- 
 
 infants. 
 
 Si 
 
 u 
 
 a. . 
 
 I* 
 
 0) 
 
 o o> . 
 
 u 
 a 
 
 0. . 
 
 - 
 
 = - 
 
 3 
 
 - 
 
 philes. 
 
 cells. 
 
 
 ••£ 
 
 ■ = 
 
 ~- = = - 
 
 J a 
 
 - = 
 
 = ± = 
 
 
 = £- 
 
 
 
 cytes. 
 
 
 
 « u 
 
 - - 
 
 H™§ 
 
 gj ;. 
 
 - i. 
 
 = >i 
 
 CC o 
 
 «s 
 
 6 $ r 
 
 
 
 
 
 2 
 
 § 
 
 3 
 
 u 
 
 3 
 
 § 
 
 o 
 
 3 
 
 § 
 
 o 
 
 
 
 
 1 day 
 
 12 
 
 54 
 
 12 
 
 40-50 
 
 85 
 
 39 
 
 45-55 
 
 12.5 
 
 i 
 
 7-10 
 
 .5-1.5 
 
 0-1.5 
 
 3-12.5 
 
 2-4 " 
 
 15 
 
 (14 
 
 11 
 
 40-55 
 
 87 
 
 30 
 
 40-55 
 
 12.0 
 
 2 
 
 .-, 10 
 
 0-5 (I 
 
 0-2.5 
 
 _■ 6 n 
 
 6-8 " 
 
 6 
 
 08 
 
 29 
 
 
 65 
 
 26 
 
 
 8.0 
 
 6 
 
 
 0-2.0 
 
 (i 2 
 
 2.0 
 
 From these tabulations Lande drew these conclusions: Opposed 
 to the findings in full-term infants, there is in prematures a greater 
 richness of nucleated red blood corpuscles, a more frequent appear- 
 ance of myeloblasts and myelocytes during the first days of life, 
 a lesser development of absolute and relative leukocytosis, and a 
 greater number of immature leukocyte forms. 
 
 The blood picture from the third week of life to the age of six 
 months is expressed by the following figures (Lande) : 
 
 Hemoglobin. 
 
 Erythrocytes. 
 
 Age of 
 
 No. of 
 
 
 
 
 
 
 
 infants. 
 
 cases. 
 
 Max., 
 per cent. 
 
 Min., 
 per cent. 
 
 Commonest 
 
 value, 
 
 per cent. 
 
 Max., 
 Millions. 
 
 Min., 
 
 Millions. 
 
 Commonest 
 
 value, 
 Millions. 
 
 1 .0 month 
 
 13 
 
 105 
 
 70 
 
 80-85 
 
 5.5 
 
 3.3 
 
 3.6-4.6 
 
 1.5 " 
 
 9 
 
 95 
 
 50 
 
 60-70 
 
 3.9 
 
 2.7 
 
 3.2 
 
 2.0 " 
 
 17 
 
 80 
 
 50 
 
 60 70 
 
 4.4 
 
 2.4 
 
 3.0-3.6 
 
 2.5 " 
 
 7 
 
 80 
 
 50 
 
 60-65 
 
 4.0 
 
 2 . 3 
 
 3.0-3.6 
 
 3-3.5 " 
 
 24 
 
 80 
 
 50 
 
 60-70 
 
 4.9 
 
 2.4 
 
 2.9-3.9 
 
 4-4.5 " 
 
 18 
 
 75 
 
 50 
 
 60-70 
 
 5.2 
 
 2.7 
 
 3.3-4.0 
 
 5-5.5 " 
 
 15 
 
 85 
 
 55 
 
 65-75 
 
 4.7 
 
 3.4 
 
 3.9-4.6 
 
 Lande noted a fall in the hemoglobin content from 80 to 85 per 
 cent to 60 to 65 per cent in the third month, which slowly rises to 
 65 to 75 per cent in the sixth month. At the same time the number 
 of erythrocytes sinks from about 4,000,000 to 3,300,000, in order 
 to again approach the normal value by the end of the first year. 
 
 Nathan and Langstein 1 have found the blood in the new-born 
 very low in antitoxic, bactericidal and hemolytic properties. 
 
 Blood-sugar determinations in three healthy prematures fed on 
 mother's milk were studied by Heller. 2 In no case was sugar 
 
 1 Ztschr. f. Kinderh., 1919, 22, 299. 
 
 2 Der Blutzuckergehalt bei Neugeborenen und Fruhgeborenen Kindern, Ztschr. f. 
 Kinderh., 1913, 9, 44.
 
 72 PHYSIOLOGY 
 
 found in the urine, this being explained by the fact that in 
 no instance was there an evident hyperglycemia. The per- 
 centage of blood sugar noted between ten and a half and twelve 
 hours after birth was 0.095, 0.089, 0.082; these figures are for 
 infants weighing respectively 1500 gm., 1380 gm. and 930 gm. The 
 diets were increased so that on the seventh day the two heavier 
 infants were both getting 160 gm. while the smaller was given 80 
 gm. of milk. The percentage of blood sugar was then noted; 
 0.104 for both heavy infants (twins) and 0.065 for the other. All 
 observations were taken from one -half to two hours after the 
 feeding. There was a steady fall in blood sugar in the twins until 
 the sixth day. 
 
 These blood-sugar findings are similar to those of Gotzky, 1 who 
 found an average of 0.085 mg. in the full-term new born, somewhat 
 lower findings in prematures, and 0.095 mg. in later infancy, as com- 
 pared with 0.102 mg. in later years. Because of the relationship 
 of blood sugar to diet, comparative studies must be undertaken 
 with a knowledge of the quantity and quality of food and the time 
 to the meal. 
 
 Lymphatic System.— This is well developed and does not differ 
 materially from that of the new born, unless possibly its circulation 
 is slowed as a result of the slowing of the general circulation. 
 
 Thymus and Thyroid Glands.— These organs present the highest 
 degree of development of any glandular structures. In fetal life 
 these organs contribute to the formation of blood and during the 
 first few weeks of life have a phagocytic action. 
 
 Genito-urinary System.— In the female the labia minora usually 
 overlap the labia majora, while in the male the testicles are often 
 high in the inguinal canal, though it can happen that they are 
 found in the scrotum as early as the seventh month. 
 
 An examination of the urine of the premature throws but little 
 light upon the metabolism of these infants. The proportion of 
 ammonia N to the total N is below normal, while ~ is increased. 
 This speaks for an increase in the processes of decomposition. 
 Nobecourt and Lemaire 2 found that the freezing-point of the urine 
 of prematures was lowered. 
 
 The amount and character of the urine during the first few 
 days of the life of the premature depend upon the intake of fluid, 
 upon the absolute body weight and upon the absolute and relative 
 amounts of water within the body tissues. 
 
 If the quantity of fluids taken is small the amount of urine 
 secreted is proportionately small. When the quantity is larger, as 
 is usually the case if the infant is given feedings to substitute 
 
 i Ztschr, f. Kinderh.. 1913, 9, 44. 
 2 Quoted by Pfaundler.
 
 CHARACTERISTICS OF VARIOUS ORGANS 73 
 
 the mother's milk and frequent feedings of water, the relative as 
 well as the absolute amount of urine secreted is larger. Cramer 1 
 found that with an abundant supply of milk during the first few 
 days of life the urinary output amounted to 54 to 60 cc for every 
 100 cc of milk consumed. 
 
 The frequency of urination during the early days of the prema- 
 ture is less than at an older age. While the infant may urinate 
 during its passage through the birth canal or immediately after, 
 yet, as a rule, during the first few days the urinations are very 
 infrequent, at most three or four and more often only one or two 
 times during the twenty-four-hour period. It is not at all uncom- 
 mon that no urine is passed during the first day. This failure 
 to urinate during the first day of life is not of much moment, but 
 in those instances of absence of urination for as long as four days, 
 as have been reported, some anomaly was undoubtedly present. 
 With the increase in the fluids taken, which occurs usually on the 
 third or fourth day, the frequency of urination also increases. 
 
 During the period of greatest concentration the reaction of the 
 urine is strongly acid. As it becomes more dilute, the acidity 
 becomes less marked. 
 
 Albuminuria is a symptom shown by almost all infants just 
 after birth, full-term as well as premature. The length of time 
 during which this persists is short, seldom more than the first 
 few days, and the quantities of albumin present are small: 0.25 
 gm. of albumin per 100 cc of urine is a maximum which is fre- 
 quently reached in the full-term infant. Yon Reuss 2 found the 
 urine of only 4 per cent of new-born infants to be free from albumin 
 during the first four days of life. After that time the amount of 
 albumin present rapidly falls, unless the concentration of the urine 
 remains high, and it retains the turbidity characteristic of infant 
 urine, when the albumin persists for a longer period. 
 
 Albumin in the urine of the new born would seem to be some- 
 what of a physiological condition, certainly having no relation of 
 a causal nature to the infections or other toxic factors of the later 
 periods of life. Albuminuria at this time seems to have a certain 
 analogy with the orthostatic albuminuria of older individuals, both 
 probably to be accounted for by circulatory disturbances of the 
 kidney. Von Reuss believes the condition is most easily explain- 
 able on the basis of circulatory stagnation which occurs in a more 
 or less pronounced degree after every delivery. Uric-acid infarcts 
 may also have some bearing as a cause of albuminuria. The 
 deficient blood supply of the kidney and the lack of water passing 
 through the organ as a result of the small quantity taken during 
 
 1 Arch. f. Kinderh., 1901, 22, 1. 
 
 2 Verhandl. d. Ges. f. Kinderh., Miinster, 1912, 29, 145.
 
 74 PHYSIOLOGY 
 
 the first few days of life probably increases the amount of albumin 
 passed. 
 
 Nothmann 1 found milk sugar in the urine of premature infants 
 who were breast fed, and he reports that he found no such cases 
 among the full-term infants. Sugar was found by Hoeniger 2 in 
 the urine of several infants delivered by forceps. It was excreted 
 for three or four days and then gradually disappeared. It was 
 believed to be the result of the force used during the operative 
 delivery. 
 
 Acetone bodies are found in small quantities in the urine of poorly 
 nourished and underfed weaklings. 
 
 During icterus neonatorum bilirubin occurs in the urine in the 
 form of a precipitate. It is also found in solution in septic condi- 
 tions and in hemorrhage of the new born. 
 
 Creatin and creatinin have not been studied in the premature. 
 
 Occasionally hyaline casts in small numbers, often covered with 
 urates, are seen. These are probably due to the same causes as 
 the albumin and have no pathological significance. 
 
 Special Senses.— Over the eyes of the youngest prematures 
 occasionally there can be seen more or less well-marked vestiges 
 of the pupillary membrane, the cornea is inclined to be somewhat 
 thicker, the anterior chamber less deep and the iris less pigmented. 
 Strong light impressions are followed by reflex closure of the lids, 
 but sudden movements are not followed by such closure, as the 
 reflex is psychic, depending upon fear. 
 
 The eye movements of the premature infant are incoordinated, 
 motion being most often in a horizontal direction, occasionally 
 outward, but more often and in a comparatively strong manner, 
 inward. It is not uncommon to see this tendency to convergence 
 persist until the second month. The light reflex is present before 
 birth and the pupil, when exposed to a strong light, contracts only 
 to dilate again in two or three seconds. This secondary dilatation 
 is particularly well marked in the premature as a result of the poor 
 development of the nerve fibers, which are easily fatigued (Fur- 
 maim). 3 The convergence reflex is absent in prematures as well 
 as in the more mature infant because fixation does not occur. 
 
 Skin and Adnexa.— The skin is thin, soft and usually of a more or 
 less vivid red appearance, occasionally of a peculiar cyanotic hue, 
 and the transparent dermis allows the circulatory network to be 
 clearly distinguished. The skin is partly or completely covered 
 with lanugo hairs which are seen most commonly between the 
 
 1 Monatschr. f. Kinderh., 1909, 8, 377. 
 
 2 Deutsche med. Wchnschr., 1911, 500. 
 
 3 Die Reflexe der Siiuglinge. Diss., Petersburg, 1903, Loc. cit., Gundobin, Berlin, 
 1912.
 
 CHARACTERISTICS OF VARIOUS ORGANS 
 
 75 
 
 Fig. 27. — Embryological eye section. (Normal size and enlarged 5 diameters.) 
 
 The conjunctiva has reached its full development and shows subconjunctival lymph- 
 follicles beginning to develop into separate entities. 
 
 The cornea is still in the developmental stage and shows some interesting conditions. 
 The corneal epithelium is uniform and is a two-cell layer well developed and without 
 mitotic figures. Bowman's membrane is just beginning to be differentiated from the 
 anterior corneal stroma, but does not form an entity as yet. The development of 
 the membrane is not uniform throughout but appears in scattered areas and without 
 continuity. (This would tend to place the specimen in the first half of the fifth 
 month). The anterior corneal stroma is well developed and is dense. The posterior 
 corneal stroma is well developed. Both stroma show fixed corneal cells. Decemet's 
 membrane is fully developed and is intact from angle to angle. 
 
 The anterior chamber has begun to form by the retraction of t he anterior lens capsule 
 and pupillary membrane from the posterior surface of the cornea and the iris is push- 
 ing into the anterior chamber in front of the lens. The chamber angle is already 
 differentiated and wide spaces exist in the pectinate ligament, much wider than in 
 adult life. 
 
 The iris is recognizable as a separate entity. The anterior surface is smooth and 
 uniformly covered with smooth endothelium. No crypts have developed as yet. 
 (This speaks for an age of less than six months) . The iris stroma is still very thin ami 
 loose, but is well vascularized. The retinal pigment epithelium of the iris is differ-
 
 76 
 
 PHYSIOLOGY 
 
 entiated and well-developed, although the posterior layer is thinner and less heavily 
 pigmented than the anterior. The sphincter iridis can be recognized as a separate 
 entity and already fills the pupillary margin of the iris fairly well. Individual 
 dilator fibers are present but the muscle as a whole is still undeveloped. 
 
 The ciliary body is still small and is posterior to the position occupied in adult life. 
 The retinal pigment layer and the ciliary processes are well-developed and are fairly 
 well anterior. But the main body is well back, is thin, and is still undifferentiated 
 into its component parts. Bruecke's muscle can be recognized, although it has not 
 formed into the complete muscle as yet; but Mueller's muscle is still missing. 
 
 The lens is nearly spherical and in the periphery can be found a few proliferating 
 lens fibers. The anterior capsule is a two-cell layer and in intimate association in the 
 pupillary membrane which has not entirely disappeared. No trace of vascularization 
 remains. The posterior capsule is missing. No zone of Zinn fibers can be found. 
 
 The vitreous is missing. 
 
 The retina is distinctly behind the rest of the eye in its development. A definite 
 separation of the layers is present, but a differentiation of rods and cones has not yet 
 taken place. Even differentiation of the cones (the first to appear as an entity) 
 cannot be recognized, although the external limiting membrane is developed and in 
 place. Nerve fibers are in the process of development and their presence has swollen 
 the optic nerve head to its usual size. There is much glia in this area. Just anterior 
 to the optic nerve head is a bit of hyaloid artery still visible, although in the process 
 of absorption. 
 
 The optic nerve is fairly well developed although there is more glia than usual in an 
 eye of this size. 
 
 The chorioid is well developed and is fairly well vascularized. 
 
 The sclera is well developed but is rather loose in structure. (Description of speci- 
 men by Dr. Harry S. Gradle, Chicago.) 
 
 Fig. 28. — Embryological section of petrous portion of temporal bone. (Normal 
 size and enlarged 5 diameters). Vertical section through the petrous portion of the 
 temporal bone of a fetus of five and a half months, exposing the cochlea, the cochlear 
 nerve, two semicircular canals and adjacent caseous tissue.
 
 CHARACTERISTICS OF VARIOUS ORGANS 77 
 
 shoulder blades, but also frequently upon the face and upon the 
 
 extensor surfaces of the extremities. There is also noted extensive 
 milium and flaccidityof the auricleand ahe nasi, whose cartilage is 
 not properly developed. 
 
 Icterus is usually more pronounced than at term and erythema 
 is slower to disappear. If hypothermia develops the redness of 
 
 the skin usually fades. 
 
 The absence of subcutaneous fat betrays itself by an angular 
 appearance of the face, the chin is pointed, the head is small and 
 narrow and the wrinkles of the skin impart an oldish appearand e to 
 the face which is especially marked after a few days when the loss 
 of weight has been material and the skin often hangs in folds over 
 the muscles and bones. Not infrequently the skin appears glossy 
 as if on tension and this is seen especially in small prematures in 
 the presence of sclerema and scleredema. Patches of skin may be 
 absent, especially over the heels. 
 
 The hairs on the scalp are short and feebly colored, the'nails are 
 often poorly developed and do not reach the end of the fingers or 
 toes and the nose is covered with small white comedones. The 
 navel is closer to the symphysis than at term. 
 
 Mammary Glands.— The mammary glands are, as a rule, poorly 
 developed, usually not palpable and particularly in the younger 
 prematures do not often attempt to secrete milk. If fluid is present, 
 as it may be in the older prematures, it usually makes its appear- 
 ance about the eighth day, is most abundant up to the fifteenth 
 day and may last until the third month. It is equally common 
 in either sex. In most cases the secretion amounts to only a few 
 drops, but occasionally larger quantities are seen. 
 
 Skeletal Development.— The lack of exact anatomical data as to 
 the skeletal development of the premature infant has caused the 
 author to resort to the use of roentgenographie studies. The 
 stage of ossification of the skeleton of the fetus as observed in 
 roentgenograms is of considerable practical importance in deter- 
 mining the age of the fetus. In addition observation by the roentgen- 
 ographie method is more reliable than determination of age based on 
 length and other measurements, since osseous development is more 
 regular and offers many more factors for consideration. Pathology 
 may often be readily recognized. Our studies thus far have shown 
 that in the early months more accurate determination is possible 
 than in the later months, because many more new centers appear in 
 the first months, and the time of appearance is more constant. 
 
 The study of the roentgenograms for diagnostic purposes discloses 
 that the cephalad segments, including the upper axial skeleton and 
 upper extremities, are far more constant as to time of development 
 of their osseous centers than the caudad segments and those of the
 
 78 
 
 PHYSIOLOGY 
 
 lower extremities. This should be borne in mind in making com- 
 parative studies. 
 
 The figures as to length and other measurements of the fetus 
 have been discussed earlier (p. 29). Basing our facts on the roent- 
 genographic studies of a series of 55 normal cases, whose ages 
 were determined from the history of menstruation and pregnancy 
 and from their measurements, the normal process of development 
 of the human skeleton was found to be as follows: 
 
 Fig. 29. — Development of centers in weeks. Diagram showing osseous develop- 
 ment of infant at full term, and development of ossification centers in weeks. Centers 
 shown which are frequently absent at birth: (1) head of tibia; (2) coccyx. Centers 
 omitted in outline: (1) sternum; (2) hyoid.
 
 CHARACTERISTICS OF VARIOUS ORGANS 
 
 79 
 
 Other Measurements of the Fetus.— Von Winckel regards the 
 
 circumference of the head as of importance for the diagnosis of the 
 age of the fetus and gives the following figures: 
 
 4th month . 
 
 . . 10-14 cm. 
 
 8th month . 
 
 . . 25-30 cm 
 
 5th " . . 
 
 . . 13-18 " 
 
 9th " . . 
 
 . . 29 33 " 
 
 6th " ... 
 
 . . 19-24 " 
 
 10th " . . 
 
 . . 32-37 " 
 
 7th " . . 
 
 . . 23-28 " 
 
 
 
 The weight is entirely unreliable for the estimation of the age of 
 the fetus, because it is subject to too many variations and is much 
 influenced by the mother's general condition, and more especially 
 by her diet. 
 
 Thus, it is seen that even the length, which up to this time has 
 been regarded as the most reliable criterion for the determination of 
 the age of the fetus, has many shortcomings and may result in an 
 error of several weeks. 
 
 The ossification of the human skeleton begins in the upper part 
 of the body and spreads very rapidly in both directions. 
 
 Fig. 31 
 
 Figs. 30 and 31. — Roentgenogram Fig. 30 and diagram P'ig. 31 of fetus at seven weeks, 
 
 actual size. 
 
 Seventh Week. — The first centers of ossification develop in the 
 clavicles in the sixth to seventh week of intra-uterine life (Kreibel- 
 Mall, Rauber-Kopsch 1 ), but they do not become visible in the 
 roentgenograms until in the seventh week. The ossification center 
 appears in the middle of each clavicle and spreads rapidly in both 
 directions. 
 
 Soon after the ossification has started in the clavicle one center 
 appears in each half of the mandible. 
 
 Outside of these centers of ossification usually no other centers, 
 except occasionally that of the maxilla, are visible in roentgenograms 
 of the seven weeks' old fetus. 
 
 1 Lehrbuch der Anatomie des Menschen, Thieme, Leipzig, 1914, 2, ed. 10.
 
 80 PHYSIOLOGY 
 
 Eighth Week.— Osseous development makes rapid progress in the 
 eighth week, and a large number of centers of ossification become 
 visible at this time. 
 
 Figs. 32 and 33. — Roentgenogram Fig. 32 and diagram Fig. 33 of fetus at eight 
 
 weeks, actual size. 
 
 The following bones show centers of ossification demonstrable 
 in roentgenograms. 
 
 Skeleton of the head: The squamous portion of the occipital 
 bone and superior maxilla. In the latter the ossification begins 
 soon after that of the mandible, the center appearing above the 
 region where the alveolus of the incisor tooth is later located. 
 
 TABLE 3.— TIME OF APPEARANCE OF CENTERS OF OSSIFICATION 
 
 HEAD 
 
 Mandible 7th week 
 
 Occipital bone (squamous portion) 8th week 
 
 (lateral and basilar portion) 9th to 10th week 
 
 Superior maxilla 8th week 
 
 Temporal bone (petrous, mastoid and zygoma) 9th week 
 
 Sphenoid (inner lamella of pterygoid process) 9th week 
 
 (great wings) 10th week 
 
 (lesser wings) 13th week 
 
 (anterior body) 13th to 14th week 
 
 Nasal bone 10th week 
 
 Frontal bone 9th to 10th week 
 
 Bony labyrinth . 17th to 20th week 
 
 Milk teeth (rudiments) 17th to 28th week 
 
 Hyoid bone (greater cornua) 29th to 32d week 
 
 Usually no centers of ossification are present in the axial skeleton 
 in this week. 
 
 Shoulder girdle: In the scapula a center of ossification usually 
 appears in the eighth week, sometimes in the ninth week. The 
 center corresponds to the position of the middle of the spine of 
 the scapula.
 
 CHARACTERISTICS OF VARIOUS ORGANS M 
 
 Upper extremity: The humerus is the first bone of the free 
 extremities to show a center of ossification, which appears in the 
 diaphysis early in the eighth week. Radius and ulna follow in 
 the order given, the centers appearing very soon after those of the 
 humerus. 
 
 The ribs begin their ossification in the eighth week, an ossifi- 
 cation center appearing in the region of the angle and extending 
 slowly toward the veretebral column, but rapidly in the opposite 
 direction. The fifth, sixth and seventh ribs, which ossify first, 
 are visible in this period. From this region the process of uni- 
 fication progresses with equal rapidity both cephalad and caudad. 
 The last ribs to ossify are usually the first pair. Shortly before 
 the first pair, the twelfth pair usually ossifies, but this is very 
 irregular and we found it absent in several of our cases in old 
 fetuses although other bones of the body and all the other ribs 
 were very well developed. 
 
 TABLE 4.— TIME OF APPEARANCE OF CENTERS OF OSSIFICATION 
 
 BODY 
 
 Clavicle (diaphysis; 7th week 
 
 Scapula 8th to 9th week 
 
 RIBS. 
 
 Ribs, 5th, 6th, 7th 8th to 9th week 
 
 2d, 3d, 4th, 8th, 9th, 10th, 11th 9th week 
 
 1st 10th week 
 
 12th (very irregular) 10th week 
 
 STERNUM. 
 
 Sternum 21st to 24th week 
 
 UPPER EXTREMITY. 
 
 Humerus (diaphysis) 8th week 
 
 Radius (diaphysis) s 'h week 
 
 Ulna (diaphysis) 8th week 
 
 Phalanges, terminal 9th week- 
 basal, 3d and 2d 9th week 
 
 basal, 4th and 1st 10th week 
 
 basal, 5th 11th to 12th week 
 
 middle 3d, 4th, 2d 12th week 
 
 middle 5th 13th to 16th week; 
 
 Metacarpals, 2d and 3d 9th week 
 
 4th, 5th, 1st 10th to 12th week 
 
 Lower extremity: Centers of ossification may be occasionally 
 seen in the diaphyses of the femur, but usually they become visible 
 in the ninth week. The femur is the first to show a center, the 
 tibia starting in its ossification a little later, and the fibula following 
 very soon after the tibia. 
 
 Ninth If >f A-.— Portions of the hand and of the foot enter the 
 stage of ossification, these being the most important new develop- 
 ments in this week. 
 6
 
 82 PHYSIOLOGY 
 
 The following additional centers of ossification are visible in the 
 head: Inner lamella of the pterygoid process of sphenoid and 
 mastoid portions of the temporal bone. The zygomatic process of 
 the temporal bone begins to cast a shadow, its shape being some- 
 what pointed anteriorly and somewhat convex externally, thus 
 resembling a needle. Bony trabecular are often seen in the poste- 
 rior root of the mastoid process. The superior maxilla forms at 
 this time a simple triangular plate, the base of which is parallel 
 to the margin of the maxilla, the apex pointing toward the root of 
 the nose. The malar bone may become visible toward the end of 
 this week or during the next week. 
 
 TABLE 5.— TIME OF APPEARANCE OF CENTERS OF OSSIFICATION 
 
 VERTEBRA 
 
 Arches, all cervical and upper 1 or 2 dorsal 9th week 
 
 all dorsal and 1 or 2 lumbar 10th week 
 
 lower lumbar 11th week 
 
 upper sacral 12th week 
 
 4th sacral 19th to 25th week 
 
 Bodies from 2d dorsal to last lumbar 10th week 
 
 from lower cervical to upper sacral 11th week 
 
 from upper cervical to lower sacral 12th week 
 
 5th sacral 13th to 28th week 
 
 1st coccygeal 37th to 40th week 
 
 structural arrangement 13th to 16th week 
 
 odontoid process of axis 17th to 20th week 
 
 Costal processes, 6th and 7th cervical 21st to 33d week 
 
 5th cervical 33d to 36th week 
 
 4th, 3d, 2d cervical 37th to 40th week 
 
 Transverse processes, cervical and dorsal 21st to 24th week 
 
 lumbar 25th to 28th week 
 
 Axial skeleton: Arches of all the cervical and upper one or two 
 dorsal vertebrae show centers of ossification, usually no centers for 
 bodies being visible. One center develops in each arch, the process 
 beginning in the first cervical vertebra and proceeding caudally. 
 
 Shoulder girdle: The acromion process of the scapula begins to 
 ossify in this week. The first formations of these centers are diffi- 
 cult to study in roentgenograms on account of their small size, 
 but the later stages can be easily demonstrated. Development of 
 the centers of ossification in terminal phalanges is followed by the 
 appearance of centers in the metacarpals which become visible in 
 the ninth to tenth week. The following is the order of ossification 
 in the metacarpals: second, third, fourth, fifth, first, of which the 
 second and the third are usually visible in the ninth week. 
 
 Ribs: All the ribs, except the first and the twelfth cast shadows. 
 
 Pelvic girdle : The ilium usually appears in this week, rarely at the 
 end of the eighth week. Ossification begins in the region of the 
 greater sacrosciatic foramen and near the acetabulum.
 
 CHARACTERISTICS OF VARIOUS ORGANS 83 
 
 Lower extremity: Centers of ossification in femur, tibia and 
 fibula are seen. Centers begin to develop in the phalanges, the 
 first one being a center for the diaphysis of the terminal phalanx 
 of the big toe. Diaphyses of the metatarsals follow in the same 
 sequence and almost at the same time as corresponding portions of 
 the hand, but with far less regularity. 
 
 TABLE (). — TIME OF APPEARANCE OF CENTERS OF OSSIFICATION 
 
 PELVIC GIRDLES. 
 
 Ilium 9th week 
 
 Ischium (descending ramus) 16th to 17th week 
 
 Os pubis (horizontal ramus) 21st to 28th week 
 
 LOWER EXTREMITY. 
 
 Femur (diaphysis) 8th to 9th week 
 
 (distal epiphysis) 35th to 40th week 
 
 Tibia (diaphysis) 8th to 9th week 
 
 (proximal epiphysis) 40th week 
 
 Fibula 9th week 
 
 Os calcis 21st to 29th week 
 
 Astragalus 24th to 32d week 
 
 Cuboid 40th week 
 
 Metatarsal, 2d and 3d 9th week 
 
 4th, 5th and 1st 10th to 12th week 
 
 Phalanges, terminal 1st 9th week 
 
 terminal 2d, 3d, 4th 10th to 12th week 
 
 terminal 5th 13th to 14th week 
 
 basal 1st, 2d, 3d, 4th, 5th 13th to 14th week 
 
 middle 2d 20th to 25th week 
 
 middle 3d 21st to 26th week 
 
 middle 4th 29th to 32d week 
 
 middle 5th 33d to 36th week 
 
 Tenth Week.— Comparatively few new centers of ossification are 
 added in this week. 
 
 Skeleton of the head: Xasal bone and frontal bone show centers 
 of ossification. The great wing of the sphenoid becomes visible. 
 
 Axial skeleton: Bodies of the vertebrae begin to cast shadows. 
 The process starts in the bodies of the lower dorsal vertebra?, pro- 
 gressing from this region with unequal rapidity in both directions. 
 Usually the lower ten dorsal and all the lumbar vertebra* show 
 centers of ossification in their bodies in this week. The process of 
 ossification of the arches, progressing downward, has become more 
 or less advanced in all the thoracic vertebra 3 , invading occasionally 
 the upper lumbar region. 
 
 Shoulder girdle: Ossification of the scapula spreads to the 
 supraspinous fossa. 
 
 Upper extremity: Diaphyses of basal phalanges of fingers develop 
 centers of ossification, the following being the sequence: third, 
 second, fourth, first and fifth. Of these, usually the third, only, 
 shows a center in this week.
 
 84 
 
 PHYSIOLOGY 
 
 Ribs: At this time ossification, as a rule, is seen in all the ribs, 
 the twelfth behaving very irregularly. It was found absent in 
 some comparatively old fetuses far beyond the tenth week. 
 
 Lower extremity : Beginning with this week centers of ossification 
 are present also in the terminal phalanges of the second and of the 
 third toes. 
 
 Fig. 34 
 
 Fig. 35 
 
 Figs. 34 and 35. — Roentgenogram Fig. 34 and diagram Fig. 35 of fetus at ten weeks, 
 
 actual size. 
 
 Eleventh to Twelfth Week.— In this period almost as many centers 
 of ossification are present in the fetal skeleton as at the time of 
 birth, so that but few are added during the period of development 
 following the third month, and further changes in the fetal skeleton 
 consist mostly of growth of the centers of ossification, of their fusion 
 and of the formation of the internal structure of the bones. A 
 fine, somewhat irregular, medullary cavity forms in the long bones, 
 usually being seen first in the tibia. 
 
 Skeleton of the head : The tympanic ring usually becomes visible 
 in this week, rarely at the end of the eleventh week. In pictures 
 taken from the side, its shadow lies between the angle of the man- 
 dible and the basilar portion of the occipital bone. The median 
 lamella of the pterygoid process reaches considerable size and is 
 visible as a hook-shaped, curved plate with concavity posteriorly, 
 lying behind the lower portion of the perpendicular part of the 
 palate bone. The malar bone joins the end of the zygomatic 
 process of the superior maxilla and that of the temporal bone.
 
 CHARACTERISTICS OF VARIOUS ORGANS 85 
 
 Four centers are now present in the occipital bone. The anterior 
 sphenoidal body begins to ossify. 
 
 Axial skeleton: Ossification of the arches invades the lower lum- 
 bar region. The ossification of the bodies now appears in the lower 
 cervical region and in the upper part of the sacrum, the inter- 
 mediary bodies having been visible previously. There are, how- 
 ever, considerable variations in the time of appearance of centers 
 of ossification in the sacral vertebra?. 
 
 Shoulder girdle: Xo new centers develop, the old ones increasing 
 in size. 
 
 Upper extremity: The diaphyses of all the basal phalanges cast 
 shadows. Middle phalanges of the third, fourth and occasionally 
 of the second finger develop centers of ossification in their diaph- 
 yses. The middle phalanx of the fifth finger ossifies much later. 
 
 Fig. 36. — Photograph (a) and roentgenogram (b) of transparent specimens of fetus 
 at ten weeks. One-half actual size. 
 
 Up to the end of the third month the bony diaphyses of the humerus, 
 radius and ulna remain longer and thicker than the corresponding 
 bones of the lower extremity. 
 
 Pelvic girdle : Either in this period or shortly after, a third center 
 of ossification develops in the ilium, being situated ventrally from 
 the fused first and second centers. There is a marked irregularity 
 in the time of appearance of the third center of the ilium, since 
 occasionally it may appear almost three weeks after this time. 
 
 Lower extremity: The terminal phalanges of the fourth and 
 fifth toes usually develop centers of ossification; in the fifth, how- 
 ever, the center may occasionally appear as late as in the thirteenth 
 week. The bony diaphysis of the femur, which up to this time has 
 been shorter and thinner than the bony diaphysis of the humerus, 
 has almost reached the length of the latter, remaining, however, 
 still somewhat thinner.
 
 Fig. 37 
 
 Fie. 3S 
 
 Figs. 37 and 38.— Roentgenogram Fig. 37 and diagram Fig. 38 of fetus at eleven to 
 
 twelve weeks, actual size.
 
 CHARACTERISTICS OP VARIOUS ORGANS 
 
 87 
 
 Thirteenth to Sixteenth Week.— Characteristic in the osseous 
 development of this period is the appearance of structural arrange- 
 ment in the bodies of some vertebrae and the presence of centers 
 of ossification in the diaphyses of all of the long bones of the hand 
 and of the foot, except the middle phalanges of toes. 
 
 Skeleton of the head: The lesser wing of the sphenoid is visible 
 at the beginning of this period. The posterior body of the sphenoid 
 appears about the fourteenth week. 
 
 Fig. 39 
 
 Fig. 40 
 
 Figs. 39 and 40. — Roentgenogram Fig. 39 and diagram Fig. 40 of fetus at thirteen to 
 sixteen weeks, one-half actual size. 
 
 Axial skeleton: At the end of this period all the vertebra', with 
 the exception of first and second lower sacral and the coccygeal, 
 have at least one center of ossification. Arches are ossified also 
 in the upper sacral region and the bodies from the upper cervical 
 down to the lower sacral region. Structural arrangement becomes 
 visible in the bodies of some vertebrae. Upper and lower plate, 
 casting denser shadow, become differentiated. A zone of lighter 
 shadow is seen between these two plates and in the central portion
 
 ss 
 
 PHYSIOLOGY 
 
 of the body a flat, darker shadow appears. The greatest diameter 
 of this darker shadow corresponds to the longitudinal axis of the 
 fetus in lumbar and lower dorsal vertebra?; in other dorsal vertebrae 
 it lies horizontally. These shadows appear in the bodies of the 
 vertebrae in the region in which the primary centers made their 
 first appearance. 
 
 Upper extremity: In the fifteenth to sixteenth week a center of 
 ossification appears in the diaphysis of the middle phalanx of the 
 fifth finger, so that at this time the diaphyses of all the long bones 
 of the hand possess centers of ossification. 
 
 Pelvic girdle: At the end of this period or somewhat later a 
 center becomes visible in the descending ramus of the ischium. 
 Instead of one center, two separate centers may develop in this 
 portion of the innominate bone and they may remain separate for 
 a long time afterward. 
 
 Fig. 41.- 
 
 - Roentgenograms of skull showing ossification centers at (a) eleven to 
 twelve weeks and (b) thirteen to sixteen weeks, actual size. 
 
 Lower extremity: In the thirteenth week a center of ossifica- 
 tion develops in the diaphysis of the terminal phalanx of the fifth 
 toe, if it did not appear earlier. In the fourteenth Meek ossifica- 
 tion in the basal phalanges begins, first in the big toe, and proceeds 
 toward the fibular side in other toes, and at the end of this period 
 it usually reaches the last toe. 
 
 Seventeenth to Twentieth Week.— In this period the bony labyrinth 
 first appears and bone tissue begins to be formed in the rudiments 
 of the milk teeth. 
 
 Skeleton of the head: Several new centers of ossification appear 
 in the petrous portion of the temporal bone, but they do not show
 
 CHARACTERISTICS OF VARIOUS ORGANS 89 
 
 well in roentgenograms. The bony labyrinth begins its development. 
 In the rudiments of milk teeth, bone tissue begins to be formed 
 and casts a shadow. The process starts in the lower incisors. 
 
 Axial skeleton: A center of ossification appears in the odontoid 
 process of the axis. The darker shadows in the bodies of the 
 vertebrae become more distinct and external formation and internal 
 structure of osseous bodies of vertebra 1 become visible in roentgeno- 
 grams. Ossification of the arches may reach the fourth sacral 
 
 Fig. 42.— Photomicrograph of cross section of arm of twenty-two weeks :• 
 Enlarged 6 diameters. Small figure actual size. 
 
 vertebra at the end of this period, although this frequently occurs 
 later. 
 
 Pelvic girdle: The twentieth week is the earliest time of appear- 
 ance of a center in the horizontal ramus of the pubic bone; this, 
 however, varies between the twentieth and the twenty-eighth week. 
 The center is located near the margin of the obturator foramen, 
 two centers developing occasionally. 
 
 Lower extremity: In the twentieth week a center of ossification
 
 90 
 
 PHYSIOLOGY 
 
 may develop in the middle phalanx of the second toe, but this 
 usually occurs in the twenty-first to the twenty-fourth week and 
 frequently even later than this. On the whole, there are marked 
 differences and also individual variations in the time of appear- 
 ance of centers of ossification, and also in the sequence of ossi- 
 fication in the phalanges of toes, especially in the basal phalanges 
 and even more so in the middle phalanges. In the hand, however, 
 
 Fig. 43.— Photograph of cross-section of forearm of twenty-two weeks fetus. 
 Enlarged 6 diameters. Small figure actual size. 
 
 the sequence of ossification in the phalanges is far more constant 
 and the time of appearance of the centers is much less changeable 
 than that of the centers in the phalanges of toes. 
 
 Twenty-first to Twenty-fourth Week. — In this period ossifica- 
 tion usually starts in the tarsus, os calcis being the first to show 
 a center of ossification. The sternum begins to develop by several 
 centers of ossification, but there are considerable variations in the
 
 CHARACTERISTICS OF VARIOUS ORGANS 
 
 01 
 
 arrangement and size of these centers and also in the time of their 
 appearance. 
 
 Skeleton of the head: The superior maxilla shows a large amount 
 of spongiosa. Toward the twenty-fourth week the alveolar por- 
 tion of the superior maxilla begins to overhang the level of the 
 palatal plate, but develops as a real process only during the cutting 
 of the teeth. 
 
 Axial skeleton : The costal process of the sixth cervical vertebra 
 starts in its ossification. Shadows of transverse processes are seen 
 in vertebra 3 down to the twelfth dorsal. 
 
 Fig. 44 
 
 Fig. 45 
 
 Figs. 44 and 45. — Roentgenogram Fig. 44 and diagram Fig. 45 of fetus at seventeen 
 to twenty weeks, one-third actual size. 
 
 Upper extremity: In this period the ossified portion of the 
 diaphysis of the humerus reaches the articular ends and begins to 
 overlap these so that at the distal end of the humerus both fossae 
 (olecranon and cubital) and ulna and olecranon become visible, 
 and later, on the proximal end of the humerus an indication of 
 medial and posterior portion of the neck appears. 
 
 The sternum begins its ossification. Usually one center forms 
 in the manubrium first and this is followed soon afterward by
 
 92 
 
 PHYSIOLOGY 
 
 several centers in the body of the sternum. The centers form a 
 longitudinal row first, and soon they assume a round or elliptical 
 form. Not seldom the first centers of ossification appear in the 
 upper part of the body between the second and the third costal 
 cartilages. The position of the ossification centers of the sternum 
 corresponds usually to the level of the intercostal spaces. 
 
 
 IV 
 
 
 ^r 
 
 a 
 
 > * 
 
 Fi<;. 40 Fig: 47 
 
 Figs. 46 and 47. — Roentgenogram Fig. 46 and diagram Fig. 47 of fetus at twenty-five 
 to twenty-eight weeks, one-fourth actual size. 
 
 Lower extremity: A center of ossification develops in os calcis, 
 its appearance being occasionally delayed by from four to eight 
 weeks. Sometimes it is followed by the appearance of a center in 
 the astragalus. The middle phalanx of the second toe, and occa- 
 sionally that of the third toe, acquire a center of ossification in 
 their diaphyses. 
 
 Tiventy-fifth to Twenty-eighth Week.— The rudiments of all the 
 milk teeth have entered the stage of ossification in this month.
 
 CHARACTERISTICS OF VARIOUS ORGANS 
 
 03
 
 Fig. 49 
 
 Fig. 50 
 Figs. 49 and 50. — Roentgenogram Fig. 49 and diagram Fig. 50 of fetus at twenty- 
 nine to thirty-two weeks, one-fourth actual size.
 
 Fig. 51 
 
 Fig. 52 
 Figs. 51 and 52.— Roentgenogram Fig. 51 and diagram Fig. 52 of fetus at thirty- 
 three to thirty-six weeks. Roentgenogram one-fourth actual size. Diagram some- 
 what less.
 
 96 PHYSIOLOGY 
 
 The development of the transverse processes of the vertebra? 
 progresses down to the last lumbar vertebra. At the end of this 
 period a center of ossification may develop in the lateral masses 
 of the first and of the second sacral vertebrae. The body of the 
 fifth and the arches of the fourth sacral vertebra? become ossified 
 at this time, rarely earlier. 
 
 A center of ossification develops in the astragalus. 
 
 In the horizontal ramus of the pubic bone the center may develop 
 as late as in this period. 
 
 Twenty-ninth to Thirty-second Week.— The greater cornua of 
 the hyoid bone usually become visible, appearing as cone-shaped 
 processes directed obliquely upward at the level of the second 
 cervical vertebra. 
 
 The lateral masses of the first and second sacral vertebrae ossify 
 usually at this time. 
 
 In the sternum three or more large centers of ossification are 
 visible. 
 
 The middle phalanx of the fourth toe frequently begins its 
 ossification during the period. 
 
 Thirty-third to Thirty-sixth Week.— This period is the earliest 
 time at which the first epiphyseal center may appear, that of the 
 distal epiphysis of the femur. Usually, however, this center 
 appears later, at about the time of birth. 
 
 The costal process of the sixth and of the fifth cervical vertebra? 
 begin their ossification. 
 
 Thirty-seventh to Fortieth Week.— The middle turbinates ossify at 
 the end of the fetal period and shortly before birth the rudiments 
 of the first permanent molar teeth begin to ossify. 
 
 The costal process begins to ossify in the fourth, the third and 
 the second cervical vertebra?; the first coccygeal vertebra usually 
 ossifies during the last weeks before birth and vertical arrangement 
 of trabecular becomes visible in the bodies of the vertebra?. 
 
 A center of ossification appears in the proximal epiphysis of the 
 tibia just before birth in a majority of cases, and ossification in the 
 cuboid frequently starts before birth, usually by several centers, 
 although in some cases it may not be visible even in the new born. 
 
 The Neiv Born.— A center of ossification in the distal epiphysis 
 of the femur is so frequent in the new born that Lambertz calls 
 it a sign of maturity. This is frequently the only epiphyseal 
 center present in the new born. Poirier 1 gives a summary of the 
 literature on the time of the appearance of the epiphysis at the 
 distal end of the femur. Schwegel found it to appear between 
 birth and the third year. Casper in the ninth fetal month, Hart- 
 
 1 Traite d'anatomie, 1, 227,
 
 CHARACTERISTICS OF VARIOUS ORGANS 
 
 97 
 
 maun found it lacking in 12 per cent of cases at birth and in 7 per 
 cent of cases present as early as the eighth fetal month. 
 
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 g x 
 
 55 ™ 
 
 'to *L 
 
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 98 PHYSIOLOGY 
 
 The four parts of the occipital bone (basilar, two lateral and 
 the squamous) are separated from each other by thin layers of 
 cartilage. The mastoid portion of the temporal bone is not ossified 
 in its entire extent, a serrated line marking the boundary between 
 bony and cartilaginous portions of the mastoid part. The lateral 
 halves of the frontal bone are separated. The body of the hyoid 
 bone is usually ossified. Both halves of the mandible, as a rule, 
 are united by connective tissue. 
 
 The vertebrae are ossified in all their essential parts, including 
 transverse and articular processes of the arches, but the centers of 
 ossification are separated from each other by cartilage. The first 
 coccygeal vertebra is usually ossified by this time. 
 
 In some cases the proximal epiphysis of the humerus is ossi- 
 fied. In the hand all bones are ossified except the carpus, in 
 which centers of ossification in os magnum and unciform may be 
 seen only very rarely. 
 
 At birth the ossified portion of the os pubis surrounds usually a 
 portion of the anterior boundary of the obturator foramen, but 
 the region of the symphysis and upper margin of the horizontal 
 ramus of os pubis remain cartilaginous. The following portions of 
 the innominate bone are not ossified in the new born: The crest 
 of the ilium with superior spines, acetabulum, spine of ischium and 
 ascending ramus of ischium. 
 
 The middle phalanx of the fourth toe is frequently, that of the 
 fifth toe always, cartilaginous in the new born; in the fourth toe, 
 however, the middle phalanx may start in its ossification in the 
 eighth fetal month. The following portions of the leg are usually 
 not ossified in the new born: Proximal epiphysis of tibia and of 
 the fibula, epiphyses of metatarsal bones and of phalanges, the 
 cuboid and the three cuneiform bones. 
 
 Other Methods of Studying Osseous Development Compared.— We 
 have compared the process of ossification, as observed in the 
 roentgenograms of the fetuses studied with the roentgenographic 
 studies of Alexander, 1 Bade, 2 Hasselwander 3 and Lambertz, and 
 found that the time of appearance of centers of ossification pretty 
 well agrees, in general, there being minor differences only. 
 
 Compared with the studies of Mall, who used transparent speci- 
 mens of embryos and fetuses for observing the appearance of 
 centers of ossification, we find that by the use of these specimens 
 he was able to demonstrate the minute centers of ossification gen- 
 
 1 The Development of the Osseous Vertebral Column, Fortschr. a. d. Geb. d. 
 Rontgenstrahlen, Suppl. 13. 
 
 2 Short Description of Ten Roentgenologically Examined Fetuses, Centralbl. f. 
 Gynak., 1899, p. 1031. 
 
 3 Studies of Ossification of the Skeleton of the Human Foot, Ztschr. f. Morphol. u, 
 Anthropol., 1903, 5, 438,
 
 CHARACTERISTICS OF VARIOUS ORGANS 99 
 
 erally about one week earlier than they are demonstrable by roent- 
 genograms. This observation also agrees with text-books of 
 anatomy (Rauber-Kopsch, Gray 1 ) which have been consulted for 
 this purpose, and it is found that they place the time of appearance 
 of various centers about one week ahead of the time at which the 
 centers cast shadows large enough to be visible in roentgenograms. 
 By courtesy of Dr. Roy Lee Moodie, of the Department of 
 Anatomy of the University of Illinois, we obtained transparent 
 specimens of a pair of twins from his embryologic collection and 
 made roentgenograms of them. By studying these roentgenograms 
 and specimens (Fig. 36) we found the following differences: 
 
 Roentgenograms Transparent specimens 
 
 Basal phalanges of fingers 3d 2d, 3d, 4th 
 
 Terminal phalanges of toes . 1st, 2d, 3d . . . 1st, 2d, 3d, 4th 
 Bodies of vertebrae .... 9 lower dorsal . . 9 to 10 lower dorsal, respec- 
 
 tively 
 All lumbar . . . All lumbar 
 1st sacral . . . 1st, 2d sacral 
 Bodies of vertebrae .... Upper 3 lumbar . Upper 3 to all lumbar, 
 
 respectively 
 
 Thus the transparent specimens show in the tenth week centers 
 that become visible in the roentgenogram only in the eleventh to 
 twelfth week. 
 
 Variations in Osseous Development.— There are, as might be 
 expected, some variations in the normal process of ossification, 
 and it is also influenced by pathological conditions of the mother 
 and of the fetus (for example, syphilis, rickets, osteogenesis imper- 
 fecta, etc.). In general, these pathological processes may well be 
 diagnosed in the roentgenograms so that an error may easily be 
 prevented. In some portions of the skeleton the ossification is 
 less regular than in others, and as a general rule the more caudad 
 the portions of the skeleton are, the more they are subject t<> 
 variations in the process of ossification; and the centers which 
 develop at a later period of fetal life are also more variable. Thus, 
 there are considerable variations in the time of appearance of 
 centers of ossification in the sacral vertebra 1 . The foot, as a 
 general rule, is unreliable as an indicator of the age of the fetus. 
 The ossification of the sternum is also irregular in the time of 
 appearance, size and arrangement of the centers of ossification. 
 The twelfth rib is also very irregular, and we found it absent in 
 roentgenograms of the fetus from the thirteenth to sixteenth week, 
 and also in some other older ones, although, as a rule, the twelfth 
 rib appears in the tenth or in the eleventh week. Some of the 
 
 1 Anatomy, Descriptive and Applied, Ed. 18, Lea. A: Febiger, Philadelphia ami 
 New York, 1910,
 
 100 PHYSIOLOGY 
 
 centers, although demonstrable by careful examination, are so 
 small as to be easily overlooked, and this may lead to an error. 
 For this reason it is necessary to know what centers we may expect 
 at that particular age of the fetus, and we should look for them in 
 good light with a magnifying glass. 
 
 Bade has examined roentgenograms of twin fetuses, one of which 
 was 5.8 cm. long, weighing 8 gm., and the other 6.3 cm. long, 
 weighing 11 gm. The only difference in the stage of ossification 
 was that the larger fetus showed two more centers in the arches 
 of the vertebrae and two additional centers in terminal phalanges 
 of the fingers. 
 
 In the twins from Dr. Moodie's collection, which we have studied, 
 the only differences in the stage of ossification are in the axial 
 skeleton, one fetus showing centers for seventeen bodies and 
 twenty-four arches on each side and the other only fifteen bodies 
 and twenty-two arches on each side. 
 
 The process of ossification is more constant for a particular age 
 than the length of the fetus. Mall, 1 in his article on ossification 
 in embryos up to one hundred days old, concludes that " the remark- 
 able regularity of the appearance of the bones makes of them the 
 best index of the size and of the age of embryo we now possess." 
 
 Limitations of Accuracy. — In the first half of pregnancy the esti- 
 mation of the age of the fetus may be made with greater accuracy 
 because many more new centers appear in the first months, and 
 also because the time of appearance of the earlier centers is more 
 constant. In later months most centers in the lower part of the 
 skeleton are available for study, although these are less constant 
 in the time of their appearance. We have intentionally made our 
 groupings broad enough to cover minor errors in diagnosis, but more 
 careful subsequent studies may refine the diagnosis to such a degree 
 that determination of age will be possible within the period of one 
 week in the first half of the pregnancy, and within two weeks in the 
 second half of the pregnancy. 
 
 Different Values of the Different Portions of the Body.— In the very 
 early period (second month) the stage of ossification of clavicle 
 and mandible is of chief importance, and on the basis of presence 
 or absence of these centers determination of the age is made. 
 Both roentgenograms and transparent specimens show that the 
 time of appearance of these centers is almost constant, which 
 makes them of cardinal value in diagnosis. 
 
 Next in importance are the centers of the upper extremity, and 
 especially of the hand (metacarpals and phalanges) which are very 
 regular, not only in the time of their appearance, but also in their 
 
 1 On Ossification Centers in Human Embryos Less Than One Hundred Days Old, 
 Am. Jour. Anat., 1906, 5, 433-
 
 CHARACTERISTICS OF VA RIO US ORG, 1 MS 101 
 
 sequence. The ossification of the diaphysis of the long bones of 
 the arms extends from the eighth to the sixteenth week, and (luring 
 this period the determination of the age may frequently he made 
 from a good roentgenogram of the hand alone. 
 
 The progress of ossification of the head is also of considerable 
 diagnostic importance, but the centers in many bones of the head 
 are very difficult of demonstration. Those, however, that can 
 he well demonstrated are of much value in the determination 
 of the age. This is especially true of the occipital bone, superior 
 maxilla, tympanic ring, nasal bone and hyoid bone. 
 
 The axial skeleton (the vertebral column) is less reliable than 
 the foregoing named portions of the skeleton, and especially its 
 lower portion is of little value in diagnosis of age. It is not the 
 absolute number of arches or of the bodies ossified which decides 
 the diagnosis as to the age of the fetus, but more the region involved 
 and the extent of the development in the particular region of the 
 vertebral column (cervical, dorsal, lumbar, sacral). On the other 
 hand, however, the facts that the process of ossification of the 
 vertebral column extends from the ninth week throughout the life 
 of the fetus, and all its centers, as a rule, are well demonstrable, 
 make it of special value for at least approximate determination, 
 although it must not be forgotten that occasionally the process 
 of ossification may be delayed in the vertebral column, while it is 
 normal and regular in other portions of the body. 
 
 The sternum is unreliable as an index of age and its centers are 
 frequently difficult to demonstrate. The ribs are fairly constant, 
 except the twelfth pair, which, as previously mentioned, may not 
 show at all in roentgenograms of comparatively old fetuses. 
 
 While the ossifications of the long bones of the legs are pretty 
 regular, since they appear at an early period, ossification in the 
 foot is very irregular and the stage of ossification of the foot is 
 of little value in the determination of the age of the fetus. The 
 osseous development of the foot extends from the ninth week 
 to the end of the fetal period (not being, however, completed even 
 at this time) and during this time there are very marked variations, 
 especially in the centers which appear late in the fetal period. 
 
 From the above it may be seen that, as a general rule, the earlier 
 a center appears the more regular it is, and since the process of 
 ossification starts in the cephalic region and spreads caudally, it is 
 also true that the more caudad a skeletal segment is situated the 
 more it is subject to variations and irregularities. 
 
 Advantages of the Roentgenographic Method.— The peculiar advan- 
 tage of the roentgenographic method for determining the age of 
 the fetus lies in the fact that while in the determination of age 
 according to the length we base our final conclusions usually on
 
 102 PHYSIOLOGY 
 
 one, rarely on two or three measurements expressing different 
 lengths of the fetus, in the roentgenographic method many centers 
 of ossification are the factors taken into consideration before 
 arriving at a final conclusion; and they act as check on each other 
 and quite frequently the roentgenograms alone give us information 
 as to whether the fetus is normal or not, a point which seldom may 
 be determined from measurements alone. 
 
 Technic. — In studying the roentgenograms it is well to use a 
 reading glass of about four inches in diameter, since some centers 
 of ossification may be so small as to be very easily overlooked when 
 sought for with the naked eye. 
 
 If only one exposure of the fetus is made then the best position 
 to show as many ossification centers as possible is as follows: The 
 back lying flat on the plate, head turned completely to one side so 
 that the side of the head lies on the plate and lateral exposure is 
 obtained. (It should be remembered in the study of the skull that 
 both halves of the skull are usually visible.) Arms and fingers 
 should be extended and fingers spread as far as possible from one 
 another. One hand should be pronated and the other supinated, 
 the lateral exposure, which is often of so much value in roentgeno- 
 grams taken for the purpose of surgical diagnosis, not being of 
 much value, since in this position shadows of phalanges of fingers 
 and of metacarpals are superimposed and cannot be well differen- 
 tiated. The legs should also be extended and feet put into such a 
 position that all metatarsals and phalanges are shown.
 
 CHAPTER IV. 
 PATHOLOGICAL FINDINGS IN PREMATURES. 
 
 Vert little careful work has been done with reference to the 
 pathological changes in the premature infant. The discussion 
 which follows is a summary, largely taken from the recent excellent 
 work of Arvo Ylppo. 1 
 
 Premature infants must be classified into two groups: Those 
 that are born "weaklings" owing to congenital deformities or 
 malformations, congenital diseases, especially lues, and the con- 
 genital weaklings born of nephritic, eclamptic or tuberculous 
 mothers, or those suffering from chronic toxemia. In the second 
 group are those fully developed and normal for their fetal age. 
 
 One is often amazed at the life energy of these prematures, in 
 view of the high grade pathological changes in the various organs, 
 especially the hemorrhages into the brain and spinal cord. 
 
 Premature birth should be considered a traumatic process, in 
 which the characteristic pathological processes are most frequently 
 noted in three groups of organs, for which there appears to be a 
 predilection : 
 
 1. The skull with the brain and its membranes, inclusive of the 
 spinal cord. 
 
 2. The lungs. 
 
 3. The gastro-intestinal canal. 
 
 Intracranial hemorrhages are especially important. Ylppo 
 believes that they are responsible for 30 per cent of the deaths of 
 prematures in the early days of life. In the skull there are sub- 
 arachnoidal or intrapial hemorrhages, while in the spinal column 
 they are extradural. 
 
 The so-termed subdural hemorrhages and those from tears of the 
 tentorium, which are present in full-term infants, are only excep- 
 tionally seen in prematures. 
 
 Ventricular hemorrhages are frequently found in prematures, but 
 hemorrhage into the brain substance proper is quite rare. High- 
 grade edema of the pia is, as a rule, also present along with these 
 intracranial hemorrhages. Bacteria easily settle in the injured 
 brain membranes and meningitic processes are not uncommon. 
 
 1 Arvo Ylppo, Ztschr. f. Kindeih., xx, 212, 1919.
 
 104 PATHOLOGICAL FINDINGS IN PREMATURES 
 
 In the later life of the premature the appearance of spastic 
 states (Little) and of disturbances in intelligence are often seen 
 and are explained as a rule, undoubtedly, as a consequence of old 
 hemorrhages into the brain and spinal cord. 
 
 The condition spoken of in the literature as hydrocephalus of 
 the premature, has, as a rule, nothing to do with hydrocephalus. 
 The brain represents one-fourth of the body weight and appears 
 normal macroscopically and developmentally. Ylppo suggests the 
 term "megacephalus." This megacephalus is due to the fact that 
 the brain develops at practically the normal rate, while the growth 
 of the body is retarded. 
 
 Hemorrhages into the lungs appear not only under the pleura, 
 but are scattered through the entire parenchyma. The alveolar 
 septums are thickened because of the extravasations of blood. 
 The normal circulation in the lung is hindered and in the extra- 
 uterine life there appears a stasis, which hinders the taking up of 
 air and predisposes secondarily to atelectasis. Following stasis 
 and bacterial changes, there may appear in the lungs of prematures 
 a high grade, almost total, inhibition of the circulation of the blood. 
 
 Inflammatory changes in the lungs or bronchi appear infrequently 
 and atypically in the first days of life. Bronchopneumonia, after 
 the second week of life, begins to play an important part in causing 
 death. 
 
 Epicardial hemorrhages are of common occurrence. They appear 
 just as do the subpleural hemorrhages and those in all the other 
 organs. 
 
 Subcapsular liver hemorrhages are on a par with other sub- 
 serous hemorrhages. They are important only insofar as they 
 may be extensive, and with rupture of the capsule may result 
 in hemorrhage into the peritoneal cavity with death. 
 
 Hemorrhages into the kidney are frequent. They have two pre- 
 dilections: In the interstices of the apices of the pyramids, or in 
 the neighborhood of the venae et arteriae arciformes. Hemor- 
 rhages into the Malpighian bodies and cortex are rare. Infarcts 
 appear in the same sites as the hemorrhages. 
 
 The hemorrhages of the digestive tract are next in importance 
 to those of the brain. In small prematures, dying shortly after 
 birth, one often finds hemorrhages scattered through the entire tract. 
 The areas of predilection are: The lower portion of the esophagus, 
 the cardia and fundus of the stomach, the mucous membrane 
 folds in the corpus ventriculi, the duodenal margin of the pylorus, 
 and the entire duodenal mucosa. In the deeper portions of the 
 intestines, hemorrhages occur infrequently about the ileo-cecal valve 
 and in the mucosa of the large bowel. These hemorrhages appear 
 chiefly under the epithelial cells in the tunica propria. Blood often
 
 PATHOLOGICAL FINDINGS IN PREMATURES 105 
 
 appears in the bowel lumen after rupture of the mucosa. These 
 hemorrhages in extra-uterine life arc important only insofar as 
 they predispose to infection, which readily occurs. As a result, 
 within one and a half days prematures may show a marked mucous 
 membrane necrosis and peritonitis. 
 
 Inflammatory processes within the digestive tract, especially in 
 the esophagus and duodenal mucosa are also common. From the 
 inflamed intestinal mucosa, bacteria easily invade the blood, with a 
 following general sepsis. 
 
 The mucosa of the stomach is frequently involved in the septic 
 processes of the prematurely born, especially in their early days 
 of life. Involvement of the stomach is often followed by peritonitis 
 and by Bacillus coli septicemia. 
 
 The histopathological inflammatory processes, due to bacteria, 
 appear atypically in prematures. This is associated with a very 
 ineffective exudation of fibrin and scanty mobilization of leuco- 
 cytes. Because of these factors general sepsis in all infections 
 appears easily. 
 
 The hemorrhages are due to diapedesis, rhexis, or both, and vary 
 with the intensity and duration of stasis and the grade of the infec- 
 tions—toxic damage to the capillary walls. 
 
 The preceding summary of the pathological changes in the 
 premature has been concerned chiefly with the question of hemor- 
 rhage. (Specific pathology will be discussed later under the 
 "Diseases of the Prematurely Born.")
 
 PART II. 
 NURSING AND FEEDING CARE. 
 
 CHAPTER V. 
 MATERNAL NURSING. 
 
 NURSING AXIOMS. 
 
 The following may be laid down as nursing axioms: 
 
 A diet similar to what the mother was accustomed to, with 
 moderate limitations, may be taken. 
 
 There should be one bowel evacuation daily. 
 
 From three to four hours daily should be spent in the open air 
 in exercise which does not fatigue 
 
 At least eight hours out of every twenty-four should be given 
 to sleep. 
 
 There should be absolute regularity in nursing and expression. 
 
 There should be no worry and no excitement. 
 
 HYGIENE OF THE MOTHER. 
 
 The Diet of the Mother.— A plain, more or less restricted diet is 
 desirable. This must be enforced in the management of the wet- 
 nurse, but to a less degree with the mother. 
 
 Nursing is a perfectly normal function, and a woman should be 
 permitted to carry it out along the natural lines. Inasmuch as 
 there are two lives to be provided for instead of one, more food, 
 particularly of a liquid character, may be taken than the mother 
 may be accustomed to. It is our custom to advise that milk be 
 given freely. A glass of milk may be taken in the middle of the 
 afternoon, and 8 ounces of milk with 8 ounces of oatmeal or corn- 
 meal gruel at bedtime, if it does not disagree with the mother. Our 
 only evidence that a food is disagreeing is the condition of the 
 digestion. When any article of food disagrees with the mother, 
 or if she is convinced that it disagrees, whether or not such be 
 really the case, the food should be discontinued. In a general
 
 108 MATERNAL NURSING 
 
 way, milk (1 quart daily), eggs, meat, fish, poultry, cereals, fresh 
 vegetables and fruits constitute a basis for selection. 
 
 For more detailed suggestions see page 122. 
 
 The Bowel Function.— A very important and often neglected 
 matter in relation to nursing is the condition of the bowels. 
 There must be one free evacuation daily. For the treatment 
 of constipation in nursing women we have used different methods 
 in many cases. The dietetic treatment by increasing the whole 
 cereals, rough breads and cooked vegetables with plenty of recrea- 
 tion and exercise promise most. Manipulation of the diet should 
 not be such as to interfere with the milk production Three other 
 methods are open to use; massage, local measures and drugs. 
 Massage is available in comparatively few cases. Local measures 
 consist in the use of enemas and suppositories. Every nursing 
 woman under our care is instructed to use an enema at bedtime if 
 evacuation of the bowels has not taken place during the previous 
 twenty-four hours. For a laxative in such cases, and in many 
 others, a capsule of the following composition has served well: 
 
 1$ — Extracti nucis vomicae 0.015 gm. (j gr.) 
 
 Extracti cascarae sagradae . 0.325 gm (v gr.) 
 
 Sig. — To be taken at bedtime. 
 
 The amount of the cascara sagrada may be varied as the case 
 may require. In not a few instances we have found it necessary 
 to give two capsules a day in order to produce the desired result. 
 Neither the nux vomica nor the cascara appears to have any 
 appreciable effect on the child. 
 
 Air and Exercise.— Outdoor life and exercise are not only as 
 desirable here as they are under all other conditions, but to the 
 nursing woman, with her added responsibility, they are doubly 
 valuable. In order to get the best results exercise or work should 
 be so adjusted as not to reach the point of fatigue. The mother 
 whose nights are disturbed should be given the benefit of a midday 
 rest of an hour or two. It should be our duty, however, to explain 
 to the mother and to other members of the family that an import- 
 ant element in satisfactory nursing is a tranquil mind. 
 
 Care of the Breasts.— A well-established routine should be insti- 
 tuted for the care of the breasts. To facilitate this a readily 
 accessible tray with the necessary utensils should be provided. 
 This should contain a glass-stoppered bottle with a saturated solu- 
 tion of boric acid, a jar of cotton pledgets on toothpicks, to be used 
 as applicators for the boric acid, a graduated glass or beaker. The 
 nipples should be thoroughly washed before and after nursing with 
 a saturated solution of boric acid poured fresh from the bottle for 
 each cleansing, and the surplus thrown away. The boric acid 
 should be applied with the cotton pledgets. The fingers should
 
 CONDITIONS INFLUENCING THE BREAST MILK 109 
 
 not come in contact with the nipples if the child is to nurse directly 
 at the breast. If the nipples are tender they should be anointed 
 with a sterile mixture of 5 per cent tincture of benzoin in liquid 
 vaseline. 
 
 All utensils, including the breast-pump, if one is in use, should 
 be sterilized by boiling. In case of the breast-pump the rubber 
 bulb may be removed for this purpose. Where the milk is to be 
 expressed the hands must be thoroughly disinfected by washing 
 with soap and water and rinsing before manipulation of the breasts. 
 Under all conditions soap and water should be freely accessible, 
 and their use required before handling the breast of the mother. 
 
 CONDITIONS INFLUENCING THE BREAST MILK. 
 
 Secretion.— Spontaneous failure of lactation is extremely rare 
 and probably always occurs in consequence of an incomplete 
 emptying and an insufficient stimulation of the breasts. This is 
 especially true in the feeding of premature infants, and nursing 
 must be supplemented by other methods of emptying the breasts, 
 such as expression, pumping, or the nursing of a second infant. 
 
 The ability to restore the milk supply in breasts which have 
 not been nursed for days and even weeks, when proper stimulation 
 is applied is the best proof of this assertion. 
 
 When the milk supply is temporarily insufficient the necessary 
 complemental feedings should be obtained from some other source 
 and only as a last resort should mixed feeding be instituted. 
 
 Fissures.— Fissures offer serious difficulties to nursing because of 
 the severe pain and danger of mastitis. 
 
 Relief of the pain is frequently accomplished by elevation of 
 the breasts by a binder. Among the best local applications are 
 silver nitrate solution 5 per cent, followed by an ointment. (Bal- 
 sam of Peru 1, castor oil 30; or silver nitrate 1, balsam of Peru 2 
 and petrolatum 30.) 
 
 The nipples must be thoroughly cleansed before each nursing. 
 
 Simple Engorgement.— The first essential to relief is the restriction 
 of fluids by mouth and the administration of laxatives. In our 
 experience compound jalap powder in teaspoonful doses once or 
 twice daily is best. Saline laxatives are effective but more likely 
 to pass into the milk. Citrate of magnesia is least likely to do this. 
 The breasts are tightly bandaged and an ice-bag is applied to each, 
 external to the bandage. If this does not relieve the breasts mas- 
 sage and expression should be practised and the bandage and 
 ice-bags reapplied. 
 
 If the cold applications produce discomfort as they occasion- 
 ally do, hot boric dressings, protected by oil silk may be used, a
 
 110 MATERNAL NURSING 
 
 compression bandage being applied external to the dressings. 
 These should be repeated at hourly intervals. 
 
 The infant should be put to breast regularly at four-hour inter- 
 vals if able to take them. The wet-nurse's baby may be used 
 for this purpose if at hand. 
 
 Mastitis.— Ice-bags are best applied early. Later, warm moist 
 applications are more useful. When incision is necessary it should 
 be radial and must not enter the mammilla. This should be per- 
 formed as soon as pus is localized and is to be followed by expres- 
 sion through the incision. In order to prevent further congestion 
 of the breasts gentle expression should be practised at regular 
 intervals. This not only relieves the congestion, but, in a very 
 large percentage of cases, it tends to localize infection and a normal 
 secretion is retained after the healing of the incision. 
 
 Menstruation.— The advent of this physiological function is 
 frequently attended by a lessened milk secretion which leads the 
 infant to become fretful due to underfeeding. Occasionally men- 
 struation is attended by attacks of colic or indigestion in the infant, 
 but, under no circumstances, should the advent of menstruation be 
 considered as an indication for weaning, as all of the symptoms 
 disappear within two or three days. 
 
 Factors influencing the mental condition of the mother, such as 
 anger, fright, worry, shock, distress, sorrow, or the witnessing of 
 an accident may affect the milk secretion sufficiently to cause no 
 little discomfort to the child, and oftentimes the lessening of the 
 flow for a day or two. At times, especially when the mother is 
 under the influence of shock or grief, it may be necessary to substi- 
 tute artificial feeding for a few nursings during these periods, until 
 the mother has again resumed her mental equilibrium, her breast 
 being emptied by mechanical means in the meantime. 
 
 Asthenia and Anemia without a definite underlying organic- 
 pathology must not be considered sufficient causes for weaning. 
 Most of such women receive benefit to their own health, increasing 
 in weight and strength and often overcoming their anemia. This 
 is probably due to the more complete involution during the puer- 
 perium and stimulation of the glands of internal secretion and 
 blood-making organs. 
 
 Drugs. — Alkaloids of opium, hyoscyamus, belladonna and similar 
 drugs, when given in large quantities not infrequently pass into 
 the milk, and should therefore never be administered in large 
 quantities to the nursing mother. Belladonna may cause a decrease 
 in milk secretion, and should be administered with caution during 
 the period of lactation. Mercury, iodides and the newer salts of 
 arsenic are also secreted in the milk, and may be used to advantage 
 when a luetic mother is nursing a luetic infant.
 
 THE NURSING PROPER 111 
 
 THE NURSING PROPER. 
 
 Regularity in Nursing.— The breast which is emptied at definite 
 intervals invariably functionates better than does one which is 
 not, not only as regards the quantity, but also the quality, of the 
 milk, thus regular habits in breast-feeding are as essential to milk 
 production as to its digestion and assimilation. The baby should 
 be wakened to be fed. 
 
 The average mother will supply the needs of the individual meal 
 with one breast, and the breasts should be alternated in successive 
 feedings. Thorough emptying of the breast should be encouraged 
 under all circumstances, as this is our best method for increasing 
 the milk supply, and the baby is the best means at hand by which 
 this is accomplished. This should be encouraged in every instance. 
 It is most readily thwarted by allowing a lazy baby to partially 
 empty both breasts. This will soon lead to a diminished milk secre- 
 tion. Expression or the nursing of a second baby will usually 
 prevent the loss of milk supply. Massage will often be of great 
 assistance in retaining the milk flow. It should be carefully 
 and gently applied at regular intervals. 
 
 Sometimes, however, it is advisable to give both breasts at each 
 feeding, i. e., under the following conditions: (1) During the first 
 few days to stimulate secretion, and a little later to relieve the 
 congested breasts; (2) to weak babies when there is an abundance 
 of milk, and they are not strong enough to get the last milk that 
 comes harder; (3) to overfed babies, where it is desirable to give 
 them only the first and weakest milk, and to lessen the yield of 
 milk from the breast; (4) as the milk supplied by one breast 
 fails to meet the needs of the infant, both breasts should be given 
 at each nursing— the first breast should be thoroughly emptied 
 before allowing the baby to take the second breast, and the next 
 nursing started on the second breast given in the last feeding. 
 
 When to Begin First Feedings.— Little is to be gained by placing 
 a premature infant to the mother's breast during the first twenty- 
 four hours and as they do not stand starvation the limited supply 
 of milk needed should be obtained from some other mother. Water 
 should be administered four or five times during the first twenty- 
 four hours. When the premature is unable to take the breast, 
 massage and expression should be begun on the second day and 
 continued at first four, and later six, times daily. When a wet- 
 nurse's baby is available it should be left to suckle the mother's 
 breast at stated intervals. 
 
 Number of Feedings in Twenty-four Hours. — During the second, 
 third and fourth days the infant may be placed at the breast at 
 four- to six-hour intervals, and if strong enough to nurse these may
 
 112 MATERNAL NURSING 
 
 be increased so that it will be nursed every three or four hours. 
 If it does not obtain sufficient food by this means it may be given 
 hand feedings of expressed milk between nursings. 
 
 Length of Nursing.— As a rule, a robust baby takes three-fourths 
 of the milk obtained from a good breast in the first five minutes 
 of a twenty-minute nursing. Fifteen to twenty minutes should be 
 the limit for the nursing period. If a baby is doing well on shorter 
 periods and seems satisfied, let it be its own judge of the nursing 
 time. While premature infants may nurse well during their first 
 three or four days of life, frequently when they become intensely 
 jaundiced they develop a marked apathy and under such circum- 
 stances they must be awakened during the nursing period to keep 
 them at work. At such times they must at least be partially hand 
 fed. It may also be necessary to feed them more frequently. 
 
 Administration of Water.— At least one-twentieth to one-twelfth of 
 the body weight of the infant, in the form of inert fluids, should be 
 fed daily during the first two days. A 1 per cent milk-sugar solution 
 (boiled) will answer. For further fluid intake needed see Tables I, 
 II and III, pages 181 and 182. Otherwise there will be unnecessary 
 loss of weight and perhaps a high degree of fever due to inanition. 
 A high temperature during the first days of life is more commonly 
 due to "inanition" than infection in present-day obstetrics. The 
 best differential test is administration of water or sugar water at 
 regular intervals. In case of water inanition sufficient fluid intake 
 results in a rapid drop in the temperature. 
 
 Nursing in Difficult Cases.— When the weight curve remains sta- 
 tionary or the gain is less than should be expected the possibility 
 of underfeeding as the cause must not be lost sight of. The esti- 
 mation of the twenty-four-hour secretion of milk is of first import- 
 ance because of the relationship between demand and supply. 
 The quantity taken by the infant at each nursing should be meas- 
 ured by weighing before and after feeding at the breast, and also 
 by measuring the amount of milk fed by hand. Conclusions 
 should be made only after such estimation for a period of at least 
 twenty-four to forty-eight hours. Expression of both breasts after 
 each nursing may be of advantage to the mother even though 
 the baby is only nursing on one breast. Expression when thor- 
 oughly and properly applied will, in itself maintain a full and 
 free milk supply without placing an infant at the breast. In some 
 instances this may be continued for many months. It may be 
 stated that the small flat breast offers greater difficulties to proper 
 manipulation than the full conical breast. For details as to the 
 method of expression see page 126. 
 
 The classes of cases which are most likely to necessitate hand 
 feedings are those suffering from cleft palate and harelip and those
 
 THE NURSING PROPER 113 
 
 in which there is deformity of the mother's nipples. We have 
 recently had an opportunity to observe some of the cases being 
 treated by the Minneapolis Breast Feeding Bureau. Among these 
 a very severe case of harelip and cleft palate, nine months of age, 
 and a case of congenital absence of nipples in the mother, whose 
 infant was five months of age. Both of these infants had been 
 fed exclusively on expressed milk and had attained the average 
 weight and development of breast-fed infants of their respective 
 ages.
 
 CHAPTER VI. 
 WET-NURSING. 
 
 THE WET-NURSE. HER SELECTION AND HER BABY. 
 
 The Problem.— When there is a positive inability on the part 
 of the mother to nurse her offspring, either through inadequate 
 functioning on the part of the breast or systemic disease, we are 
 confronted with the problem of securing human milk from another 
 source, as notwithstanding the numerous isolated reports on suc- 
 cessful raising of premature infants on artificial foods, the statistics 
 of infants fed by artificial foods, when compared with those of 
 infants fed on human milk are so strikingly in favor of the latter 
 that the obtaining of human milk must be considered imperative. 
 
 How Obtained.— In our experience, even in a large city, great 
 difficulty has been met in obtaining a regular supply of wet-nurses. 
 On several occasions various charitable and hospital societies have 
 attempted to establish a wet-nurses' registry as a clearing house 
 for the several maternity and general hospitals of Chicago. These 
 attempts have not been successful for two reasons: (1) Because 
 of the irregularity in the demand, and (2) because of the lack of 
 cooperation on the part of the various institutions caring for this 
 class of cases. 
 
 The Nationality of the Wet-nurse.— This is of considerable signifi- 
 cance where the supply allows of a selection. The phlegmatic 
 temperaments as seen in women of Northern and Central Europe 
 of Teutonic and Slavic descent, offer the ideal material, while other 
 nationalities, such as Italians, and the Southern negroes when 
 removed from their home environment to a Northern climate with 
 the consequent change in diet, secrete a milk poor in quality. 
 However, even the latter in an emergency should not be neglected. 
 
 Requirements of a Good Wet-nurse. — 1. She should be in good 
 health, and, especially, free from all contagious and infectious 
 diseases, and also from local diseases of any kind, such as those 
 involving the nose, throat, skin, etc. 
 
 2. Her mammary glands should be of such quality that she can 
 secrete sufficient milk of good quality, and the nipples sufficiently 
 developed to allow of nursing, or proper expression of the milk 
 (Figs. 54 and 55). 
 
 3. Whenever possible her age should be not less than eighteen 
 and not more than thirty-five years.
 
 THE WET-NURSE— HER SELECTION AND HER BABY 115 
 
 4. The age of her baby, as compared with that of the baby she 
 is to nurse, is a matter of indifference in most instances. However, 
 
 Fig. 54. — A good secreting spherical breast with well developed nipples. The 
 breast is composed largely of glandular tissue. The engorged veins are plainly visible. 
 This young primipara acted as a wet-nurse for over eighteen months. See p. 124. 
 
 Fig. 55. — Large, pendulant breasts composed mainly of fat and connective tissue, 
 
 the type to be avoided in the selection of a wet-nurse. 
 
 the first weeks, or if possible the first two months, of lactation should 
 be avoided, because of the presence of colostrum and the rapidly
 
 116 WET-NURSING 
 
 changing quality of the breast milk, which not infrequently causes 
 serious gastric and intestinal disturbances in very susceptible 
 infants, as evidenced by vomiting, colic and diarrhea. Multipar- 
 ity may be considered an asset, if the nurse has demonstrated her 
 ability to care for and feed previous cases. A multipara is also 
 less likely to be affected by her new surroundings, especially if 
 this be a private home. When the wet-nurse has more or less 
 direct charge of the infant, one who has been nursing her own or 
 other infants will be likely to meet the technical difficulties in the 
 care of her charge. 
 
 Examination of the Wet-nurse.— The examination of the wet- 
 nurse should always be made in a systematic manner to insure 
 against overlooking important things. 
 
 1. A careful history should be taken as to the number of her 
 children, miscarriages and the presence of constitutional diseases 
 in her family. 
 
 2. She should be thoroughly examined, all parts of the body 
 being exposed, and the examination should include the skin and 
 hairy parts of the body for the presence of skin lesions and para- 
 sites, as well as for old luetic scars. The organs of the chest and 
 abdomen should be subjected to careful examination. 
 
 3. The breasts should be examined. 
 
 4. The genitalia, including the cervix and the urethra, and in 
 all cases a cervical (and where suspicious, a urethral) smear should 
 be taken and examined for gonococci. As a single smear is often 
 misleading, in cases of the slightest suspicion where a girl baby is 
 to be nursed the examination of the cervical and urethral smears 
 should be repeated. 
 
 5. An examination and search should be made for chronic infec- 
 tions, especially for syphilis. A Wassermann test should be made 
 in every case, and reported upon before she is allowed to supply 
 milk, as it is well known that a syphilitic mother in a very great 
 number of cases shows no clinical evidence of syphilis. The mouth 
 and pharynx, neck, anus and genitalia, entire skin and lymphatic 
 glands should also be examined for evidence of syphilitic lesions. 
 
 Tuberculosis.— The lungs, glands and osseous system should be 
 examined, and a careful history as to susceptibility to colds and to 
 recurring bronchitis elicited. 
 
 6. Acute Infections.— She should be questioned as to exposure to 
 contagious disease, and she should be examined for evidence of 
 acute infections of the nose, throat and ears. 
 
 7. Her teeth should be examined and defects and pyorrhea cor- 
 rected, if necessary, at the expense of the family. 
 
 8. The urine should be examined (a) for evidence of nephritis, 
 (6) for evidence of diabetes. It should, however, be remembered
 
 THE WET-NURSE— 11 EH SELECTIOh AND HER BABY 117 
 
 that a positive reaction for sugar should not lie overestimated, 
 unless the sugar is proven to be dextrose, as very commonly in our 
 experience during the early weeks of lactation a lactosuria is pres- 
 ent. The kind of sugar can easily be determined by the phenyl- 
 hydrazine test, followed by a microscopical examination of the 
 crystals. 
 
 9. Nervous and psychic disturbances, such as epilepsy, insanity, 
 hysteria, should, if found, by all means exclude the subject. 
 
 10. Her child should be examined for evidence of syphilis. 
 Possibly one of the best arguments for the non-employment of a 
 wet-nurse during the first two months of her lactation is the possi- 
 bility of a latent syphilis. Where there is the slightest doubt, a 
 Wassermann reaction should be made on the infant. The general 
 condition of the child gives us the best evidence both as to the 
 quantity and to the quality of the maternal milk. Unless the 
 source of the nurse be known, it is well to be certain that she is 
 nursing her own baby. In case of its death or its absence, every 
 effort should be made to obtain its condition at birth and its later 
 development. 
 
 So far as possible she should not be subjected to annoying ques- 
 tioning on the part of the family, which is entirely unnecessary, 
 if she has been properly examined by the physician. It has been 
 our experience that such unnecessary questioning has led to ner- 
 vousness, and not infrequently has caused her to decline the position, 
 at a time when she was most needed. 
 
 Her Place in the Household.— She should be treated neither as a 
 guest nor as a menial, but so far as possible should be graded accord- 
 ing to her previous station in life. There is grave danger of mental 
 depression on the part of a woman, well-born and sensitive, who, 
 through misfortune or necessity, is forced to seek this means of 
 employment, and also of an exaggerated estimate of self-importance 
 on the part of a woman but little accustomed to the luxuries of 
 life upon her entrance into the home of employment, particularly 
 if attentions are paid to her. As has been previously stated, all 
 instructions and demands should be made by the person best 
 qualified in the individual case. A divided responsibility will 
 always lead to future complications. 
 
 Her quarters should be well located; their ventilation should 
 be supervised, and she should be held responsible for their general 
 cleanliness. The wet-nurse's baby should always be kept in the 
 room with her, so that she may feel the full responsibility for 
 its health and care. 
 
 The Quantity of Milk to be Expected from a Good Wet-nurse.— The 
 quantity and quality of milk supplied must vary greatly with 
 the glandular development of the individual wet-nurse, the state
 
 118 WET-NURSING 
 
 of her health, and the factors quoted elsewhere which would affect 
 it temporarily. The amount and variety of stimulation applied to 
 the breasts, of which the direct nursing by a full-term infant is 
 the most valuable (at least for the purpose of stripping the breasts), 
 must be given due consideration. In view of the many emergencies 
 and influencing factors, no absolute standard for quantity and 
 quality can be set for general rule. A wet-nurse who does not 
 secrete sufficient milk during the first few days in her new employ- 
 ment should not be discharged until every effort has been made to 
 improve her milk production. Frequently the change in environ- 
 ment is sufficient to reduce it temporarily. 
 
 Cost of Milk.— The wet-nurses in the Sarah Morris Hospital 
 receive their board and room and $10 per week. Figuring the 
 former at $8 per week, this would total a cost to the institution 
 of $18 per week for each nurse. With an average of 30 to 40 ounces 
 of milk per nurse daily, or 210 to 300 ounces per week, the average 
 cost will be about 6 to 9 cents per ounce, or approximately $2 to 
 $3 per quart. 
 
 When milk is dispensed to patients outside of the hospital, a 
 charge of 15 cents an ounce is made for it, which is a reasonable 
 price when all of the contending factors are taken into consideration. 
 
 Number of Nurses Needed. — Each good wet-nurse can care for 
 the needs of about two infants, depending upon their weight and 
 development, beside allowing the strippings for her own child. 
 
 Length of Lactation.— No time limit is placed upon the employ- 
 ment of a wet-nurse as long as the quality and quantity of her milk 
 is sustained, and she continues in good health. One of our nurses 
 had a lactation period of eighteen months. Such long periods of 
 lactation, however, are not to be advised. 
 
 The Wet-nurse's Baby.— The presence of the wet-nurse's baby 
 predisposes to her peace of mind, and wherever possible, she should 
 take it with her. Her baby's state of health is by all means the 
 best indication as to her ability as a nurse, and, with this, of the 
 presence of constitutional disease in herself. It may be of immense 
 value, if the baby is strong and healthy, to keep up the flow of 
 of milk, in case the baby to be nursed is a weakling. It may also 
 be used to estimate the functional capacity of a wet-nurse by 
 nursing at regular intervals, and weighing before and after the 
 nursing for twenty-four-hour periods. If in perfect health it may 
 be put to the breast, after the weakling has taken such milk as it 
 has strength to draw. If this is not practicable then the weakling 
 should be nursed alternately with the well baby on each breast. 
 It is also of immense value in emptying the breast after the wet- 
 nurse has removed as much milk as it is possible by expression or 
 by the breast-pump, if this is the means of drawing the milk for
 
 THE HYGIENE OF THE WET-NURSE 119 
 
 the weakling. It is a well-known fact in all institutions where 
 wet-nurses are used, that the greater the degree to which the 
 breasts are stimulated by suckling infants, the greater will he the 
 reward in production. If the milk is insufficient for both babies, 
 partial or entire meals of artificial food may be substituted for the 
 wet-nurse's infant. 
 
 At the first sign of an acute illness on the part of the wet-nurse's 
 baby, it should be separated entirely from the other baby, and 
 removed from the breast; its illness should be given the same 
 serious consideration as that of the other infant, so that the mother's 
 anxiety may be relieved. It should receive as much of its mother's 
 milk as can be spared. This can be expressed from the breasts 
 and fed from a bottle. 
 
 Feeding of the Wet-nurse's Baby.— When a single infant is to be 
 nursed the second baby is often a necessity in the promotion of 
 the development and stimulation of her breasts. No breast can 
 be developed to its fullest capacity with the breast-pump or hand 
 expressions. It is a well-known fact that the breasts will respond 
 in proportion to the demand placed upon them, and in most 
 instances during the first few weeks of the premature's life, when 
 its demands are met by from 4 to 1(3 ounces of milk, the wet-nurse 
 can supply sufficient milk for both babies. When her supply 
 becomes insufficient to meet the demands, her baby can be put 
 upon partial bottle feedings of the strength as indicated by its 
 age and development. The progress of the wet-nurse's baby has 
 great influence on her peace of mind, which may spell success or 
 failure in her ability to carry out her work. When the premature 
 infant gives evidence of sufficient strength to be placed upon the 
 breast, we have found the application of the wet-nurse's baby to 
 the other breast a very valuable expedient in aiding the flow of 
 milk into the breast which is to be nursed by the weakling. In 
 many instances we have seen the milk flow T from the second breast 
 by this method so freely that but very little effort was required 
 on the part of the weakling to obtain its food. 
 
 THE HYGIENE OF THE WET-NURSE. 
 
 In general, everything that has been said in the chapter on 
 hygiene of the nursing mother applies also to the wet-nurse— of 
 course, with the proper modifications, made necessary by peculiar- 
 ities of her position. 
 
 Clothes.— Her clothes should be simple, and in every part wash- 
 able. As the care of her undergarments is of even greater import- 
 ance than her outer clothing, it is well that her laundry should be
 
 120 
 
 WET-NURSING 
 
 done with the family work, so that the family laundress who is 
 trusted by the family may be charged with its inspection. 
 
 Fig. 56. — Wet-nurse uniform. Her dress should be of a simple type, and made of 
 a material of different color from that worn by the nursing staff. One lapel of dress 
 raised and thrown over shoulder, one lapel of undervest raised and breast exposed 
 for nursing. 
 
 To simplify nursing or the drawing of milk, the author has 
 devised two garments for wet-nurses. The material used for the 
 
 Fig. 57.— Wet-nurse uniform. Undervest, with one lapel raised, exposing breast. 
 
 outer garment is of yellow gingham, such as is used in the making 
 of hospital uniforms— the yellow color being selected to distinguish
 
 THE HYGIENE OF THE WET-NURSE 121 
 
 the wet-nurse from the blue, as used by the nursing corps. The 
 corset-waist is to be made of heavy muslin. The corset, if worn 
 at all, should be of a very low type so as to avoid ;dl pressure on 
 the breasts. It is best of a cheap quality so that it can be replaced 
 frequently for sanitary reasons. Each wet-nurse should be supplied 
 with four uniforms and six nursing corset-waists (Figs. ">(> and 57). 
 
 The Diet of the Wet-nurse.— There is danger of the creation of 
 indolent habits through neglect of regular exercise and the lack of 
 regular household duties, but even greater danger lies in the direc- 
 tion of overfeeding with unusual foods. The average wet-nurse 
 is either obtained from an institution or a home in which the luxu- 
 ries of life are limited, and she has been accustomed to a simple 
 nutritious diet. Every attempt should be made to supply the 
 nursing woman with a well-rounded diet of simple foods, with 
 milk and cereals as the basis, and these supplemented with meats, 
 soups, the common vegetables, limited amounts of fruits and 
 plain desserts. Insofar as possible the aromatic vegetables, unripe 
 and highly acid fruits, fried meats and rich pastries are to be 
 avoided. We believe that, on the whole, too great stress has 
 been laid upon the danger of the diet in the mother of a full-term 
 infant, and in most cases the average mother can partake of a very 
 full diet. However, in the case of the woman nursing premature 
 infants, it should become a custom to allow only such foods during 
 the first few days after her installation as can be given with perfect 
 impunity. When a full, free flow of milk is established other vege- 
 tables and fruits can be added, one at a time, and after each addi- 
 tion to the diet a try-out should be given the milk. We have on 
 numerous occasions seen marked intestinal distention and diar- 
 rheal attacks following even seemingly slight indiscretions of the 
 diet on the part of the wet-nurse. 
 
 The diet should be so constituted as to meet the following 
 requirements : 
 
 1. Furnish enough food of the proper kind to satisfy hunger 
 and meet the physiological requirements of her body and produce 
 a milk of good quality. This includes keeping the food elements 
 in their proper proportions. 
 
 2. Prevent the presence of any obnoxious substances in the milk. 
 
 3. Prevent gastric and intestinal indigestion, constipation, or 
 anemia in the wet-nurse. 
 
 4. Maintain the weight of the wet-nurse with little or no varia- 
 tion. 
 
 It is our hospital practice to furnish each wet-nurse with two 
 quarts of good wholesome milk daily, and at least one pint of 
 cereal gruel, preferably farina or cornmeal. A mixture of milk 
 and cereal gruels makes a very good combination for drinking
 
 122 WET-NURSING 
 
 midway between meals. The remainder of the milk may be taken 
 with the meals, either pure or in the form of cocoa, tea or weak 
 coffee, in whichever form it is best taken by the individual woman. 
 The latter is of considerable importance, as in the forced diets 
 which are required, where an abundance of milk is demanded, 
 distasteful foods soon become obnoxious. 
 
 DIET FOR WET-NURSES, PARTICULARLY FOR PREMATURE 
 BABIES. 
 
 Meats.— Beef, lamb, chicken, fish, bacon. 
 
 Eggs.— Soft cooked only. 
 
 Vegetables.— Potatoes, carrots, spinach, lettuce (no vinegar), 
 beets, string beans, canned corn, squash, asparagus, celery. 
 
 Fruits.— Prunes, apples, oranges, peaches, pears, apricots, rasp- 
 berries, blackberries, cherries, strawberries (stewed only). 
 
 Cereals.— Rolled oats, rice, farina, cream of wheat, hominy 
 grits, Wheatena, Pettyjohn's and all cooked wheat, oats, rice and 
 corn cereals. 
 
 Fats.— Cream, butter, olive oil. 
 
 Desserts. — Soft puddings, gelatines. 
 
 Breads.— Wheat, rye, bran, corn, crackers, zwieback, coffee 
 cakes and plain cakes. 
 
 Liquids. — Milk, buttermilk, kazol, cocoa, weak tea and coffee, 
 malted milks. 
 
 Soups.— Broths and soups made with beef, chicken or lamb. 
 Vegetable soups made with milk or with meat stock and vegetables. 
 
 A void.— Aromatic vegetables (onions, cabbage, turnips, cauli- 
 flower) ; acid vegetables (tomatoes, pie-plant, cucumbers) ; acid 
 fruits; highly spiced or seasoned foods; salads with acid dressings; 
 raw fruits, except oranges; fried foods. 
 
 MENU FOR ONE DAY. 
 
 Breakfast: 
 
 Fruit (orange, prunes or apple-sauce) . 
 
 Cereal with cream and sugar. 
 
 Bacon (2 slices), or some other easily digested meat if desired. 
 
 Bread, toast or rolls. 
 
 Butter. 
 
 Cocoa or milk or weak coffee. 
 Dinner: 
 
 Broth or soup. 
 
 One meat from list given (roast beef or broiled chop). 
 
 Potatoes (old) in any form except fried. 
 
 Vegetables (squash, beets).
 
 THE HYGIENE OF THE WET-NURSE 123 
 
 Light dessert (custard, gelatin). 
 
 Bread (white, rye or bran). 
 
 Butter. 
 
 Cocoa or milk or weak tea or coffee. 
 Supper: 
 
 One meat from list given (chicken). 
 
 Potatoes (creamed). 
 
 One vegetable (asparagus). 
 
 Cereal with cream and sugar (rice). 
 
 Stewed fruit (peaches). 
 
 Bread and butter. 
 
 Cake occasionally. 
 
 Milk or cocoa. 
 No candies should be allowed except as a dessert with one of the 
 main meals. 
 
 If the nurse's appetite demands more food because of the large 
 amount of milk secreted, or if insufficient fluids are taken with 
 the meals to cover the fluid requirements, as previously stated, one 
 or two midday, and one night luncheon may be given. These 
 should consist of milk, milk and tea, malted milk or cereal decoc- 
 tions, with crackers, coffee cake, etc. 
 
 Beers, malt-extracts and other rich drinks are not forced upon 
 the nurse unless she is accustomed to them, and feels their need. 
 It must always be remembered that an excess of fluids would 
 naturally tend to dilute the milk unless the secreting gland be of 
 exceptional development. Excessive feeding by giving of too fre- 
 quent meals in the presence of anorexia will retard rather than 
 increase the milk flow. 
 
 Exercise of the Wet-nurse and Her Work.— She should be impressed 
 before her engagement with the fact that she will be required to 
 do a moderate amount of work and exercise regularly out of doors. 
 The former will be of service in promoting her general health, and 
 both the work and the exercise will serve as a nerve tonic and pre- 
 vent her becoming indolent. This does not mean that she should 
 become a drudge, but that she should at least be required to care 
 for her own room and her own infant's clothes, and should be made 
 to feel that in return for her laundry work she would be requested 
 to do some light general w T ork about the house. Her exercise in 
 the open air should so far as possible be at regular times. The 
 question as to the care of the napkins of both babies is open to 
 considerable discussion; and it may be stated that whenever it 
 becomes necessary for the nurse to express her milk by hand, she 
 should not be subjected to the handling of soiled napkins, whenever 
 this can be avoided.
 
 124 WET-NURSING 
 
 OTHER CONDITIONS INFLUENCING THE QUALITY OF 
 THE BREAST MILK. 
 
 The Nervous and Mental State of the Nurse.— The nervous and 
 mental state of the nurse is of the utmost importance, and wherever 
 possible an emotional, nervous, erratic woman should be excluded, 
 because of the tendency of these influences to suppress the flow of 
 milk. Therefore, whenever possible, a woman of more or less 
 phlegmatic temperament is to be selected. This is especially true 
 in the case of a woman who is to be in close contact with and is 
 to nurse an infant with neurotic tendencies. There is also the 
 possibility of the same influence being manifest in time of slight 
 indisposition on the part of her own infant, and such an indi- 
 vidual is also more likely to resent the necessity of partial or entire 
 artificial feeding of her own child to the advantage of the premature 
 infant, when it has reached such an age when it may make greater 
 demands on her supply. 
 
 Menstruation.— Menstruation rarely produces any serious dis- 
 turbances. It is always a safe procedure to dilute the milk during 
 the first and second day of menstruation when the nurse suffers 
 considerable pain at these times. 
 
 Period of Lactation.— Period of lactation may or may not be a 
 considerable factor, depending upon the individual woman. We 
 had in our employ a nurse who had been with the institution for 
 sixteen and a half months, and whose infant was eighteen months 
 old, and who supplied us with the largest quantity and the best 
 quality of milk of the four nurses in the institution. 1 
 
 When possible a nurse should be selected after the first few 
 weeks of lactation, at which time the colostrum has disappeared 
 from the milk, and the quantity and quality of her milk has become 
 established. After the first few weeks of lactation but little or 
 no attention is to be paid to the age of the wet-nurse's baby as 
 compared with that of the infant to be fed, and we have never 
 noted any ill effects following the rule. 
 
 1 The milk of this nurse was examined in the laboratories of the University of 
 Chicago after seventeen months of lactation with the following result: 
 
 Albumin 1.30 percent 
 
 Casein 0.69 " 
 
 Fat 3.54 " 
 
 Lactose 7.025 " 
 
 Salts 0.1885 " 
 
 It must be remembered that this is an exceptional case, and but few women 
 under the stress of ordinary life can properly nurse their infants after the ninth to 
 twelfth month.
 
 THE NURSING 125 
 
 THE NURSING. 
 
 The Infant's Bedroom.— Under ideal circumstances, this should 
 be separated from that of the wet-nurse. This is especially true 
 where a trained attendant has care of the infant. It should under 
 all circumstances also be separated from the wet-nurse when she 
 is of a low degree of intelligence and of a type not to be trusted 
 with the care of the infant. 
 
 Method of Drawing Milk.— Numerous methods of obtaining milk 
 from the breasts have been described, but only those most practi- 
 cable of application will be detailed. These should be divided: (1) 
 Into those in which the baby is placed directly at the breast, and 
 (2) those methods by which the milk is drawn from the breasts 
 and fed to the infant. Two methods are especially applicable 
 where the baby is fed directly on the breast, and needs assistance 
 because of its weakness. 
 
 Fig. 58. — Proper method of holding baby during nursing. The nurse is seated on a 
 low nursing chair with her right foot elevated on a low stool. 
 
 1. The premature infant is placed at the breast, and is sup- 
 ported there by the nurse's right arm while nursing at the right 
 breast, and the left hand is used to grasp the breast just above 
 the nipple between two fingers and the milk is expressed directly 
 into the baby's mouth. In this way the baby is taught to take the 
 breast, and at the same time receive its food with little effort.
 
 126 
 
 WET-NURSING 
 
 This method can be continued until the baby has gained sufficient 
 strength to nurse without assistance. 
 
 2. Much the same result can be accomplished by placing the 
 wet-nurse's baby on the opposite breast during the nursing period, 
 whereupon the simultaneous nursing on both breasts will cause a 
 free flow of milk into both sides. 
 
 The methods by which the milk is drawn from the breasts and 
 fed to the infant by hand or by other means are : 
 
 1. By the breast-pump. The modification of Holz vacuum 
 apparatus, as devised by the author (Fig. 60), by which means the 
 milk is drawn directly into two graduated 2-ounce flasks, which 
 
 Fig. 59. — Premature infant nursing one breast and wet-nurse's baby nursing the 
 other. If there is a choice of breasts the premature should have the better one 
 reserved for its use. This leaves the strong infant to develop the poor breast. If 
 the premature is unable to empty its breast, nursing should be followed by expression 
 or application of the wet-nurse's baby, if both are well. 
 
 can be filled to the quantity desired, and stoppered for future use, 
 so that the milk is free from handling, and thereby avoid con- 
 tamination. This type as well as other hand pumps are less practical 
 than drawing milk by expression. Dr. I. A. Abt, of Chicago, has 
 recently designed an electric breast-pump which promises to be of 
 great value. 1 
 
 2. By direct expression which is by all odds the method of choice 
 and which is performed as follows: 
 
 Scrub the hands and nails with soap, warm water, and a nail- 
 brush for at least one full minute. Wash the nipple with fresh 
 
 1 Tr. Am. Ped. Soc, 1921.
 
 THE NURSIXd 127 
 
 absorbent cotton and boiled water or a freshly made boric solution. 
 Dry the hands thoroughly on a clean towel and keep them dry. 
 Have a sterilized graduate glass tumbler or large-mouthed bottle 
 to receive the mi!k 
 
 (a). Grasp the breast gently but firmly between the thumb placed 
 in front and the remainder of the fingers on the under surface of 
 the breast. The thumb in front and the first finger beneath should 
 rest just outside of the pigmented area of the breast. 
 
 (b). With the thumb a downward pressing motion is made on the 
 front against the fingers on the back of the breast, and the thumb 
 in front and fingers behind are carried downward to the base of 
 the nipple. 
 
 ^ J 
 
 ^ ... r. || 
 
 f? - 
 
 
 kk. 
 
 **■ i jHB ^ 
 
 
 *Ld 
 
 - iB 
 
 — ^H 
 
 Fig. 60. — The pump is made in two types, the first fitted with a large rubber bulb 
 of a size considerably larger than is ordinarily sold with breast pump, and the second 
 attachment to which the Holz vacuum pump can be fitted. In place of the ordinary 
 collecting bulb at the lower surface, an arm is so constructed as to allow the milk to 
 flow into specially designed graduated 2-ounce milk flasks. 
 
 (c). This second act should end with a slight forward pull with 
 gentle pressure at the back of the nipple, which causes the milk 
 to flow out. 
 
 The combination of these three movements may be described as 
 " back-down-out." 
 
 It is not necessary to touch the nipple. 
 
 This act can be repeated thirty to sixty times a minute after 
 some practice. 
 
 Both breasts may be emptied if necessary, or they may be used 
 alternately. 
 
 The act should be carried through with such gentleness as to 
 cause little or no inconvenience to the nurse even in the first days
 
 128 
 
 WET-NURSING 
 
 Fig. 61. — Direct expression, first motion. 
 
 Fig. 62. — Direct expression, second motion.
 
 HOSPITAL RULES FOR HANDLING WET-NURSES 129 
 
 of lactation. Some nurses prefer to use one hand for both breasts, 
 others become ambidextrous and prefer to change hands. 
 
 By this means, following a little practice, the nurse can express 
 from 6 to 8 ounces of milk from two good breasts in fifteen to 
 twenty minutes. While drawing, each 2 ounces of milk is poured 
 directly into sterile, stoppered bottles to prevent the fingers of 
 the nurse coming in contact with the milk by overfilling the glass. 
 
 The milk should be covered at once by a sterile cloth held in 
 place by a rubber band and kept on ice until used. 
 
 Daily Number of Expressions.— Expression is performed six times 
 daily at regular intervals of four hours during the day and night. 
 
 HOSPITAL RULES FOR HANDLING WET-NURSES. 
 
 Samples of breast milk should be examined from each wet-nurse 
 at regular intervals. Her breasts and method of expression should 
 be inspected. It is not uncommon for wet-nurses to dilute their 
 milk by adding cows' milk to increase the quantity when they 
 experience a shortage. 
 
 Sick babies are not permitted to nurse from the wet-nurses' 
 breasts; the expressed milk should be fed to the sick baby, when- 
 ever possible while it is yet warm. 
 
 If there be any question as to the reliability of the wet-nurse 
 the milk must be drawn in the presence of a second person. 
 
 Wet-nurses for prematures must not be allowed to go to a gen- 
 eral table for their meals, but must have their meals brought to 
 them where they may partake of their food under the eye of a nurse 
 who understands what their diet is to be. Wet-nurses have pre- 
 carious appetites, as a rule, and they are more likely than not to 
 have a craving for something that will either diminish the amount 
 of their milk or impart some condition that will make it disagree 
 with the sick babies. 
 
 Wet-nurses should be kept rigidly within regular hours in the 
 institution. They should not be permitted to go out after night 
 because they will do indiscreet things, eat foods calculated to 
 interfere with their efficiency as wet-nurses, drink alcoholic stimu- 
 lants, and so upset themselves generally and the milk supply will 
 be diminished. On the other hand, the wet-nurses should be 
 made comfortable, and should be given a sufficient amount of 
 work in the institution to keep them busy. They are disposed to 
 resent restraint and unless their time is fully occupied, they will 
 be sure to fret and thus diminish their milk supply. 
 
 The wet-nurse should be obliged to observe the laws of health 
 and cleanliness; they should be obliged to bathe regularly and it 
 should be the duty of the head nurse of the department to see that 
 9
 
 130 WET-NURSING 
 
 their bowels are kept in proper condition and that their genitals 
 are clean and healthy. 
 
 Wet-nurses should never be employed until the Wassermann 
 test has been made, and until a competent physician has given 
 them a thorough examination to determine the presence or absence 
 of specific disease. They should never be permitted to go on 
 duty with running ears, sore eyes, sore throat, bad teeth or any 
 discharge from a mucous membrane, or any skin eruption. 
 
 The wet-nurse should be given a certain number of babies to 
 feed, and as long as her milk agrees with them, and she is in perfect 
 health, should be kept to the same babies without any admixture 
 of the milk of any other nurse This acts as a check on any 
 indiscretion as it would be reflected in the baby.
 
 CHAPTER VII. 
 (ARE AND NURSING OE PREMATURE INFANTS. 
 
 All infants born three weeks or more before full term should 
 be considered premature and treated as such. Every infant 
 born after the sixth month should be given an opportunity for 
 life by the administration of necessary care and diet. Healthy 
 premature infants when properly cared for will frequently reach 
 the full development of the full-term infant by the end of the 
 first year, and the majority of those surviving usually develop a 
 normal body and mind, notwithstanding the fact that they are 
 more commonly subject to megacephalus, rickets, spasmophilia, 
 anemia, gastro-intestinal, respiratory and circulatory affections, 
 all of which can be overcome without leaving any sequelae, unless 
 based upon some congenital anomaly. 
 
 To be successful with these infants a certain routine must be 
 followed : 
 
 1. Preparation for their home or hospital care must be made, 
 whenever possible before labor begins. 
 
 2. Their immediate care after birth is of greatest importance. 
 
 3. Their general care must be adapted to their individual needs. 
 (a) Refrigeration must be prevented. 
 
 (6) Skilled nursing is essential. 
 
 4. Human milk must be provided for those born before the 
 thirty-sixth week. 
 
 5. The daily routine must be adapted to the infant's age and 
 development. 
 
 6. Contact between the infant and individuals not concerned in 
 its immediate care must be avoided. Attendants ill with colds 
 and other forms of infection should observe most rigid rules of 
 asepsis to avoid cross infections. 
 
 PREPARATIONS FOR THE INFANT'S BIRTH. 
 
 In case of expected premature labor immediate preparations 
 must be made for the reception of the infant into a proper 
 environment. The preparation must not be delayed until 
 labor has begun, otherwise many viable premature infants will 
 be lost. If the proper facilities cannot be furnished in the 
 home, the mother should be persuaded to enter a hos-
 
 132 CARE AND NURSING OF PREMATURE INFANTS 
 
 pital before confinement. She should be impressed with the 
 fact that every day of added intra-uterine life will improve the 
 infant's chances not only for life, but also for normal development. 
 Preparation for the proper conduct of labor should be complete 
 whether in the home or hospital. The mother should be prepared 
 with great care and every effort made to conduct an aseptic labor. 
 The room should be selected and prepared to meet the needs for 
 labor and the requirements of the infant. It should be well venti- 
 lated and properly heated to at least 70° F. Blankets and pads 
 into which the baby is to be received should be warmed. The 
 basket-bed or incubator-bed should be prepared for its reception 
 by proper sterilizing and heating, so that all exposure to cold will 
 be avoided. Everything must be in readiness for the care of the 
 cord, eyes, mouth, skin and treatment of asphyxia. These should 
 include a catheter and hot bath, and facilities for transportation 
 of the infant to a hospital, if necessary. 
 
 IMMEDIATE CARE OF THE PREMATURE INFANT. 
 
 Asepsis.— The greater susceptibility of the prematures demands 
 even more painstaking observation of the rules that hold good for 
 new-born infants in general. These infants succumb more readily 
 to infection and are much less resistant than are the full-term 
 infants. Again, the frequently complicated feeding technic gives 
 more opportunity for disturbances of the digestive tract so that 
 in every form of indirect feeding careful attention to details must 
 be insisted upon. Also the danger of infection of the respiratory 
 passages by careless exposure and aspiration of food are not to be 
 underestimated. 
 
 Reception of the Infant. A warm sterile pad, towel or preferably 
 a blanket should be in readiness to receive the infant. As soon 
 as the head is born the face and eyelids should be gently sponged 
 with sterile warm water, and the mucus should be removed from 
 the air passages by carefully wiping the nose and mouth with a 
 soft pledget of gauze. The body and cord should be protected 
 from all contact with feces and other infected matter. After the 
 body is born the infant should be placed so that the head is 
 dependent, allowing the mucus and secretions which may have 
 accumulated in the respiratory passages to escape. 
 
 Preservation of Body Temperatures.— The preservation of tempera- 
 ture demands a very careful supervision immediately following 
 birth, proper attention must be paid to the thermolability and 
 tendency to subnormal temperatures. The chief object in the 
 preservation of the temperature is the prevention of excessive 
 heat loss, which in itself may be a danger to the infant. This will
 
 IMMEDIATE CARE OF THE PREMATURE INFANT 133 
 
 also diminish the energy loss. The infant must be wrapped in 
 material with poor heat conduction, and then placed in a warmed 
 bed. Both are essential to a successful maintenance of body tem- 
 perature. 
 
 The preservation of heat must be begun immediately after 
 birth of the infant, preferably on the confinement bed itself, as the 
 extent of the initial temperature loss is of no mean consequence to a 
 premature infant. After severing the cord the infant should be 
 placed in a heated basket or incubator-bed, which should be a 
 part of the equipment of the delivery-room. 
 
 In the home, hot-water bottles, a properly protected electric 
 pad (p. 224), or an improvised incubator (p. 223) will answer the 
 purpose. It should be remembered that these infants are easily 
 burned and such burns are usually fatal. 
 
 In small prematures the cotton-pack, completely enveloping the 
 infant, except for the face and genito-anal region, answers very 
 well. To the genital region and anus a napkin of cotton or gauze 
 combination may be applied. A jacket may be placed on the 
 outside of the cotton to hold it in place. 
 
 Treatment of the Cord.— The time of tying and section of the cord 
 will depend entirely on the general condition of the infant and to 
 some extent on the obstetrician's ability to prevent undue exposure 
 of the infant to cold. In the absence of marked asphyxia it is 
 well to allow the pulsation of the cord to become weakened or to 
 disappear before ligation. This usually requires from one to five 
 minutes during which time the infant will receive from 30 to 60 
 cc of blood from the placenta. This blood should be conserved, 
 when possible. 
 
 The cord should not be tied too close to the skin. Great care 
 must be exercised in tying the cord to prevent cutting it in two with 
 the ligature which is easily accomplished in the premature, therefore 
 it is always well to leave sufficient space for a second ligature 
 behind the first in case of an accident. 
 
 Asphyxia.— The possibility of asphyxiation of the premature 
 infant must be borne in mind throughout the entire labor. The 
 heart tones should be carefully watched and in cases of prolapse 
 of the cord, if it cannot be successfully replaced, it may be neces- 
 sary to induce a rapid delivery of the infant. Any accumulated 
 secretions or aspirated material must be removed by inversion of 
 the child and if necessary by aspiration by means of a catheter. 
 In more extreme degrees of asphyxia early separation of the cord 
 may be necessary so that artificial respiration and a hot bath may 
 be instituted (p. 244). 
 
 The irritation of the catheter in the pharynx will frequently 
 reflexly stimulate respiration. It should, however, be remembered 
 that the use of the catheter is not without danger to the operator
 
 134 CARE AND NURSING OF PREMATURE INFANTS 
 
 because of the frequency of syphilis as a cause of premature birth. 
 If these procedures fail to bring about the desired result the infant 
 should be suspended by the feet, the forehead resting lightly on 
 the bed or table so as to deflect the chin and straighten out the 
 trachea and then the chest is compressed between the thumb of 
 the right hand resting on the back and the four fingers of the same 
 hand resting on the anterior wall of the chest. 
 
 This act should be repeated from sixteen to twenty times a minute 
 by compressing and suddenly relaxing the chest wall. This should 
 be continued for at least one minute in severe cases to insure success. 
 At the same time a nurse or assistant should wipe the excess of 
 mucus from the nose and throat. The child is then placed in a 
 warm bath (about 105° F.) for five minutes, and then placed in a 
 heated bed. In extreme cases the procedure must be repeated. 
 Administration of oxygen, about 120 bubbles per minute, may be 
 of value, if administered through a catheter inserted in the mouth 
 or a properly constructed mask. Careless handling and traumatiz- 
 ing the infant or too rapid performance of artificial respiration is 
 productive of more harm than good and must therefore be avoided. 
 There must be definite indications for all manipulations undertaken. 
 If the infant appears to be recovering spontaneously it should be 
 left alone. 
 
 It must be borne in mind in the conduct of all premature labors 
 that the anesthetics, if used in labor, tend to weaken the uterine 
 contractions, thus prolonging labor and favoring asphyxia and a 
 sufficient quantity of the drug may pass into the infant to seriously 
 affect it, which is especially true of scopolamine-morphine anes- 
 thesia. 
 
 All premature infants whether asphyxiated at birth or not should 
 be carefully watched for cyanotic attacks during the first days of 
 life, as such attacks may develop suddenly and without warning. 
 They may be due to a disturbance in the pulmonary circulation, to 
 a congenital atelectasis, or to injury of, or hemorrhage into the respi- 
 ratory center in the medulla. At other times they are precipitated 
 by intra-abdominal distention which may interfere with cardiac 
 or respiratory action. For further discussion of this condition see 
 Cyanosis (p. 241). 
 
 Care of the Mouth and Nose. — Every effort must be made to avoid 
 trauma of the mucous membranes of the nose and mouth, because 
 of the danger of secondary infections. Cleansing of the nose 
 should be done by the use of soft cotton pledgets or applicators. 
 In wiping out the mouth only soft material is permissible. Much 
 can be accomplished by facing the child with the mouth down- 
 ward or laterally with the trunk elevated, so that the mucus can 
 gravitate toward the mouth.
 
 GENERAL HYGIENE AND ENVIRONMENT 135 
 
 Care of the Eyes.— One per cent silver nitrate solution or 25 per 
 cent argyrol should be used to prevent ophthalmia neonatorum. 
 The nitrate of silver solution should be neutralized with a normal 
 saline solution instilled in the eyes. Not infrequently the application 
 of silver nitrate will result in some inflammatory reaction of the 
 conjunctiva in the first six to twelve hours after its application. 
 This is especially frequent in premature infants and is usually 
 relieved by the application of cold boric-acid solution to the lids. 
 It is not to be confused with the more serious specific ophthalmia 
 which develops on the second or third day. In case of doubt a 
 microscopic examination of the purulent discharge must be made. 
 In all cases an old silver nitrate solution which has undergone 
 decomposition should be avoided, as such solutions are far more 
 prone to irritate the sensitive conjunctiva. 
 
 Care of the Skin and Genitalia.— It is of the greatest importance 
 that premature infants shall be handled as little as possible. And 
 when there is doubt as to the advisability of giving the initial 
 warm bath, it is best omitted, because of the danger of causing a 
 collapse. When the bath can -be given without chilling it is 
 indicated in most infants weighing 1500 gm. or more. In smaller 
 infants and those showing evidence of atelectasia or asphyxia, it 
 may be needed to stimulate the respiratory functions. Oiling the 
 body is unnecessary and is to be avoided. The genitalia should 
 be carefully cleansed with a boric-acid solution or sterile water with- 
 out trauma. The same is true of the buttocks, after which a small 
 pad of cotton or combination is applied to the genitalia and but- 
 tocks. 
 
 Dressing the Cord.— Either a dry or alcohol dressing should be 
 applied. The cord usually dries by mummification and drops off in 
 most instances by the end of the first week, averaging somewhat 
 later than in full-term infants. Every precaution should be taken 
 to prevent trauma of the stump and secondary infection. This 
 applies more especially to the bathing of the infants in emergencies 
 for cyanotic spells and hypothermia. 
 
 Examination for Congenital Anomalies and Disease.— Before the 
 infant is left by the physician it should be examined for congenital 
 anomalies and evidence of syphilis and other diseases. 
 
 GENERAL HYGIENE AND ENVIRONMENT. 
 
 Requirements of a Hospital Nursery Unit.— This depends greatly 
 upon the method used for maintaining external heat. 
 
 1. Superheated rooms without heated beds. 
 
 2. Individual heated beds. 
 
 When the superheated rooms are in use separate rooms for the
 
 130 
 
 CARE AND NURSING OF PREMATURE INFANTS
 
 GENERAL HYGIENE AND ENVIRONMENT 137 
 
 older and better-developed infants must be supplied to gradually 
 accustom them to ordinary room temperature. However, this extra 
 room is not necessary when external heat is applied in individual 
 beds in which the temperature can be regulated to meet the needs 
 of each infant. In using the latter the room can be held at a 
 temperature approximating 70° F. In point of economy of space 
 and special care for the infant the latter method has every 
 advantage. 
 
 When individual heated beds are used the following units are 
 required in a properly regulated department. 
 
 Room Containing Heated Bed.— A room with a south exposure 
 is preferable. In such a room the matter of ventilation will 
 depend to a large extent upon the type of heated bed which is 
 used. When the old type of closed incubator is used, it must 
 necessarily receive fresh air through a pipe passing through the 
 wall of the building or an opening in a window, thereby sup- 
 plying the bed with air from the outside (Fig. 136). When an 
 electrically heated bed or home improvised bed is used the infant 
 is dependent upon the general ventilation of the room for its supply 
 of fresh air. 
 
 Such a room is best constructed with double windows and tran- 
 som which can be regulated at will according to the season and 
 existing weather conditions. Such a system of ventilation should 
 be sufficiently flexible to permit regulation to meet exigencies 
 which may arise due to instability of the general heating plant. It 
 has been our experience that when a well-constructed superheated 
 bed is used, variations of from 6 ° to 8° F. in the room temperature 
 during the twenty-four hours cause little inconvenience to the 
 infant. 
 
 It should be remembered that the beds should not be placed in 
 a direct line of draft between the windows and the doors. The 
 room should be built or selected with this in mind. Such a room 
 should also contain a hygrometer and special thermometers which 
 register not only the present temperature but also the extremes 
 for twenty-four hours (Taylor Instrument Company). Such a 
 thermometer is one of the best methods of testing an efficient 
 nursery. Further discussion of incubator rooms, incubators, super- 
 heated beds and similar apparatus are covered under the special 
 chapter on Incubators. 
 
 This room is to be used only for well new-born prematures in 
 their individual beds and older infants who have been gradually 
 accustomed to ordinary room temperature. 
 
 The Nursery.— The nursery should be a room independent of 
 the station in which the superheated beds are kept. It should be 
 provided with double windows, a good system of heating, and
 
 138 
 
 CARE AND NURSING OF PREMATURE INFANTS 
 
 must be kept immaculately clean. Good ventilation and general 
 cleanliness are essential. Unless a special bathroom can be pro- 
 
 Fig. 64. — Hospital bathroom, located between two small wards for infants, 
 showing two metal water jackets resting on a porcelain sink. These can be filled 
 with water and have a registering thermometer for indicating the temperature before 
 giving the bath. They are covered with a clean towel for each baby. Baby is 
 showered from an automatic mixing tank which registers temperature of the water 
 in the tank. The room further contains a scale and a low dressing table with the 
 various dressings, powders and ointments to be used. Also low nursery chairs, col- 
 lapsible bags for soiled linen and waste basins. 
 
 L 
 
 Fig. 65. — Divan bath with thermostatic mixing control.
 
 GENERAL HYGIENE AND ENVIRONMENT 
 
 139 
 
 Fig. 66. — Electrically warmed dressing table. (DeLee.) 
 
 Fig. 67. — Large unheated dressing table, provided for dressing of two babies. Scale 
 in center and closed cabinet for clothes. (Couney.)
 
 140 
 
 CARE AND NURSING OF PREMATURE INFANTS 
 
 vided, the nursery should be furnished with the following equip- 
 ment. 
 
 jm w 
 
 S/ ^ 
 
 
 
 
 
 HH 
 
 
 I jjlj 
 
 
 
 
 
 
 ■]i Mi 1 
 
 
 
 
 
 
 Fig. 68. —Scale for weighing infants. 
 
 Fig. 69. — Thermometer registering present 
 and extreme room temperature during the 
 twenty-four hours. It is to be adjusted by 
 a small magnet once daily. 
 
 Fig. 70. — Hygrometer. 
 Wet and dry bulb. 
 
 1. A bathing slab or board. We find a metal jacket which can 
 be filled with warm water very serviceable (Fig. 64). The Divan 
 bath with thermostatic mixing valve is well designed for this purpose.
 
 GENERAL HYGIENE AND ENVIRONMENT 
 
 141 
 
 2. A heated dressing table provided with cabinets for storing 
 and warming clothes. 
 
 3. Supply closets for linens. 
 
 Reading 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 of dry 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 bulb 
 ther. 
 
 1° 
 
 2° 
 
 3° 
 
 4° 
 
 5 U 
 
 6 U 
 
 7° 
 
 8° 
 
 9° 10° 11° 
 
 12 u 
 
 13° 
 
 14° 
 
 15° 
 
 16° 
 
 17° 
 
 17.5 
 
 18° 
 
 18. S 
 
 19° 
 
 19.5 
 
 20° 
 
 20.5 21° 
 
 
 Relative Hfmidity. 
 
 
 
 
 05° . . 
 
 95 90 85 
 
 80 
 
 75 
 
 70 
 
 66 
 
 62 
 
 57 
 
 53 
 
 48 44 40 
 
 36 32 28 25 
 
 23 
 
 21 19 
 
 17 
 
 15 
 
 13 12 10 
 
 66° . . 
 
 95 90 85 
 
 so 
 
 76 
 
 71 
 
 66 
 
 62 
 
 58 
 
 53 
 
 49 !45! 41 
 
 37 33 29 26 
 
 24 
 
 22! 20 
 
 is 
 
 17 
 
 15 13 11 
 
 fi7° . 
 
 95 ! 90 85 
 
 so 
 
 76 
 
 71 
 
 67 
 
 62 
 
 58 
 
 5-1 
 
 50 
 
 46J42 
 
 38 34 30 1 27 
 
 25 
 
 23 
 
 21 
 
 :>o 
 
 is 
 
 16 15 13 
 
 68° . . 
 
 95 90 85 
 
 SI 
 
 76 
 
 72 
 
 67 
 
 63 
 
 59 
 
 55 
 
 51 
 
 47143 
 
 39 
 
 35 
 
 31 | 28 
 
 26 
 
 24 
 
 23 
 
 21 
 
 19 
 
 17 16 
 
 14 
 15 
 
 69° . . 
 
 95 90 SB 
 
 81 
 
 77 
 
 72 
 
 68 
 
 1 
 
 59 
 
 55 
 
 51 
 
 47 44 
 
 40 
 
 36 
 
 32 29 
 
 27 
 
 25 
 
 24 
 
 :>:> 
 
 20 
 
 19 i 17 
 
 70° . . 
 
 95 | 90 j 86 
 
 81 
 
 77 
 
 72 
 
 68 
 
 64 
 
 60 
 
 56 
 
 52 
 
 48 44 
 
 40 
 
 37 33 30 
 
 28 
 
 26 
 
 25 
 
 23 
 
 21 
 
 20 18 17 
 
 71°. . 
 
 95 90 ! 86 
 
 82 
 
 77 
 
 73 
 
 m 
 
 01 
 
 00 
 
 56 
 
 53 
 
 49 
 
 45 
 
 41 
 
 38 
 
 34 
 
 31 
 
 29 
 
 27 
 
 26 
 
 24 
 
 22 
 
 21 
 
 19 
 
 18 
 
 72° . . 
 
 95 | 9l| 86 
 
 S2 
 
 7S 
 
 73 
 
 69 
 
 65 
 
 61 
 
 57 
 
 53 
 
 49 
 
 46 
 
 42 
 
 39 
 
 35 
 
 32 
 
 30 
 
 28 
 
 27 
 
 25 
 
 23 
 
 ?,? 
 
 20 
 
 19 
 
 73° . . 
 
 95 91 
 
 st; 
 
 82 
 
 7S 
 
 73 
 
 69 
 
 65 
 
 61 
 
 58 
 
 54 
 
 50 
 
 46 
 
 43 
 
 40 
 
 36 
 
 33 
 
 31 
 
 29 
 
 28 
 
 26 
 
 24 
 
 23 
 
 21 
 
 20 
 
 74° . . 
 
 95 91 
 
 86 
 
 S2 
 
 78 
 
 74 
 
 70 
 
 66 
 
 62 
 
 58 
 
 54 
 
 51 
 
 47 
 
 44 
 
 40 
 
 37 
 
 34 
 
 32 
 
 30 
 
 29 
 
 27 
 
 25 
 
 24 
 
 22 21 
 
 75° . . 
 
 96 91 
 
 87 
 
 82 78 
 
 74 
 
 70 
 
 00 
 
 63 
 
 59 
 
 55 
 
 51 
 
 is 
 
 44 
 
 41 
 
 38 34 
 
 33 
 
 31 
 
 30 
 
 :>s 
 
 26 
 
 25 
 
 23 22 
 
 76° . . 
 
 96 91 
 
 87 83 78 74 
 
 70 
 
 07 
 
 63 
 
 59 
 
 55 
 
 52 
 
 48 
 
 45 
 
 42 
 
 38 35 
 
 34 
 
 32 
 
 30 
 
 29 
 
 27 
 
 26 
 
 24 23 
 
 77° . . 
 
 96 91 
 
 87 83 79 75 
 
 71 
 
 67 
 
 63 
 
 60 
 
 56 52 49 
 
 10 
 
 42 39 36 34 
 
 33 31 
 
 30 
 
 28 
 
 27 25 24 
 
 Fig. 71. — Humidity table for use with wet and dry bulb hygrometer. 
 
 Fig. 72. — A milk station consisting of three rooms. Room 1. — For all used bottles, 
 bottle washers and steam bottle sterilizers. Room 2. — A clean room for preparation 
 of formulae. This room also contains milk separator, fat testing apparatus and 
 butter churn. Room 3. — Pasteurizing and sterilizing apparatus.
 
 ISCANLAN-MORRISCOl 
 
 ISUFACTURERS 
 MS USA 
 
 Fig. 73. — Portable bath basin for individual use of infected infants. Basin can be 
 removed for sterilization. 
 
 Fig. 74. — Individual bed with utensil compartment for infected cases.
 
 SPECIAL QUARTERS FOR SICK INFANTS 143 
 
 4. A well-constructed balance scale graduated to 4 gm. 
 
 5. A hygrometer (Figs. 69 and 70). 
 
 (). Thermometers registering the present and extreme tempera- 
 tures for twenty-four hours (Fig. 70) . 
 
 7. A time clock should also be provided and all feedings registered 
 by this method, so that the supervisor may have a constant check 
 on the activities of her assistants. 
 
 The general hygiene and care of the infant in the nursery is 
 second only in importance to an ample supply of human milk and 
 a maintenance of the body temperature of the infant. 
 
 Milk Stations.— A milk station for preserving and dispensing 
 breast milk and artificial diets should be a part of the equipment 
 of every general and special hospital (Fig. 72). 
 
 Wet-nurses' Quarters.— Wet-nurses' quarters should provide living 
 and sleeping-rooms for the wet-nurses and their babies. The ideal 
 requirements for such a unit are described under the chapter on 
 Wet-nurses, p. 117. 
 
 A shower bath and toilet facilities should be provided for the 
 special use of wet-nurses but not in living quarters. 
 
 SPECIAL QUARTERS FOR SICK INFANTS. 
 
 It is of the greatest importance that infected premature infants 
 be grouped according to their ailments and that complete facilities 
 for caring for these infants be established, in order to avoid cross 
 infections. Two such units should be provided whenever it is 
 expected that a considerable number of premature infants are to 
 be cared for, and should include facilities for bathing, feeding, and 
 the general care of patients. Gastro-intestinal and respiratory 
 infections must be kept separated and treated as septic cases. 
 Syphilitic infants and cases of gonorrheal ophthalmia must also be 
 provided with separate quarters. Thrush and furunculosis which 
 frequently develop into severe types should also be isolated. 
 
 Aseptic nursing is imperative to the welfare of the department. 
 Soiled linens, clothes, bottles, thermometers and all other utensils 
 must be handled as infected material. 
 
 A complete department should therefore provide for: 
 
 A. Well Infants.— A room containing heated beds for the early 
 care and cribs for graduates. The further needs are: A heated 
 dressing table, a supply closet, thermometer (high and low), hygrom- 
 eter, time clock, electric heater for emergency, screens and a 
 lavatory. 
 
 A nursery with bathing facilities, supplied with: A bath slab, a 
 lavatory, a heated dressing table, shelves for toilet articles, a gas
 
 144 CARE AND NURSING OF PREMATURE INFANTS 
 
 or electric plate, an electric heater for emergency, a scale, ther- 
 mometer, supply closet. 
 
 A special bath-room when possible should be provided so that 
 bathing in the nursery may be avoided. 
 
 Quarters for wet-nurses with independent bath and toilet facili- 
 ties, equipped with: Beds, cribs, chiffoniers, dressing table, nursery 
 
 Fig. 75. — Emergency robe with hood made of gauze and cotton combination. 
 
 chairs and lavatory. The bath room should have a shower bath, 
 dressing room, toilet and lavatory. 
 
 A milk station containing a sink, refrigerator, work table, tubs 
 for washing utensils, steam sterilizer, bottle and food racks. 
 
 Nursing staff including a directing nurse and assistants. 
 
 Wet nurses.
 
 SPECIAL QUARTERS FOR SICK INFANTS 145 
 
 B. Infected Infants. — Room equipped with heated beds and cribs 
 and provided with bathing facilities. This room should further 
 contain a lavatory, heated dressing table, scale, thermometer, 
 hygrometer, emergency electric heater, supply closet and screens. 
 The bath tub in this room may be of the small ambulatory type 
 or of the Divan slab type. Both may be easily sterilized. 
 
 Fig. 76. — Emergency robe applied to infant. 
 
 The nursery should be considered as the center of the unit and 
 when a separate bath room is provided, the former may be used 
 for housing the graduates. The temperature of this room should 
 range between 78 and 80° F. during the hour of bathing, at other 
 times 70 to 75° F. The entire station must be thoroughly cleaned 
 10
 
 146 CARE AND NURSING OF PREMATURE INFANTS 
 
 at least every second day and disinfected by scrubbing immediately 
 after the diagnosis and removal of infectious cases. 
 
 The Nursery Staff.— The selection of a personnel for the nursing 
 staff of a unit established for the care of premature infants requires 
 great care. Nurses assuming these responsibilities must be intensely 
 interested in their work. They must be willing to make many 
 necessary sacrifices while the infant is passing through the critical 
 stages. They must, at all times, be prepared to meet the emergen- 
 cies of asphyxia and to counteract the spells of cyanosis. These 
 two factors in themselves require almost constant diligence, other- 
 wise the work of previous days will go unrewarded. They must 
 use good judgment to prevent over- and underfeeding, as to a very 
 great extent the size of the individual meal will be dependent upon 
 the physical condition of the infant at the time of feeding. In no 
 other class of patients is it so necessary to change or modify on 
 short notice previous orders for diet. The nurse must know the 
 indications for and the methods of administering catheter feedings, 
 colonic flushing, tubbing and the application of artificial respiration. 
 
 In our hospital wards we have found the constant changing of 
 nurses, as is so frequently the case in meeting the curriculum for 
 nurses' training in general hospitals, to be of the greatest dis- 
 advantage. Far better results are obtained when the nurse in 
 charge has under her care assistants who need not necessarily be 
 nurses in training, but preferably young women who are especially 
 preparing themselves for the care of young infants, and who can 
 be relied upon to stay in the station for long periods of time. Such 
 women become expert in the handling of these infants, can fre- 
 quently feed them with a minimum of excitement of their reflexes, 
 and soon learn to bathe and give them their exercise and massage, 
 which is so essential to every infant in order to prevent " hospitali- 
 zation." 
 
 The ideal nursing staff for such a station is, therefore, one con- 
 sisting of a well-trained supervising nurse and a corps of assistants 
 desiring this training, and who are willing to remain in this service 
 for a long period of time. 
 
 DAILY ROUTINE. 
 
 Removal of Infants from Their Beds.— The position of the infant 
 in bed should be changed at regular intervals. The removal of 
 infants from their beds should be practised with forethought. The 
 small infants should, so far as possible, be manipulated only upon a 
 definite indication: (1) For cleanliness, including bathing; (2) 
 exercise, including gentle massage after the first week or two. In
 
 DAILY ROUTINE 147 
 
 most instances the food, when administered other than by catheter, 
 can be given without removing the baby from the bed. ( 'atheter 
 feeding in infants not subject to cyanotic spells can often be per- 
 formed to advantage without removal from the bed. When cya- 
 nosis is present or easily precipitated the infant should be removed 
 from the bed during feeding. 
 
 In preparing the infant for permanent removal from the heated 
 bed the room temperature should be gradually lessened until 70° F. 
 is approached. 
 
 Next the infant is placed in an infant's crib, the sides of which 
 have been padded to prevent extreme currents of air from coming 
 in contact with the infant and thereby increasing radiation. These 
 cribs may remain in the same room as the individual heated beds, 
 or may be kept in the nursery if it be the more desirable room of 
 the two, when there is a separate bath room. The infant should 
 not be kept permanently in a room in which a considerable number 
 of infants are being bathed throughout the day. There is no need 
 for shortening the stay of the infant in the heated bed if the tem- 
 perature of the surrounding air is gradually being lowered as the 
 infant develops. Depending upon the age and development, the 
 average length of time in a heated bed varies from one to six weeks. 
 It is good practice to place the older infants in the crib during the 
 day and to replace them in the heated bed during the night when 
 the heating of the house or ward is uncertain. 
 
 The Bath. — In the very weak infants it is frequently advisable to 
 omit the first and the daily bath for two or three days. It may, 
 however, be necessary to use the warm bath to stimulate the infant 
 during its cyanotic attacks. 
 
 It should be a fixed rule in the care of premature infants to 
 handle them as little as possible, because of the danger of provoking 
 cyanotic attacks and the regurgitation of food. It should be our 
 object to keep the skin clean and active. The practice of oiling 
 the infant as a routine measure is to be avoided. If the bath 
 cannot be undertaken without danger of chilling the infant, it 
 should be either dispensed with or postponed for a more opportune 
 time; or a partial bath may be given without removing it from the 
 heated bed by washing the face, buttocks and genitalia. 
 
 Indications for and Methods of Administering Baths.— The earliest 
 baths should consist of a sponging with water at 105° F., one part 
 of the body only being exposed at a time to prevent chilling and 
 the process carried forward as rapidly as possible in a room of 
 not less than 75° F., otherwise it is best omitted in the very small 
 infants. 
 
 As infants grow older they may be dipped in or sprayed with 
 water heated to 100° F., and this may be gradually lowered to 95° F.
 
 148 CARE AND NURSING OF PREMATURE INFANTS 
 
 Under no circumstances should the infant be bathed without 
 first taking the temperature of the water and the room. 
 
 Infants with subnormal temperature may frequently be stimu- 
 lated and the temperature raised by placing them in a warm bath 
 which is held between 103° and 106° F. 
 
 In cases of hyperpyrexia a bath from 4° to 5° lower than the 
 infant's temperature with cold to the head is of therapeutic value. 
 
 In the presence of cyanotic attacks the plain warm bath or weak 
 mustard bath with slight friction repeated as indicated are prob- 
 ably the best therapeutic measures. During such attacks the 
 infant should be handled gently as not infrequently careless and 
 rough handling will result in death during these cyanotic attacks. 
 
 All bathing before separation of the cord should be carried out 
 with the idea of promoting surgical cleanliness. 
 
 Gentle friction and light massage are of great value following 
 the bath. Neither of these methods of stimulating the circulation 
 must be overdone. Bathing should always be done before feeding. 
 
 Care of the Eyes.— If properly cared for at the time of delivery 
 and if there is no reaction to the solutions used at that time, they 
 require no further attention except ordinary cleanliness. The 
 nurse should be warned against getting bath water, or more danger- 
 ous, mustard water in the eyes. In cases of ophthalmia the treat- 
 ment is practically that as used for full-term infants with greater 
 care for the prevention of trauma and destruction of the eye. 
 
 The Nose and Mouth.— Unless there is a direct indication due to 
 plugging of the nose or an infection of the nose and mouth, there 
 should be no manipulation of these mucous membranes, because of 
 the danger of abrading them and opening fresh surfaces for infec- 
 tion. In the presence of upper respiratory tract infections or 
 stomatitis, the greatest care should be taken in applying local 
 treatment as advised in the special chapter dealing with these 
 diseases. 
 
 The use of the nasal catheter is always a dangerous procedure 
 and even the passing of the catheter through the mouth may result 
 in trauma if not carefully performed. 
 
 The Breasts. — In simple mastitis the breasts should be anointed 
 with camphorated oil and a light pad of cotton held in place by a 
 snug breast binder. The dressing may be changed every second, 
 third or fourth day as indicated. In case of abscess formation, 
 which is of very infrequent occurrence in prematures, incision and 
 drainage should be performed. 
 
 The Genitalia.— The genitalia more especially the vulva in girls 
 should be handled with extreme care in order to avoid trauma 
 and infection. Small cotton combination pads should be applied 
 to the buttocks and genital organs in order to receive the feces and
 
 DAILY ROUTINE 149 
 
 urine. They should he frequently changed in order to avoid irri- 
 tation from the excreta. By the use of these small pads which are 
 described under the chapter on clothing, the frequent change of 
 
 diapers can he avoided. 
 
 When there is evidence of infrequent or painful urination, which 
 is more especially true in a male infant, it should be immediately 
 inspected for evidence of occlusion due to the drying of secretion 
 or exudate in the presence of an ulcer at the meatus. The but- 
 tocks are easily irritated by the decomposing urine and acid 
 stools, and these parts readily become infected. In most instances 
 the napkin can be changed without removal from the bed. In 
 the treatment of all lesions about the genitalia an attempt should 
 be made to keep the parts dry and clean. If water proves irritat ing 
 a starch water may be substituted or the parts may be cleansed 
 with benzoated lard. The parts are then dusted with stearate of 
 zinc or rice starch. When these simple methods fail, a 1 per cent 
 mixture of balsam of Peru in castor oil or lanolin may be used. ( )ur 
 best results have been obtained in older infants when the buttocks 
 are exposed to warm dry air through the medium of an incandescent 
 electric light or sunlight if the latter is possible without the 
 danger of chilling the infant. In small prematures the parts may 
 be left uncovered in the heated bed. Small rolls of cotton ma}' be 
 used to separate the folds of the skin. 
 
 The present-day use of washing powders, which are retained in 
 improperly rinsed diapers and which lead to a rapid decomposition 
 of the urine, may be a source of intertrigo. 
 
 Delayed urination is not infrequent and should lead to an inspec- 
 tion of the genital organs. A delay of twenty-four hours in the 
 passage of the first urine is quite common in premature infants. 
 If the infant is otherwise apparently normal, it should not be a 
 cause for too great concern, and it is to be remembered that a small 
 quantity of colorless urine may dry out and go unobserved. The 
 best treatment is the administration of fluids approximating one- 
 twelfth to one-twentieth of the body weight of the infant during 
 the first day or two, and later approximating one-sixth of the body 
 weight. This is inclusive of all fluids administered. A warm 
 moist pad over the lower abdomen and pelvis or a warm bath will 
 frequently cause spontaneous urination. 
 
 Uric-acid crystals and urates are very commonly found in the 
 urine of the premature causing a pinkish stain on the napkin and 
 are most commonly due to marked concentration of the urine. At 
 autopsy, however, more frequently than in the full term, do we find 
 these salts deposited in the kidneys. Considerable pain may be 
 caused by the passage of these deposits through the ureter. In 
 every case fluids should be pushed.
 
 150 CARE AND NURSING OF PREMATURE INFANTS 
 
 The Bowels. — The anus should be carefully inspected shortly after 
 birth to ascertain the presence or absence of anomalies. Delay in 
 passing the first stool may be due to one of many causes, such as 
 delayed peristalsis, weak abdominal wall, contracted sphincter and 
 accumulation of feces, most commonly in the sigmoid or cecum. 
 
 We believe it is a good custom to attempt to promote a bowel 
 movement before the beginning of milk feedings. Frequently the 
 administration of inert fluids per mouth will promote peristalsis. 
 We do not hesitate to give a 1- or 2-ounce normal saline colonic 
 flushing. The amount used depends upon the development of 
 the infant. A small glycerin or soap suppository answers. If 
 there remains doubt as to the patency of the intestinal tract, a 
 small dose of castor oil, 0.5 to 1 cc (8 to 15 drops), may be admin- 
 istered per mouth. Once the patency of the intestinal tract has 
 been established, intestinal evacuations are usually spontaneous, 
 more especially so with infants fed on breast milk or with high 
 carbohydrate mixtures. For further treatment see Constipation. 
 
 Care of the Skin.— The skin of the premature is very delicate and 
 covered with lanugo and prominent sebaceous glands. There is 
 a great tendency for the skin to dry and crack and to desquamate 
 in large flakes. This is especially true in infants suffering from 
 marked jaundice. There is- also great tendency for papular, 
 vesicular and pustular eruptions of various types to develop. 
 Erythematous eruptions are of frequent occurrence. All of these 
 conditions will call for a modification of the daily routine, insofar 
 as the baths and local skin care are concerned. The greatest 
 danger is due to secondary skin infections which is especially true 
 of the syphilitic infant. The various forms of dry treatment of 
 these lesions offer the best results with the least danger of spread- 
 ing. The application of silver nitrate to each pustule and vesicle 
 after cleansing with alcohol have given us the best results, except 
 in the case of syphilitic infants where local mercurial treatment is 
 indicated. 
 
 The daily care of the skin should therefore consist of the avoid- 
 ance of trauma and exposure to secondary infections in the bathing 
 and handling of the infant, the removal of all excretions, the sepa- 
 ration of irritated folds by a layer of cotton, and the dry treatment 
 of all non-suppurating skin lesions, and antiseptic treatment, 
 cauterization or specific treatment of open lesions. 
 
 Delayed Separation of the Cord.— Delayed separation of the cord 
 may be hastened by the application of 5 per cent silver nitrate 
 solution or 50 per cent alcohol dressings. In the use of the latter 
 a few drops of alcohol may be applied to the dressing at regular 
 intervals. When the hard, dry cord remains intact far beyond the 
 usual time for separation it may be necessary to cut through the
 
 DAILY ROUTINE 151 
 
 remaining strands, using great care to avoid the live tissues. Granu- 
 lations are best treated by the application of silver nitrate solution 
 or hard stick. 
 
 Body Temperature.— The body temperature must be taken 
 through the rectum. It should be recorded morning and evening. 
 An individual thermometer should be furnished for each infant. 
 Fluctuations in body temperature are more marked than in the full- 
 term infant with a tendency toward hypothermia. A minimum of 
 97° F. should be considered the lowest compatible with progress. 
 Attempts should be made to limit the daily fluctuations to 1.5° F. 
 
 Subnormal temperature may result from undue exposure at birth, 
 subsequent carelessness, lack of development of the nervous system, 
 absence of a good layer of subcutaneous fat, respiratory insufficiency 
 circulatory weakness and insufficient heat production due to lack 
 of food or defective metabolism. 
 
 These etiological factors are to be counteracted by definite thera- 
 peutic measures. 
 
 Prevent undue exposure and trauma from the moment of birth. 
 
 The infant should be placed in a heated bed of proper construc- 
 tion and kept there under constant supervision. The temperature 
 of the heated bed should be varied with the needs of the individual 
 infant. Small prematures and congenital weaklings with marked 
 hypothermia should temporarily have a surrounding temperature 
 varying from 85° to 95° F. Older and stronger infants are better 
 placed in a bed at 75° to 80° F. As the infant develops its vital 
 functions and the subcutaneous fat increases, the temperature 
 of the bed should be gradually lowered to that of the nursery, which 
 should be kept at about 70° to 75° F. It should be the rule to 
 regulate the temperature of the heated bed by the rectal temper- 
 ature curve, and while it may be impossible to bring the body 
 temperature to normal, the degree of hypothermia is our best 
 guide in the application of external heat. 
 
 It may be necessary to place the infant in a hot bath to raise 
 the temperature and stimulate respiratory and cardiac function 
 following syncope. 
 
 Removal from the bed should follow definite indications, ordinary 
 feeding, changing napkins and the ordinary routine measures can 
 be carried out in the bed. 
 
 The body must be insulated by proper clothing to be described. 
 
 The body fluids, after the first few days, must be maintained 
 by an intake of from one-sixth to one-eighth of the body weight in 
 fluids in twenty-four hours, and this must include a caloric intake 
 of more than a sustaining diet, 70 calories per kilo after the first 
 ten days of life (p. ISO). 
 
 Respiratory and circulatory functions must be protected and at 
 times stimulated.
 
 152 CARE AND NURSING OF PREMATURE INFANTS 
 
 Hyperpyrexia frequently results from an overheating of the bed, 
 and when a high temperature is noted the temperature of the 
 bed should be considered as a possible cause. 
 
 Infections of all kind tend to the development of fever, but on 
 the whole the reaction is le^s than in the full term, however, the 
 exception may be true. We have found massive pneumonias at 
 autopsy which were unassociated with temperature above the 
 average normal. 
 
 The Pulse.— The pulse may be imperceptible in the extremities 
 and require auscultation of the heart for timing. The cardiac 
 action will usually range from 100 to 180 per minute in the small 
 and weak infants, although occasionally a very slow pulse is noted, 
 which latter usually precludes a bad prognosis. The best indi- 
 cator of proper cardiac function is the infant's general circulatory 
 condition; it gives far more information than the number of heart 
 beats. 
 
 Respiration.— The respirations normally vary from 20 to 00 per 
 minute in different infants and are to a large extent dependent on 
 the heart action in infants not suffering from atelectasis or central 
 disturbances. During cyanotic attacks they become almost 
 imperceptible and may be temporarily suppressed. Again the 
 general condition of the infant is the best guide. 
 
 Weighing should be done at a specified time each day as part of 
 the general routine, with a good scale. The infant should, unless 
 contraindicated, be undressed for this purpose, and this is best 
 done before the bath. The relation between the time of the last 
 feeding and passing of feces should be noted. 
 
 In older well infants daily weighing may not be indicated but 
 in prematures it should be done as a routine, more especially in 
 difficult feeding cases. Those fed at the breast must be weighed 
 before and after nursing, and the food taken is to be recorded. 
 
 Loss of Body Weight during the First Days of Life.— This occurs 
 almost constantly in premature infants, the percentage loss being 
 greater in the premature than in the full-term infant, and, on the 
 whole, they are much slower in regaining their birth weight. In 
 the group of cases studied by the author the average loss in the cases 
 weighing between 1000 and 2000 gm. was 10.9 per cent. More 
 recently we have been able to reduce the initial loss to approximately 
 5 per cent in a number of cases by carefully increasing the fluid 
 intake after the first twelve hours. 
 
 Most of our cases have regained their birth weight by the 
 eighteenth to the twenty-first day, with a daily gain averaging from 
 12 to 40 gm. after reaching their lowest weight, which is usually 
 about the fifth day. Infants under 1500 gm. may be considered 
 as progressing satisfactorily on an average of from 10 to 20 gm.,
 
 DAILY ROUTINE 153 
 
 and doubling their birth weight in seventy-five to one hundred days; 
 and those from 1500 to 2000 gm. when they are making a daily 
 gain of from 15 to 25 gm. after they have reached or passed their 
 birth weight with a doubling of that weight in from fifty to one 
 hundred days. 
 
 The Infant's Clothes.— The wardrobe should be planned and 
 completed in advance of labor. In emergencies this may not be 
 possible. It is imperative to remember that preservation of the 
 body heat must be begun immediately after birth; on the con- 
 finement bed itself. Insulation of the body is the prime thought to 
 be borne in mind when planning the wardrobe. The clothes must 
 fit the body snugly, providing only for a thin layer of air between 
 the body and the dress. The material must be selected with 
 some knowledge of the method by which external heat is to be 
 supplied. The head, except the face, and the extremities must be 
 equally protected with the body. 
 
 At birth the infant is received into a warm blanket and imme- 
 diately placed in a heated basket, heated bed or incubator. 
 
 In supplying external heat it should be remembered that these 
 infants are easily burned, and such burns are usually fatal. 
 
 In small prematures for temporary emergency use a sterile 
 cotton-pack which completely envelopes the infant, except for the 
 face and genito-anal region, may be applied. It should, however, 
 be remembered that cotton is far inferior to wool in prevention of 
 heat radiation. An improvised jacket, preferably of flannel, may 
 be placed on the outside of the cotton to hold it in place. 
 
 To the genital region and anus an easily changed small pad of 
 cotton or gauze combination may be applied. Whenever the infant 
 becomes soiled, it is only necessary to change the pad. This should 
 not be neglected. 
 
 If special outer garments are not available, the infant should 
 at once be wrapped in a small heavy woolen blanket, or cotton 
 combination, which can be fastened about the body loosely by 
 bandages or safety-pins in papoose fashion. The greatest dis- 
 advantage of such a dress is the limitation of body movements, 
 which is of considerable importance even in these infants. All 
 pressure and constriction must be avoided (Figs. 75, 70 and 7" I. 
 
 In a well-equipped station several sets of special cloths should be 
 provided. These should be kept sterilized in packets. The outfits 
 will differ somewhat, depending upon whether the open or closed 
 incubator beds are used. 
 
 With the open type of heated beds, all garments next to the body, 
 except the napkins, should be made of light-weight flannel. 
 
 A set of clothing should consist of woolen bands of small size; 
 small woolen undershirts; overshirts; pinning skirts; woolen stock-
 
 154 
 
 CARE AND NURSING OF PREMATURE INFANTS 
 
 ings; diapers; pads; bibs; and a woolen bag, with an attached 
 head-piece, with a slit over the upper part in front to allow passing 
 over the head. The bag should be open at the bottom to allow of 
 its being raised for changing of napkins, dressing the cord and 
 general care of the infant (Fig. 77). The overshirt should be some- 
 what longer and larger than the undershirt and may to very good 
 
 Fig. 77. — Woolen bag with hood. For further protection it may be drawn together 
 beneath the infant's chin. 
 
 advantage be made from French pique which is less impervious to 
 air than flannel. 
 
 In the absence of a sleeping bag the infant may be wrapped 
 in a light flannel blanket, so applied that the upper part will form 
 a hood. 
 
 With the closed type of bed, the sleeping bag and blanket are 
 unnecessary.
 
 DAILY ROUTIXK 
 
 l.v, 
 
 A complete outfit for use with an open bed should contain: 
 
 Four bands 12 inches long and 4 inches wide (flannel or knit 
 wool). 
 
 Four undershirts with blind sleeves and draw string at neck 
 (flannel). 
 
 Four overshirts (flannel or French pique fleeced). 
 
 Fiu. 7S. — Wool flannel undershirt with 
 
 Fig. 79. — Heavy overshirt made from French pique. 
 
 Four pinning skirts (French pique 24 by 2S inches). 
 
 Two bags with hoods 30 inches long and 20 inches wide (woolen). 
 
 Or two blankets 1 yard square (flannel, knit wool or cashmere). 
 
 Four pairs of stockings (woolen). 
 
 Two dozen diapers size 18 by 20 inches (fine bird's eye). 
 
 Small genital pads (absorbent cotton and gauze). 
 
 Bibs (same material as jackets).
 
 156 
 
 CARE AND NURSING OF PREMATURE INFANTS 
 
 How to Dress the Baby.— The clothes must be put on quickly with- 
 out undue exposure. First, the abdominal band is applied, if needed 
 
 Fig. 80. — Pinning skirt or blanket for the lower half of the body. 
 
 French pique.) 
 
 (Made from 
 
 Fig. 81.— Bib. 
 
 to retain cord dressing, otherwise it may be omitted, then the under- 
 shirt, followed by the overshirt, both of which are pinned at the side, 
 next the small genital pads and diapers, to be followed by the
 
 DAILY ROUTINE 
 
 157 
 
 pinning blanket, the latter being turned up over the feet and pinned 
 at the back. 
 
 The infant may then be placed directly in its bed and its head 
 and body covered by a blanket, or it may be put in one of the 
 woolen bags before being put in its bed. The selection of the last 
 article of dress will depend largely on the condition of the infant. 
 
 Fig. 82.— Pattern for designing under- and overshirts. Diagram of body and sleeve 
 
 patterns. 
 
 The essentials of the dress are: 
 
 1. Good insulation. 
 
 2. Cleanliness. 
 
 3. Protection from changes in temperature. 
 
 4. Ease of application and removal with a minimum manipula- 
 tion of the infant.
 
 158 
 
 CARE AND NURSING OF PREMATURE INFANTS 
 
 In the emergency and in very small and weakly infants these 
 indications may be met temporarily by a complete envelopment in 
 cotton, but as soon as safe and convenient the infant should be 
 dressed in the simple and easily applied garments described. These 
 
 Fig. 83. — Dressing the baby. Under- and overshirts applied. 
 
 garments are so applied that they may be described as upper and 
 lower garments. For the changing of soiled napkins the upper 
 half of the clothes need not be removed. Complete undressing is 
 required only for the purpose of bathing. 
 
 Fig. S4. — Dressing the baby. Under- and overshirts and pinning shirt applied. 
 
 Many of these little infants vomit repeatedly and if it were not 
 for the heavy texture of bib and jacket, it would necessitate very 
 frequent complete undressing of the infant, instead of removal 
 of the soiled linen only, which is but part of his dress. These 
 clothes are easily ironed. Absorbent cotton can be used as a bib. 
 
 We also provide for fresh bedding preferably by the use of 
 untarred jute in our bed and pillows, if the latter are used, which 
 can be thrown away at will because of its cheapness. 
 
 The infants should be watched very closely and the wet and
 
 DAILY ROUTINE 159 
 
 soiled linen changed immediately to prevent intertrigo, as the urine 
 dries very quickly in the heated bed and when concentrated erodes 
 the skin, which is severe and disastrous to these children. After 
 each change the infant should be carefully cleansed, either with 
 water, benzoated lard or mineral oil, before being replaced in the 
 heated bed. The clothes should fit snugly and are to be preheated 
 before applying and must be absolutely dry. This especially applies 
 to diapers. In laundering the baby's clothes no bluing, lye or strong 
 alkaline soaps should be used, the best for this purpose being a 
 neutral or nearly neutral soap of the type of which Ivory soap is an 
 example. The clothes should then be rinsed in pure water before 
 drying. 
 
 The child should not be wiped with the soiled diaper, but with 
 absorbent cotton which can then be destroyed. The same should 
 apply for bathing purposes, where cotton is far more cleanly than 
 a sponge. 
 
 Arranging the articles on and in a heated dressing table expedites 
 dressing the infants with the above style of dress. The child can 
 be dressed in one or two minutes without undue manipulation. 
 
 Watch for Sickness.— The possibility of grave pathological changes 
 with minor clinical manifestations must be constantly borne in 
 mind in the care of prematures. In order to diagnose and properly 
 counteract the dangers which may follow the overlooked simple 
 ailments, at least one daily general inspection and examination, 
 quickly but carefully performed, is required. The exception to 
 this rule is the immediate danger due to handling extremely delicate 
 infants. 
 
 In no other group of infants is a careful study of the individual 
 functioning of the heat centers and the respiratory, circulatory, 
 nervous, genito-urinary and gastro-intestinal organs so imperative. 
 
 The Hospital Records.— The records should include the following 
 forms: 
 
 1. A history and physical examination blank (Fig. 85). 
 
 2. A graphic record chart (Fig. 86). 
 
 3. A special feeding card for recording the amount of individual 
 feedings and stamped by the time clock. Time of urination and 
 stools and a description of the latter can be recorded on this same 
 card. Inspection of the infant at feeding times will prevent neglect 
 in changing the infant and assist in the prevention of local and 
 ascending bladder infections. The data from the feeding card 
 should be transposed to the graphic record sheet daily (Fig. 87). 
 
 4. Temperature chart for room and bed. On this sheet is 
 recorded the temperature of the bed in which the baby is kept. 
 It should be charted at six-hour intervals, best at 6 a.m., 12 M. and 
 6 and 12 p.m. These are the most likely times for maximum changes
 
 160 CARE OF NURSING AND PREMATURE INFANTS 
 
 in the ward temperature which might call for an increase or decrease 
 in the external heat to be applied to meet the desired bed tempera- 
 ture. At the same time the ward temperature should be recorded 
 and the humidity in the room and bed should be noted and recorded 
 (Fig. 88). _ 
 
 5. Physician's order blank (Fig. 89). 
 
 6. Milk station order blank (Fig. 90). 
 
 7. Wet-nurse's record blank (Fig. 91). 
 
 The Clinical Record.— A careful history is most important, as 
 much evidence which Avill have a direct bearing on the prognosis 
 will frequently be elicited as well as suggestions for feeding and 
 therapy. The maternal history as to illness, previous pregnancies 
 and their outcome must be elicited. The paternal history is also 
 of prime importance. The presence or absence of acute illness in 
 the home, more especially whooping-cough, scarlet fever, diphtheria 
 and septic infections should be investigated before the infant is 
 discharged. 
 
 Every hospital record should show the data of at least two social- 
 service investigations. This, while usually neglected, frequently 
 reveals conditions in the home which make the early discharge of 
 these retarded infants impossible, if their lives are to be conserved. 
 
 The first investigation should be made in the shortest time 
 possible after the infant enters the hospital, the last just previous 
 to the infant's discharge. 
 
 Conserving the Mother's Breasts. — If the mother does not accom- 
 pany the infant she should be encouraged to conserve her breast 
 milk. This may be accomplished by one of several methods: 
 (1) By expression at regular intervals, and if this is the method 
 used she should be encouraged to send her milk to the hospital 
 once or twice daily, if for no other reason than to keep a record 
 of her faithfulness. (2) By nursing a neighbor baby, one loaned 
 to her from the hospital or some other source. Later by having 
 her come to the institution to nurse her own or a full-term hospital 
 baby. (3) By placing a puppy to her breasts. While this latter 
 at first thought may seem repulsive, it has in our own experience 
 proved to be a most desirable expedient. 
 
 REQUIREMENTS FOR THE CARE OF PREMATURE INFANTS 
 IN THE HOME. 
 
 The establishment and maintainance of properly equipped 
 hospital stations are essential to the lowering of mortality, more 
 especially in the large cities and particularly among the poorer 
 classes. A careful consideration of the requirements for and 
 results to be expected from their care in the home is equally essential.
 
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 Cyanosis 
 
 Hemorrhages 
 
 Stridor 
 
 Rhinitis 
 
 Icterus 
 
 Convulsions (Early, Late) 
 
 Difficult Nursing 
 
 \ itii.n 
 
 Meleorism 
 
 Diarrhea 
 
 ( loQstipation 
 
 Atelectasis 
 
 Bronchitis 
 
 Pneumonia 
 
 Edpma 
 
 
 Cerebral Hemorrhages 
 
 
 Encephalitis 
 
 Adenitis 
 
 Otitis 
 
 Cord (Condition of) 
 
 Pyelitis 
 
 
 Rachitis 
 
 Mr-gaecphalus 
 
 Spasmophilia 
 
 Hydrocephalus 
 
 Anemia 
 
 Meningitis 
 
 Scurvy 
 
 SOf)- 
 
 Conitgenol Deformities 
 l Iperations 
 
 Important details of diseases. 
 
 -During first week- 
 
 First ten days (Breast, bottle, 
 Amount 
 
 Subsequent feedings. Kind- 
 Interval 
 
 ;ed). Number- 
 
 Administered (Breast, dropper, bottle, catheter). 
 Method 
 
 Present Feeding (Able t 
 
 MOTHER'S general health: 
 
 Quality of breasts (good, fair, poor) 
 
 Is she pumping, expressing, olln-r inHln,.|- 
 
 Why was nursing discontinued? 
 
 Does the baby take all of its feedings? 
 
 Does the baby vomit?. . How 1 
 
 Does the baby have colic? Whc 
 
 How many times a day do the bowels move 
 Color 
 
 Is she available? (Ye 
 
 Xipiilc mood, bad, inverted) — 
 
 PHYSICAL EXAMINATION 
 . . . —Respiration. (Underlii 
 
 INSPECTION: Bright Apathetic 
 
 GENERAL CONDITION: Fat Tli 
 
 SKIN: 
 
 Normal Prickly Heat 
 
 Tissue turgor Seborrhea 
 
 MUSCLES: Biceps and thighs 
 
 HEAD : Normal Deformities 
 
 i 'raniotabes _ . Megacep 
 
 EYES: Pupils equal, unequal 
 
 Blepharitis 
 
 NARES: Clear Crusted Discharge Chara 
 
 MOUTH : Normal 
 
 Deformities, hare-lip, cleft palate, et 
 
 ■ each word describing condition) 
 Fair Poor 
 
 -jStomatitis (type)—
 
 PREMATURE INFANTS 
 Date 
 
 I 
 
 Telephone _ . 
 Guardian's Na 
 
 i;. fi i red i o 
 
 House Flat Front Roar Floor. 
 
 WHY IS INFANT BROUGHT TO THE HOSPITAL? (Mother's 
 
 in hospital. homc„ 
 
 Method by which l»>dy t nn| ..i ;M ui .■ lei- lnrn maintained— 
 
 HISTORY OF PREGNANCY dm^t. duration ami [.rounds of illnesses, 
 
 L&sl Menstruation (first day of) 
 
 HISTORY OF LABOR (Length)- 
 
 -hours, Spontaneous, Indued, i >)„,■, 1 1\ .. 
 
 FAMILY HISTORY 
 
 Living Dead Age Condition of Health Caiis.-ui I ><..,> I, 
 
 Order of Pree,ji:tinie> 
 
 PERSONAL HISTORY 
 
 ! i birth 
 
 ( londition at birth 
 
 Single, Tw ins, Triplets 1 1 Irder oi bii I 
 
 sight of each and number i 
 
 Calculated Fetal Age. By History- 
 Bj Radiograms 
 
 ind Abnormalitit
 
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 PHYSICAL EXAMINATION Continued i 
 
 TONGUE : 
 THROAT : 
 GLANDS : 
 
 EARS: 
 NECK: 
 
 CHEST: 
 LUNGS: 
 
 Moist, dry, injected 
 
 Normal, injected, membrane (type) 
 Normal Enlarged 
 
 Others. 
 
 I !'H ti :ir. Intniinul 
 
 a! 1 
 
 — * 
 
 „,„, 
 
 left. 
 
 Dis 
 
 terse 
 
 ight, 
 
 ,(i r-liir'.ctir 
 
 
 barrel flat funnel pigeon rosar? 
 
 n->j.irriti(iti isj.Mi]it:,[R'oU8, induced). Degree "i asphyxia 
 
 s Respiration (thoracic, abdominal). Evideno i>f an k'i'ta 
 
 i to left of mid-sternal line, 
 i to right of mid-sternal line. 
 ti space in mid-clavicular line. 
 1 outside, inside, raid-clavicular lit 
 
 Aotion; Numl ■< i . 
 
 — reguli " 
 
 irregular 
 
 .Sounds : 
 
 Clear 
 
 impure 
 
 Rlnr.rt.priJssi.ro 
 
 LIVER: 
 SPLEEN : 
 KIDNEYS : 
 GENITALS : 
 
 FEET: 
 SPINE: 
 REFLEXES : 
 
 Hernia umbilical 
 
 Cord (condition of) 
 
 Palpable Enlarged 
 
 Palpable Yea No Sis 
 
 Hydros lo lit. I-i. 
 
 1 lefoi Mm i- - 
 
 Normal 
 
 Patellar 
 
 Kernig 
 
 Birth 
 
 Doubled 
 
 pine to ■■ ' rtex 
 l fOeal ion i entei ol bodj 
 Date 
 
 ndarii's in Mid. < '1, L. 
 
 Circumcised Undescended testicle Kt. 
 
 Vaginitis Anus rmal, al i 1} 
 
 Deformity (acquired, congenital)- Fra 
 
 Rickets 
 
 Acquired Congenital 
 
 Deformities 
 
 Brudsinski Oppenheim 1 
 
 Babinski ( 'hvostek 
 
 CIRCUMFERENCE: I l.-.t, I mi ri|.it.i-fn,i,iah-
 
 RECOMMENDATIONS : 
 FEEDING 
 
 i:\TKH\AL HEAT- 
 
 SUMMARY OF HISTORY AND EXAMINATION: 
 
 Father's History 
 
 Mother's History. Para 
 
 Patlmtogy r, f Pregnancy 
 
 Patli"l"L'> nf lalicir. Length— 
 
 -hours. Character 
 
 Infant.. Simile, Twins, Triple 
 
 Length of gestation 
 
 Temperature when rece 
 
 Congenital disease (Luesi i Kvitl.-n.-.- i_ 
 Other - __ . _ 
 
 Congenital deformities— 
 Birth injuries 
 
 Post natal diseases. First week- 
 Previous care, i Artificial heat, c 
 
 Previous reeding. Kind 
 
 Birth weight ! 
 
 .days, Age when receivec 
 "P. Condition when t 
 
 _lni(ial lnss of wi'i«ht_ 
 
 Age when B. W. regained— 
 Anemia 
 
 -Age when B. W, doubled— 
 Spasmophilia 
 
 Other pathological findings— 
 
 i i.lisi-harge. Age, etc.. 
 
 A|i|i:in ill eanse of Prematurity- 
 Cross Index 
 
 Future Development [Mental, Physical)
 
 V M 
 
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 LABORATORY AND SPECIAL EXAMINATIONS 
 
 _Di acetic Acid— 
 
 RADIOGRAM: Skek-tmi. Clu-st, Digestive Truel I Fur Aur, ilrf.irmity, infection). 
 
 BLOOD: Date- 
 
 ._( 'ejaculation Tinie_ 
 
 
 B 
 B. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 V inal Smea 
 
 S inal Puncti 
 
 
 Electrical Ren' 
 
 First Visit, Date 
 
 Mother's attitude— 
 
 Siilisi-qucnt Visits, Dates 
 
 SOCIAL SERVICE REPORT 
 
 Neigliljurliouil 
 
 _Smiitary coinlitions. 
 Breast Milk 
 
 Home good poor 
 
 _F.\pns>ioi]. pump, 
 
 SUBSEQUENT TREATMENT
 
 SUBSEQUENT TREATMENT 
 
 Date I Age I Weight ' Temp.
 
 
 
 
 
 
 
 (Da 
 
 discharge)'* 8 
 
 J We 
 
 
 
 
 
 Dr. 
 
 
 Diagnosis 
 
 
 
 
 
 
 
 
 
 entrance/* 6 
 
 )We 
 
 
 
 
 
 P 
 
 { Tniulitint. 
 
 
 
 
 
 
 
 
 
 
 Weight 
 
 Urn, 
 
 Date 
 
 
 ,..„. 
 
 ♦•»■ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 "|" 
 
 
 
 Lb. 0s.- 
 Lb. 0l.- 
 Lb. 0«.- 
 Lb. 0z- 
 Lb. 0«.- 
 Lb. 0i.- 
 
 108°— 
 107"- 
 106"— 
 
 103"- 
 102"- 
 101"- 
 100"- 
 99°- 
 98°— 
 97°- 
 96°- 
 959— 
 
 O 5 *- 
 P 4 « 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 S 
 O 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 FEEDING 
 ORDERS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 FOOD 
 CONSUMED 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 j oypo 
 
 nSImI'b'" 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 » Quality 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i ia B6. 
 
 
 A l.ri.l description of the clin 
 
 oal sheet ust 
 
 
 s may bo of v 
 
 luo a, it an. 
 
 vers both the I 
 
 i'.i|- til' [i his 
 
 orj Bheel an< 
 
 iii a dull*, ili. ul a.- iii 11. The pi.int^ illustrated 1 > v 
 
 influence thi 
 
 
 '!','.," !'s 
 
 ' . «" >< ir>i- r t.-, Ufiui,!, (juiiiity and quantity <>f food taken, and the end-results on the stools and urine, Ueo separate epae, ar- provided f.. r . ■..n. plications which may 
 
 . . '" "" :t '" [1 - "' ^ymptoius, it.Lr.'tli.T with spaces for treatment .,ther than dietetic, energy value of foods, vomiting. Mood examinations, tul.erculin reactions, etc. The small figures 1 to 10 are 
 ' u " ' "I'M- in eases showing a spasmophilic diathesis. 
 

 
 HOSPITAL RECORDS 
 Case No. 
 
 101 
 
 Name 
 
 Date of Admission- 
 Present Weight 
 
 TIME 
 
 FOOD 
 
 AMOUNT 
 
 STOOLS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 TOTAL 
 
 
 Fig. S7. — Individual diet record sheet. 
 
 11
 
 162 
 
 CARE AND NURSING OF PREMATURE INFANTS 
 
 
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 HOSPITAL RECORDS 
 
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 164 CARE AND NURSING OF PREMATURE INFANTS 
 
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 HOSPITAL RECORDS 
 BREAST MILK SUPPLY 
 
 165 
 
 
 
 DATE 
 
 HOUR 
 
 AMOUNT DISPOSITION 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Fig. 91. — Wet-nurse milk supply record sheet.
 
 166 CARE AND NURSING OF PREMATURE INFANTS 
 
 In many instances the premature is born unexpectedly with little 
 time for preparation for its reception. The expectancy of a pre- 
 mature labor is almost always associated with more or less excite- 
 ment in which thought for the baby's needs are likely to be over- 
 looked, the mother usually being given first consideration. 
 
 It will, therefore, be our object to outline a proper routine for 
 the establishment of an emergency home unit. 
 
 In the home care of these infants the same rules for hygienic 
 maintainance of body temperatures, breast feeding, and daily routine 
 must be maintained as suggested for their hospital care. 
 
 Fig. 92. — Special bath room equipment for private home, showing dressing table 
 (padded) with drawers, built over radiator. Shelves for dressing, etc., above the 
 table. Bathing board over one end of bath tub. 
 
 The Nursery Unit.— Whenever possible two rooms should be set 
 aside for the infant's use; one equipped as a nursery with furnish- 
 ings similar to those described for the hospital nursery. The second 
 room is to be used for sleeping quarters and must be equipped with
 
 REQUIREMENTS FOR CARE OF PREMATURE INFANTS 167 
 
 a heated bed. These rooms must be well ventilated and at the same 
 time well heated. In both these rooms all draperies and unnecessary 
 furniture must be removed. 
 
 Fig. 93. — Plan for arrangement of stations in a private home, consisting of one 
 large, well ventilated and heated room and a bath room. 
 
 A bath room properly equipped (Fig. 92) makes a splendid second 
 room in which the general care of the infant can be administered.
 
 168 CARE AND NURSING OF PREMATURE INFANTS 
 
 This room should be given over to the exclusive use of the infant. 
 When such a bath room is available only one other room is 
 needed. 
 
 While the baby is being dressed or bathed the nursery or bath- 
 room temperature should be in the neighborhood of 80° F. A gas 
 or electric stove will be of assistance in accomplishing this. When 
 a superheated bed is in use the sleeping room may be kept between 
 70 to 75° F. These rooms should be devoid of all excessive furniture 
 and draperies. All visitors other than the attendants and physician 
 must be excluded. 
 
 The equipment of the room or rooms should include a heated bed, 
 a dressing table, preferably heated, or placed over a warm radiator, 
 a small electric or gas stove for emergency use, a scale, bathing and 
 feeding utensils, a thermometer, a hvgrometer and surgical supplies 
 (Fig. 93). 
 
 The Superheated Bed.— In the home hot-water bottles, a properly 
 protected electric pad or an improvised incubator will answer the 
 purpose (p. 223). 
 
 A thermometer should be placed alongside the baby as too great 
 emphasis cannot be laid on the dangers and fatalities due to over- 
 heating and burning of prematures. There is a great tendency to 
 hyperthermia which must be recognized and properly interpreted. 
 There is usually a rapid return to the normal body temperature 
 without bad effects upon removal of the cause unless too long 
 continued. The general care of the heated bed has been described 
 on p. 218. 
 
 The Nurse.— She must be experienced in the feeding and handling 
 of such infants and must be tireless in her efforts to prevent compli- 
 cations. She must be diplomatic in order to permit the overcoming 
 of the mother's anxiety, with its consequent effect upon her milk 
 secretion. She must be able to control the habits of the wet-nurse, 
 if one is employed. She must insist upon taking orders from the 
 physician and no one else. She must be able to keep a careful 
 record, practise aseptic nursing, avoid accidents and be cleanly in 
 her personal habits. 
 
 A second person should be present, who can assist and relieve 
 the nurse. She must be willing to work under the nurse's supervi- 
 sion. Such a person is indispensable in the presence of emergency. 
 Only those directly interested in the care of the baby should come 
 in contact with it. 
 
 The Infant's Food.— Breast milk should be considered indispen- 
 sable and during the first days of life it may be necessary to obtain 
 a temporary supply from a neighboring mother, a wet-nurse or a 
 hospital. A small amount, 90 to 240 cc daily will usually meet
 
 REQUIREMENTS FOR CARE OF PREMATURE INFANTS 1G9 
 
 the emergency. Only when these sources of supply fail absolutely 
 should artificial feeding be instituted. 
 
 Preparation for Labor.— The protection of the infant must begin 
 with the first stage of labor. The room, receiving clothes and its 
 bed must be properly warmed. Refrigeration is the direct cause 
 of more deaths among prematures than any other extraneous factor. 
 All routine measures described for the hospital care in Chapter Vll 
 should be, so far as possible, observed in the home. 
 
 Clothes.— The clothes best suited have been described. Simplicity 
 in dress with a minimum manipulation or changing being the object 
 to be attained, because of the dangers of exposure, trauma and 
 infection. The infant should be received into warm blankets. 
 One of the most common errors is to allow the infant to remain in 
 such a loosely applied robe, which does not provide for proper 
 insulation of the skin because of the large air space between the 
 blanket and the infant. This allows rapid radiation of the body 
 heat. Therefore, at the earliest possible moment the infant should 
 be protected from head to foot by closely applied warm clothes. 
 The body, if woolen clothing is not at hand, should be wrapped in 
 cotton. The cotton should be applied in two parts, the upper 
 half encircling the head except the face, together with the trunk 
 and upper extremities, the lower half should encircle the lower 
 extremities, a small pad being applied to the genitalia and buttocks. 
 This allows for cleansing the genital region with a minimum of 
 manipulation. The upper part of the body may then be covered 
 by a small-sized infant's shirt on the outside of the cotton jacket 
 and the infant is then wrapped in a woolen blanket in its bed. The 
 clothes best adapted for later use can be made according to the 
 description on page 155, and should be supplied as soon as possible. 
 A woolen blanket should cover about three-quarters of the basket, 
 the head being left open. 
 
 The Bath.— The advisability of giving a warm bath has been dis- 
 cussed but it is our desire to emphasize the conclusion that the 
 initial bath is to be omitted whenever there is danger of unduly 
 exposing the infant. In a proper environment the warm cleansing 
 bath should be given in the absence of cardiac and respiratory 
 complications. 
 
 Further Early Care.— The baby must, under all circumstances, be 
 under constant observation during its first hours because of the 
 dangers of cardiac and respiratory complications, over- and under- 
 heating, overcovering, and overlying, the latter due to careless 
 placing of the infant in the bed. Whenever feasible the infant 
 should be placed in a properly prepared room away from the mother. 
 Its personal attendant, other than for special care, need not neces-
 
 170 CARE AND NURSING OF PREMATURE INFANTS 
 
 sarily be a trained one. When a dependable person is not at hand it 
 should be kept in the room with the mother. 
 
 The general care should be that as described for hospital care. 
 
 The Results Obtained.— With human milk, a skilled nurse, an 
 adequate bed, a good nursery and proper feeding and nursing 
 technic the same good results are to be expected as in hospital care. 
 
 Transportation to a Hospital.— Removal to a hospital station should 
 not be delayed when nursing and feeding needs cannot be fulfilled 
 in the home. It should be moved in a specially prepared bed so 
 that it will not be exposed en route. When the infant is to be sent 
 to the hospital which is provided with a transportation incubator, 
 the institution should be called upon to transfer the infant.
 
 CHAPTER VIII. 
 
 METHODS OF FEEDING. 
 
 It is necessary to consider these infants as belonging to two large 
 groups: 
 
 1. Those able to nurse at the breast. 
 
 2. Those too weak to nurse at the breast. 
 
 INFANTS NURSING AT THE BREAST. 
 
 This presupposes that the infant has the proper physical develop- 
 ment to withdraw milk from the human breast in the presence of 
 an abundant supply and well-developed nipples. Such an infant 
 may be placed at the breast two or three times during the last half 
 of the first day after the circulatory and respiratory functions are 
 well established. Following the first day it should be placed at 
 the mother's breast regularly for two- or three-minute periods at 
 three- or four-hour intervals, even though the breast contains little 
 milk. Following these attempts at nursing, food should be supplied 
 from another mother or a wet-nurse, whenever such a supply is 
 obtainable rather than to institute artificial feeding. In the 
 hospital it is our custom to give these additional feedings by hand; 
 in private practice the infant may be placed to the wet-nurse's 
 breast, one of the breasts being set aside for this purpose, and if 
 there is a difference in the breasts the better one is selected for the 
 premature. Whenever possible this is the best method of getting 
 the food to the baby, as it prevents contamination of the milk, 
 stimulates the breasts and develops the baby's independence as well 
 as his sucking muscles. However, it is to be remembered that 
 congenital syphilis is to be excluded, both in the infant and wet- 
 nurse, in all cases where the infant is put directly to a breast other 
 than the mother's. Not infrequently great assistance may be given 
 the infant in securing its milk by one of two methods: Either by 
 expressing the milk directly into the baby's mouth or by placing 
 the wet-nurse's baby on the opposite breast (Fig. 94) which reflexly 
 stimulates the flow of milk into the opposite breast, thereby assist- 
 ing the weak infant in obtaining its food. Overfeeding becomes a 
 danger in this direct application of the infant to the breast, and 
 weighing before and after nursing should be practised. Under- 
 feeding is an even greater danger, and here again the infant must
 
 172 
 
 METHODS OF FEEDING 
 
 be weighed before and after feeding to ascertain the amount of food 
 taken. If insufficient, further food can be supplied by hand feeding. 
 
 Fig. 94. — Feeding premature infant by direct expression from right breast. Wet 
 nurse's baby on left breast assists in stimulating the flow of milk into the right breast. 
 
 INFANTS TOO WEAK TO NURSE AT THE BREAST. 
 
 In this group of infants careless exposure must be avoided. In 
 the absence of cyanosing they may be fed without removal from the 
 bed. If cyanosis threatens they should be fed on the dressing table. 
 The inability to nurse may be due to improper development of the 
 nursing center, or lack of coordination on the part of the pharyngeal 
 muscles and tongue. The latter is usually made evident by a return 
 flow of milk from the mouth. Again, the infant may be too weak to 
 nurse, or it may not have learned to suck, or vomiting or perhaps 
 cyanosis may prevent its feeding properly. In this group of infants 
 we may, of necessity, resort to one of several procedures : 
 
 The use of a fruit spoon (Fig. 95) or, better a large size medicine 
 dropper (Fig. 96). 
 
 In those infants who can assist themselves: 
 
 A small nursing bottle (Fig. 97). The 1-ounce bottle is provided 
 with small nipples the size of those commonly sold on doll nursing 
 bottles, which can usually be obtained of proper quality. Such a 
 nipple can be made by perforating the rubber bulb of a better 
 quality medicine dropper. Our 2-ounce bottle has a larger neck 
 which takes the ordinary size nipple. One with a small mouth 
 piece must be used. It should be made of a soft elastic rubber. 
 The semitransparent nipples usually answer best.
 
 INFANTS TOO WEAK TO NURSE AT THE BREAST 173 
 
 Fig. 95. — Fruit spoon which can bo used for mouth or nasal feeding. The latter is 
 
 not recommended. 
 
 Fig. 96. — Large medicine dropper with a short piece of soft rubber tubing over 
 lower end to prevent injury to the baby's mouth. Most infants soon learn to suckle 
 on the soft rubber tube when inserted into the mouth. When sufficiently developed 
 a small bottle and nipple can be substituted. 
 
 Fig. 97. — One ounce graduated nursing bottle with small nipple approximately 
 the size of the end of an ordinary medicine dropper. Two ounce graduated bottle 
 with a special nipple with a small mouth piece. This nipple will fit on the larger neck 
 bottle sold on the market and can also be inverted for cleansing. Another good 
 nipple is that shown in type two Breck feeder. (Fig. 98.)
 
 174 
 
 METHODS OF FEEDING 
 
 The Breck feeder in the original, or a modification which can be 
 made by flanging the ends of a urethral syringe, using a heavy 
 rubber finger-cot on one end and a small nipple or perforated soft 
 medicine-dropper tip on the other, will usually suffice (Fig. 98). 
 The second type illustrated has the disadvantage of having the milk 
 enter the bulb on filling from the large end. The bulbs are difficult 
 to clean. 
 
 Fig. 98.— Modified Breck Feeders. Type I: with a small nipple at the lower 
 end and an ordinary finger cot at the upper end. Type II: has a large nipple at 
 the lower end and a medicine dropper bulb at the upper end. The latter is not a 
 safe model because the milk must be poured into the large end and therefore enters 
 the bulb which is difficult to clean. Type III can be made by flanging a straight 
 piece of large tubing and using the large nipple at one end and the finger cot at the 
 other. The glass part can be blown by any specialty glass company or the barrel 
 of an ordinary glass syringe can be drawn and flanged to take the rubber parts. 
 
 Direct expression of milk into the infant's mouth has proved 
 one of the most valuable expedients in our hands as a method of 
 teaching the infant the act of nursing. 
 
 Catheter feeding is the simplest and best method of procedure in 
 the smaller infants, if carefully practised by an experienced nurse.
 
 INFANTS TOO WEAK TO NURSE AT THE BREAST 175 
 
 Catheter feeding should be instituted as soon as fatigue or cyanosis 
 is noted following other methods of feeding. A catheter (No. 12 
 French, No. 8 American, No. 5 English) about 14 inches in length 
 may be attached to a small funnel, graduated glass tube, or, in case 
 of emergency, the glass barrel of a small syringe may be used. All 
 food should be carefully measured and administered slowly with a 
 minimum elevation required to obtain a free flow of the milk. The 
 
 Fig. 99. — Utensils for catheter feeding. Glass barrel of syringe, No. 12 French 
 catheter and one ounce graduate glass. The catheter should be marked at 2 cm. 
 intervals between the distances 12 to 20 cm. above the tip. 1 
 
 infant should be upon its back on a flat surface with the head either 
 in the median line or turned to the right. The passage of the 
 catheter is usually effected without difficulty by passing it in the 
 midline to the pharynx, gradually pushing it into the esophagus. 
 The poorly developed reflexes rarely cause retching. The dis- 
 
 1 As there are no short catheters marked in the metric system on the market it is 
 advisable to mark several for ward use between 12 and 20 cm.
 
 176 METHODS OF FEEDING 
 
 tance to which the catheter is to be passed is of great importance 
 when we consider that this procedure must be repeated at least six 
 to eight times daily over a considerable period of time. It has 
 been our rule to measure the distance from the bridge of the nose to 
 the tip of the ensiform cartilage, which is usually in the neighbor- 
 
 Fig. 100. — Catheter feeding. The catheter has been passed for a distance equal 
 to that from the bridge of the nose to the tip of the ensiform cartilage measured with 
 the chin at right angles to the body. The lower end is seen about 1 cm. above the 
 cardia in A, Fig. 101. 
 
 hood of 12 to 15 cm. (Full-term new-born infants average about 
 16 cm.) The catheter is marked at this point with indelible ink 
 and is passed to this point or about 1 cm. further than this distance 
 which allows it to reach the lower end of the esophagus just above 
 the cardia, from which point the food will flow through the patent 
 cardia. We thereby avoid irritating the gastric mucosa and 
 stimulation of the reflexes at the cardia. One soon learns the
 
 INFANTS TOO WEAK TO NURSE AT THE BREAST 177 
 
 Fig. 101. — Feeding baby with catheter. Catheter feeding as carried out by one 
 person. The head is held at right angles by the left hand, the catheter is passed 
 with the right hand. Next the funnel is passed to the left hand and elevated to allow 
 the air to escape from the stomach. The catheter is now compressed and slightly 
 elevated and part or all of the feeding is poured in from the graduate and allowed to 
 flow slowly into the stomach. The small sketch illustrates the point to which the 
 lower end of the catheter should be passed. 
 12
 
 178 METHODS OF FEEDING 
 
 distance the catheter can be passed in each case in order to avoid 
 retching. The milk is now allowed to flow into the stomach slowly, 
 the funnel being raised only slightly above the level of the body, 
 usually 6 or 8 inches will suffice. After the feeding the catheter 
 is firmly compressed to avoid spilling milk into the pharynx during 
 its removal (Figs. 99, 100 and 101). 
 
 The infant should be turned on its right side following the feeding. 
 In the presence of gastric distention, raising the infant before and 
 after feeding to the vertical position, avoiding flexion of the body, 
 will allow of the eructation of air and frequently prevent cyanosis. 
 When the stomach is noticeably distended with gas before feeding 
 the catheter should be passed 1 or 2 cm. further than the mark on 
 the catheter before starting feeding, in order to allow the gas to 
 escape. It is then retracted as directed and feeding started. The 
 catheter should be passed with the funnel empty, so as to allow of 
 this procedure. The catheter should then be compressed and the 
 milk poured into the glass funnel. This allows the air in the funnel 
 to escape thereby preventing overdistention of the stomach by the 
 mixture of food and air. The feeding period should be as short as 
 possible without undue haste. Too rapid feeding is more dangerous 
 than too slow. Usually one to three minutes are needed. Two 
 nurses can be used to advantage in catheter feeding, but, as so 
 frequently happens, only one is available during the night feedings. 
 Every nurse should be trained to undertake catheter feedings with- 
 out assistance. We believe that turning the infant on the right side 
 following feedings reduces the emptying time. Its position should 
 be changed at least once between feedings to avoid localized pulmo- 
 nary congestion. 
 
 The Number of Feedings.— This will, of necessity, depend in many 
 instances upon the question of catheter versus other methods of 
 feeding. Larger infants fed by catheter can often be given sufficient 
 food at four-hour intervals to meet their needs. In small infants 
 fed by dropper, bottle or other methods we have experienced great 
 difficulty in administering a sufficient quantity of food by the long- 
 interval feeding. As the attendants in charge are frequently not 
 to be trusted with the catheter feeding, the short-interval feeding 
 must be resorted to. 
 
 For this purpose we have grouped our infants into two classes— 
 those weighing under 1500 gm. and those weighing above this figure. 
 These figures are arbitrary and will not require rigid adherence. 
 The classification is based on the tendency of the smaller infants 
 to become exhausted when the feedings are too long continued. 
 The smaller hand-fed infants are fed at two-hour intervals during 
 the day and three hours at night. The larger on the three-hour 
 basis. When catheter feeding is the method of choice, even in 
 the smaller infants six to eight is usually the maximum number
 
 INFANTS TOO WEAK TO NURSE AT THE BREAST 170 
 
 needed in twenty-four hours. It must be remembered that all 
 feedings are dependent on the general development of the infanl 
 in relation to its digestion and metabolism and its ability to retain 
 the food administered, as well as on the attendant complications to 
 feeding, such as asphyxia, cyanosis and gastric distention. 
 
 When to Start Regular Feeding.— This is a question of great 
 importance to these infants, because of the tendency to develop 
 acute inanition. Therefore a regular feeding regimen must be 
 started early. Human milk is essential to a low mortality. As 
 little can be expected from the mother for several days, it becomes 
 necessary to obtain the limited supply necessary from another 
 mother, preferably a wet-nurse. If for any reason it is unlikely 
 that the mother may be depended upon, either because of illness or 
 local breast conditions, immediate search should be begun for a 
 supply of breast milk. 
 
 Feeding During the First Day.— During the first day it is our custom 
 to withhold milk for twelve hours until the respiratory and circula- 
 tory functions are well established. During the second twelve hours 
 one to three feedings of breast milk may be started if the infant's 
 condition warrants. 
 
 Feeding from the Second to the Tenth Day.— The second to the 
 tenth days may be grouped together as the second feeding period 
 for practical purposes. 
 
 From the second day they should be fed regularly, day and night, 
 the number and time of feedings depending to a great extent on 
 whether the food be given with or without the use of a catheter; 
 second, upon the gastric capacity; third, upon the infant's general 
 condition. 
 
 Further fluids, preferably inert, such as water or 1 per cent 
 lactose solution, are administered to compensate for the loss of 
 body fluids through the kidneys, bowels, lungs and skin. The 
 infant requires about one-sixth of its body weight of water, inclu- 
 sive of that contained in the milk, in twenty-four hours while in 
 the heated bed. Such quantities, however, should not be attempted 
 on the first days; usually it will be possible to approximate one- 
 eighth of the body weight by the fourth day. The early feedings 
 must necessarily be small and the increases gradual. 
 
 Each Infant Fed Individually . —They must be considered individu- 
 ally, as it is impossible to formulate definite rules for feeding, at 
 least during the first ten days. 
 
 1. We must have a definite idea of the minimum food require- 
 ments for life. 
 
 2. The amount of food necessary to maintain at least a stationary 
 weight. 
 
 3. The amount of food needed to meet the requirements for 
 growth and development.
 
 180 METHODS OF FEEDING 
 
 Approximately one-seventh of the body weight of fluids and 
 human milk of a food value of 70 calories per kilo every twenty- 
 four hours are required to maintain life. Little can be expected 
 in the way of weight increase until 90 calories are reached, and 
 depending on their weight, body surface and physiological develop- 
 ment, their later needs will approximate 100 to 140 calories per 
 kilo body weight (Table IV). In exceptional cases it may be 
 necessary to feed breast milk in amounts equaling 160 to 200 calories 
 per kilo. Such infants are usually markedly underweight for their 
 fetal age. 
 
 Infants, to fulfil all their needs, will therefore require from 140 
 to 200 cc of breast milk per kilo, or about one-seventh to one-fifth 
 of their body weight daily. They can, however, maintain life 
 on 100 cc and hold their weight in most cases on 130 cc per kilo. 
 Exceptionally, we have fed as high as 300 cc per kilo in under- 
 weight infants. The latter must be carefully observed for signs of 
 overfeeding, such as vomiting, gastric dilatation and cyanosis. 
 
 Beginning (in most cases by the second day) with 20 to 40 cc 
 human milk per kilo of body weight, the quantity may be 
 increased by 8 to 15 cc daily per kilo until, usually by the tenth 
 dav, feedings averaging from 80 to 140 cc per kilo can be fed 
 (Tables I, II and III). 
 
 AVERAGE HUMAN MILK DIETS REQUIRED BY PREMATURES 
 DURING THEIR FIRST TWENTY-ONE DAYS. 
 
 After the tenth day in larger infants the milk can be increased 
 more rapidly, usually by 15 and occasionally 20 cc per day, until 
 from 140 to 200 cc (100 to 140 calories) per kilo are fed, the methods 
 of giving food, as well as its frequency being dependent on the 
 general development of the infant. 
 
 The size of individual feedings will vary with the method of feed- 
 ing. When catheter fed, six to eight feedings a day are given, with 
 an average of from 4 to 6 cc per feeding during the second day. 
 The feedings are now increased daily by an average of 2 cc per 
 feeding. When feeding from the bottle or by dropper, smaller 
 feedings are usually given more frequently— usually from eight to 
 ten daily, although twelve may be needed when larger feedings are 
 not retained. Begin with 2 to 4 cc and increase by 1 or 2 cc per 
 feeding on each succeeding da}', until 140 to 200 cc per 1 kilo per 
 day is reached. 
 
 The food and water to be administered should be noted in writing 
 for the nurse's instruction each day, after a thorough inspection 
 of the infant and its clinical chart. 
 
 The diet of a premature infant making a satisfactory gain in freight 
 should not be changed arbitrarily without a well-defined indication.
 
 TABLE I. 
 
 — INFANTS APPROXIMATING 1000 
 
 3M (2 POUNDS) 
 
 IN WEIGHT. 
 
 
 Milk for 
 
 twenty-four 
 
 hours, 
 
 cc. 
 
 Bottle fed. 
 
 Catheter fed. 
 
 Addi- 
 tional 
 
 water. 
 
 Total 
 
 fluids. 
 
 Calories, 
 per kilo. 
 
 Fluid 
 intake 
 
 Day. 
 
 Number. Amount . 
 
 Number. 
 
 Amount. 
 
 vs. 
 body 
 
 weight. 
 
 1 
 
 4-12 
 
 3 to 2 2-4 
 
 3-2 
 
 4 
 
 45 
 
 50-60 
 
 3-8 
 
 1/20 
 
 2 
 
 20-40 
 
 10 to 8 2.0- 5.0 
 
 6 
 
 5 
 
 60 
 
 80-100 
 
 14-28 
 
 1/12 
 
 3 
 
 30-50 
 
 " 
 
 3.0- 6.0 
 
 u 
 
 5-8 
 
 70 
 
 100-120 
 
 21-35 
 
 1/9 
 
 4 
 
 35-60 
 
 " 
 
 3.5- 7.5 
 
 " 
 
 6-10 
 
 80 
 
 115-140 
 
 21 42 
 
 1/8 
 
 5 
 
 45-70 
 
 " 
 
 4.5- 9.0 
 
 " 
 
 7-12 
 
 " 
 
 125-150 
 
 31-49 
 
 1/7 
 
 6 
 
 50-80 
 
 " 
 
 5.0-10.0 
 
 " 
 
 8-13 
 
 " 
 
 130-160 
 
 35-56 
 
 " 
 
 7 
 
 00-90 
 
 n 
 
 6.0-11.0 
 
 " 
 
 10-15 
 
 <t 
 
 140-170 
 
 42-63 
 
 " 
 
 8 
 
 65-100 
 
 6.5-13.0 
 
 " 
 
 11-16 
 
 " 
 
 145-180 
 
 45-70 
 
 1/6 
 
 9 
 
 75-110 
 
 7.5-14.0 
 
 " 
 
 12-18 
 
 " 
 
 155-190 
 
 52-77 
 
 " 
 
 10 
 
 80-120 
 
 8.0-15.0 
 
 " 
 
 13 20 
 
 70 
 
 150-190 
 
 50 si 
 
 " 
 
 11 
 
 90-130 
 
 9.0-16.0 
 
 " 
 
 15-22 
 
 " 
 
 160-200 
 
 63-91 
 
 
 12 
 
 95 140 
 
 9.5-17.0 
 
 " 
 
 16-23 
 
 " 
 
 165-210 
 
 66-98 
 
 " 
 
 13 
 
 105-150 
 
 10.5-18.0 
 
 " 
 
 18-25 
 
 " 
 
 175-220 
 
 73-105 
 
 1/5 
 
 14 
 
 110-160 
 
 11.0-20.0 
 
 " 
 
 19-2G 
 
 60 
 
 170-220 
 
 77-112 
 
 " 
 
 15 
 
 120- 170 
 
 8 13-21 
 
 " 
 
 20-28 
 
 " 
 
 180-230 
 
 84-119 
 
 " 
 
 16 
 
 125-180 
 
 15-23 
 
 " 
 
 21-30 
 
 " 
 
 185-240 
 
 87-126 
 
 " 
 
 17 
 
 135-190 
 
 17-24 
 
 " 
 
 22-31 
 
 50 
 
 185-240 
 
 94-133 
 
 it 
 
 18 
 
 140-200 
 
 18-26 
 
 " 
 
 24-33 
 
 " 
 
 190-250 
 
 98-140 
 
 
 19 
 
 150-210 
 
 19-27 
 
 " 
 
 25-35 
 
 40 
 
 190-250 
 
 105-147 
 
 
 20 
 
 160-220 
 
 20-28 
 
 " 
 
 26-36 
 
 " 
 
 200-260 
 
 112-154 
 
 " 
 
 21 
 
 165-230 
 
 21-29 
 
 
 27-38 
 
 30 
 
 195-260 
 
 115-161 
 
 
 The caloric requirements are figured on the basis of a retained birth weight. Water additions 
 recommended are calculated on the average between high and low milk requirements. The necessity 
 for further water after the twenty-first day must of necessity vary with the individual case. Water 
 may often be discontinued when one-fifth of the body weight in breast milk is being fed in twenty- 
 four hours. 
 
 TABLE II. 
 
 — INFANTS APPROXIMATING 1500 
 
 3M. (3 
 
 pounds) 
 
 IN WEIGHT. 
 
 
 Milk for 
 
 twenty-four 
 
 hours. 
 
 ce. 
 
 Bottle fed. 
 
 Catheter fed. 
 
 Addi- 
 tional 
 water. 
 
 Total 
 fluids. 
 
 Calories, 
 
 per kilo. 
 
 Fluid 
 intake 
 
 Day. 
 
 Number. Amount. 
 
 Number. 
 
 Amount. 
 
 vs. 
 
 body 
 
 weight. 
 
 1 
 
 6-15 
 
 3 to 2 
 
 3-5 
 
 3-2 
 
 5 
 
 60 
 
 65-75 
 
 3-7 
 
 1/20 
 
 2 
 
 30-60 
 
 10 to 8 
 
 3-7 
 
 6 
 
 5-10 
 
 90 
 
 120-150 
 
 14-28 
 
 1/12 
 
 3 
 
 40-75 
 
 tt 
 
 4-9 
 
 " 
 
 6-12 
 
 100 
 
 140-175 
 
 18-34 
 
 1/10 
 
 4 
 
 50 90 
 
 " 
 
 5-11 
 
 " 
 
 8-15 
 
 " 
 
 150-190 
 
 24-42 
 
 1/9 
 
 5 
 
 60-105 
 
 " 
 
 6-13 
 
 " 
 
 10-17 
 
 120 
 
 180-225 
 
 28-49 
 
 1/8 
 
 6 
 
 70-120 
 
 " 
 
 7-15 
 
 " 
 
 12-20 
 
 " 
 
 190-240 
 
 32-56 
 
 1/7 
 
 7 
 
 80-135 
 
 " 
 
 8-17 
 
 " 
 
 13-22 
 
 " 
 
 200-255 
 
 36-63 
 
 it 
 
 8 
 
 90-150 
 
 " 
 
 9-19 
 
 " 
 
 15-25 
 
 " 
 
 210-270 
 
 42-70 
 
 " 
 
 9 
 
 100-165 
 
 " 
 
 10-21 
 
 " 
 
 17-22 
 
 " 
 
 220-285 
 
 46-77 
 
 1/6 
 
 10 
 
 110-180 
 
 " 
 
 11-23 
 
 " 
 
 18-30 
 
 " 
 
 230-300 
 
 52-84 
 
 " 
 
 11 
 
 120-195 
 
 " 
 
 12-24 
 
 " 
 
 20-32 
 
 " 
 
 240-315 
 
 56-91 
 
 " 
 
 12 
 
 130-210 
 
 " 
 
 13-26 
 
 " 
 
 22-35 
 
 " 
 
 250-330 
 
 60-98 
 
 " 
 
 13 
 
 145-225 
 
 " 
 
 14^28 
 
 " 
 
 23-37 
 
 " 
 
 260-345 
 
 66-105 
 
 1/5 
 
 14 
 
 150-240 
 
 " 
 
 16-30 
 
 " 
 
 25-40 
 
 " 
 
 270-360 
 
 70-112 
 
 " 
 
 15 
 
 160-255 
 
 8 
 
 18-32 
 
 " 
 
 27-42 
 
 100 
 
 260-355 
 
 74-119 
 
 " 
 
 16 
 
 170-270 
 
 20-34 
 
 " 
 
 2S I.". 
 
 80 
 
 250-350 
 
 80-126 
 
 " 
 
 17 
 
 180-285 
 
 22-36 
 
 " 
 
 30-47 
 
 " 
 
 260-365 
 
 M 133 
 
 « 
 
 18 
 
 190-300 
 
 24-38 
 
 " 
 
 32-50 
 
 60 
 
 250-360 
 
 88-140 
 
 u 
 
 19 
 
 200-315 
 
 " 
 
 26-40 
 
 " 
 
 33-52 
 
 " 
 
 260-375 
 
 94-147 
 
 " 
 
 20 
 
 210-330 
 
 " 
 
 28-42 
 
 " 
 
 35-55 
 
 40 
 
 250-370 
 
 98-154 
 
 " 
 
 21 
 
 220-345 
 
 
 30-44 
 
 
 37-57 
 
 
 260-385 
 
 102-161 
 
 
 Water administration recommended is for infants taking the average between low anil high milk 
 requirements. If diet is well taken and one-fifth the body weight in milk is being fed, the water may 
 now be discontinued.
 
 182 METHODS OF FEEDING 
 
 TABLE III.— INFANTS APPROXIMATING 2000 GM (4 POUNDS) IN WEIGHT. 
 
 
 Milk for 
 
 twenty-four 
 
 hours, 
 
 CO. 
 
 Bottle fed. 
 
 Catheter fed. 
 
 Addi- 
 tional 
 water. 
 
 Total 
 
 fluids. 
 
 Calories, 
 per kilo. 
 
 Fluid 
 intake 
 
 Day. 
 
 Number. 
 
 Amount. 
 
 Number. 
 
 Amount. 
 
 i 8. 
 
 body 
 weight. 
 
 1 
 
 20-30 
 
 4 
 
 5-8 
 
 3 
 
 7-10 
 
 80 
 
 100-110 
 
 7-10 
 
 1/20 
 
 2 
 
 40-80 
 
 8 
 
 5-10 
 
 6 
 
 7-13 
 
 100 
 
 140-180 
 
 14-28 
 
 1/12 
 
 3 
 
 55-100 
 
 " 
 
 7-12 
 
 " 
 
 9-16 
 
 120 
 
 175-220 
 
 20-35 
 
 1/10 
 
 4 
 
 70-120 
 
 " 
 
 8-15 
 
 " 
 
 11-20 
 
 " 
 
 190-240 
 
 24-42 
 
 1/9 
 
 5 
 
 85-140 
 
 " 
 
 10-18 
 
 14-23 
 
 160 
 
 245-300 
 
 30-49 
 
 1/8 
 
 6 
 
 100-160 
 
 " 
 
 12-20 
 
 " 
 
 16-27 
 
 
 260-320 
 
 35-56 
 
 1/7 
 
 7 
 
 115-180 
 
 " 
 
 14-22 
 
 a 
 
 19-30 
 
 
 275-340 
 
 40-63 
 
 " 
 
 8 
 
 130-200 
 
 u 
 
 16-25 
 
 " 
 
 21-33 
 
 
 290-360 
 
 45-70 
 
 " 
 
 9 
 
 145-220 
 
 " 
 
 18-27 
 
 " 
 
 24-37 
 
 
 305-380 
 
 50-77 
 
 1/6 
 
 10 
 
 160-240 
 
 " 
 
 20-30 
 
 " 
 
 26-40 
 
 
 320-400 
 
 56-84 
 
 " 
 
 11 
 
 175-260 
 
 " 
 
 22-32 
 
 " 
 
 29-43 
 
 
 335-420 
 
 61-91 
 
 " 
 
 12 
 
 190-280 j 
 
 24-35 . 
 
 32^7 
 
 
 350-440 
 
 66-98 
 
 " 
 
 13 
 
 205-300 
 
 26-37 
 
 34-50 
 
 
 365-460 
 
 72-105 
 
 1/5 
 
 14 
 
 220-320 
 
 28-40 
 
 37-53 
 
 140 
 
 365-460 
 
 77-112 
 
 
 15 
 
 235-340 ! " 30-42 
 
 39-57 
 
 120 
 
 355-460 
 
 82-119 
 
 << 
 
 16 
 
 250-360 1 " 32-45 
 
 42-60 
 
 100 
 
 350-460 
 
 87-126 
 
 " 
 
 17 
 
 265-380 34-47 
 
 44-63 
 
 80 
 
 345-460 
 
 92-133 
 
 " 
 
 18 
 
 280-400 
 
 36-50 
 
 47-67 
 
 60 
 
 340-460 
 
 98-140 
 
 " 
 
 19 
 
 295-420 
 
 38-52 
 
 49-70 
 
 40 
 
 335-460 
 
 103-147 
 
 " 
 
 20 
 
 310-440 
 
 40-55 
 
 52-73 
 
 20 
 
 330-460 
 
 108-154 
 
 " 
 
 21 
 
 325-460 
 
 
 41-57 
 
 
 54-77 
 
 
 
 345-460 
 
 113-161 
 
 
 The necessity for further water diet after the twenty-first day, or increases over amounts recom- 
 mended in the schedule must of necessity vary with the individual case. 
 
 TABLE IV. — CALORIC REQUIREMENTS PER KILOGRAM BODY 
 
 WEIGHT. 
 
 Values Recommended by Different Authors. 
 
 Salge 1 130 to 150 
 
 Samelson 2 115 to 150 
 
 Oppenheimer 3 120 to 130 
 
 Czerny-Keller 4 100 to 120 
 
 Langstein-Meyer 5 120 to 130 
 
 Budin 6 (average) 140 
 
 Birk 7 100 to 160 
 
 Reiche 8 (in those under 2000 grams) 120 to 130 
 
 (in those over 2000 grams) 95 to 110 
 
 Oberwarth" 120 to 160 
 
 Morse and Talbot 10 (average) 120 
 
 E. Moll 11 110 to 120 
 
 Cook, P. 12 120 to 200 
 
 1 Einfiihring in die moderne Kinderheilkunde, Berlin, 1909. 
 
 2 Ztschr. f. Kinderh., 1911, 11, 18. 
 
 3 Med. Klin., 1908, 6, 92. 
 
 4 Des Kindes Ernahrung usw. Leipsig u. Wien, 1912. 
 
 6 Siluglingsnahrung u. Sauglingsstoffwechsel, Wiesbaden, 1914. 
 
 6 The Nursling, London, 1907. 
 
 7 Sauglingskrankheiten, 1913. 
 
 s Ztschr. f. Kinderh., 1914, 12, 369. 
 
 9 Ergeb. d. Inn. Med. u. Kinderh., 1911, 7, 191. 
 
 10 Diseases of Nutrition and Infant Feeding, Macmillan & Co., New York, 1920. 
 
 11 Ztschr. f. Kinderh., 1919, 21, 329. 
 
 12 Arch. Pediat... 1921, 37, 201.
 
 AVERAGE HUMAN MILK DIETS 183 
 
 These feedings should, as rapidly as possible, be supplemented 
 by water or sugar water by mouth, or saline by rectum to meet 
 the required 140 to 200 cc per 1 kilo of fluids required daily. 
 
 Initial Weight Loss.— The lower the birth weight, the greater is 
 the percentage weight loss to be expected. Artificially-fed infants 
 lose more weight than breast-fed infants in whom the diet is started 
 early. An average loss of not more than 8 to 12 per cent of the 
 birth weight may be considered as satisfactory. By regular admin- 
 istration of inert fluids during the first days the total loss can fre- 
 quently be reduced to 5 per cent. 
 
 Daily Gains.— These are not necessarily in proportion to the 
 changing quantity of milk administered, as many factors, such as 
 condition of the bowels, quantity of urine passed, temperature of 
 the infant's surroundings and numerous other factors will necessarily 
 influence the weight. 
 
 An average daily gain greater than 20 gm. is unusual when the 
 infant's food is limited to one-sixth of its body weight. 
 
 Although occasionally an infant holds its birth weight, most 
 infants do not regain their birth weight before the end of the second 
 or third week. 
 
 In the very small prematures an average daily gain of 10 to 15 
 gm. with a doubling in birth weight in from seventy-five to one 
 hundred days may be considered satisfactory. In the larger 
 infants a gain of 15 to 20 gm. may be expected with a doubling in 
 birth weight in from fifty to one hundred days. The birth weight 
 is frequently trebled within one hundred and eighty days. 
 
 Special Feeding Rules.— 1. Food requirements which have been 
 recommended must, of necessity, be considered as relative, varia- 
 tions being to a great extent influenced by the physiological and 
 anatomical developments and to a not inconsiderable extent by 
 the temperature and humidity of the air surrounding the infant 
 and the type of clothes in which it is dressed. 
 
 2. Each day the total amount of food as indicated for the indi- 
 vidual infant is to be estimated, in order that the required food 
 and water will be administered. The number and amount of 
 feedings will, of necessity vary, but each must also be estimated 
 for each day. 
 
 3. When a number of infants are to be fed by one wet-nurse, 
 careful calculation of the day's needs of each infant must be made 
 by the floor nurse for the information of the nurse in charge of the 
 milk supply. 
 
 4. Expression of breast milk should be performed at regular 
 intervals, preferably six times a day at four-hour periods day and 
 night. The sixth expression during the night may, however, be 
 omitted if the supply is in excess. It is only by regular and com-
 
 184 METHODS OF FEEDING 
 
 plete emptying of the breasts by expression that a milk supply 
 can be maintained for an indefinite period, unless there is a second 
 baby which can be placed at the breast. 
 
 5. Human, as well as cows' milk, must be obtained under aseptic 
 conditions and kept clean and cool until ready for the infant. 
 To preserve milk properly, the ice box must register less than 50° F. 
 The food should be slowly warmed before feeding. 
 
 6. The boiled water to be fed must be carefully calculated, 
 and it must represent the difference between the total fluids indi- 
 cated which will usually average from one-eighth to one-fifth of 
 the body weight of the infant for twenty-four hours and the amount 
 of fluid given as milk. The water for each day should be measured 
 and set aside in an individual stoppered bottle each morning. 
 
 It should be administered between the milk meals or occasionally 
 there may be an indication for diluting the milk with part of it. 
 In order to administer the full day's water supply in some of the 
 small infants and those who vomit, it may be necessary to give 
 water in small quantities one, two and even three times between 
 milk feedings. If unable to swallow properly water must be given 
 by catheter. In larger infants only a few water feedings a day 
 may be needed, and usually by the third or fourth week, one-seventh 
 or one-fifth of the body weight in milk can be fed daily. At this 
 time the water may be discontinued unless it is necessary to supply 
 external heat of considerable degree, or the infant has a fever, 
 both of which necessitate increased amount of fluids. 
 
 The maximum feeding figures as given in the tables for 1000-, 
 1500- and 2000-gm. infants from the seventeenth to the twenty- 
 first days and which range from 140 to 161 calories may seem exces- 
 sive, but it should be remembered that in figuring these feedings 
 they are based on birth weight without allowance for weight increase 
 which is usually seen during the third week of life of these infants. 
 Allowance for these weight increases are covered by the maximum 
 total diet recommended. Not infrequently the infant requires 
 more rapid increases in its diet than those quoted as the maximum 
 feedings. The physician must be the best judge of the needs of 
 the individual case. 
 
 Feedings After the Twenty-first Day. — Usually by the twenty-first 
 day, the food requirements of the infant are quite well established 
 and a careful observation of the infant's weight, stools, disposition 
 and equally important, its body temperature will decide the future 
 food requirements. 
 
 The water requirement will, to a great extent, be dependent 
 upon the supply of artificial heat and the presence of fever. Ordi- 
 narily by the beginning of the fourth week, one-seventh to one- 
 fifth (140 to 200 cc or 100 to 140 calories per kilo) of the infant's 
 body weight in the form of breast milk is needed to maintain proper
 
 MENACE II T MAX MILK DIETS 
 
 185 
 
 growth. Occasionally it is necessary to exceed these amounts in 
 the poorly nourished premature. If the physiological functions are 
 seemingly normal the scale is the deciding factor in indicating 
 food increases or decreases. 
 
 As the infant takes on weight and becomes fat with a rounding 
 of the features and the body as is the case in successfully breast- 
 milk-fed prematures, the total milk administration can be held at 
 one-sixth and not infrecpiently one-seventh of the body weight, 
 and normal weight increases may still be maintained. 
 
 Mixed Feeding. When human milk, even though in small quan- 
 tities, is available, it should form the basis of the diet, and cows' 
 milk mixtures should be supplemental (Cases 1 to 14). Experience 
 has taught us to expect a rapidly increasing mortality when less 
 than 50 per cent of the food is other than human milk. 
 
 Fig. 102. — Baby Juanita. Age, one day; weight, 1070 gm. 
 
 2200 
 2000 
 
 1800 
 
 WEIGHT 1G0 
 GM. 14Q0 
 
 1200 
 
 1000 
 
 500 
 
 FOOD 400 
 
 CC. 300 
 
 200 
 
 100 
 
 June July August September 
 4 7 10 M 1019332328 1 4 7 101310 193S23S8S1 I C 13 15 18812427 SO 3 3 8 111417 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 LJ _ 
 
 L 
 
 j- 
 
 1 
 
 
 il 
 
 
 
 -r 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ir 
 
 V. 
 
 
 
 
 
 
 
 
 
 
 L 
 
 lJ 
 
 
 
 
 
 
 
 
 
 J | 
 
 
 
 
 
 
 i 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C M nR|[ q PE 1,' Kit O. 
 
 
 
 
 
 
 
 
 15 'J 152 K.2 1''.2 107 170 171 103 
 
 
 i,> 
 
 10a 140 1:/.' 
 
 
 
 
 Fig. 103. — Baby Juanita. Weight and food curves and calories per kilogram 
 weight. The patient entered June 4, aged one day; weight, 1070 Km.; condition 
 fair. Discharged September 18; aged one hundred and five days: weight, 21S0 gm. 
 An ideal curve with an energy quotient ranging between 132 and 170, and an average 
 daily gain of 12.5 gm. over a period of ninety days.
 
 186 
 
 METHODS OF FEEDING 
 
 Fig. 104. — Baby Silvis B. Age when taken, seven months; weight, 13 pounds. 
 
 July August September 
 
 8 11 14 17 20 23 27 30 3 5 8 11 14 17 20 23 2G 29 1 4 7 10 14 
 
 2200 
 2009 
 1800 
 
 WEIGHT 
 
 GM. loOO 
 
 1100 
 1200 
 1C00 
 
 500 
 400 
 FOOD c.c. 300 
 200 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 15 
 
 ^0 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 H 
 
 ON 
 
 E 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CALORIES PER KILO. 
 
 11 
 
 54 
 
 
 95 
 
 
 no 
 
 
 ni 
 
 
 110 
 
 
 
 i:;i 
 
 
 142 
 
 |148| 
 
 162 
 
 
 
 Fig. 105. — Baby Silvis (Italian). Weight and food curve and calories per kilo- 
 gram. Born July 5, admitted July 8; weight, 1050 gm.; lowest weight, 980 gm., 
 on his tenth day of life. Initial loss, 70 gm. Discharged September 11; aged 
 sixty-five days; weight, 1580 gm. Regained entrance weight fourteenth day in 
 hospital when seventeen days old.
 
 Average human milk diets 
 
 18? 
 
 1 week aver 
 
 2 
 
 3 
 
 4 
 
 5 
 
 G 
 
 7 
 
 8 
 
 9 
 
 Average Daily Gains in Grams. 
 
 age loss per day == 8.57 gm.; average 48.9 cal. per kilo, 
 gain 
 
 10.0 " 
 
 91.0 
 
 4.28 " 
 
 109.0 
 
 8.5 " 
 
 121.8 
 
 10.0 " 
 
 119.0 
 
 10.0 " 
 
 137.6 
 
 14.0 " 
 
 136.0 
 
 11.8 " 
 
 142.6 
 
 11.8 " 
 
 1 12.6 
 
 Fig. 106.— Baby Allen B. Age, eight days; weight, 1135 gm. 
 
 J 
 1700 
 
 1500 
 
 WEIGHT 
 GM. 
 
 1300 
 1100 
 
 500 
 
 400 
 
 FOOD c.c. 300 
 
 200 
 100 
 
 cine July August 
 
 2 15 18 21 24 83 30 3 G 9 12 15 18 21 24 97 80 3 5 8 11 14 17 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CALORIES PER KILO. 
 
 SO 
 
 
 .,.; 
 
 
 75 
 
 
 
 
 9G 
 
 
 kki 
 
 
 107 
 
 
 mi 
 
 
 
 
 I 'JO 
 
 
 
 122 
 
 
 Fig. 107. — Baby Allan B. Weight and food curves and calories per kilogram. 
 Born June 5, admitted June 12; weight 1135 gm. Discharged August 1G, weight, 
 1655 gm.; age, sixty-four days. Regained entrance weight fifteenth day in hospital 
 Initial loss = 35 gm.
 
 188 
 
 METHODS OF FEEDING 
 
 Average Daily Gain in Grams. 
 
 1 week average loss per day = 5.0 gm.; average 30.2 cal. per kilo. 
 
 2 " " gain " = 2.14 " " 62.87 
 
 3 " " " " = 6.4 " " 75.3 
 
 4 " " " " = 14.28 " " 94.7 
 
 5 " " " " = 5.7 " " 96.4 
 
 6 " " " " = 7.1 " " 105.6 
 
 7 " " " " = 15.7 " " 107.1 
 
 8 " " " " = 14.1 " " 95.6 
 
 9 " " " " = 12.1 " " 112.6 
 
 Fig. 108. — Baby Peggy. Age, three days; weight, 1185 gm. 
 
 Fig. 109. — Baby Peggy. Age, forty-three days; weight, 2155 gm.
 
 AVERAGE HUMAN MILK DIETS 
 
 189 
 
 2300 
 
 2100 
 1900 
 
 WEIGHT 
 
 GM. lt0Q 
 
 1500 
 
 1300 
 
 1100 
 
 GOO 
 500 
 
 FOOD 400 
 
 cc - 300 
 200 
 100 
 
 August September 
 10 13 1C 1!> 22 25 2* 31 3 O !) 12 15 18 21 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r _ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 -ALORIES PER KILO. 1 50 
 
 
 Hi 
 
 
 i:.: 
 
 
 !.-.< 
 
 
 131 
 
 
 1 •.'." 
 
 
 171 
 
 
 16: 
 
 
 Fig. 110. — Baby Peggy. Weight and food curve and calories per kilogram. 
 Admitted August 7; weight, 1185 gm. Discharged September 19; weight, 2155 
 gm.; age, forty-three days. No initial loss. 
 
 Average Daily Gain in Grams. 
 1 week average gain per day = 7.14 gm.; average 105.7 cal. per kilo. 
 
 2 ' 
 
 ' " " ' 
 
 = 22.8 " 
 
 142.5 
 
 3 ' 
 
 ' " " ' 
 
 = 15.7 " 
 
 155.9 
 
 4 ' 
 
 ' " " ' 
 
 = 20.0 " 
 
 114.15 
 
 5 ' 
 
 ' " " ' 
 
 = 30.7 " 
 
 145.3 
 
 6 ' 
 
 ' " " ' 
 
 = 33.1 " 
 
 146.0 
 
 7 ' 
 
 ' (3 days) " 
 
 = 28.33 " 
 
 149.0 
 
 Fig. 111.— Baby Grace A. Age, three days; weight, 11S0 gm.
 
 190 
 
 METHODS OF FEEDING 
 
 Fig. 112.— Baby Grace A. Age, eighty-nine days; weight, 1875 gm. 
 
 June July iugust September 
 20 23 2G 29 2 5 8 1114 17 20 23 2G 29 1 4 7 10 13 IG 19 22 25 28 31 3 G 9 12 15 
 
 1800 
 1G00 
 
 WEIGHT U()0 
 GM. 
 
 1200 
 
 1000 
 
 600 
 500 
 FOOD c.c. 400 
 300 
 200 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — ' 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CALORIES PER KILO. 
 
 
 50 
 
 78 
 
 
 U 
 
 
 72 
 
 
 
 Til 
 
 105 
 
 
 120| 
 
 i2s; 
 
 138 
 
 
 
 11.: 
 
 fiu 
 
 
 
 w 
 
 
 
 Fig. 113.— Baby Grace A. Weight and food curve and calories per kilogram. 
 Born June 17, admitted June 20; weight, 1180 gm. Discharged September 14; 
 weight, 1875 gm.; age, seventy-seven days. Regained entrance weight thirty- 
 sixth day in hospital. Initial loss, 110 gm.
 
 Average Daily Gain in Grams. 
 
 1 week average loss per day = 13.57 gm.; average 36.36 cal. per kilo, 
 gain 
 
 3 " 
 
 4 " 
 
 5 " 
 
 6 " 
 
 7 " 
 
 8 " 
 
 9 " 
 
 10 " 
 
 11 " (4 day.) 
 
 2.14 " 
 
 74.5 " 
 
 1.4 " 
 
 72.5 " 
 
 1.4 " 
 
 70.2 " 
 
 5.7 " 
 
 82.2 " 
 
 15.0 " 
 
 105.6 " 
 
 15.0 " 
 
 120.4 " 
 
 12.14 " 
 
 128.9 " 
 
 16.4 " 
 
 131.1 " 
 
 15.0 " 
 
 129.2 " 
 
 20.0 " 
 
 113.3 " 
 
 Fig. 114.— Peter P. 
 
 Taken when sent home. Weight at birth, 1220 gm.; weight 
 when sent home, 2810 gm. 
 
 May June July August Sept. 
 
 20 20 1 i J10131010222528 1 1 7 10131010222528313 6 0121518212427 80 2 5 8 11 
 
 2500 
 2300 
 2100 
 1900 
 
 WEIGHT 1700 
 
 1500 
 1300 
 1100 
 1900 
 
 600 
 500 
 
 FOOD 400 
 
 c.c. 300 
 200 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 
 
 
 
 
 "" 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r 
 
 1_ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ,_ 
 
 - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CALORIES PER KILO. 
 
 
 10 
 
 80 | 110 | 1)0 
 
 ■•: 
 
 
 115 
 
 
 105 
 
 
 1 120 
 
 122 
 
 135 
 
 155 
 
 111 
 
 
 
 
 Fig. 115.— Baby Peter P. Weight and food curves and calories per kilogram. 
 Born May 26, admitted May 26; weight 1175 gm. Discharged September 11; 
 weight 2480 gm.; age, one hundred and eight days. Regained entrance weight 
 on thirty-second day in hospital, when thirty-two days old. Initial loss = 220 gin. 
 Double birth weight in one hundred days,
 
 192 
 
 METHODS OF FEEDING 
 
 Average Daily Gain in Grams. 
 
 1 week average loss per day = 15.0 gm.; average 22.6 cal. per kilo. 
 
 2 ' 
 
 ' " " ' 
 
 = 12.14 " 
 
 82.23 ' 
 
 
 3 ' 
 
 " gain 
 
 = 13.57 " 
 
 107.0 
 
 
 4 ' 
 
 t it a i 
 
 = 12.14 " 
 
 111.0 ' 
 
 
 5 ' 
 
 i " " " = 10.0 " 
 
 102.0 ' 
 
 
 6 ' 
 
 ' " " ' 
 
 = 8.7 " 
 
 115.0 ' 
 
 
 7 ' 
 
 t it n t 
 
 = 10.0 " 
 
 113.8 ' 
 
 
 8 ' 
 
 (nut 
 
 = 8.5 " 
 
 108.0 ' 
 
 
 9 ' 
 
 ' " " ' 
 
 = 15.7 " 
 
 117.0 ' 
 
 
 10 ' 
 
 ' " " ' 
 
 = 15.0 " 
 
 126.0 ' 
 
 
 11 ' 
 
 ' " " ' 
 
 = 14.2 " 
 
 132.0 ' 
 
 
 12 ' 
 
 t it it t 
 
 ' = 22.8 " ' 
 
 143.0 ' 
 
 
 13 ' 
 
 ' (in 12 days) ' 
 
 = 22.0 " 
 
 150.0 ' 
 
 
 14 ' 
 
 ' (in 12 days) ' 
 
 = 28.75 " 
 
 145.4 ' 
 
 
 Fig. 116.— EthnaH,
 
 AVERAGE HUMAN MILK DIETS 
 
 193 
 
 1 
 
 July August September Octolier 
 12 IS 1*2124 27 SO 8 5 8 11 14 17 SO 23 SO 89 14 7 10 IS 1G10S8 85 88 1 4 7 
 
 2G00 
 2400 
 2200 
 
 WEIGHT 2000 
 GM. 
 
 1800 
 1G00 
 1400 
 
 500 
 400 
 
 FOOD C.C. 300 
 
 200 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r^. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Lp 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 rL 
 
 1 
 
 
 
 r 
 
 r^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 n 
 
 / 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 P 
 
 
 
 
 
 
 s 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 IT 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CALORIES PER KILO. 
 
 
 120, 
 
 
 
 
 L37 
 
 
 
 
 
 ■u 
 
 •JIG 
 
 
 
 817 
 
 i 
 
 3 
 
 
 
 ;-ji 
 
 
 
 '.ID 
 
 
 
 Fig. 117. — Baby Ethna H. Showing weight and food curves and calories per 
 kilogram weight. The patient entered the hospital July 9, aged one day; weight, 
 1360 gm.; condition fair. Discharged October 5; aged eighty-eight days; weight, 
 2512 gm. Showed a steady increase after 137 calories was reached and continued 
 to grow steadily until 220 was fed. The growth averaged only 13 gm. daily, being 
 lower than several infants fed with a much lower energy quotient. 
 
 Fig. 118. 
 
 13 
 
 -Joseph and Edward R. (twins). Age, three days. 
 Edward, 1360 gm.; Joseph, 1190 gm. 
 
 Birth weight:
 
 194 
 
 METHODS OF FEEDING 
 
 May June July May June July 
 203326391 4 7 1013161922252S1 4 7 1013 202326291 4 7 10 13161922252* 1 4 7 10 13 
 
 2100 
 1900 
 
 1700 
 
 WEIGHT 1500 
 GM. 
 
 1300 
 
 1100 
 
 GOO 
 
 FOOD 500 
 
 F ° 400 
 
 cc. 300 
 
 2C0 
 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 l_ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 — 
 
 i— 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 _ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CALORIE 1 ; PER KILO. 
 
 
 (0 
 
 
 86J IK 
 
 
 
 .05 
 
 
 Ji 
 
 
 H- 
 
 
 
 
 
 
 t:> 
 
 
 -•■ 
 
 
 10 
 
 
 
 
 12! 
 
 
 
 ... 
 
 V?l 
 
 Fig. 119. — Baby Joseph R. and Baby Edward R. (twins). Born May 17, admitted 
 May 20. Discharged July 13; age, sixty days. Mother died third day after labor. 
 
 Joseph R. — Age, three days; entrance weight, 1190 gm.; discharge weight, 1950 
 gm. Regained entrance weight on twelfth day in hospital, when fifteen days old. 
 Initial loss = 40 gm. 
 
 Average Daily Gain in Grams. 
 
 1 week average loss per day 
 
 gain 
 
 (6 days) 
 
 = 3.57 gm.; average 33.5 cal. per kilo. 
 
 = 8.57 " " 86.8 " 
 
 = 19.29 " " 110.7 " 
 
 = 10.0 " " 107.0 " 
 
 = 17.8 " " 106.2 " 
 
 = 15.0 " " 98.9 " 
 
 = 20.7 " " 140.7 " 
 
 = 20.0 " " 144.4 " " 
 
 Edward R. — Age, three days; entrance weight, 1360 gm.; discharge weight, 2100 
 gm. Regained entrance weight fourteenth day in hospital, when seventeen days 
 old. Initial loss = 80 gm. 
 
 Average Daily Gain in Grams. 
 
 1 week average loss per day = 9.28 gm.; average 32.8 cal. per kilo. 
 
 2 " " gain " = 11.42 " " 82.5 
 
 3 " " " " = 23.57 " " 104.13 
 
 4 " " " " = 15.7 " " 100.2 
 
 5 " " " " = 29.29 " " 107.4 
 
 6 " " " " = 14.27 " " 114.7 
 
 7 " " " " = 10.7 " '•' 126.6 
 
 8 " (6 days) " " = 16.66 " " 122.6
 
 AVERAGE HUMAN MILK DIETS 
 
 195 
 
 Fig. 120. — Baby Grace B. Taken at admittance. Birth weight, 1395 gm. 
 
 3000 
 2800 
 2000 
 2400 
 
 WEIGHT 9900 
 
 GM - 2000 
 
 1800 
 
 1600 
 
 1400 
 
 600 
 food 500 
 
 c.C. 400 
 300 
 
 Hay June July August 
 
 18 1019288588(1 S C 9 18 15 18818187 SO 1 4 7 10131G19i->2Ji->31 1 4 7 101310198825 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 \— 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ,_ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 200 
 
 100 
 
 
 
 D 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CALORIES PER KILO. 
 
 
 l 1 
 
 - 
 
 - 
 
 
 HJ 
 
 '1 
 
 
 ids-t 
 
 &+ 
 
 
 i 
 
 
 i 
 
 ■•■ 
 
 
 
 r 
 
 
 ii 
 
 
 
 
 :. 
 
 
 II * 
 
 
 
 - 
 
 
 
 
 Fig. 121. — Baby Grace B. Weight and food curves and calories per kilogram 
 weight. The patient entered May 13. Age, one day; weight, 1440 gm.; condition 
 fair. Discharged August 27, aged one hundred and six days; weight, 2960 gm. 
 Showed initial gain on 102 calories, followed by a loss when the same was i 
 below 100; followed by a gain at 100, and a steady loss at 91; a moderate gain at 
 109; the loss was again repeated at 90.5 and was followed by a rapid gain at 130 
 to 137, averaging daily 24.5 gm., and a less rapid growth, with greater fluctuations, 
 at 115 to 109.5, averaging 10 gm. daily and again rapidly rising with 124.
 
 196 
 
 METHODS OF FEEDING 
 
 Fig. 122. — Baby Glenn. Age, two days. One of twins. Other twin died on first 
 
 day. 
 
 
 V 
 
 r ^ 
 
 |^ \ 1% '• 
 
 ** '"•■iiiiiii, J -V _. 
 
 N - 
 
 Fig. J23, — Baby Glenn. Age, one hundred and eight days,
 
 AVERAGE HUMAN MILK DIETS 
 
 197 
 
 Fig. 124. — Baby Glenn. Age, five years. 
 
 May Juuc July August Sept. 
 nnrt# 282029 1 1 7 10181619823598 1 1 7 10181010222523818 6 9 12151881212780 2 5 S 
 
 3100 
 2900 
 2700 
 2500 
 
 WEIGHT 2300 
 
 GM - 2100 
 
 1900 
 
 1700 
 
 1500 
 
 1300 
 
 1100 
 
 GOO 
 500 
 
 FOOD 400 
 
 cc. 300 
 200 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 1 
 
 r- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r— 
 
 r^ 
 
 rJ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CALORIES PER KILO. 
 
 
 26 
 
 
 
 :,.. 
 
 
 96 
 
 
 
 
 l.-io 
 
 130 
 
 
 140 
 
 Hi; H7, 
 
 
 
 123 | Ho i;,o 
 
 Fig. 125. — Baby Glenn. Weight and food curves and calories per kilogram. 
 Admitted May 23; weight, 1340 gm. Discharged September 8; weight, 3245 gm., 
 age, one hundred and eight days. Regained entrance weight twenty-eighth day 
 in hospital. Initial loss = 155 gm. Doubled birth weight in eighty-six days.
 
 Average Daily Gain in Grams. 
 
 1 week 
 
 average loss per 
 
 day = 1.4 
 
 2 " 
 
 
 ' " ' 
 
 = 1.4 
 
 3 " 
 
 
 ' gain 
 
 = 4.18 
 
 4 " 
 
 
 
 ' ' 
 
 = 15.0 
 
 5 " 
 
 
 
 ' ' 
 
 = 15.7 
 
 G " 
 
 
 
 ' ' 
 
 = 15.0 
 
 7 " 
 
 
 
 ' ' 
 
 = 23.5 
 
 8 " 
 
 
 
 ' ' 
 
 = 24.18 
 
 9 " 
 
 
 
 ' ' 
 
 = 32.1 
 
 10 " 
 
 
 
 ' ' 
 
 = 27.8 
 
 11 " 
 
 
 
 ' ' 
 
 = 16.4 
 
 12 " 
 
 
 
 ' ' 
 
 = 31.4 
 
 13 " 
 
 
 
 ' ' 
 
 = 31.4 
 
 14 " 
 
 
 
 ' ' 
 
 = 15.7 
 
 15 " 
 
 (3 days) 
 
 ' ' 
 
 = 15.0 
 
 16 " 
 
 (7d 
 
 ays) 
 
 ' ' 
 
 ' = 24.2 
 
 gm.; average 25.1 cal. per kilo. 
 
 55.8 
 94.33 
 115.0 
 112.3 
 125.9 
 104.9 
 1.V.I.7 
 146.5 
 147.9 
 123.2 
 136.7 
 141.9 
 135.8 
 132.7 
 143.3 
 
 Fig. 126. — Baby Ann C. Age, eighteen days. 
 
 Fig. 127. — Baby Ann C. Age, one hundred and thirty-six days.
 
 ARTIFICIAL FEEDING 
 
 199 
 
 May June July Jtncnii 
 
 U172I>232C2!H 1 7 10l:( lii l'J222.">2* 1 1 7 10 1311. 1U22232S31 :l « !) 12 l.'ilH2l248Tt01 5 9 11 
 
 3500 
 
 3300 
 3100 
 2900 
 2700 
 
 WEIGHT 
 
 ™ 2500 
 GM. 
 
 2300 
 
 2100 
 
 1900 
 
 1700 
 
 1500 
 
 1300 
 700 
 
 FOOD 600 
 
 M ,ls 500 
 
 cc - 300 
 
 200 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 >-— — ^— — V 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 <-n 
 
 _ 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CALORIES PER KILO. 
 
 
 
 20 
 
 
 
 U) 
 
 i:.i 
 
 
 
 M 
 
 51 
 
 
 
 
 '■■' 
 
 
 
 
 71 
 
 
 
 
 
 
 ; 
 
 
 
 
 
 •" , 
 
 26 
 
 1..LI 
 
 
 Fig. 128. — Baby Ann C. Weight and food curves and calories per kilogram. 
 Born April 26, Admitted May 14; weight, 1340 gm. Discharged September 9; 
 weight 3265 gm.; age, one hundred and thirty-six days. No initial loss. 
 
 Average Daily Gain in Grams. 
 
 1 week average gain per day = 19.2 gm.; 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 11 
 
 12 
 
 13 
 
 14 
 
 15 
 
 16 
 
 loss 
 Standstill 
 
 = 11.4 
 = 24.1 
 = 25.7 
 = 27.0 
 = 31.4 
 = 22.8 
 = 30.4 
 = 42.8 
 = 23.5 
 = 27.9 
 = 16.4 
 = 10.0 
 = 0.7 
 = 2.0 
 
 average 120.0 cal. per kilo. 
 
 123.0 " 
 
 122.7 " 
 
 143.0 " 
 
 159.0 " 
 
 166.0 " 
 
 135.0 " 
 
 119.6 " 
 
 140.5 " 
 
 139.0 " 
 
 180.0 " 
 
 162.5 " 
 
 140.6 " 
 140.0 " 
 129.6 " 
 125.0 " 
 
 ARTIFICIAL FEEDING. 
 
 There can be no comparison between the results to be expected 
 in feeding premature infants on human milk and those to be obtained 
 with artificial food. This is especially true of infants with a weight 
 below 1500 gm. Therefore, if it becomes necessary to resort to 
 artificial feeding, the selection of a food, its preparation, and its 
 adaptation to the infant must all be given the most painstaking
 
 200 METHODS OF FEEDING 
 
 consideration. Many varieties of artificial diet have been sug- 
 gested by many different authors, such as simple milk dilutions 
 cream and top-milk mixtures, skimmed milk and buttermilk prepa- 
 rations, malt soup preparation, condensed and evaporated milk, 
 etc. The results with these various diets are to a great degree 
 dependent upon the physician's intimate understanding and 
 directions for the use of the individual food (Fig. 129). 
 
 Fig. 129.— Utensils needed for artificial feeding: Double boiler (small), pan, 
 funnel, bottle-brush, 250-cc (8-oz.) graduated glass or pitcher, six nursing bottles 
 and rack, paper caps for bottles (sterile) , nipples, milk, sugar, flour, milk of mag- 
 nesia, citrate of soda, tablespoon, dairy thermometer, vegetable mill. 
 
 Quantity of Food.— It must be remembered that the figures quoted 
 for the feeding on breast milk are the maximum that can be assimi- 
 lated and are excessive quantities for artificial feeding in the first 
 weeks of life because of greater difficulty in the digestion of cows' 
 milk. These infants when artificially fed must at all times be 
 closely watched for evidences of overfeeding, and the first evi- 
 dence of digestive disturbances or of intercurrent infections should 
 lead to the feeding of human milk whenever possible. 
 
 From the foregoing statement, it is quite evident that smaller 
 and slower weight increase may be expected of the artificially fed. 
 
 Quality of Food.— As previously stated, opinions vary greatly as 
 to the best food for artificial diet. Most clinicians have obtained 
 the best results with the feeding of low-fat mixtures. Boiled milk, 
 skimmed milk and buttermilk, with carbohydrates added, are 
 among the best. 
 
 In feeding with buttermilk and skimmed milk with added carbohy- 
 drates, the fat-free mixtures must not be too long continued, other- 
 wise the infants will suffer from fat inanition. By the end of the 
 third week some whole boiled milk may be added or the lactic-acid 
 milk should be prepared from partly skimmed milk. It is our 
 routine to boil all artificial food mixtures for at least two minutes. 
 
 In feeding with a buttermilk high carbohydrate mixture, the 
 caloric requirements are lower than in feeding with the full milk 
 (chymogen) mixture with its loiver carbohydrate content, because 
 the energy for digestion and assimilation requirements are lower
 
 ARTIFICIAL FEEDING 201 
 
 with high-carbohydrate low-fat feeding as compared with high-fat 
 low-carbohydrate mixture. 
 
 BUTTERMILK AND SKIMMED MILK MIXTURES. 
 
 Buttermilk or skimmed milk 1000 
 
 Flour (dextrinized) 10 
 
 Sugar (cane) 40 
 
 The above being used for the first weeks. 
 
 Buttermilk or skimmed milk 1000 
 
 Flour (dextrinized) 15 
 
 Sugar (cane) 60 
 
 For later feedings. 
 
 Maltose-dextrin compounds can be substituted for the cane sugar 
 if desired. 
 
 Directions for Preparation.— Add the flour to a few tablespoon- 
 f uls of buttermilk or skimmed milk and rub to a paste. Add butter- 
 milk or skimmed milk to 1 liter. 
 
 Bring mixture to a boil and withdraw from the fire. 
 
 Add the sugar and bring to a boil for the second time. 
 
 This process should require about twenty minutes. 
 
 Make up to 1 liter with boiled water. 
 
 Keep on ice. 
 In the use of the buttermilk mixture it must be remembered that 
 infants are not to be kept on this low-fat mixture for too long a 
 time, addition of whole milk being indicated after the first few weeks, 
 beginning with one-third whole milk and two-thirds skimmed ; by the 
 fourth week equal parts whole and skimmed milk should be used in 
 the preparation of the lactic acid milk. 
 
 Chymogen Mill:. 
 
 Requirements for Preparation. 
 
 Milk. 
 
 Single boiler, 1- or 2-quart. 
 
 Dairy thermometer. 
 
 Chymogen powder (Armour & Co.). 
 
 Teaspoon. 
 
 Egg beater. 
 Directions for Preparation.— Boil milk for five minutes over 
 direct flame, cool to 104° F., and add one full teaspoonful of chy- 
 mogen to each quart of milk, and stir for one-half minute. Let it 
 come to a clabber by allowing it to stand for fifteen minutes, 
 holding it as near 100° F. as possible by keeping it in a warm place; 
 then beat it well until the curd is finely divided. Put it in indi-
 
 202 METHODS OF FEEDING 
 
 vidual feeding bottles and place on ice. Do not heat above 100° F. 
 when preparing individual bottles for feeding, otherwise curds will 
 clump and will not pass through the nipple. Reheating is best 
 accomplished by placing the individual feeding bottle in a cup of 
 warm water not over 115° F. and allowing it to stand for ten minutes. 
 Replenish the warm water if necessary. 
 
 We have found this predigestion of boiled milk, by the addition 
 of rennet (chymogen) assures the infant's stomach of a fine, floccu- 
 lent curd, which is about the size of that of human milk. In 
 beginning feedings with the above preparation it is usually diluted 
 with 3 parts of water and increases in quality made as indicated, 
 and the quantity increased as in the feeding of human milk. In 
 feeding with tjie diluted predigested milk, 15 gm. (§ ounce) of 
 lactose should be added to each liter during the first few days, and 
 the amount gradually increased to 30 gm. (1 ounce). When chy- 
 mogen is not available, whole milk boiled for five minutes may be 
 used. 
 
 In the feeding of these food mixtures the relative caloric values 
 of the mixtures as compared with breast milk must be borne in 
 mind, otherwise inanition will be the result. 
 
 Human milk equals 700 calories per liter or 21 per ounce. 
 
 Skimmed milk or buttermilk mixture containing 10 gm. dextri- 
 nized flour and 40 gm. sugar per liter equals 16 calories per ounce 
 or 525 per liter. 
 
 Chymogen milk (whole milk) equals 700 per liter or 21 per ounce. 
 
 Chymogen milk when diluted with 3 parts water and 15 gm. of 
 sugar per liter equals 235 calories per liter or 7 per ounce. 
 
 Chymogen milk when diluted with equal parts water and 30 gm. 
 of sugar per liter of mixture equals 470 per liter or 14 per ounce. 
 Each individual ounce of sugar per liter of mixture increases its 
 food value by 4 calories per ounce. Rarely should more than 2 
 ounce of sugar be added for each liter of the mixture, which repre- 
 sents an addition of 8 calories (6.5 per cent) of carbohydrate to that 
 already contained in the milk. It is, therefore, of the greatest 
 importance that the milk itself either skimmed, buttermilk or whole 
 be increased gradually along with the sugar. 
 
 Amounts to be Fed.— Depending upon the weight and develop- 
 ment of the infant, the tables as given for human milk feeding 
 should be followed. It must be remembered that while the artificial 
 diets recommended have a lesser caloric value per cc than human 
 milk, they represent for most infants the maximum capacity for 
 digestion and assimilation. Of necessity, lesser weight increases 
 and slower progress are to be expected. The infants are paler, 
 tissue turgor is lacking and they are less immune to infection.
 
 ARTIFICIAL FEEDING 203 
 
 Other Dietetic Requirements.— To counteract the effects of boiling, 
 orange-juice feeding should be instituted by the third week, 
 beginning with 0.5 cc (8 drops) and increasing 2 to 4 cc (^ to 1 dr. I 
 daily by the eighth week, in order to avoid scurvy. Cod-liver oil 
 as an antirachitic should be fed by the fourth week, beginning 
 with 0.5 cc (8 drops) daily divided into two feedings and increased 
 to 2 cc (30 drops) daily by the eighth week. It may be mixed 
 with the orange juice. To counteract the low iron content of these 
 diets, carbonate of iron in 0.03 gm. (gr. |) or citrate of iron and 
 ammonia in 0.03 gm. (gr. \) once daily should be started by the 
 fourth week. The latter may be prescribed in solution. 
 
 Mixed Diet.— These food additions apply for breast-fed as well as 
 bottle-fed infants. 
 
 Fifth month, a little well-cooked cereal may be added to one of 
 the meals (begin with one teaspoonful) , adding it to the bottle of 
 milk. 
 
 At the sixth month, infants readily take a broth and vegetable 
 meal as a substitute for one of the milk feedings, in the form of 
 a vegetable and meat soup. Begin with one ounce and follow by 
 a second bottle containing the milk mixture with one ounce less 
 than full feeding. Gradually replace an entire milk feeding. 
 
 Ninth month, a vegetable soup or a clear broth (chicken, lamb 
 or veal), and toast or zwieback crumbs, with an additional portion 
 of stewed fruits (apples, prunes) or a strained vegetable (spinach, 
 carrots or turnips) . The broth is usually given in the same quantity 
 as the bottle, if given alone, or somewhat less if either the vegetable 
 or fruit is given in addition. 
 
 Cereal. ■ 
 
 Two tablespoons of cereal. 
 
 One-half pint of water and one-half pint of milk. 
 
 One pinch of salt. 
 
 Cook in double boiler for one hour. 
 
 Begin feeding one and a half tablespoonful, gradually increasing 
 to two tablespoonfuls. 
 
 Add the cereal to the milk mixture or pour part of bottle over 
 the cereal and feed with a spoon. Finish the meal with remainder 
 of the bottle. 
 
 Toast or zweiback (one-half slice crumbed) at about the eighth 
 month. 
 
 Vegetable Soup. 
 
 Lean lamb cut into small pieces (f lb.). 
 One potato. 
 One carrot.
 
 204 METHODS OF FEEDING 
 
 Two stalks of celery. 
 
 One tablespoonful of pearl barley. 
 
 Two tablespoonfuls of rice. 
 
 Two quarts of water. 
 
 One pinch of salt. 
 
 Finely divide the vegetables. Add the vegetables barley and 
 rice to two quarts of water. Boil down to one quart, cooking 
 three hours. Add pinch of salt. Pass through fine sieve. 
 
 Begin feeding one ounce, gradually increasing to eight ounces, 
 cutting out an ounce of milk mixture for each ounce of soup given. 
 
 When less than a full feeding is fed finish the meal with sufficient 
 milk mixture, from a second bottle, to make a full feeding.
 
 CHAPTER IX. 
 INCUBATORS. 
 
 The History of Incubators.— The first records of the use of incuba- 
 tors are found in description of their employment for the hatching 
 of eggs of fowls in Alexandria, and it is possible that it may have 
 occurred to the Egyptians to apply this method to the new horn. 
 One cannot, however, assume this, for no author of that period has 
 mentioned it. Hippocrates, in his writings of 460 B.C., makes the 
 following statement: "No fetus coming into the world before 
 the seventh month of pregnancy can be saved." We note that the 
 literature of our day records only a limited number of exceptions to 
 these conclusions that infants born before the end of the twenty- 
 eighth week are viable. 
 
 Pasquad quotes a thesis of the Eleventh Century of the Republic 
 wherein the author, Rudellet, writing on the vitality of infants, 
 reports the following which we think well worth citing. He quotes 
 from Baillet ( Decisions of Savants, Paris, 1722) as follows : " Among 
 the records of celebrated children Baillet reports that of Fortunio 
 Liceri, whose mother gave birth to him long before the ordinary 
 time during the fatigue and shocks of a sea voyage. This fetus 
 was no larger than the palm of your hand, but his father who was 
 a physician, having examined it, had carried it to the place which 
 was to be the end of his voyage. There he had other physicians 
 see it. They found that there was lacking nothing essential to 
 life, and his father undertook to finish Nature's task and to work 
 at the formation of the child with the same skill that men exhibited 
 in hatching chickens in Egypt. He instructed a nurse in all that 
 she had to do in the maintaining of exactly measured artificial 
 heat and the requirements for his general care and feeding. He 
 lived to be seventy-nine years of age and distinguished himself in 
 science by a large number of works." 
 
 This is a tale the recording of which leads us to believe that 
 use was made of the knowledge of the methods used at that age in 
 incubating fowls. We will dispense with any remarks and will 
 content ourselves with mentioning the fact, in citing the reflection 
 of the historian himself: "One must admit," says the author in 
 concluding the narrative of which we have just given the analysis, 
 " that all which is unbelievable is not always false, and that proba- 
 bility is not always on the side of truth,"
 
 206 
 
 INCUBATORS 
 
 Little is recorded from 1722 to 1857, the time when Denuce 
 described his incubator. Modern French writers attribute the 
 origin of the first incubator for infants to Denuce, of Bordeaux, 
 who in 1857 described his model which consisted of a double-walled 
 tub which was to be filled with warm water at intervals (Fig. 130). 
 
 Clementovsky states that a somewhat similar contrivance was 
 used by Riihl in St. Petersburg as early as 1835. 
 
 Crede, in 1866, published the results which he obtained with a 
 similar apparatus which had been in use in his clinic in Leipzig 
 since 1860, with the use of which he was able to lower his mortality 
 by 18 per cent. This simple tub has been modified by some of the 
 continental clinicians by putting it on a stand and providing it 
 with a hose attachment for connection with a hot-water faucet 
 (Fig. 131). 
 
 Fig. 130. 
 
 -Warm tub with double wall jacket. First used by Denuce in 1857 and 
 Crede in 1860. 
 
 In 1879 Winckel described a permanent bath in which the infant 
 floated. This apparatus was an attempt at imitating intra-uterine 
 conditions, but needless to say, because of the danger of drowning 
 and infection, it proved unpopular. The water in this tub was 
 kept between 36° and 38° C. 
 
 In 1680 Tarnier had an infant incubator constructed similar to 
 those used as chicken incubators. This incubator was built for 
 him by Odile Martin, director of the Paris Zoo, and was built of 
 such size that it could hold several children; and was installed in 
 the Maternity Hospital of Paris in 1881 (Fig. 132). 
 
 This is the first closed incubator which may be qualified as 
 modern, for the perfected apparatus of our day differs from it only 
 in detail. 
 
 This is the time that dates the principal work undertaken on 
 incubator construction, and the most varied modifications have 
 followed each other almost without interruption until our day.
 
 THE HISTORY OF INCUBATORS 
 
 207 
 
 The first important work on the results obtained by their use 
 is an account by Auvard in 1883. In this interesting work the 
 
 Fig. 131. — Modified warm tub. 
 
 Fig. 132. — Tarnier incubator. 
 
 author gives the first statistics on the use of the incubator in the 
 Maternity in this period under the scientific direction of Tarnier.
 
 208 INCUBATORS 
 
 Berthod, an interne of Tarnier, in an excellent thesis (1887), 
 continued this study, adding thereto some new data on the condi- 
 tions indicating the use of an incubator for the new-born infant. 
 His statistics are still most imposing, and they treat upon almost 
 a thousand cases in which the incubator was used. Among the 
 most influential of these was Budin. 11 
 
 The monographs of Auvard and Berthod are the only two import- 
 ant early works treating of the study of incubators and the results 
 of their use. Their work shows the importance of the prevention of 
 hypothermia, and they lay particular stress upon the protection 
 of the infant from the moment of its birth. It may be stated with 
 justice that the early progress in the care of premature infants was 
 to a great extent influenced by the interest of the French 
 obstetricians in the care of these infants. 
 
 Since then a large number of authors have written on this subject, 
 but it is rather to modify certain details or to propose new forms 
 of apparatus than to give new rules. 
 
 From that time on until our day the incubator has undergone 
 changes— some quite radical, while some have remained as rudi- 
 mentary as when first originated. 
 
 Only those models demonstrating more important changes and 
 improvements will be described. 
 
 Hearson introduced automatic temperature regulation within the 
 incubator. His apparatus was so constructed as to set off an 
 electric alarm clock when the maximum temperature desired was 
 past. This apparatus was modified by Eustache who attempted 
 to attach automatic gas or oil-heating apparatus to the so-called 
 "thermostat nurse of Hearson." 
 
 In 1896 Diffre, of Montpelier, and Lion built metal incubators, 
 providing for what they termed final perfection which provided for 
 automatic heating through thermostat control, the heat being 
 furnished through a hot-water system heated by an oil or gas stove 
 at the side of the incubator. In this incubator refinements in 
 ventilation and control of humidity were introduced. 
 
 A giant incubator was prepared by Prof. Pajot, in 1885, for use 
 in his clinic, consisting of a large heated chamber, practically an 
 oven; the congenitally feeble infants, entirely separated from their 
 mothers, being fed and tended by wet-nurses. 
 
 Budin, in stating the disadvantage of the Pajot apparatus, said: 
 "The wet-nurses were obliged to feed and tend the infants in this 
 oven; and the mothers, separated from their infants, soon lost all 
 interest in those whom they were unable to nurse and cherish. It 
 is better by far to put the little one in an incubator by its mother's 
 bedside." 
 
 Prof. Hutinel, of Paris, whose studies on the subject are of
 
 THE HISTORY OF INCUBATORS 
 
 209 
 
 interest, constructed a couveuse composed of a boat-like vessel of 
 enameled crockery whose bottom was replaced by a plate of gal- 
 vanized sheet-iron pierced by holes. The plate served as a cover 
 to a metal box, which contained three bowls filled with hot water. 
 The top of the apparatus was closed by a heavy glass which could 
 be raised to a desired degree by the aid of a screw, and which allowed 
 the airing of the box. The water bowls were replenished every two 
 or three hours to maintain the temperature. The crockery tub 
 could be disinfected with ease by wiping it with a cloth saturated 
 with bichloride of mercury solution, which was its best feature. 
 
 Fig. 133.— Finkelstein incubator. 
 
 Simple and cheap in its operation is Finkelstein's incubator. 
 The essentials of its construction may be seen from the accompany- 
 ing illustration (Fig. 133). The circular holes in the side walls of 
 the box for inserting hot-water vessels also serve as inlets for the 
 incoming air, while the used air escapes through the holes at the 
 upper part near the cover. 
 14
 
 210 
 
 INCUBATORS 
 
 Rommel's apparatus proved to be good and is at the same time 
 like the latter easily carried from one place to another (Fig. 135). 
 The chamber is 0.83 cubic meter large, enclosed on three sides by 
 mirror glass, the corner being rounded to facilitate cleaning. The 
 ventilating shaft permits the air to be renewed 100 to 120 times 
 every hour. The humidity regulation is simple. The large supply 
 of hot water of about 15 to 20 liters permits a pretty constant 
 temperature, the fluctuations according to Rommel being less than 
 1°. For heating electric incandescent lamps are used. 
 
 Fig. 134. — Reinach heated bed. 
 
 Moll's incubator (Fig. 138) distinguishes itself by the fact that 
 the head of the infant remains outside the warm box and breathes 
 the air of the room, this having a great advantage for respiration of 
 debilitated infants, since, because of stronger respiratory stimulus, 
 attacks of asphyxia may be more easily avoided. 
 
 To this class of incubators, which are all modifications of the 
 origional Lion type, belong the models of Couney, DeLee and others 
 now on the market in the United States (Fig. 136 and 137). 
 
 These models differ but slightly in principle, the chief variation 
 being in the maimer of heating and distributing the air and supply- 
 ing moisture. They may be heated by gas or oil stoves situated 
 at the side of the incubator, heating the air as it enters, or by a
 
 THE HISTORY OF INCUBATORS 
 
 211 
 
 system of electric bulbs within the incubator. In the latter models 
 the bulbs are usually located either in the floor or sides. The best 
 models are those in which the heating system is modelled after that 
 used in hot-water heating plants for houses. The temperature is 
 automatically controlled by a thermostat. 
 
 A thermometer is fastened near the side window, so that it may 
 be easily read, and a hygrometer is used to indicate the degree of 
 moisture. 
 
 Fig. 135. — Rommel incubator. 
 
 This type of incubator has in the past ten years lost considerable 
 of its early popularity, as is evidenced by a visit to most of the 
 large hospitals. A great deal of this deserved unpopularity is due 
 to the inability to ventilate them in the ward and the necessity for 
 furnishing a trained attendant. To properly supply these incuba- 
 tors with a free current of air it is necessary to connect them so
 
 212 INCUBATORS 
 
 that they will receive a supply of air from outside of the building. 
 To counteract the tendency to an insufficient air current in the 
 absence of winds or when they are in the wrong direction an electric 
 fan should be incased on the outside of the building in such posi- 
 
 Fig. 136. — Lion-type incubator (Couney model). The fresh air is forced through a 
 large air-shaft by an electric fan on the outside of the building. 
 
 tion that air may be blown directly through the incubator. This 
 is difficult of arrangement when the incubators are located above 
 the first floor of the building. When the station is located on the 
 first floor it is necessary to avoid the dampness and dust of the 
 street level, and this can be accomplished by installing a large
 
 THE HISTORY OF INCtfBATORS 
 
 213 
 
 funnel 15 or 20 feet above the ground level, some 24 to 36 inches 
 in diameter, to which is attached a 10-inch stack which can be 
 connected with a cage at its base in which the electric fan is installed. 
 From this point the air is blown through the system of incubators. 
 
 Fig. 137. — Lion-type incubator. I »eLee model.) 
 
 When such a considerable quantity of air is blown into the incu- 
 bator system, it becomes necessary to filter it through several layers 
 of cotton. This is best done at the side of the individual incubator. 
 
 The Cincinnati Hospital uses an electrically heated bassinette.
 
 214 
 
 INCUBATORS 
 
 The temperature is regulated by a series of electric lamps under 
 the mattress. The apparatus consists of a double wall frame, with 
 
 Fig. 138.— Moll heated bed. 
 
 Fig. 139. — Hess water-jacketed infant bed.
 
 THE HISTORY OF INCUBATORS 
 
 215 
 
 hot air rising in this double wall and escaping through small holes 
 near the top which can be opened or closed as may be required by 
 a slide damper. 
 
 In 1914 the writer designed an electric heated water-jacketed 
 infant bed. 
 
 It combines the double-wall water jacket with insulation to pre- 
 vent external loss of heat, and electric heating by a large plate with 
 rheostat control. 
 
 Fig. 140.— Cross-section of Hess heated bed. 1, Cooper wall covering asbestos 
 layer; 2, asbestos layer insulating water-jacket; 3, 4, copper walls covering water- 
 jacket; 5, water surrounding side and floor of bed; 6, water glass; 7, funnel for 
 filling jacket; 8, cock for emptying jacket; 9, removable crib; 10, air space under- 
 neath crib; 11, electric heating plate; 12, rheostat; 13, electric plug. 
 
 For hospital and home equipment the bed answers many require- 
 ments, because of its simplicity of operation in any well-ventilated 
 and moderately heated room. 
 
 It can be used for the care of premature infants, for the protec- 
 tion of the new-born full-term infant immediately after delivery 
 and for infants suffering from hypothermia from other causes. 
 
 This bed fulfils the following needs of the infant: (1) Safety. 
 The maximum temperature which can be obtained within the bed 
 is about 110° F. when the lid and canopy are in place with a room 
 temperature of 70° F. While such a temperature would be injurious
 
 210 
 
 INCUBATORS 
 
 if maintained for a long period of time, such surroundings if tempo- 
 rary can cause but little injury. (2) Simplicity of operation. It 
 requires practically no attention unless there are extreme ranges 
 of temperature within the ward, since the asbestos insulation pre- 
 vents radiation from the outer surface of the bed and the heater 
 holds the water at a constant temperature. (3) Ventilation. This 
 apparatus assures the baby of an adequate supply of fresh air if 
 placed in an ordinary room which is well ventilated. (4) Humidity 
 
 Fig. 141. — Cross-section of Hess bed showing direction of air currents. 
 
 is maintained at nearly the same degree as the surrounding air 
 because of the almost constant change of air within the bed and 
 moisture supplied by an evaporation pan beneath the crib. (5) 
 It is easily cleaned and disinfected. 
 
 The construction of the bed is such that it can be used in an 
 ordinary ward or room, giving the infant the advantage of a most 
 perfect room ventilation. 
 
 The following suggestions will aid in the practical application of 
 this bed for use in hospitals or the home.
 
 THE HISTORY OF INCUBATORS 217 
 
 A special room should lie provided. This has a practical advan- 
 tage as it impresses the nurses to consider this room as barriered. 
 This will make a demand upon the nursing staff for observation of 
 all of the rules of aseptic nursing. 
 
 This room should he supplied with an ample system of heating 
 coils controlled by a thermostat for winter use, thereby facilitating 
 the maintenance of a more or less stable temperature in the room 
 which should, in so far as possible, range between (>8 and 75° F. 
 
 The temperature within the room and bed should be read and 
 charted at six-hour intervals, best at G a.m., 12 M., and G and 12 p.M. 
 as the most likely time for maximum changes in the ward tempera- 
 ture. 
 
 Ventilation should be adequate but not excessive, and the room 
 should be so constructed that the beds may be placed without 
 the line of direct air currents. This is accomplished by having the 
 ventilating window r s and transoms on one side of the room, while 
 the opposite side is built with non-ventilating windows or blank 
 walls at either end. 
 
 Humidity in so far as the room is concerned will require little 
 attention except at such time when considerable artificial heating 
 is necessary. To supply the needed moisture during cold weather 
 when ventilation of the room is more or less limited, a large eva] to- 
 rating pan should be in direct contact with the radiator coils. 
 When these means fail to furnish the desired moisture, a wet 
 sheet may be hung in the room and remoistened as indicated by 
 the hygrometer. 
 
 In so far as possible the relative humidity should be kept at 
 about 55 per cent. However, amounts less than this down to 
 45 per cent will usually cause little or no discomfort or retardation 
 of progress. It has been our experience that with a good free 
 ventilation through open transoms or windows when the tempera- 
 ture of the room does not exceed 80° F., the normal water content 
 of the air is quite sufficient and little or no attempt at influencing 
 the room humidity is necessary. However, this will not answer 
 the purpose where a closed room is used. 
 
 When a special room cannot be provided the beds for well pre- 
 matures should be kept in the nursery used for normal infants. 
 They must never be brought into contact with infected infants 
 because of the danger of crossed and mixed infections. Neither 
 should infected prematures be placed among well new-born infants. 
 
 All infants should be removed from this room to the nurserj 
 once daily, so that it may be thoroughly ventilated and cleaned 
 by the use of soap and water. Before replacing the infants the 
 air should be reheated to remove excessive humidity.
 
 218 INCUBATORS 
 
 CARE OF THE BED. 
 
 General Care.— Once daily the infant should be removed from 
 the bed to allow of cleaning the interior with a damp cloth. This 
 is best done at the time of renovating the room. The crib itself 
 should also be wiped with a damp cloth. All linens should be 
 changed at least once daily and at other times when soiled. Extra 
 mattresses should be supplied so that they may be given an airing 
 on alternate days and a thorough renovating as frequently as 
 soiled. Renovation is imperative between cases. Mattresses 
 should be protected by rubber sheeting. A thick pad, however, 
 must be placed between the rubber sheeting and the infant. 
 
 The heating apparatus consists of a plate with a 6-inch surface 
 in direct contact with the floor of the water jacket, and especially 
 constructed to carry a maximum capacity of 300 Watts, which 
 makes it impossible to heat the water above 155° F. and the interior 
 of the bed above 110° F. at a room temperature of 70° F. 
 
 A rheostat with seven contacts is fastened to the standard. 
 Six of them are graduated to take current varying from 25 Watts 
 on contact 1 to 300 Watts 6n contact 6. The first contact shuts 
 off the current. 
 
 For the protection of very frail infants a partial cover for the 
 tub, 21| inches in length, is provided to shield them more com- 
 pletely from outside air currents. It is provided with a ther- 
 mometer, so that the temperature within the tub can be ascertained 
 by the nurse at all times. Further, a brass nickel-plated frame 
 covered by a removable linen cover is provided in the form of a 
 hood. This can be set over the open space not covered by the 
 metal lid in case of great air currents and extremely cold nights. 
 This allows a free circulation of air to enter at the front of the 
 canopy while at the same time preventing direct downpour of cold 
 air onto the infant's head. The hood raises the temperature 
 within the bed on an average of from 5° to 10° F., depending on 
 the room temperature and current used, but does not interfere 
 with perfect ventilation. The hood is made collapsible, and may 
 be set at any angle desired, as may be indicated. 
 
 The hood is used in combination with the lid for very small or 
 frail infants where a high temperature is desired or when the room 
 temperature is more or less beyond our control, because of a defec- 
 tive heating system or extremely cold weather. Both are used 
 when it is desired to heat this bed rapidly in an emergency. 
 
 The removable metal lid, which also holds the thermometer for 
 temperature reading, is used alone for most cases, the length of 
 time varying from a few days to several weeks. The hood and 
 lid are both left off for the more mature cases and those being
 
 CARE OF THE BED 219 
 
 prepared for graduation from the heated bed to the nursery or 
 home. 
 
 With the lid on it is rarely necessary to pass contact 4 of 
 the rheostat to obtain a temperature of 90° F. in a room approxi- 
 mating a temperature of 70° F. When it is desired to heat the 
 bed rapidly preparatory to its use, the rheostat may be set at point 
 (i with the hood and lid on until the bed is heated to the tempera- 
 ture that may be needed when it may be returned to points 2, 3 
 or 4, depending upon the fetal age and development of the infant. 
 
 As the infant develops it should be gradually prepared for gradu- 
 ation from the incubator by lowering the temperature of the bed 
 by degrees to that of the room temperature. This may cover a 
 period of several days or weeks. At this time the lid may be 
 removed. We have found it of advantage to remove the lid of 
 the bed when the infant has developed sufficiently to thrive in 
 the room temperature of 75° F., after which the temperature of 
 the bed with the lid off can be left a few degrees above the room 
 temperature by advancing the rheostat by one or two points. 
 The temperature of the bed is now measured by placing a ther- 
 mometer alongside of the baby within the sleeping bag or under 
 the blanket. 
 
 It is our custom to cover the infant when in the bed with a 
 light sleeping bag or light woolen blanket, in order to more com- 
 pletely stabilize its body temperature, as our beds are kept in a 
 well- ventilated room. The sleeping bag should either be fitted 
 with a flap, which can be used as a hood or a small bonnet should 
 be worn or the^blanket should be so applied so that it can be used 
 as a head cover. Outer garments or covers should be applied loosely 
 so as to allow of free movements of the extremities. 
 
 In order to use the bed rationally it is necessary to have an idea 
 of the effect of the various factors influencing the crib temperature. 
 To this end the following observations are offered for the guidance 
 of the attendant. 
 
 COMPARATIVE MEASUREMENTS OF TEMPERATURE IN HEATED BED 
 UNDER DIFFERENT CONDITIONS. 
 
 The temperature as read from the lid thermometer and that of 
 a thermometer placed alongside of the infant under a light blanket 
 used as a cover will show variations which rarely exceed 1 to 3° F. 
 
 At a room temperature varying between 70° and 80° F. The lid 
 temperature will approximate the following: 
 
 bid and Canopy On.— 10° F. above the room temperature when 
 on contact 2; 15° F. above the room temperature when on contact 
 3; 20° F. above the room temperature when on contact 4; 25° F.
 
 220 
 
 INCUBATORS 
 
 above the room temperature when on contact 5; 30° F. above the 
 room temperature when on contact (). 
 
 Lid On and Canopy Off.— 5° to 10° F. above the room tempera- 
 ture when on contact 2; 10° F. above the room temperature when 
 on contact 3; 15° F. above the room temperature when on contact 
 4; 20° F. above the room temperature when on contact 5; 25° F. 
 above the room temperature when on contact (i. 
 
 Lid and Canopy Off.— The temperature alongside of the infant 
 under its blanket will average from 5° to 10° F. higher than the 
 room temperature on contacts 2, 3, 4, 5 and 6 with a room tempera- 
 ture between 70 to 80° F. 
 
 As in all other care of these infants individualization should be 
 the watchword and only by a careful observation of weather and 
 temperature changes can the best results be obtained. 
 
 September October 
 1 3 5 7 9, 11 IS 15 17,19 21 23 35 27 29 1 3 5 7 9 11 13 
 
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 1800 
 1700 
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 1500 
 1400 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 TE 
 
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 -lEATED BED 
 1ATURE 75 AN 
 
 ) 80° 
 
 F - 
 
 
 
 
 
 UNHEATE 
 TEMP. ROOM 
 
 ) CH 
 62-" 
 
 0"F. 
 
 
 
 HEATED BED 
 TEMP. 72-78" 
 
 r. 
 
 Fig. 142. — Showing variations in weight curve of an infant while in and out of 
 a heated bed. The diet was unchanged between the dates September 19 and October 
 13. 
 
 The maintenance of desired temperature for a given case resolves 
 itself into a very simple problem if the above facts relating to the 
 recording of the lid thermometer is borne in mind, in that the 
 only variable factors are the room temperature and air currents. 
 The former in most hospital rooms will average from 65 to 75° F. 
 throughout most of the day, and the ventilation of the room can 
 easily be controlled. In most cases it is only necessary to change 
 the rheostat one or two points at the extremes of the day, as at 
 midnight when the temperature is likely to fall, and in the morning 
 when the hospital temperature is again more uniform. 
 
 We require recording of the temperature of the room and bed 
 at 6 a.m., 12 m., p.m. and 12 p.m. In order to insure safety from 
 extreme heat currents and extreme fluctuations in room tempera- 
 ture the point of the rheostat ward temperatures and humidity 
 should also be recorded at these times (Fig. 88) . 
 
 The degree of temperature to be maintained within the bed 
 must of necessity vary with the individual infant and be dependent
 
 CARE OF THE BED 221 
 
 in part at least upon the infant's physical development. We 
 
 rarely find it necessary to maintain a temperature above ( M)° F. 
 for more than a limited number of hours even in extreme cases. 
 In small infants it may be necessary to hold the temperature 
 between 85 and 90° F. for several days. Most infants, after a 
 few days, do best in a temperature ranging between 75° and 80° F., 
 depending upon their development. An average of 76° to 78° F. 
 will answer the latter needs of the better developed infants. It 
 may be stated that moderate fluctuations of 3 to 5° F. in the tem- 
 perature in the bed during the course of the day have little detri- 
 mental influence on the infant's progress. Marked fluctuations 
 are extremely dangerous (Fig. 142). 
 
 Ventilation. —Ventilation within the bed is maintained automati- 
 cally when the bed is heated. This is due to the fact that the air in 
 the center of the bed is cooler than at the side walls, thereby causing 
 the cooler air to pass into the bed at its center, then to flow to the 
 floor, along the floor, to the side walls and then up and out at the 
 sides. The direction of the air currents within the bed has a 
 double advantage in that the infant receives the renewed fresh air 
 for breathing while it is surrounded by the warmed air. 
 
 Humidity.— Excessive drying of the air is prevented by the 
 constant circulation through the bed of the free air of the room and 
 by evaporation from a flat basin, containing baked porous clay 
 (as used in water filters), over which water is poured to allow of 
 evaporation. This is placed on the floor of the bed immediately 
 under the baby basket. Varying with the degrees of temperature 
 to be maintained within the bed, it is necessary once daily to supply 
 from S to 16 ounces of water to replace that lost through evaporation. 
 
 Dangers.— The dangers in the use of any heated bed which must 
 at all times be avoided to insure success are: 
 
 1. Overheating and Refrigeration.— Reading and recording of the 
 room temperature, the rheostat contact and the bed thermometer 
 at regular intervals throughout the day will furnish the necessary 
 data to avoid these dangers. 
 
 2. Water Hunger.— Fluids must be supplied to an amount not 
 less than one-sixth to one-eighth of the infant's body weight every 
 twentv-four hours as early as possible following birth. (See Feed- 
 ing, p. 181.) 
 
 It is, therefore, necessary to control the temperature, ventilation 
 and humidity of the bed, and to keep a careful supervision of the 
 feeding, more particularly the fluid intake. Respiration must also 
 be carefully watched in order to detect cyanosis and asphyxia suffi- 
 ciently early to save the infant. This requires that these infants 
 be observed day and night. 
 
 Xo attempt should be made to prevent heat loss entirely by
 
 222 INCUBATORS 
 
 keeping the air surrounding the infant at anywhere near its body 
 temperature. Leaving an infant in such an environment would 
 soon result in heat stagnation with resulting symptoms of heat 
 stroke which is early evidenced by restlessness, rapid respiration 
 and dry skin. 
 
 The bed temperature should be lowered gradually but steadily 
 until it reaches 72° F. The best method of judging the infant's 
 external temperature requirements is by taking the rectum tempera- 
 ture at stated intervals. The infant should be graduated from the 
 incubator as soon as its general condition permits. It should then 
 be kept in a clean, well- ventilated room, in which the temperature 
 can be stabilized at about 70° F. The average time that a higher 
 surrounding temperature will be indicated will vary between one 
 and eight weeks and the hospital stay from two to ten weeks. 
 "Mothering," in the form of exercise, and massage are essential 
 to every premature once its physical condition permits handling. 
 The same is true of needs for the strictest attention to its personal 
 hygiene. 
 
 The infant should be discharged to its home as soon as" possible 
 for several reasons: (1) In a good home environment it will 
 receive more individual care than in a general hospital; (2) the 
 interest of the mother in the child must be maintained; (3) placing 
 the infant at the breast is the best way of maintaining the mother's 
 milk supply, if the breasts are still actively secreting; (4) in order 
 to prevent " hospitalism" due to lack of "mothering" and a tendency 
 to secondary infections. 
 
 The bed must be kept scrupulously clean. 
 
 The infant's bedding should be of such material that it can 
 be destroyed when contaminated by vomit and excreta. Feathers 
 are not practical. Untarred jute can be used for this purpose. 
 The mattress should be covered by a heavy pad to prevent soiling. 
 
 All contact with infected cases and attendants must be avoided. 
 
 All visitors are best excluded. 
 
 The conservation of heat must be begun immediately after birth. 
 
 The infant must be properly dressed; its head as well as its 
 body should be protected. 
 
 The body temperature of the infant should not be allowed to 
 go lower than 97 ° nor above 98.6 °F. Daily fluctuations greater than 
 1.5° F. are dangerous. 
 
 The general care and feeding should receive the most careful 
 attention. 
 
 Above all else all care administered to the premature should 
 tend to individualization.
 
 HOME-MADE HEATED BEDS 22:') 
 
 HOME-MADE HEATED BEDS. 
 
 Emergency Equipment.— As many of the cases must be cared for 
 in the home and in most instances without time or facilities to 
 properly equip a nursery, every physician should have some definite 
 ideas on the construction of a bed which will meet exigencies of 
 the individual case. We have already spoken of the general care 
 and equipment of a nursery unit in the home. A number of practi- 
 cal emergency beds have been described, the specifications of a few 
 of which will be given more in detail. 
 
 A small wash basket well padded inside and outside by quilting, 
 into which is fitted a removable platform about 4 inches above the 
 padded floor of the basket, makes a fair emergency bed. Beneath 
 the platform in the floor of the basket hot-water bottles or bags are 
 placed which must be refilled from time to time. The removal of 
 the bags for refilling, which should be three or more in number and 
 which are to be filled at different times, is facilitated by cutting an 
 opening along the lower outer wall of the basket through which the 
 water bags can be removed at will without disturbing the infant. 
 A box can be built for this purpose to even better advantage. 
 
 Whether a box or basket is used it must be provided with some 
 form of cover for three-quarters of its upper surface. This may 
 be accomplished by using a heavy blanket or building a lid to fit. 
 
 In such a bed the infant must be provided with proper clothes 
 as previously described to prevent undue heat loss. 
 
 This bed should be kept in a well-ventilated warm room, the 
 temperature of which should range between 68° and 72° F. if 
 possible. 
 
 Brown 26 describes the following practical home-made heated bed : 
 
 Take a 24-inch wicker clothes basket and pad the bottom with 
 non-absorbent cotton to a depth of 8 inches. On top of this cotton 
 fit a sheet of oilcloth, sewing the edges through the sides of the 
 basket. On the oilcloth lay a double layer of white flannel and on 
 the flannel a napkin of absorbent cotton. Take half a dozen of 
 12-ounce citrate of magnesia bottles with wire and rubber corks 
 and cover them with flannel. These bottles are filled with water 
 at 110° F. and hung on the inside walls of this basket. A ther- 
 mometer hung inside should register a temperature from 80° to 
 90° F. all the time. At night an oilcloth is spread over the foot 
 half of the top of the basket. 
 
 Electric-heating pads, protected by copper jackets, have been in 
 use by the writer over a period of several years, and offer a valuable 
 means of meeting emergency requirements. They are also valu- 
 able for use in the home where the temperature cannot be well 
 regulated after infants leave the hospital station. Electric-heating
 
 224 INCUBATORS 
 
 pads have lost their popularity through the danger of fire following 
 short circuit due to broken wires, and through the poor quality 
 of the thermostat attachments of some of the pads. To avoid the 
 danger of fire from short circuits in electric-heating pads, a copper 
 receptacle is used, 16 inches long, 13 inches wide and 1J inches 
 high, into which a 12 x 15-inch heating pad is laid. To allow of 
 a maximum radiation from the lid or upper surface of the same, 
 the floor and sides are lined with asbestos sheeting, while the lid 
 is not lined. The cord passes through a small rubber insulator 
 at the side to prevent contact with the metal and injury to the 
 cord. This simple device can be used temporarily in wards and 
 homes where better facilities for the care of this class of infants are 
 lacking. It is to be placed in the bottom of a basket or crib, under 
 the mattress or pillow (Fig. 143). 
 
 Fig. 143. — Copper receptacle containing pad. 
 
 Litzenberg 27 has described a practical bed for home or hospital 
 use for which the specifications are as follows. A box 24 inches 
 long, 20 inches high, 18 inches wide. Eight inches from the bottom 
 is a false bottom dividing the box into two chambers, the heating 
 apparatus being in the smaller lower chamber and the baby in the 
 upper one. The false bottom is the support for the bed of the 
 baby and does not cover the whole bottom of the box, a space of 
 4 inches being left at one end for the circulation of hot air. The 
 top of the box may be fixed on hinges, or to slide, which is better. 
 There is a pane of glass in the top so that the baby may be watched, 
 and there are two ventilating holes near the end of the cover oppo- 
 site the place where the hot air enters. An ordinary pillow is 
 laid on the false bottom for the bed. The incubator is heated by 
 bottles filled with very hot w T ater and placed in the lower chamber 
 through a small door in the side of the chamber. Fresh air enters
 
 HOME-MADE HEATED BEDS 225 
 
 this door, passes over the hot bottles, is heated and ascends by 
 way of the 6-inch space at the end of the box to the baby's chamber 
 and out through the ventilating holes in the top, giving a constant 
 supply of warm fresh air. A thermometer is placed in the incubator 
 beside the baity, or better beneath the first fold of the enveloping 
 blanket. 
 
 By watching this thermometer a fairly constant temperature can 
 be maintained by frequent filling of the bottles. This is the method 
 usually advised for heating. He has further devised a hot-air 
 radiator made of ordinary 3-inch eaves-spouting. A temperature 
 not varying 2 to 3° F., he states, is easy to maintain. The heat 
 from the chimney of an ordinary lamp enters the spout radiator 
 through an elbow 1 inch or 2 above the chimney. This elbow curves 
 upward toward the box, which it enters by way of a hole in one 
 end of the chamber where the spout divides into two parts to give 
 more radiating surface. These two branches unite at the other 
 end of the box, and the warm air passes out through a hole in the 
 end without entering the chamber in which the infant is placed. 
 Thus, the products of combustion in the lamp do not enter to 
 injure the baby. The air for the baby enters by the door in the 
 side of the box described before, and is heated by the hot pipes 
 and ascends to the baby. Over the discharging end of the radiator 
 is a cap with a hole 1 inch in diameter. This discharge hole being 
 very small, keeps the hot air from rushing through without radiating 
 its heat. The box can easily be made collapsible so that the whole 
 thing can be slipped under the seat of a buggy and be set up complete 
 in less than five minutes. 
 
 Specifications.— Board 1 inch thick, 10 inches wide and 21 feet 
 long. Cut six pieces 2 feet long and one piece 18 inches long. 
 On four of the 2-foot pieces nail a small cleat, the full width of the 
 board, 1 inch from each end. Eight inches from the edge of two 
 of the 2-foot pieces nail a cleat parallel to the long way of the 
 piece and on the same side of the piece as the small cleat. In the 
 center of the 18-inch piece cut a hole 3.25 inches in diameter. Now 
 set the pieces with the long cleat on edge. The cleats will face 
 each other and be 8 inches from the floor. Place one of the 18-inch 
 pieces with the hole in it against the end cleats of the two side 
 pieces and fasten them there by means of two hooks screwed into 
 the short edge of the side pieces, the hook fastening in a staple or 
 ring in the 18-inch piece. Fasten the other end in the same manner 
 and then place the radiator in the two holes at the end. Now 
 lay two of the 18-inch pieces on the long cleat, and you have the 
 false bottom or bed support. The other 2-foot pieces with the 
 cleats are now put together with the two remaining 18-inch pieces 
 with hooks arranged as described, and when put together they are 
 15
 
 226 INCUBATORS 
 
 placed on top of the first set and securely fastened, thus making a 
 box 18 x 20 x 24 inches. There now remain two of the 2-foot 
 pieces which are fastened together with several cleats to make a 
 top. A hole about 8 x 10 inches is cut near one end of the top 
 for a window for observing the child, and still nearer the end are 
 cut two ventilating holes about 2 inches in diameter. 
 
 ROOM INCUBATORS. 
 
 The room incubator or so-called giant incubator claiming to have 
 all the advantages of little incubators without their inconveniences, 
 was constructed in Lyon, France, for the first time in 1886 by 
 H. Colrat. It consisted of a room 12 feet long and 8 feet wide. Its 
 two main features were an attempt to hold a constant temperature, 
 and a system of aeration permitting of renewing the air. It was, 
 no doubt, a good innovation at that time. 
 
 In 1900 Arnaud, of Turin, introduced the hot-air room, and it 
 found followers in other cities. 
 
 The incubator chambers built by Escherich and Pfaundler in 
 Graz and Vienna, Brauer in Marburg and Langstein in the Kaiserin 
 Auguste-Victoria House in Berlin are all of the same type with 
 added improvements. They are completely enclosed cells of glass 
 and metal construction, having sufficient room for two or more 
 infant beds, obtaining the air from outside and are provided with 
 automatic regulation of gas heating, ventilation and humidification. 
 Between the cells and the nursery room there is a small space 
 providing against cooling of the infant when the door of the incu- 
 bator is opened. It is possible to change the clothing of the infants, 
 to bathe them and to feed them in the room (Fig. 144). 
 
 Several clinics in the United States have built such rooms, among 
 them Washington University, of St. Louis, and Michael Reese 
 Hospital, Chicago. 1 
 
 1 Specification of Warm Room, Washington University, St. Louis. — The fresh air 
 from outside is driven in by an electric fan. It then passes over a system of steam 
 coils enclosed in a closed steel cabinet, and is moistened by steam escaping through 
 a small valve within the cabinet. Thermostat contact is used. The air makes a 
 complete circuit of the heated chamber and passes into a closed shaft and enters 
 the room through small registers located in the shaft. The used air leaves the 
 room through the out-going shafts of the ventilating system. The room itself is 
 insulated and the windows double. A thermometer and hygrometer are placed 
 near a window and are visible from the corridor. A nurse records the room tempera- 
 ture and humidity on a chart every hour. To hold the room temperature at approx- 
 imately 80° F. and humidity at 55° F., regular inspection is necessary because of 
 the unsatisfactory working of the thermostat. 
 
 Specifications of Warm Room, University of California, San Francisco. — The room 
 is 9 by 11 feet, with an 11-foot ceiling. It accommodates five infants, the cribs 
 being separated by glass partitions 4 feet high, extending 2\ feet out from the side 
 wall. Entrance is through double doors so placed that the outer one is closed before
 
 ROOM I XCU BATONS 
 
 227 
 
 I 
 
 GROUND PLAN. 
 
 Fig. 144. — Incubator room. Escherieh-Pfaundler sj stem. 
 
 the inner one is opened. A larjie window at the opposite end admits ample light, 
 and a closet is provided for gowns and supplies. Furniture consists of a dressing 
 table, chair and scales. The ventilating system delivers 200 cubic feet of air per 
 minute, thus affording a complete change of air every five minutes. A thermostat 
 and hygrometer maintain constant temperature and humidity of the entering air. 
 The room is kept at 80° F. The infants arrive from the delivery room and are 
 placed beside the radiator, additional heat being furnished by hot-water bottles if
 
 228 
 
 INCUBATORS 
 
 Some of the greater difficulties to be overcome are the automatic 
 heat regulation, the cost of equipment and maintenance when only 
 a small number of children are to be cared for, the distress caused 
 the attendants when they are required to remain for a considerable 
 period in the heated room, and most important the difficulty 
 encountered in individualizing the care of premature infants of 
 different ages and stages of development. 
 
 The disadvantages of the larger incubator room have led in many 
 clinics to their being discarded, among others that at the Michael 
 Reese Hospital. More practical is a room provided with special 
 facilities for heating and ventilation which can be used in conjunction 
 with individual heated beds. 
 
 In its primitive form an incubator room may be provided in a 
 private home by heating the room to 75° to 80° F., at the same 
 time making provision for moistening the air sufficiently by hang- 
 ing wet clothes near the stoves or radiators. It is, of course, 
 impossible to maintain a constant temperature and ventilation by 
 such crude means, so that in conjunction with a more moderately 
 
 Fig. 145. — Heated room used as station for the care of premature infants (Uni- 
 versity of California, San Francisco, California). Showing individual cubicles, 
 built on a shelf running across the room. 
 
 necessary. It is seldom necessary to keep them here longer than twenty-four hours, 
 after which they maintain a fairly steady body temperature with the room at 80° F. 
 and no additional heat in the crib. 
 
 Michael Reese Hospital Incubator Room. — The specifications of this room are as 
 follows. It is 16j feet long by 10 feet wide, with a plate-glass partition cutting off 
 a vestibule 6 by 10, in which the nurse may stay out of the greater heat of the incu- 
 bator room proper. The incubator room itself is a cube 10 feet each way, lined 
 with cork, felt and asbestos, besides the other normal coverings. There is a double 
 window with separate double transom, and exhaust fan and an intake fan.
 
 TRANSPORT AT I OX INCUBATORS 
 
 229 
 
 heated room, 70° to 75° F., some type of individual bed for the 
 further protection of the infant should be used. 
 
 A modification of the incubator room and doing away with some 
 of its disadvantages has been installed in the Sloan Maternity 
 Hospital, in New York, described by Dr. E. 15. Cragin. It is 
 possessed of many valuable features, such as filtered air, the absorp- 
 tion of air by an electric fan and the serial electric light heating. 
 The disadvantages are to be found in the inability to individualize 
 the infant care and the necessity for constant supervision (Fig.146). 
 
 m 
 
 ^n^) 
 
 ®d 
 
 ® © f 
 
 Fig. 146. — The Sloan Hospital incubator. 
 
 Selection of Method for Supplying Artificial Heat.— This must of 
 necessity depend upon the facilities at hand. Every community 
 should be supplied with the proper equipment for handling these 
 infants. Such a station should be a part of every maternity depart- 
 ment. In institutions more especially designed for the care of 
 infants, a more elaborate station should be supplied and wet nurses 
 should be available. 
 
 TRANSPORTATION INCUBATORS. 
 
 Probably the most important epoch in the life of the premature 
 infant is that period between birth and the institution of some 
 proper method for the prevention of refrigeration. It is the experi- 
 ence of all institutions receiving such infants that many of them
 
 230 
 
 INCUBATORS 
 
 are lost through carelessness in protecting them during the first 
 hours after birth. The figures of Ylppo are illuminating on this 
 point. 
 
 TEMPERATURE ON ADMISSION AND MORTALITY OF PREMATURE 
 
 INFANTS. 
 
 Temperature 37 to 35 Temperature 28 J- 
 
 degrees. Died within degrees. Died within 
 
 the first month. the first month. 
 
 Per cent. Per cent. 
 Group I< 
 
 600 to 1000 gm 66.6 100.0 
 
 Group II: 
 
 1001 to 1500 gm 37.5 85.7 
 
 Group III: 
 
 1501 to 2000 gm 21.05 60.0 
 
 Group IV: 
 
 2001 to 2500 gm. ..... 5.88 20.0 
 
 By looking at the above table we may easily come to a one-sided 
 conclusion that the mortality of the premature infants is in the 
 first place influenced by the more or less severe initial cooling 
 
 Fig. 147. — Obstetrical bag with false bottom designed by the author as a trans- 
 portation incubator. 
 
 occurring after birth, and that therefore the mortality of the 
 premature infants may be markedly reduced by painstaking care 
 in preservation of heat. 
 
 A simple trans portatiori incubator can be made by the employment 
 of an ordinary obstetrical bag with a false bottom. Hot-water
 
 TRANSPORTATION INCUBATORS 
 
 231 
 
 bags or bottles can be carried in the lower compartment, and the 
 infant in the bag proper. It is only necessary to make a sufficient 
 number of f-inch holes beneath the handle for ventilation. These 
 should be reinforced by a metal rim so that they cannot collapse 
 and cut off the supply of air. The fresh-air supply can be con- 
 trolled by a metal slide covering these holes or by using corks. 
 Eight larger holes should be made in the floor of the satchel, so 
 that the heat can pass from the lower compartment into the upper 
 compartment. These are best made close to the edge at the ends, 
 so that thev will be less likely to be covered by the bedding (Fig. 
 147). 
 
 Fig. 148. — DeLee transportation incubator. 
 
 The De Lee incubator ambulance is a minature incubator with a 
 circulating hot-water system heated from the outside by an alcohol 
 lamp. It is well ventilated and lighted by electricity. It is 21 
 inches long, 11 inches wide and 11 inches high (Fig. 14S). 
 
 Welde 25 has described a transportation incubator which is rather 
 simple in construction (Figs. 149 and 150). 
 
 Heat is supplied by a thermophor or hot water bottles placed in 
 lower compartment.
 
 Fig. 149. — Inner case, o, air compartment; A, inner metal box; b, sliding door; 
 d, removable upper wall of the double floor; c, lower air holes; e, upper air holes; 
 a, double floor. 
 
 C n 
 Tig. 150. — Outer case. B, outer wood case; K, lid of wooden case; L, glass 
 window; h, felt lining; m, carrying strap; e, upper air holes; n, handles; c, lower 
 air holes; g, windows in inner case; /, removable lid of inner case.
 
 TRANSPORTATION INCUBATORS 233 
 
 Bibliography. 
 
 1. Denuce: Jour, de med. de Bordeaux, December, 1857. 
 
 2. Clementovsky: Oesterr. Jahrb. f. Padiatrik, 1873, 3, .'50. 
 
 3. Pasquad: La couveuse artificielle chez les nouveau-nes, These de Paris, 1899. 
 
 4. Crede: Arch. f. Gyniik., 1884, 24, 128. 
 
 5. Winckel: Centralbl. f. Gynak., 1882, Nr. 1 bis 3. 
 
 6. Tarnier: Sie wurde 1881 in der Maternite aufgestellt und wohl zuerst in 
 einer Arbeit von Auvard (Arch, de Tocologie, October, 1883) beschrieben. 
 
 7. Auvard: Arch, de Tocologie, 1883, p. 577. 
 
 8. Berthod: La couveuse et le gavage a la maternite de Paris, These de Paris, 
 1887. 
 
 9. Hearson: Zit. nach Czerny-Keller, 1, 673. 
 
 10. Eustache: Jour, d sc. med. de Lille, 1885. 
 
 11. Diffre: Montpelier med., 1896. 
 
 12. Lion: Zit. nach Czerny-Keller, 1, 673. 
 
 13. Pajot: Zit. nach Budin, Manuel pratique d'allaitement, Paris, 1905. 
 
 14. Budin: Le Nourrisson, Paris, 1900. 
 
 15. Hutinel and Delestre: Revue mens, des mal. de l'enfance, 1899, 17, 529. 
 
 16. Finkelstein: Lehrbuch der Sauglingskrankheiten, Berbn, 1905, II Teil, s. 32. 
 
 17. Rommel: Miinchen. med. Wchnschr., 1900, Nr. 11. 
 
 18. Polanos: Miinchen. med. Wchnschr., 1903, Nr. 35, s. 1498. 
 
 19. Escherich and Pfaundler, L.: Mitt. d. Vereins d. Arzte in Steiermark, 1900, 
 Nr. 3. 
 
 20. Colerat: Societe des sciences medicales de Lyon, 1896. 
 
 21. Arnaud: LaSala incubatrice; Contribute alio studio della fisiopatologia dei 
 neonati prematuri, Torino, 1900. 
 
 22. Cragin, E. B.: Jour. Am. Med. Assn., No. 11, 63, 947. 
 
 23. Ylppo: Ztschr. f. Kinderheilkunde. 
 
 24. DeLee: Obstetrics for Nurses, W. B. Saunders Co., Philadelphia, 1919. 
 
 25. Welde: Jahrb. f. Kinderheilkunde, 1912, 75, 551. 
 
 26. Brown, Alan: Arch. Pediat., No. 8, 34, 609. 
 
 27. Litzenberg: J. Minnesota Med. Assn., Minneapolis, 28, 87, 91, 1908.
 
 PART III. 
 GENERAL DISEASES. 
 
 CHAPTER X. 
 DISEASES OF THE RESPIRATORY TRACT. 
 
 ASPHYXIA NEONATORUM. 
 
 Asphyxia is a condition produced by any interference with 
 oxygenation of the blood. It may be present at birth or it may 
 occur subsequent to that event. Asphyxia in the new born is 
 characterized by an absence or feebleness of respiration which is 
 accompanied by cardiac action, showing that life is present. 
 Asphyxia occurring after birth is most frequently due to pre- 
 maturity or to congenital weakness. 
 
 During intra-uterine life the wants of the fetus are supplied 
 from the maternal blood stream through the placenta, oxygen 
 being present in sufficient quantities so that respiration is unneces- 
 sary. Normally this state of apnea terminates at birth and respi- 
 ration is established, in all probability, as a result of the decreasing 
 supply of oxygen derived from the placental circulation, and of 
 the increasing amount of carbon dioxide which is accumulating 
 in the fetal blood, and upon which the stimulation of the medullary 
 center depends, the fetus passing from a condition of apnea to 
 one of dyspnea. At the same time the heart action is slowed and 
 the blood-pressure raised, both the result of the carbon-dioxide 
 stimulation. Since the respiratory center is only with difficulty 
 affected in the premature, it is sluggish in responding to the increase 
 of carbon dioxide, and if this increase is slow in appearance respira- 
 tion may not be attempted at all. Cutaneous stimulation from 
 extraneous influences in the outer world also plays a part in the 
 establishment of primary respiration. 
 
 Etiology.- Asphyxia of the premature newborn may be due to 
 any one of the many causes which interfere with the oxygen supply 
 of the fetus either before or during labor. These causes may be 
 listed as follows:
 
 236 DISEASES OF THE RESPIRATORY TRACT 
 
 1. Abnormally strong and prolonged labor pains. Such lengthy 
 and oft-repeated uterine contractions may interfere with the 
 exchange of gases in the placenta or with the oxygen-laden umbilical 
 blood stream. 
 
 2. Unequal pressure exerted by the uterus after the membranes 
 have ruptured, if applied to the placenta or the cord, may prevent 
 oxygen reaching the fetus. 
 
 3. Compression or tearing of the placenta. 
 
 4. Twisting or tearing of the cord or its compression while in 
 the uterine cavity or when prolapsed. 
 
 5. Premature separation of the placenta, either complete or 
 partial. 
 
 6. Slow labor the result of weak pains or contracted pelvis. 
 
 7. Premature respirations resulting from attempts at version or 
 from the application of forceps. In this instance the aspiration 
 of amniotic fluid or vaginal mucus usually forms the obstruction 
 to respiration. 
 
 8. Maternal anemia or asphyxia from renal, cardiac or pulmonary 
 affections, diseases of the blood, eclampsia or other forms of toxemia 
 such as are produced by morphine, chloroform, etc. 
 
 In the extra-uterine variety of asphyxia the infant attempts respi- 
 ration after birth but is unsuccessful. The reason for this failure 
 may be due to the presence of mucus, blood or liquor amnii in the 
 respiratory passages; to the presence of anomalies of the heart 
 or lungs; to injuries of the skull; to the pressure from cerebral 
 hemorrhage; or to inherent constitutional weakness or weakness 
 of the respiratory muscles. In the premature infant the respiratory 
 center is but insufficiently developed, the respiratory muscles are 
 weak and the lungs are in a state bordering more or less closely 
 upon fetal atelectasis. All of these factors favor the development 
 of asphyxia, and the younger the fetal age of the infant at the 
 time of birth, the more pronounced are these conditions, though 
 it must be remembered that not all premature infants are debilitated 
 (see Atelectasis). 
 
 Cerebral pressure from injuries of the skull or from intracranial 
 hemorrhage causes anemia of the medulla and consequently pre- 
 vents stimulation of the respiratory center with resulting lack of 
 respiratory activity, or with stimulation of the vagus with excessive 
 slowing of the pulse, which interferes with the exchange of gases 
 through the placenta or the lungs. 
 
 Our present belief is that the asphyxia occurring immediately 
 after birth is due to oxygen deficiency and to paralysis of the 
 respiratory center by overloading the blood with carbon dioxide. 
 The presence of atelectasis and pulmonary congestion and edema 
 favors the development of this state, which is so frequent in pre-
 
 ASPHXIA NEONATORUM 237 
 
 matures and leads to general acidosis. Ylppo demonstrated in 
 living premature infants alkalinity of the blood lower than thai 
 ever found in the blood of adults. Conditions are thus favorable 
 for excessive acidification of the organism, not only by carbon 
 dioxide but also by the other acid products of metabolism. Because 
 of the abnormal reaction of the blood the irritability of the respira- 
 tory center is early reduced, leading to asphyxia] attacks. In 
 addition, it must be borne in mind that the frequency of cerebral 
 and spinal hemorrhages in the smaller prematures will explain 
 asphyxial attacks occurring in the first two or three months of life. 
 Finally, traumatic lesions of the respiratory center may, in them- 
 selves, lead to disturbances in respiration and to interference with 
 oxygen intake. 
 
 Morbid Anatomy.— Examination of the body of a premature 
 new-born infant, dead of asphyxia, shows besides the evidences 
 of prematurity, marked congestion of the internal organs. The 
 right heart, sinuses of the dura and the great vessels are filled with 
 blood. The brain and the organs in the thoracic and abdominal 
 cavities are congested and edematous. Small hemorrhages are 
 found in the pleura, pericardium, peritoneum, liver, kidneys, 
 adrenals and retina. Occasionally effusions are seen in the serous 
 cavities. In the lung areas of aerated tissue are seen along with 
 areas of atelectasis, and the trachea and bronchi may be found 
 filled with mucus or amniotic fluid. Edema of the extremities 
 and scrotum may be present. Extravasations of blood are found 
 in the skin and mucous membranes as well as in the internal 
 organs. 
 
 Symptoms.— The strong premature infant at birth behaves much 
 as does the full-term healthy child; it breathes deeply, utters a 
 more or less vigorous cry, and the skin which at first is of a purplish 
 hue rapidly becomes pink. If asphyxia exists two sets of symptoms 
 may present themselves, depending upon the variety of asphyxia, 
 asphyxia livida or asphyxia pallida. 
 
 In asphyxia livida or asphyxia of the first degree the skin has 
 a reddish-blue or bluish tinge, the face is swollen, the eyes protrude 
 somewhat and the conjunctivae are injected. The extremities 
 remain passive though the muscles retain their tonicity or are 
 even hypertonic; the heart beats strongly and the apex-beat is 
 often apparent to the eye; the vessels of the cord are filled with 
 blood and pulsate; the respiratory efforts may be absent or shallow 
 and infrequent. These infants can be roused and made to cry, 
 respirations being established after suitable measures of resuscita- 
 tion have been used. 
 
 In asphyxia pallida, or asphyxia of the second degree, the vaso- 
 motor center is overstimulated by the excess of carbon dioxide
 
 238 DISEASES OF THE RESPIRATORY TRACT 
 
 in the blood and this overstimulation causes contraction of the 
 peripheral vessels with venous engorgement of the deeper vessels, 
 thus further overloading the heart. The face is of a waxy pallor, 
 the visible mucous surfaces are cyanosed, the muscle tone is lost 
 and the extremities hang lax. The reflex irritability is lost; there 
 is no attempt at respiration or at the most very feeble efforts; the 
 pulsations of the heart are weak and either fast or slow, and the 
 pulsations in the cord are absent or only weakly perceptible. The 
 distinguishing feature that separates this condition from asphyxia 
 livida is the lack of muscle tone in the pallid form, these infants 
 having a corpse-like appearance and only the presence of the heart 
 action and the few feeble respiratory gasps show that the infant is 
 not dead. 
 
 Further Course. — If an asphyxiated infant is revived it frequently 
 remains somewhat apathetic, cries very little and does not nurse 
 well, requiring artificial aid in obtaining nourishment. In the 
 stronger infants, however, this condition tends to clear up, so that 
 in a few days the cry is vigorous, the movements active and the 
 ability to nurse is good. In the weakling, whether premature or 
 full-term, such improvement is much slower. The poorly devel- 
 oped respiratory mechanism results in superficial and irregular 
 breathing and the existence of areas of atelectasis tends to delay 
 development of the lung. These weak infants may have breathed 
 spontaneously at birth though not enough to have dilated the 
 alveoli of the lungs to a sufficient degree and as a result repeated 
 attacks of cyanosis occur. These attacks of cyanosis are accom- 
 panied by a condition of apnea which lasts a moment or longer, 
 during which the infant ceases to breathe entirely. These attacks 
 appear without warning and may be very frequent in the weaker 
 infants during the first two weeks of life, and are evidently the 
 result of lowered irritability of the respiratory center. The outlook 
 for the infant in these spells is not good, despite the fact that treat- 
 ment is undertaken, because they are an indication of inherent 
 weakness in the individual. In those cases which are to recover, 
 these attacks of cyanosis become less and less severe and less 
 frequent. 
 
 The after-life of these infants may be affected to some extent 
 as the persistence of a degree of atelectasis renders them less resist- 
 ant to infection. 
 
 Sequelae.— Cerebral symptoms that develop later are not at all 
 infrequent in children asphyxiated at birth and probably depend 
 upon cerebral sclerosis secondary to minute intracranial hemor- 
 rhages. Developmental cerebral anomalies or injuries may, 
 however, be primary causes of asphyxia and may later be evidenced 
 by motor and psychic disturbances.
 
 ASPHYXIA NEONATORUM 239 
 
 Diagnosis.— Asphyxia must be differentiated from hemorrhage of 
 meningeal or cerebral origin occurring during prolonged or abnormal 
 labor or after the application of forceps. The symptoms of a 
 slight hemorrhage resemble those of asphyxia, the breathing being 
 very superficial with frequent lapses into stupor. Convulsions 
 occasionally occur and the pulse may be slow or fast. Continued 
 slow pulse with the occurrence of coma and convulsions speak 
 strongly for a cerebral hemorrhage, especially after a prolonged 
 labor or the application of forceps. The differentiation is extremely 
 difficult during the first days of life in premature and weak infants 
 and death frequently results before the etiological factor is ascer- 
 tained. Delmas 1 recommends lumbar puncture as a diagnostic 
 and therapeutic measure. 
 
 Prognosis.— The outlook for strong prematures suffering from 
 asphyxia livida is good, the majority recovering under proper 
 treatment. In the weaklings it is always grave. In asphyxia 
 pallida the prognosis is bad, the infant invariably succumbing if 
 left to itself. If the heart action improves while attempts at 
 resuscitation are being made it is a favorable sign. Endeavors to 
 revive the infant should be kept up until the heart ceases to beat. 
 At all times undue violence must be avoided, all attempts at resus- 
 citation being applied gently and at regular intervals to avoid 
 visceral injury. If cerebral hemorrhage is combined with asphyxia 
 the outlook is very poor. 
 
 The cause of death in asphyxia may be a recurrence of the 
 asphyxial attacks, lowered irritability of the respiratory center, 
 atelectasis of the lung or blocking of the air passages by inspired 
 foreign matter or cardiac failure. 
 
 Treatment.— The treatment of asphyxia is concerned with clearing 
 the respiratory passages and supplying oxygen to the tissues. In 
 the milder cases the finger is gently introduced into the pharynx, 
 or the throat stroked downward, while the child is held in an 
 inverted position, sufficient to clear out the obstruction to respira- 
 tion. In the cases of asphyxia livida there is usually mucus in 
 the trachea or bronchi, and this can frequently be removed suffi- 
 ciently to allow of respiratory activity by inverting the infant and 
 introducing a catheter as far as the upper opening of the larynx. 
 Only in the larger infants is it possible to pass the catheter into 
 the larynx. Suction is made with the lips and the mucus is drawn 
 into the catheter. Occasionally it is necessary to repeat this 
 maneuver several times. The dangers of a syphilitic infection are 
 to be remembered. 
 
 Once the passages are cleared of mucus the reflex stimulation 
 
 1 Le Progres medical, 1912, 40, 88-89.
 
 240 DISEASES OF THE RESPIRATORY TRACT 
 
 of respiration by external irritation is attempted. In the milder 
 cases the back and buttocks of the suspended child are gently 
 slapped, cool (90° F.) water is sprinkled over the body, or the 
 latter is rubbed with a warm cloth. In the severer cases the child 
 is immersed in hot water at a temperature of 40.5° C. (105° F.) 
 for a few minutes and then in a cool bath for an instant. The 
 warm bath relieves the vasoconstrictor spasm and the overloaded 
 heart, the blood being brought to the surface. Weak mustard 
 baths, warm enemata and careful compression of the chest are all 
 advocated. 
 
 In the severest cases cutaneous stimulation is not sufficient 
 and it becomes necessary to resort to artificial respiration. 
 
 Insufflation has dangers, especially for the premature infant 
 whose pulmonary tissue is very delicate. If the lung is torn emphy- 
 sema follows and only a slight tear is necessary because of the 
 very poorly developed state of the elastic tissue in the lung of 
 the premature. On this account it is best to use some method 
 by which the amount of air to be forced into the lungs may be 
 measured. The capacity of the lungs being about 30 cc, the use 
 of a thin rubber bulb of a capacity smaller than this would obviate 
 the risk of tearing the lung tissue. The difficulty of entering the 
 trachea of these small premature infants must be kept in mind. 
 
 The choice of the method to be used in inducing artificial respi- 
 ration depends upon the severity of the asphyxia. There is no 
 use wasting time in spanking the back or making traction on the 
 tongue in the severer cases. In the lighter forms the simpler 
 measures usually suffice, but in asphyxia pallida more energetic 
 measures must be practised. First the air passages are cleared and 
 then Prochownik's method is used for thirty seconds. If this is 
 unsuccessful the tracheal catheter is inserted with great care and 
 the lungs dilated with air. 
 
 The treatment of secondary asphyxia! attacks consists in the 
 use of warm baths, oxygen insufflations and artificial respiration. 
 The oxygen tank should be kept at the side of the infant's bed and 
 either continuous or intermittent showers of oxygen given in the 
 attempt to ward off cyanotic attacks (see Cyanosis). 
 
 The intracutaneous injection of oxygen with an aspirator has 
 been recommended in the treatment of asphyxia by Delmas. 1 
 He advises injecting from 30 to 60 cc beneath the skin, from which 
 region it is readily absorbed with beneficial effect. In the opinion 
 of the author such injections, because of the considerable trauma 
 and shock, might result disastrously in the treatment of premature 
 infants. 
 
 Reanimation of asphyxiated infants by the insufflation method 
 
 1 La medecine infantile, 1912, 16,[21U.
 
 CYANOSIS 241 
 
 of Meltzer and Auer is, according to Planclni, quite practicable 
 and efficient. In this method a current of air, directed as far as 
 the tracheal bifurcation through a small catheter, ventilates the 
 lungs sufficiently to oxygenate the blood even if no respiratory 
 movements occur. The necessary apparatus consists of a rubber 
 bulb, a small mercury manometer and a Xo. 12 (French sejile 
 rubber catheter. A rod of soft copper is placed in the lumen of 
 the catheter to give it the proper shape for introduction and the 
 catheter itself is marked with transverse lines at 8, 10 and 12 cm. 
 from the tip, indicating the distance from the mouth to the 
 bifurcation of the trachea in a 2000-, 3000- and 4000-gm. child, 
 respectively. 
 
 The method of the procedure is as follows: With the little 
 finger or a small gauze sponge in the hold of a forceps any mucus 
 in the infant's throat is removed and the child is then wrapped in 
 a blanket and placed with the neck slightly overextended. The 
 index finger of the left hand is introduced as far as the upper border 
 of the larynx, finding the soft opening of the glottis. The catheter 
 is introduced by the right hand between the tongue and the palmar 
 surface of the left index finger into the laryngeal opening. When 
 it has reached the proper distance the copper rod is removed, the 
 insufflation apparatus attached and air injected with the bulb 
 the pressure not exceeding 10 or 15 mm. of mercury. 
 
 The insufflation may be continued as long as needed. Soon 
 the child appears less relaxed and the heart tones become stronger 
 and more regular and respiratory movements begin. 
 
 In infants weighing under 2000 gm. the larynx and trachea are 
 passed only with great difficulty because of their small diameter, 
 and the dangers of secondary infection due to trauma of the tissue 
 is great. 
 
 The use of the pulmotor or lung motor, several modification- of 
 which are on the market, is not to be recommended in treating 
 the asphyxia of premature infants, because of the danger of rupture 
 of the delicate pulmonary tissue. 
 
 CYANOSIS. 
 
 Of all functions of the premature infant, that of respiration is 
 usually the least developed at birth, evidencing to a marked degree 
 the general lack of development of the central nervous system. 
 Failure on the part of the respiratory apparatus to respond in a 
 sufficient manner to the needs of the infant is the most frequent 
 cause of symptoms of the gravest nature in these weaklings and 
 indeed not seldom of death itself. 
 
 The underlying factors in the production of cyanosis may be 
 16
 
 242 DISEASES OF THE RESPIRATORY TRACT 
 
 divided into inherent and extraneous. The inherent causes of 
 cyanosis are: 
 
 1. Lack of development of the central nervous system, especially 
 of the respiratory center. 
 
 2. Weakness of the general musculature and softness of the 
 ribs. 
 
 3. Persistence of fetal atelectasis which tends to delay develop- 
 ment of the lungs. 
 
 4. Congenital malformations of the heart or great vessels or 
 myocardial asthenia. 
 
 5. Malformations of the respiratory tract or of the diaphragm. 
 
 6. Diseases or compression of the air passages. 
 
 7. Injuries of the skull or cerebral hemorrhage. 
 
 8. Obstruction to nasal breathing. 
 
 9. A birth weight below 1200 gm. These infants almost invari- 
 ably suffer from attacks of cyanosis. 
 
 10. Cooling of the body is given as a cause by Budin, but many 
 infants have a temperature of 95° F. or even 93° F. without the 
 occurrence of cyanosis. 
 
 11. Elevation of the body temperature to more than 102° F. 
 is given by Zahorsky as a cause. 
 
 In the premature infant the causes among the above which are 
 chiefly operative in the production of the characteristic attacks 
 of cyanosis are the weak respiratory muscles, the softness of the 
 ribs, the underdevelopment of the centers of respiration and the 
 presence of fetal atelectasis. 
 
 Involvement of the heart is ordinarily of secondary occurrence, 
 the diminished amount of oxygen in the blood resulting in a slowing 
 and weakening of the heart's action. The atelectasis which is so 
 frequently present, tends to hinder the closure of the foramen 
 ovale and the ductus Botalli and these defects in turn predispose 
 to cyanosis. 
 
 The extraneous causes include: 
 
 1. The aspiration of food or vomitus into the larynx or trachea. 
 The lack of development of the pharyngeal and laryngeal reflexes 
 is responsible for the food reaching the air passages and the lack 
 of reflex cough prevents its being ejected. Pneumonia not infre- 
 quently follows the aspiration of such foreign particles. 
 
 2. Distention of the stomach from overfeeding. This is one of 
 the most common causes of cyanosis and death in premature 
 infants. This leads to interference with the action of the diaphragm. 
 
 3. Meteorism, due to gastric and intestinal stasis. 
 
 4. Attempts at drinking are often followed by cyanosis, either 
 the direct result of the mechanical prevention of respiration or 
 secondarily through the lessened oxygen content of the blood,
 
 CYANOSIS 243 
 
 resulting in a hick of stimulation of the respiratory centers (von 
 Reuss). 
 
 5. Undernourishment is strongly advanced by Budin as a causa- 
 tive of cyanosis, and he has shown that with increased feeding 
 
 these attacks stop. 
 
 (i. An insufficient supply of water. 
 
 7. The occurrence of a local or general infection. 
 
 Symptoms.— Oftentimes, without apparent cause, attack- of 
 cyanosis appear with frequency during the first few weeks of the 
 life of the premature or weakly infant. Usually without warning 
 the respirations, which have previously been superficial and irregu- 
 lar, become still weaker and then cease entirely for a minute or 
 longer, somewhat resembling the Cheyne-Stokes' type of breathing. 
 Accompanying the apnea is a deep cyanosis which gradually dis- 
 appears as breathing is resumed. Not infrequently, if immediate 
 steps to restore the respiratory activity to something like the nor- 
 mal are not taken, the infant dies; in other cases breathing is 
 spontaneously resumed and the attack passes off, leaving the 
 infant more or less prostrated. Care must be taken in pronouncing 
 it dead before examination for heart sounds. In a few hours or 
 days cyanosis recurs, the attacks gradually increasing in length 
 and severity despite treatment, until death occurs; or they become 
 less frequent until they cease entirely. 
 
 Occasionally the attacks are preceded or accompanied by con- 
 vulsions. Generalized edema sometimes develops. 
 
 Diagnosis.— From congenital cyanosis due to other causes, 
 or acute affections of the respiratory tract with cyanosis, these 
 attacks are differentiated by the history or other evidence of 
 premature birth, and the frequently accompanying cyanotic 
 edema, the respiratory weakness, absence of the normal vesicular 
 breathing, particularly over the bases and the tendency to a 
 subnormal temperature. 
 
 Prognosis.— The prognosis of cyanosis in the premature infant 
 varies directly with the severity of the attacks which in turn are 
 more or less directly dependent upon the fetal age and physiological 
 development, the ability of the infant to maintain its body tempera- 
 ture, the quality of the food and the ease with which the infant 
 digests it. 
 
 In no other condition to which these infants are subject is the 
 previous training and experience of the attending nurse in the 
 care and handling of this class of cases, of such vast importance. 
 
 Treatment.— A premature infant must be carefully watched for 
 signs of cyanosis, otherwise it may be found dead in bed. Should 
 an attack occur while the child is being fed, the proceeding must 
 be stopped and efforts made to restore respiration. The first thing
 
 244 DISEASES OF THE RESPIRATORY TRACT 
 
 to do is to ascertain if there is any obstruction in the upper respira- 
 tory passages. Should inspired food or vomitus be present, an 
 effort must be made to dislodge these particles. Inserting the little 
 ringer into the pharynx while the child is in an inverted position, 
 often serves to clear out the respiratory tube, and then slight 
 cutaneous stimulation by pinching, friction or gentle slapping is 
 often enough to reinitiate breathing. 
 
 Again, exhaustion of the infant may be solely responsible for 
 the cyanosis. In these cases artificial respiration should be tried, 
 the chest being rhythmically pressed upon, or one of the other 
 methods of artificial respiration may be tried. Simple compression 
 of the chest may be tried without removal from the incubator or 
 bed, though removal will be found more serviceable generally. 
 
 The use of oxygen is of value in quickly reducing the degree 
 of asphyxia after breathing is once established, although it will 
 not of itself restore that function. A tank should be kept by 
 the infant's bed and any sign of approaching asphyxia should be 
 the indication for the generous shower of oxygen. The continued 
 use of the gas when properly applied is advocated as a valuable 
 measure in the checking of attacks. About 80 to 100 bubbles of 
 oxygen gas from a partially protected mask should escape in close 
 proximity to the infant's mouth. 
 
 Aromatic spirits of ammonia in one-half to two drop doses, 
 diluted, is of value, and nitroglycerin, one drop of a 1 : 1000 solution 
 may be placed on the tongue. The use of camphor, caffein, atropin 
 or other respiratory stimulants hypodermically does not offer 
 much practical help. 
 
 Sprinkling the baby with cool water will occasionally stimulate 
 respiration and as this means is always at hand it should be kept 
 in mind. 
 
 Infants suffering from repeated attacks of cyanosis should be 
 immersed in a hot bath at a temperature of 102° to 105° F., and 
 subjected to gentle friction, more especially along the spinal column. 
 The infant may be kept in the bath for from a few seconds to several 
 minutes, when it should again be placed in its warmed bed, avoid- 
 ing all chilling. The efficiency of the bath may be increased by 
 the addition of a teaspoonful of mustard to the gallon of water. 
 Care should be taken to prevent aspiration of the bath water, or 
 its entrance into the eyes, and the danger of infection of the umbili- 
 cal cord, although not great must be borne in mind. The bath 
 may be repeated as indicated. 
 
 In our own experience the warm mustard bath has proven one of 
 the most satisfactory means of overcoming prolonged attacks. It 
 is quite evident that the facilities for preparing the bath must be 
 prearranged and great care taken to keep it at an even temperature
 
 CYANOSIS • 245 
 
 throughout the immersion. To facilitate handling and to prevent 
 undue manipulation during the cyanotic attacks the infant should 
 be wrapped in a blanket. 
 
 It cannot be too strongly emphasized that the manipulation* used 
 to relieve the cyanosis should be the minimum necessary to accomplish 
 the result as cyanotic infants react poorly to trauma. After an attack 
 is over the infant should be placed in a warm bed or bath in order 
 to overcome the tendency to a reduction of temperature by the 
 previous manipulations. Afterward it is also necessary to supervise 
 carefully the feeding in order that two things may be accomplished: 
 (1) That the occurrence of further attacks of cyanosis due to 
 mechanical obstruction by food may be prevented; and (2) that the 
 nutrition of these weaklings may be immediately bettered and thus 
 the cyanosis indirectly controlled. 
 
 The prevention of cyanosis may be aided in several ways. The 
 too rapid taking of food or distention of the stomach by over- 
 feeding must be avoided (see Feedings). Underfeeding in cases 
 where too frequent feeding is undesirable can be avoided by catheter 
 feeding at longer intervals, although the maximum food quantities 
 must be carefully ascertained by starting with minimum feedings, 
 carefully increased according to the infant's tolerance. Catheter 
 feeding is not well borne by all infants and may occasionally in 
 itself induce cyanosis. The strength of the infant should be built 
 up as rapidly as possible, and the temperature of the body should 
 be maintained by the use of the heated bed inasmuch as a lowering 
 of the body temperature not only favors the development of cyanotic 
 attacks, but makes them more severe when they do occur. The 
 use of oxygen may be of value. 
 
 Insufficient supply of fluids should be avoided by the administra- 
 tion of water where the fluid intake is less than one-sixth of the 
 body weight during the twenty-four hours. 
 
 Meteorism may be relieved by small quantities of low saline 
 enemata, part of which may be left in the rectum to good advantage 
 where the fluid intake per mouth is insufficient to meet the body 
 requirements. 
 
 Gastric lavage must occasionally be resorted to as a means of 
 last resort in overdistention of the stomach with paresis of its 
 walls and should be performed with the infant's head at a lower 
 level than the body to prevent aspiration of stomach contents, as 
 passage of the tube very frequently results in vomiting. This 
 procedure is always associated with great danger during a cyanotic 
 attack. Occasionally the gas can be relieved by simple passage 
 of the catheter into the stomach with slight pressure from without 
 over the epigastric region.
 
 240 DISEASES OF THE RESPIRATORY TRACT 
 
 DISEASES OF THE NASAL PASSAGES. 
 
 The anatomy of the nasal passages of the new-born infant is 
 such that comparatively small degrees of swelling or accumulations 
 of mucus are sufficient to lead to obstruction of nasal respiration, 
 thereby interfering with the act of nursing. When during sleep 
 the tongue falls backward, thus occluding the passage between 
 the pillars, attacks of cyanosis and dyspnea may result. 
 
 A nasal discharge present at birth or developing within the 
 first two or three weeks of life should lead to a search for evidence 
 of congenital lues. When the syphilitic infection is sufficiently 
 virulent to cause premature labor the external manifestations 
 usually appear early. 
 
 Other sources of infection of the nasal mucosa can be found in 
 the passage of the child through the maternal birth canal, from 
 the bath water or by direct transmission from an individual suffering 
 from a similar infection. The organisms which may be concerned 
 include the various pyogenic bacteria, the pneumococcus, colon 
 bacillus, influenza bacillus and, less frequently, the gonococcus. 
 The diphtheria bacillus is frequently seen as a cause in institutional 
 infants. 
 
 Obstruction of the posterior nares is occasionally seen in the 
 new-born premature, the opening being closed by either a mem- 
 branous or a bony partition. When bilateral it favors respiratory 
 obstruction and may be the direct cause of attacks of asphyxia 
 and cyanosis. Xasal infections may threaten the infant by exten- 
 sion to the lower respiratory passages, while generalized septic 
 processes may have their origin in a nasal infection. 
 
 Treatment. —The prophylaxis of nasal infections requires that if 
 the mother is suffering from any infection of the respiratory tract 
 every effort should be made to prevent infection of the offspring. 
 Coughing or direct breathing into the infant's face should be 
 avoided and care taken that infectious material is not carried 
 from one to the other on the hands, or by means of infected articles. 
 The same precautions must be taken in case an attendant is the 
 one infected. A vaginal discharge from the mother at the time of 
 delivery requires that the infant's nose should be cleaned thoroughly 
 but carefully with a cotton pledget after birth. Lowered resistance 
 due to chilling of the infant is an important etiological factor and 
 must be avoided. 
 
 It may become necessary to remove crust formation with instilla- 
 tions of normal salt or weak alkaline solutions. This must be 
 carefully performed to avoid forcing the infection into the Eusta- 
 chian tube and air passages, small quantities only being used. 
 Pledgets of cotton saturated with 1:1000 solution of adrenalin chlo-
 
 CONGENITAL STRIDORS 247 
 
 ride if placed within the nostril will temporarily relieve the nasal 
 swelling. As curative agents some of the organic silver salts in 
 weak solutions may be mentioned. The use of an ointment of 
 the yellow oxide of mercury (ung. hydrarg. ox. flaw) of ().."> or 1 
 per cent strength will be found of value. A portion the size of a 
 small pea should be introduced into the anterior nares and the 
 nostril then gently massaged in order to force the ointment as far 
 into the nose as possible. In cases of syphilitic or diphtheritic 
 infections specific treatment must be instituted. 
 
 The breast-feeding of these infants with rhinitis offer- some 
 difficulty because of the interference with respiration which accom- 
 panies obstructions of the nose. Nursing at the breast is likely 
 to be a difficult matter under the most ideal circumstances when 
 the infant is as weak as many prematures are, and if added to this 
 is an inability to breathe while sucking and swallowing. The 
 difficulties are so great at times, even in infants approaching matur- 
 ity, that it becomes necessary to feed expressed milk per catheter. 
 This method of food administration must be instituted before 
 the infant shows the results of inanition. 
 
 CONGENITAL STRIDORS. 
 
 Congenital Laryngeal Stridor.— In the premature infant the 
 presence of a stridor may go unnoticed for several days because 
 of the weak inspiratory effort, in contradistinction to the full- 
 term infant in which it is usually interpreted in the first days 
 of life. It must, therefore, be expected that the croaking or crow- 
 ing sound will be much more feeble than is usually heard in these 
 cases. The stridor usually disappears when the infant is deeply 
 asleep, which in the premature is the greater part of its day. Unless 
 there is a considerable stenosis, the infant shows no distress and 
 cyanosis is absent. During intense crying and in the presence of 
 cyanotic attacks, signs of obstruction may become evident. It is 
 often difficult to make an exact diagnosis in these cases because of 
 the dangers of direct transillumination of the larynx in these small 
 infants and the diagnosis is often dependent on the ability of the 
 clinician to exclude other causes of inspiratory dyspnea. Two 
 cases examined by the author at autopsy have in both instances 
 shown similar findings, in that there was a marked narrowing 
 of the lumen of the larynx with thickening of the aryepiglottic 
 folds and deformity of the epiglottis. Nervous disturbances due 
 to arrested development in the cortical centers with resulting 
 disturbed coordination of the act of respiration may occasionally 
 be a causative factor. Arrest of development affecting the center 
 for the recurrent nerve may also be another factor.
 
 248 DISEASES OF THE RESPIRATORY TRACT 
 
 Treatment.— There is usually a spontaneous functional correction. 
 The prophylactic care should consist in the prevention of respira- 
 tory infections. 
 
 Stridor Thymicus. — The frequency of true thymic enlargement 
 with direct tracheal pressure has undoubtedly been exaggerated 
 by incomplete diagnosis. The most frequent sign proving stenosis 
 of the upper air passages is the presence of suprasternal retraction. 
 In the premature the tendency of the entire chest wall to collapse 
 with each inspiration may be mistaken for this sign and easily lead 
 to an error in diagnosis. The author has seen two such cases 
 which were verified by palpation of a soft tumor mass in the fossa 
 
 Fig. 151. — Specimen of thymus gland weighing 40 gm., and resulting in thymic 
 
 death. 
 
 jugularis during expiration as well as by percussion with flatness to 
 the right and left of the manubrium and substantiated by roentgen- 
 ray findings. In both cases the stridor developed shortly after 
 birth and disappeared spontaneously with diminution in size of 
 the thymus gland, both infants making an uneventful recovery. 
 The author has also seen a case of congenital thymus stridor in a 
 luetic infant which died on the sixth day. At autopsy the thymus 
 gland weighed 40 gm. and was the seat of numerous miliary 
 abscesses. 
 
 Prognosis.— The prognosis varies with the cause of enlargement. 
 The benign forms which disappear spontaneously undoubtedly
 
 SUFFOCATION FROM EXTERNAL CAUSES 249 
 
 belong to the vascular type. While the number of sudden deaths 
 due to causes associated either directly or indirectly with the 
 thymus gland are less frequent than one would be led to believe 
 from a review of the literature, they do occur and must be given 
 proper consideration. These deaths may be due to mechanical 
 compression of the trachea by an enlarged gland either due to a 
 true hypertrophy or hemorrhage within the gland, or death may 
 be caused by hypersecretion of the gland. Syphilitic changes in 
 the thymus with miliary abscess formation has already been de- 
 scribed as a cause of death under Thymic Stridor. 
 
 Treatment.— An expectant attitude should be adopted in the 
 absence of marked signs of stenosis. In the presence of congenital 
 lues, specific treatment should be instituted. The only other 
 form of treatment which offers any degree of encouragement is 
 that of roentgen-ray exposure in the hope of creating rapid involu- 
 tion, with the development of moderate fibrosis. Friedlander 1 
 describes prompt results, stating that dyspnea is lessened even 
 after the first treatment. 
 
 It is self-evident that the exposure of premature infants to the 
 roentgen ray, unless carefully guarded, may be disastrous not 
 alone in the too rapid atrophy of the thymus gland which is so 
 necessary to the growing organism, but also to the thyroid and 
 other parenchymatous organs as well as the danger of skin irritation. 
 
 In our wards at Michael Reese Hospital, Dr. R. A. Arens makes 
 use of the following treatment: 
 8 inch spark gap. 
 
 3 mm. aluminum filter. 
 
 10 inch S.T.I). (Skin Target Distance). 
 5 M.A. (milliamperes). 
 
 4 minutes exposure. 
 
 The treatment is guided entirely by the clinical course. Fre- 
 quently one or two treatments are sufficient. 
 
 Stridor from Other Causes.— These are most commonly due to 
 congenital enlargement of the thyroid gland which is usually of 
 the vascular type and disappears spontaneously without treatment. 
 Congenital tracheal stenosis, deformities of the mouth, congenital 
 tumors of the mouth and acute inflammatory conditions of the 
 upper respiratory passages may be further causes. 
 
 SUFFOCATION FROM EXTERNAL CAUSES. 
 
 Death from suffocation due to external causes such as faulty 
 position (infant on face), obstruction of breathing by clothing or 
 
 1 Am. Jour. Dis. Child., 6, 38.
 
 250 DISEASES OF THE RESPIRATORY TRACT 
 
 overlying on the part of the parent have been responsible for the 
 loss of many premature and weakly infants. These have often 
 been described as instances of thymic death. Death from these 
 causes is far less common in full-term, robust new-born infants, as 
 the latter possess the ability to change the position of the head 
 when threatened with suffocation. 
 
 AFFECTIONS OF THE BRONCHI AND OF THE LUNGS. 
 
 1. Congenital Anomalies. 
 
 Fetal Bronchiectasis.— Fetal bronchiectasis is a rare condition of 
 the new born which affects the whole or only part of one lung. 
 Universal bronchiectasis is the result of hydremic degeneration of 
 an entire bronchus, the lung structure being replaced by cystic 
 formations which contain a serous fluid in which are found ciliated 
 epithelium and nuclei. 
 
 The teleangiectatic bronchiectasis is characterized by the forma- 
 tion either of individual cysts or less often of multilocular sacs, 
 the walls of the cysts being lined with several layers of cuboidal 
 epithelium. 
 
 A third variety known as atelectatic bronchiectasis is due usually 
 to lack of development of certain portions of the lung which later 
 become cirrhotic from pressure from a bronchus. (Birnbaum. 1 ) 
 
 Hypoplasia and Hyperplasia.— These malformations are due 
 either to lack of sufficient development or to excessive development. 
 In hypoplasia a small airless structure is found in place of one lung. 
 Since the healthy lung in such cases usually grows into the empty 
 half of the thoracic cavity, deformity results, the thoracic wall not 
 developing well over the healthy lung. The same is true of primary 
 hypertrophy, which consists either in abnormal size or in forma- 
 tion of supernumerary lobes (Birnbaum.) 
 
 Diagnosis.— On account of the equalizing growth of the healthy 
 lung the diagnosis is possible only in the presence of deadening of 
 the sounds over one-half of the thorax. This is much more import- 
 ant in the new born than in older children, since in the latter the 
 above-mentioned physical finding is much more significant of an 
 infiltration or exudation (von Reuss. 2 ) Roentgen-ray studies are 
 of assistance in localizing the lesion although they may not deter- 
 mine the type of lesion. 
 
 Bronchiectasis in the new born is not accompanied by any dis- 
 tinctive symptoms. In the premature their existence increases 
 the respiratory handicap under which these infants labor, and if 
 
 1 Congenital Diseases of the Fetus, Springer, Berlin, 1909. 
 
 2 Diseases of the New Born, Springer, Berlin, 1914.
 
 Affect ioxs of the hroxchi and Of the WNGS 251 
 
 they are extensive, death with symptoms of asphyxia usually occur- 
 soon after birth. The occurrence of inflammatory complications 
 makes the outlook still graver. 
 
 Atelectasis.— Atelectasis is also spoken of as acquired asphyxia 
 though it may be congenital as it is a persistence of the Fetal state 
 in all or in part of the lung. In the congenital variety the lung 
 is not entirely expanded at birth, while in the acquired form collapse 
 of the previously expanded lung occurs. The congenital variety 
 is seen chiefly in the premature and debilitated, either due to a 
 developmental anomaly or insufficient strength on the part of the 
 respiratory muscles to inflate the lungs. The acquired form is 
 most frequently due to obstruction of the bronchi or alveoli by 
 intrathoracic exudates, diaphragmatic hernias and deformities of 
 the spinal column. 
 
 Atelectasis is to a degree physiological during the first few days 
 after birth, gradually disappearing with increasing strength. 
 When associated with asphyxia at birth, it is often overcome 
 entirely by the means used to revive the infant. 
 
 In the weak the methods used are not enough to cause complete 
 expansion of the lung and collapsed areas persist, the soft and yield- 
 ing thoracic wall and poorly developed respiratory muscles of the 
 premature both favoring the non-expansion. 
 
 The cyanosis which is so frequently seen in those suffering from 
 atelectasis may be directly due to the aspiration of food into the 
 larynx, the absence of the pharyngeal and laryngeal reflexes favor- 
 ing this. Mechanical interference with respiration during the act 
 of drinking may also result in cyanotic attacks; interference with 
 the action of the diaphragm through overdistention of the stomach 
 (Birk 1 ) and according to Budin 2 underfeeding, may both be respons- 
 ible for cyanosis in the premature. (See Cyanosis.) 
 
 Pulmonary atelectasis also occurs after cerebral hemorrhage, due 
 to injury to the respiratory center, and is characterized by small 
 respiratory excursions and slight exchange of gases. In the pre- 
 mature the irritability of the respiratory center is low a prion, 
 while in those suffering from natal asphyxia it is lowered by the 
 asphyxia. 
 
 Pathology.— The anterior portions of the lungs are most fre- 
 quently the portions expanded, the paravertebral parts being 
 atelectatic. Peiser 3 showed that in organs hardened in situ the 
 central portion near the hilus was also atelectatic, while the api< es 
 and borders were usually expanded, the expanded portions often 
 being emphysematous (Holt 4 ). When death occurred early a 
 
 1 Leitfaden dcr Sauglingskrankheiten, Marcus and Webers, Balm. I'M I. 
 
 2 The Nursling, Caxton Pub. Co., London, 1907. 
 
 3 Jahrb. f. Kinderh., 1908, 67, 589. 
 
 4 Diseases of Infancy and Childhood, D. Appleton & < V>., NCw York, 1913.
 
 252 
 
 DISEASES OF THE RESPIRATORY TRACT 
 
 large portion of the lung was usually not inflated. The left lung 
 is usually more atelectatic than the right. The involved parts are 
 rich in blood and thus form sites of predilection for inflammatory 
 processes. 
 
 Hemorrhages and edema frequently complicate this condition, 
 which is made worse by the deficient heart action. These hemor- 
 rhages are chiefly in the region of the hilus. In vessel injuries of 
 lesser degree there is no bleeding, only edematous extravasation. 
 
 Fig. 152. — Congenital atelectasia. Four-fifths normal size and magnification of 6 
 
 diameters. 
 
 The atelectatic lung is of brownish-red color, does not crepitate, 
 is very vascular and shows the lobular outline on the surface. 
 Usually both lungs are affected to the same degree. The heart 
 frequently shows the presence of a patent foramen ovale or other 
 congenital lesion, the liver and spleen are often congested and the 
 latter may be enlarged (Fig. 152). 
 
 Symptoms.— Very frequently the subjects of atelectasis give a 
 history of asphyxia at birth; in others there may have been 
 nothing to attract attention to the lungs. Some are noticeably
 
 AFFECTIONS OF THE BRONCHI AND OF THE LUNGS 253 
 
 quiet, cry weakly, sleep much and their voices are feeble. The 
 temperature is usually below the normal; occasionally there is 
 some edema of the extremities or slight puffiness of tlie face, 
 while the breathing is shallow and often irregular. The gain in 
 weight is slight or absent, and the children remain small and deli- 
 cate with poor circulation. At any time there may develop attacks 
 of cyanosis, which occur without warning and which may be fatal 
 in a few hours, often being preceded by convulsions. These attacks 
 may occur as late as ten or tw T elve weeks after birth. 
 
 Physical Signs. — Inspection.— The breathing is shallow, often 
 irregular and at times almost ceases. 
 
 Palpation.— This is negative unless rales are plentiful, when 
 fremitus may be felt. Vocal fremitus is absent. 
 
 Percussion.— There is usually resonance over the entire chest 
 and only posteriorly may diminished resonance be demonstrable. 
 The collapsed areas are surrounded by areas which are overdistended 
 with air and thus resonance is not much interfered with. Small 
 areas of collapse give no dullness at all. If only one lung is involved 
 a difference can usually be made out. 
 
 Auscultation.— The breath sounds are very feeble and the expira- 
 tory sound in particular may be nearly inaudible. The sounds 
 may be rather harsher than normal, but are rarely bronchial in 
 character. The most marked physical sign is the presence of 
 crepitant rales, the so-called atelectatic crepitation, which are best 
 heard usually over the bases when the infant, by flagellation or 
 otherwise, is induced to take a deep inspiration. 
 
 Diagnosis. — The diagnosis of atelectasis is to be made more from 
 the symptoms, the shallow breathing, the stupor, the asphyxia! 
 attacks and the debilitated condition of the infant than from the 
 physical signs which are likely to be ambiguous and not well 
 defined. 
 
 If the respiratory efforts of the infant are sufficient to supply 
 the needed amount of oxygen the dangers from asphyxia disappear 
 and only the inflammatory complications which may arise in the 
 uninflated lung threaten its well being. Any atelectatic area 
 may become inflated (bronchopneumonic) and thus areas of col- 
 lapse and bronchopneumonia may be present in the same lung. 
 Pneumonia in an atelectatic lung is not easy of recognition. The 
 presence of crepitant and subcrepitant rales, impaired resonance 
 and the absence of respiratory sounds, accompanied by dyspnea and 
 ineffectual cough, all speak of an inflammatory condition. The 
 percussion note may be vesiculotympanitic and auscultatory signs 
 of consolidation, such as bronchial breathing and bronchophony 
 may be inaudible because of the diminished respiratory excursion.
 
 254 DISEASES OF THE RESPIRATORY TRACT 
 
 Differential Diagnosis.— A number of conditions must he con- 
 sidered in the differentiation of atelectasis, the more important 
 of which are the following: 
 
 General debility with quantitative and qualitative lack of develop- 
 ment attended with impaired respiratory cardiac and digestive 
 functions. This is commonly associated with lack of development 
 of the thoracic wall and a tendency to collapse on the part of the 
 costal cartilages, and a poorly developed respiratory musculature. 
 
 Cerebral injury associated with hemorrhage is one of the most 
 difficult pathological conditions to differentiate, because of the 
 tendency toward involvement of the respiratory centers, more 
 especially in basilar hemorrhages. A careful inquiry should be 
 made for a history of opisthotonos and clonic contractions of 
 the extremities or facial muscles. 
 
 Hyperplasia of the thymus and occasionally the thyroid gland, 
 with associated stridulous respiration, retraction of the diaphragm 
 and local physical findings must be differentiated. When the chin 
 is brought down upon the chest respiration becomes more difficult 
 and, in turn, is made easier if the head is bent back. 
 
 Aspiration of foreign matter or food with lack of expulsitory 
 effort resulting in cyanosis may lead to error in diagnosis. 
 
 Underfeeding, with secondary asphyxia. 
 
 Congenital diaphragmatic hernia. 
 
 The differential diagnosis of this condition is based on the fact 
 that the abdominal organs containing air enter the pleural cavity, 
 thus giving rise to physical signs of pneumothorax. In addition, 
 the following signs are presented: Respiratory movements on the 
 affected side are absent or less marked than normal, and there is 
 usually bulging of the thoracic wall on the same side; pectoral 
 fremitus is slight or absent and the percussion note is deep and loud 
 and in some cases tympanitic. Not infrequently succussion sounds 
 can be elicited. The normal breath sounds are absent over the 
 affected area and the heart is found displaced to the right. More- 
 over, these findings change with a change in the position of the 
 patient. From the foregoing it will be seen that the findings of 
 percussion and auscultation are very important but variable, as 
 they depend entirely on the amount of air or semisolid material 
 contained in the abdominal organs present in the pleural cavity. 
 
 Radiographic examination is of special value in differentiating 
 atelectasis pulmonum, hyperplasia of the thymus and diaphragmatic 
 hernia. 
 
 Prognosis. — This depends upon the degree of atelectasis which 
 in turn usually depends upon the degree of debility of the child. 
 When accompanied by attacks of asphyxia and cyanosis which 
 appear with frequency during the first two weeks of life, the out-
 
 AFFECTIONS OF THE BRONCHI AND OF THE LUNGS 255 
 
 look is had, despite the institution of proper treatment, as these 
 attacks commonly result fatally. In favorable cases they become 
 less frequent and finally cease. Pneumonia in atelectatic areas 
 often leads to a fatal issue. 
 
 Infants who have suffered from congenital atelectasis may 
 remain in delicate health for a long time, although many ultimately 
 recover completely. 
 
 Fig. 153. — Diffu.se congenital atelectasis. 
 
 Treatment.— The physical condition of these weaklings is often- 
 times so precarious that undue roughness in the application of 
 restorative measures can work infinitely more harm than they 
 may do good, and so it must be remembered that the less the 
 manipulation necessary to overcome the cyanotic attacks, the 
 less is the danger of injuring the infant at this critical time either 
 by overstimulation mechanically or by medication. The object of 
 treatment is directed toward the expansion of the lungs through 
 deep breathing. This is done by crying, and if the child does not 
 cry strongly every day, it should be made to do so. In the mild
 
 256 
 
 DISEASES OF THE RESPIRATORY TRACT 
 
 cases cutaneous stimulation is sufficient, the child being very 
 gently spanked thrice daily for fifteen or twenty times, thus tending 
 to expand the collapsed portions of lung and to expel mucus from 
 the bronchi. The mustard bath is made by adding one tablespoon 
 of powdered mustard to one gallon of water at a temperature of 
 100° to 105° F. Alternate immersions in warm water with a 
 
 Fig. 154. — Incomplete diaphragmatic hernia (case of Dr. Irving Stein). Roent- 
 genogram taken three and six hours after ingestion of bismuth. Stomach and 
 bowel in chest. 
 
 temperature of 104° F. and cool water of 95° F. may be tried, 
 always beginning and ending with the warm immersions. These 
 may be repeated at intervals as indicated by the physical condi- 
 tion of the infant. The objects of the bath are the diversion of 
 the blood from the lungs to the cutaneous vessels, and expansion 
 of the collapsed areas. Expansion of the collapsed lungs is much
 
 AFFECTIONS OF THE BRONCHI AND OF THE LUNGS 257 
 
 easier during the first few days, the difficulty of doing this increas- 
 ing proportionally with the length of time elapsing since birth. 
 
 The infant should not be allowed to lie quietly in one position, 
 but its position must be changed frequently and the child picked 
 up several times a day. Particularly where many infants are 
 housed with but little individual attention atelectasis is seen most 
 
 Fig. 155. — Incomplete diaphragmatic hernia (case of Dr. Irving Stein). Roent- 
 genogram taken soon after death with postmortem injection of bismuth in the bronchi. 
 Only lower lobe of right lung admitted the bismuth emulsion. The gas distention 
 of the stomach and bowels here beautifully portrays the extent of eventration. 
 
 frequently. The further treatment should be similar to that 
 advised for attacks of cyanosis. 
 
 As the temperature is so often subnormal, these children must be 
 kept warm, either by being surrounded with hot-water bottles or 
 else kept in some form of heated bed. The feeding of these children 
 is an important problem (see chapter on Feeding). It is essential 
 to increase the general nutrition in order to increase the function 
 17
 
 258 DISEASES OF THE RESPIRATORY TRACT 
 
 of the respiratory center and muscles. Aside from this, it is improb- 
 able that increased feeding as recommended by Budin is of any 
 direct value as a therapeutic measure. 
 
 During attacks of asphyxia, oxygen inhalations are recommended, 
 and are valuable when the infant can be made to inspire, a tank 
 being kept in close proximity to the infant's bed. Other measures 
 of resuscitation mentioned under asphyxia (see Cyanosis)— cuta- 
 neous stimulation and artificial respiration, or even the use of forcible 
 means of inflating the lung with a catheter in the trachea— may 
 be necessary but their danger must not be underestimated. The 
 use of drugs hypodermatic-ally, such as camphor, caffeine, atropin, 
 etc., is not of much value. Aromatic spirits of ammonia in one- 
 half to three-drop doses, well diluted, is worth trying. 
 
 CONGESTION AND INFLAMMATORY CHANGES OF THE 
 
 LUNGS. 
 
 Congestion of the Lungs.— Congestion of the posterior lower 
 portions of the lung most commonly results from long-continued rest 
 without change of position, congenital or other anomalies of circu- 
 lation. At first there may be extravasations of serum or blood in 
 the alveoli and later, especially in the greater degree of congestion, 
 tissue infiltration. 
 
 Clinically, the condition is manifested by disturbances of respi- 
 ration, shallow breathing and asphyxial attacks. The impairment 
 of resonance and auscultatory findings may be confounded with 
 those of atelectasis or inflammations. The findings are usually 
 bilateral and in dependent parts; these facts aid in the differential 
 diagnosis. They develop post partum thereby differing from 
 atelectasis and are primarily associated with fever. 
 
 Congenital Pneumonia. —That congenital pneumonia may exist 
 seems to be well substantiated, although the number of cases 
 reported in which the infection was hematogenous and transmitted 
 by way of the placenta is small. 
 
 Infection of the fetus may also occur through infected amniotic 
 fluid before labor. However, when it is the result of the aspira- 
 tion of infectious material during the passage through the birth 
 canal, these cases must be classed as extra-uterine pneumonia. 
 
 Post-natal Pneumonia.— Etiology.— Bronchitis during the first 
 few days of life may be the result of aspiration of infectious material, 
 or it may accompany a general septic infection. The fact that the 
 vaginal secretion always contains microorganisms offers every 
 opportunity for infection, should aspiration occur during the 
 infant's passage through the birth canal. Infection of the bronchi 
 may reach the child from an infected mother or attendant, or from
 
 CONGESTIOX AND INFLAMMATORY CHANGES OF LUNGS 259 
 
 a third person through the agency of feeding utensils, spoon-, or 
 other articles. Infections in the upper air passages may spread 
 by direct extension to the deeper structure of the respiratory 
 passages and there occasion a bronchitis or a bronchopneumonia. 
 
 Atelectatic areas, so common in the lungs of the premature or 
 weakling, and the frequency of aspiration of food or vomitus in 
 the debilitated favors the occurrence of pneumonic inflammation. 
 The richness of the atelectatic portions of lung in blood and tissue 
 fluids make them a most favorable medium for the multiplication 
 of the invading bacteria. 
 
 The organisms found in the bronchopneumonias of early life are 
 the pneumococcus and staphylococcus most commonly, less fre- 
 quently the Bacillus coli, the streptococcus and the influenza 
 bacillus. 
 
 Meyer 1 emphasizes the fact that the "grippe" with respiratory 
 involvement may cause a surprisingly extensive infection. 
 
 Pathology.— In the majority of cases both lungs are involved, 
 the parts most frequently affected being the lower posterior portions. 
 The principal lesion is an inflammation of the walls of the bronchi, 
 and the walls of the alveoli surrounding the bronchi. Micro- 
 scopically before section there is often no visible evidence of con- 
 solidation, and seemingly all of the lung can be inflated. The walls 
 of the bronchi and alveoli are thickened and infiltrated with round 
 cells. The involved alveoli are filled with an exudate which is at 
 first composed of desquamated epithelial cells and later of leuko- 
 cytes. On section there are seen grayish-red or yellowish-gray 
 areas which correspond to the cut bronchi and the surrounding 
 peribronchitis. From the cut bronchi the fluid contents exude, 
 composed of epithelium, pus cells and mucus. Many of the smaller 
 bronchi become occluded by the excessive exudate and collapse 
 of the contributory alveoli follows. The collapsed portions arc 
 depressed beneath the surface of the surrounding lung and are of 
 a beefy-red color. 
 
 In some cases, particularly in those instances where the strepto- 
 coccus is the causative organism, the inflammation may be of a 
 hemorrhagic nature. In these cases the bloodvessels of the affected 
 areas are deeply congested, the lung tissue is studded with small 
 hemorrhagic patches whose size varies from that of the head of a 
 pin to several centimeters in diameter, the latter being true infarcts. 
 They are distinguished from the zone of congestion that surrounds 
 them by their projecting above the surrounding tissues, their dark 
 color and their durability. On section they are of triangular shape 
 with the apex more or less deeply in the lung substance. They 
 
 1 IYUt den Hospitalismua der Sauglinge, Berliu, 19
 
 260 
 
 DISEASES OF THE RESPIRATORY TRACT 
 
 are seen particularly in the lower lobes. The mucous membrane 
 of the large and small bronchi is the seat of a catarrhal inflammation 
 with round-cell infiltration. 
 
 Death in the case of these prematures and weaklings is not 
 always the result of the virulence of the invading organism but 
 may be attributed rather to mechanical phenomena secondary to 
 the involvement of the lung. Because of the excessive amount of 
 exudate and intraparenchymatous hemorrhage the alveoli are filled 
 with fluid, the bronchial ramifications are obstructed and the 
 gaseous exchange limited or prevented almost entirely. Pneumonia, 
 therefore, and particularly hemorrhagic bronchopneumonia kills 
 the premature by asphyxia. In other instances death is the result 
 of a true toxemia. 
 
 For contrast and comparison we have the recent investigations 
 of Ylppo 1 who found that typical bronchopneumonic changes were 
 very rarely observed in very young prematures. 
 
 The following table shows the frequency of lobular pneumonia 
 in his series: 
 
 FREQUENCY OF BRONCHOPNEUMONIA IN PREMATURES. 
 
 
 Death of the age of: 
 
 Weight. 
 
 1 
 day. 
 
 2 
 days. 
 
 3 
 
 days. 
 
 4 to 15 
 days. 
 
 1 
 mo. 
 
 Older. 
 
 f Number of sections. 
 Under 1000 gra. \ Bronchopneumonia 
 [ in these 
 
 f Number of sections. 
 1000 to 1500 gm. < Bronchopneumonia 
 [ in these 
 
 f Number of sections. 
 1501 to 2000 gm. •! Bronchopneumonia 
 [ in these 
 
 f Number of sections. 
 2001 to 2500 gm. < Bronchopneumonia 
 [ in these 
 
 14 
 
 
 24 
 
 
 10 
 
 2 
 
 
 9 
 
 
 18 
 
 1 
 
 1 
 
 
 2 
 
 1 
 
 9 
 
 1 
 8 
 
 1 
 
 
 6 
 
 2 
 
 6 
 3 
 3 
 2 
 1 
 1 
 
 2 
 2 
 
 10 
 
 8 
 3 
 1 
 2 
 
 
 1 
 
 1 
 
 14 
 12 
 16 
 11 
 12 
 3 
 
 Ylppo 's histological investigations showed that the broncho- 
 pneumonic areas in prematures were not at all as frequent as the 
 bronchopneumonic areas in the full terms in the first days of life. 
 Hess Thaysen 2 stated that in newly born infants dying in the first 
 
 1 Ztschr. f. Kinderheilk., 1919, 20, 212. 
 ? Jahrb. f. Kinderheilk., 1914, 79, 140.
 
 CONGESTION AND INFLAMMATORY CHANGES OF LUNGS 261 
 
 three days of life there could be demonstrated small bronchopneu- 
 monia areas in 42 per cent of the cases. These changes are not 
 due to aerogenous infection but to the aspiration of infected material 
 from the mother during birth. Hochheim 1 showed that the vaginal 
 secretion and amniotic fluid was aspirated and demonstrated the 
 presence of foreign bodies, as squamous epithelium, fatty bodies, 
 meconium and lanugo hairs in the lung alveoli. 
 
 Symptoms.— The onset is most often insidious in the weakly 
 new born. At first there is noticed possibly a slight nasal dis- 
 charge and a cough of varying severity. Soon increased frequency 
 of respiration makes its appearance accompanied by dilatation of 
 the alse nasi. The cough in the more mature becomes worse and 
 the respiration increases to 60 or 80 per minute. Now and again 
 slight attacks of cyanosis occur, which in the severe cases are 
 correspondingly more marked. There is great restlessness in 
 older infants with inability to sleep, and the cyanosis becomes 
 continuous. Convulsions occur with more or less frequency, while 
 the temperature may be slightly elevated or may be subnormal 
 even in the severest cases. There is a marked loss of weight, the 
 stools become dyspeptic, and greenish with mucus and undigested 
 particles. The prostration may be extreme. 
 
 There is often a singular lack of symptoms and the disease may 
 go unrecognized. The respirations range from 40 to 60 or even 
 80 to 100 per minute, but are usually not labored, the pulse-rate is 
 increased to 140, 160 or may be uncountable; the cough may be 
 absent entirely, and there is often apathy and even deep stupor. 
 The course in these infants is usually acute, either immediate 
 improvement or death occurring. 
 
 The severity of these early symptoms is to be explained either 
 on the basis of the sudden intense congestion of the small alveoli 
 interfering with the bronchopulmonary apparatus almost as much 
 as does consolidation, or their severity may be due to the intensity 
 of the infection. 
 
 Physical Signs.— The usual physical findings of a bronchitis 
 or bronchopneumonia are often lacking or only suggested in the 
 pulmonary inflammation of the premature and debilitated, espe- 
 cially when the involved areas are small in size. This is due to the 
 fact that the respiratory efforts are weak and their amplitude 
 small. In addition it is often the atelectatic portion of the lung 
 which is involved and if this is situated centrally the air may fail 
 to gain access to it. 
 
 On inspection there is seen more or less marked dyspnea, with 
 inspiratory retraction of the lower ribs; the face may be pale or 
 
 1 Path. Anat. Arbeiten, Berlin, 1903 (Hirschwald) .
 
 262 DISEASES OF THE RESPIRATORY TRACT 
 
 cyanosed; cough if present is frequent, short and non-productive. 
 Palpation may reveal nothing. Evidence of consolidation such 
 as increased resistance may be entirely lacking. 
 
 Percussion may give indication of consolidation if impaired 
 resonance or slight dulness is demonstrable, but this occurs only 
 in the presence of massive involvement. Occasionally the note 
 over the whole posterior chest may tend toward the tympanitic. 
 
 Auscultation usually offers the most reliable findings. The 
 breath sounds are often entirely absent over collapsed areas or 
 the respiratory sounds are weak and possibly higher pitched than 
 normal. In other instances the breathing is exaggerated, and 
 bronchial in character. Probably the most characteristic finding 
 of pneumonia in these infants is the occurrence of fine sibilant or 
 moist rales. These are often heard behind over the lower lobes 
 and are the most distinctive sign of the disease. The voice sounds 
 are, as a rule, unchanged. 
 
 Diagnosis.— Pneumonia may, in these infants, be easily con- 
 founded with atelectasis. If the premature infant is strong and 
 possesses a loud cry, congenital atelectasis may be excluded; in 
 the weak the latter condition is most commonly present and the 
 physical signs of pneumonia are absent. It must be remembered 
 that the two conditions may exist side by side in the same infant. 
 It may be necessary to make the infant cry or breathe deeply by 
 mechanical irritation in order to bring out the various abnormal 
 sounds. A careful study of the history from birth may be of great 
 assistance. 
 
 Prognosis.— If the inflammation complicates infection in the upper 
 air passages, such as rhinitis or bronchitis, the outlook is better 
 than in primary pulmonary infections. Mixed infections with 
 the influenza bacillus, staphylococci and streptococci, offer a more 
 serious prognosis than primary pneumococcus. Involvement of a 
 large portion of both lungs or an extremely weakened condition of 
 the infant, both militate strongly against recovery. The younger 
 the infant the shorter the intra-uterine life the higher the mortality 
 and when hypothermia exists death usually occurs soon. Cases 
 which run their course with little or no temperature are usually 
 fatal, probably because they occur in infants who are very feeble, 
 of low vitality, with limited resistance to infection. 
 
 Treatment. — Prophylaxis.— The prevention of pneumonia in the 
 premature requires that the little weaklings shall be protected 
 against infection from every source. The lungs are most frequently 
 the site of bacterial invasion, as there the organism finds a most 
 favorable medium for its growth. In the adult there exist at the 
 entrance to the respiratory tract defensive agents capable of stopping 
 the invading bacteria but in the premature these defenses are
 
 CONGESTION AND INFLAMMATORY CHANGES OF LUNGS 2G3 
 
 absolutely rudimentary and consequently offer but slight impedi- 
 ment to the entrance of pathogenic germs (Delestre 1 ). 
 
 The transmission of respiratory infections occurs by means of 
 infected hands or other objects or through the medium of air. 
 No one suffering from any infection of the nasal or respiratory 
 passages should handle the infant. If the mother is affected with 
 a coryza or bronchitis she should take care that her hands are not 
 < ontaminated with nasal or bronchial secretions and that she doc-, 
 not breathe, or especially cough, in the face of the infant. A mask 
 must be worn by the nurse or mother if she has a respiratory tract 
 infection. In institutions where many babies are taken care of by 
 one nurse, the hands of the attendant should be washed before the 
 handling of each baby. Isolation of the premature should be 
 practised if respiratory affections exist among the other members 
 of the family, or in the common wards if the infant is in an institu- 
 tion. Only if the attendants are thoroughly trained in the principles 
 of aseptic nursing is it safe to leave the infant in close proximity to 
 others suffering from respiratory affections. These of all infections 
 are hardest to prevent. All utensils should be individual and should 
 be sterilized before use; feeders, spoons, glasses, nipples, bottles, 
 stomach tubes, etc., must all be boiled before they touch the child 
 or its food. The French insist on the restricted use of the incu- 
 bator in the management of premature and weak infants when the 
 closed type is used, and believe that their success in the handling 
 of prematures depends upon the fact that they remove them from 
 the closed incubator as soon as the body temperature reaches 37° C, 
 and their vitality permits. As soon as these babies can be removed 
 from the incubators they are kept in large, well-ventilated rooms, 
 which are not overheated. They should be given the benefit of 
 open air and sunshine as their development warrants. In favor 
 of the open-air treatment is the fact that most of the late deaths 
 occur during bad weather. The mortality drops with improved 
 atmospheric conditions. 
 
 General Treatment.— The treatment of pneumonia is preeminently 
 that of watchful expectancy, and overtreatment must he avoided, 
 as these feeble infants are unable to withstand overmanipulation 
 or stimulation. As a rule, pneumonia in robust infants is an acute 
 self-limited disease, but in premature infants the course is apt to 
 be somewhat subacute without the tendency to limitation. The 
 indications in the treatment are to support the heart and conserve 
 the strength. The feeding problem is difficult at any time in the 
 premature and during an attack of pneumonia it becomes doubly 
 difficult. 
 
 1 Ktudc sur les infect. des prematures, These de Paris, 1901.
 
 264 DISEASES OF THE RESPIRATORY TRACT 
 
 The hygiene of pneumonia requires that the child receive plenty 
 of fresh air, and to insure this in an incubator of the closed type 
 is difficult. The use of the open type in part overcomes this diffi- 
 culty. The position of the child should be changed frequently in 
 order to obviate any tendency to hypostasis. If the sick infant 
 has been housed in a closed incubator with questionable ventilation 
 it should be removed to an open, well-heated room, and placed in a 
 properly warmed crib or incubator bed. The prime indication is 
 for the promotion of elimination and sufficient administration of 
 inert fluid. Stimulation of the respiratory tract is best accom- 
 plished by mild counterirritation to the chest and the use of hot 
 applications to the extremities. The use of drugs such as cardiac 
 and respiratory stimulants is not to be regarded with favor but 
 strychnine sulphate in ^fa grain (0.00012 gm.) doses, or atropine 
 sulphate in yww^ to 3- 0V0 S ram (0.00006 to 0.00002 gm.) doses given 
 hypodermically may be of some help. The use of whisky or brandy 
 is permissible in quantities varying from 3 to 10 drops every two or 
 three hours depending upon the indications. Aromatic spirits of 
 ammonia in 1 to 5-drop doses is one of the best stimulants at our 
 command. Both the whisky and the ammonia should be given 
 well diluted in at least 8 parts of water. In cases of emergency, of 
 sudden heart failure or of weakness accompanying a sudden fall 
 in temperature, the use of camphor-in-oil 2 to 10 minims to the 
 dose given hypodermically will be found to be a rapidly acting, 
 reliable heart and respiratory stimulant. 
 
 If the infant shows a marked rise in temperature the use of 
 hydrotherapy may be considered. Temperatures up to 103° F. are 
 well borne, and do not require interference. As a general thing 
 the temperature tends to remain subnormal in these weaklings 
 and cool or even tepid baths must be avoided and instead warm 
 or hot mustard baths resorted to. Even if there is an excessive 
 amount of fever, should it be accompanied by a cold surface, feeble 
 pulse and shallow respirations, cold is contraindicated. The best 
 hydrotherapeutic measure used for the reduction of an unduly high 
 temperature is the tepid pack. The use of cold baths or packs is 
 probably never justified in the premature or weak infant. The 
 temperature of the tepid bath may range from 100° to 105° F., 
 depending upon the condition of the child. 
 
 The treatment of attacks of collapse with cyanosis, which are so 
 frequent in the atelectatic prematures, should be prompt. The 
 infant should be immediately placed in a mustard bath (one tea- 
 spoonful of powdered mustard mixed with one gallon of tepid 
 water being of sufficient strength), of about 102° to 106° F. together 
 with gentle massage. Respiratory and cardiac stimulants may be 
 needed. Oxygen should be administered continuously.
 
 CONGESTION AND INFLAMMATORY CHANGES OF LUNGS 265 
 
 Disturbance of the nervous system, occasionally so prominent 
 in older and stronger children, is not marked in the premature 
 during a pneumonic process. When present mild hydrotherapy 
 offers the best results. 
 
 The use of the coal-tar products is contraindicated. 
 
 The diet is an extremely important part of the treatment of 
 pneumonia and will he considered under "The Feeding of the 
 Premature." 
 
 Frequent changes at regular intervals of the infant's position in its 
 
 bed arc imperative to successful care of the pneumonias in the premature.
 
 CHAPTER XL 
 DISEASES OF THE GASTRO-INTESTINAL TRACT. 
 
 A. DISEASES OF THE ORAL CAVITY. 
 
 Sprue (Thrush, Soor or Mycotic Stomatitis).— Etiology.— Prema- 
 ture infants, weaklings and more especially those suffering from 
 nutritional disturbances are subject to this affection. It occurs 
 only where a lesion of the mucous membrane is present. The 
 abrasions of the epithelium may, however, be very slight and in 
 the premature is usually caused by wiping out of the mouth or 
 through other mechanical injury. The source of infection is very 
 commonly from the nipple. However, it may be carried into 
 the mouth through utensils or soiled pledgets. 
 
 Symptoms.— The importance of thrush is probably always 
 secondary and its significance above all symptomatic. It is improb- 
 able that thrush itself may cause a general serious infection. It 
 may be an indicator of a serious general affection or an essentially 
 lowered resistance; not infrequently it is seen in those apparently 
 in good health. In the premature it sometimes invades the esopha- 
 gus, and it has been described as invading the blood stream. In the 
 more robust premature infants it is usually seen as small white 
 punctiform and flat eruptions on the tongue, gums and inside of 
 the cheeks. In infants with lowered vitality it may assume the 
 form of extensive membrane covering the whole buccal cavity. 
 The latter is especially true where it accompanies septic diseases. 
 In the severe forms it is also frequently associated with Bednar's 
 aphthae. 
 
 Usually the most serious symptom is the inclination on the 
 part of the infant to refuse its food. However, it may be associated 
 with vomiting and as has been stated, is frequently a complicating 
 factor in the severe nutritional disturbances. 
 
 Prognosis.— While thrush is usually curable within a week in' 
 the full- term infant, in the premature, unless the treatment is 
 very carefully undertaken, the traumatism in the course of local 
 applications may cause new- local lesions which become readily 
 infected, thus frequently prolonging the course of the disease. 
 
 Treatment. — Prop hy la xis. — Thrush being due to lack of cleanli- 
 ness and trauma, these two factors should by all means be avoided, 
 and every effort made to avoid trauma of the mucous membrane in
 
 DISEASES OF THE ORAL CAVITY 267 
 
 the first care of the mouth of the new born. It is not contagious 
 and if the proper prophylactic means are observed in the daily 
 routine, it should not be spread from one infant to the other. In 
 the breast-fed the mother's nipples must be,washed with a saturated 
 solution of boric acid and moistened with one-half strength alcohol, 
 which should be allowed to evaporate from the nipples before nurs- 
 ing. In the bottle-fed the nipples and bottles should be carefully 
 boiled after each nursing, and only such nipples should be used 
 as can be completely everted so that both the inside and the outside 
 can be thoroughly cleansed, following which they should be pre- 
 served in a borax solution of one ounce to a pint of water. The 
 nurse should use every precaution in the care of the hands, dress 
 and all objects which may be carried between the crib-. 
 
 Local Treatment. — Every form of local treatment must be care- 
 fully and gently applied so as not to abrade the sensitive mucous 
 membrane. Gently sponging the mouth with a solution of borax, 
 10 grains to 1 ounce of boiled water (this is preferable to boric 
 acid), using a very soft pledget of cotton on the finger if the mouth 
 is not too small, otherwise on a swabbing stick or toothpick after 
 each feeding, will usually cure the disease. Traumatism of the 
 tender mucous membranes must be avoided. The solution may 
 also be used as an irrigation by allowing it to come gently in con- 
 tact with the infected surfaces, including the tongue if involved, 
 the infant being turned on its side so that the solution will flow 
 out of the mouth. A small sucker containing equal parts of borax 
 and sodium bicarbonate may be placed into the mouth of larger 
 infants for a few minutes four or five times daily. In severe and 
 persistent cases it may be necessary once or twice daily to gently 
 paint the mucous membrane with a one-fourth of 1 per cent solu- 
 tion of silver nitrate. Following the application of the silver 
 nitrate 2 drops of olive oil or castor oil can be used in the mouth to 
 allay the irritation. Mixtures of honey and borax as well as all 
 sugar preparations should be avoided. 
 
 Internal Treatment.— Vf here the infant refuses to nurse it may he 
 necessary to resort to feeding with spoon, medicine dropper, Breck 
 feeder or even to gavage. Every effort should be made to improve 
 the general health of the premature infant by proper feeding, clean- 
 liness and good hygienic surroundings. 
 
 Various Types of Stomatitis.— The term "stomatitis" is applied 
 to inflammations of the mucous membrane of the mouth. In the 
 full-term infant three types are usually described: the catarrhal, 
 the aphthous and the ulcerative. The classification in the prema- 
 ture is far less distinct than in the full term. The typo as most 
 commonly seen are the traumatic ulcerations, usually involving 
 the palate. They may be very slight and superficial or by second-
 
 268 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 ary infection become serious lesions. The simple traumatic patches 
 are usually seen as yellowish, superficial lesions often covered by 
 a slimy membranous film which can be easily removed, such removal 
 being followed by small punctate hemorrhages. They are usually 
 seen from the second to the fourth day after birth, decreasing in 
 intensity and showing a tendency to rapid healing with proper 
 care, usually disappearing within a week. Even in the premature 
 this variety is usually harmless, except insofar as it interferes with 
 nursing. However, the dangers of secondary infections must never 
 be overlooked. 
 
 Etiology.— Although the cause may vary it is usually trauma of 
 the mucous membrane through cleansing of the mouth. This is 
 especially true of the handling of asphyxiated and cyanotic pre- 
 mature infants and follows injury due to mechanical removal of 
 mucous from the mouth. More serious lesions over the pterygoid 
 processes which have been described as Bednar's aphthae and which 
 are usually due to more intense trauma of the mucous membrane 
 in the cleansing of the pharynx, may lead to more serious compli- 
 cations. Similar ulcerations may be found in other areas where a 
 thin mucous membrane is in close contact with the hard bony 
 structure. 
 
 Syphilitic stomatitis is not uncommon in infants suffering from 
 congenital syphilis. The ulcerations are more commonly seen about 
 the lips unless secondary to trauma. 
 
 Gonorrheal stomatitis is a rare condition. The tongue, palate 
 and gingival folds are the seat of small whitish deposits, usually 
 appearing on a non-inflammatory base. It is rarely manifest 
 before the fifth or sixth day after birth. After one or two days 
 the patches assume a yellowish color and become elevated above 
 the surrounding tissue. 
 
 Prognosis.— The tendency to secondary infections and deeper 
 ulcerations should always lead to a guarded prognosis, because of 
 the influence on the future health of the infant and the difficulties 
 of feeding. 
 
 Gonorrheal stomatitis, while usually healing without unfavorable 
 results in the full-term infant, when properly treated, is always a 
 serious complication in the premature. 
 
 Treatment. — Prophylactic— This should consist of the avoidance 
 of all trauma at birth and the absolute prohibition of subsequent 
 mechanical cleansing of the mouth, unless there are special indi- 
 cations. The latter is entirely superfluous when the proper care 
 is taken in the preparation and administration of the infant's 
 food. Infants suffering with ulcerative stomatitis should be 
 isolated to impress the attendants with the dangers of spreading 
 the infection by careless handling.
 
 DISEASES OF THE GASTRO-INTESTINAL TRACT 269 
 
 Curative. — The curative treatment is the same as that described 
 under thrush and even greater care should he taken in the appli- 
 cation of local treatment. The deeper ulcerations in the mouth 
 can be treated to advantage with small quantities of peroxide of 
 hydrogen or 1 per cent potassium chlorate solution, or careful 
 application of 1 or 2 per cent of nitrate of silver solution. In all 
 cases, however, in the premature infant the attendant should not 
 become overzealous in the administration of local treatment, 
 because of the dangers of further traumatizing the sensitive mucous 
 membrane. The feeding offers the same difficulties as in the 
 severer cases of thrush necessitating hand feeding of expressed milk 
 in most cases. 
 
 In syphilitic and gonorrheal stomatitis the local measures are 
 the same as for the other varieties of stomatitis. The general 
 measures for the former are such as are described under the treat- 
 ment of congenital lues. 
 
 Cancrum Oris (Noma).— Etiology.— Xo single microorganism has 
 proved to be the cause of noma. Spirilla? and fusiform bacilli have 
 been found (Weaver and Tunnicliff 1 ) not only in the necrotic tissue, 
 but in the surrounding healthy parts. Whether these organisms 
 represent the primary cause of the lesion or only secondary invaders 
 is not known. In other instances the Bacillus diphtheria? alone 
 has been found. 
 
 Symptoms.— The site of the disease is usually the inner side of 
 one or both cheeks. The gangrenous process usually begins as 
 a small inflamed, infiltrated area in the mucous membrane. Local- 
 ized destruction of tissue follows, and this process extends with 
 great rapidity until the tissue sloughs away in masses. 
 
 Prognosis.— The disease usually occurs in weakly, marantic 
 infants, who die from exhaustion and sepsis within ten days or 
 two weeks from the onset of the disease. Hemorrhage is rarely 
 a complication. The disease is usually fatal even under the best 
 management. 
 
 Treatment.— Treatment at best is very unsatisfactory. The 
 procedure followed in ulcerative stomatitis together with the use 
 of surgical measures affords the best possibilities. Xicoll 2 reported 
 a case which had resulted in recovery following the intravenous 
 injection of salvarsan. 
 
 B. DISEASES OF THE GASTRO-INTESTINAL TRACT. 
 
 In a consideration of this very important section as relating 
 to the premature infant, we must recognize: (1) The possibility 
 
 1 Jour. Inf. Dis., 1907, 4, 8. 
 » Arch. Pediat., L911, 28, 912.
 
 270 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 of congenital malformations and other prenatal factors which 
 might have an important bearing on the function of the digestive 
 organs; (2) the lack of proper physiological development necessarily 
 present in the prematurely born, the importance of which varies 
 inversely with the fetal age; (3) postnatal pathological conditions, 
 developing in the gastro-intestinal tract; and (4) the importance 
 of systemic infections in their influence on the processes of 
 metabolism. 
 
 When the great importance of the interdependence of the second 
 and third factors is recognized even in the absence of any congenital 
 anomalies, we at once realize the marked tendency toward the 
 development of disturbances involving the nutrition and well- 
 being of the entire organism. The use of the term "nutritional 
 disturbances" rather than that of "digestive disturbances" is 
 beyond any question more generally applicable to the premature 
 than to any other stage of life, as in these individuals the rapid 
 development of general nutritional disorders is the rule following 
 even moderate causes. 
 
 It must also be borne in mind that all factors which affect the 
 general well-being of the premature infant, such as exposure and 
 infection, have an almost direct effect upon gastric and intestinal 
 functions. The very important relationship between the fetal age 
 of the infant and the quality of the food and the method of its 
 administration will be emphasized in the chapter on "Feeding." 
 
 The subject of gastro-intestinal disturbances in the premature 
 infant offers a far more complex problem than do those of the 
 new-born full-term infant. As previously stated, they require a 
 consideration of possible developmental defects, constitutional 
 anomalies, a low grade of immunity to infection, and a general 
 lack of physical and functional development. The last two often 
 lead to inability to take and assimilate the required food. 
 Further complications are due to the rejection of the food or the 
 development of gastro-intestinal irritation upon the slightest 
 indiscretion in feeding. All of these have an important bearing 
 upon adequate digestion, resorption from the intestinal tract and 
 the further intermediary functions. 
 
 It cannot be too strongly emphasized that the immediate insti- 
 tution of the proper hygiene, and the establishment of the proper 
 prophylaxis toward the prevention of nutritional disturbance by 
 the early administration of human milk whenever possible, are 
 absolutely necessary to avoid disaster. It cannot be disputed 
 that a great number of premature infants die, not because their 
 organs lack that degree of maturity necessary to proper functions, 
 but because of early neglect, either through lack of adequate 
 facilities or ignorance of exact methods of feeding and care.
 
 DISEASES OF THE G ASTRO-INTESTINAL TRACT 271 
 
 Our acquaintance with the tendency to the rapid development 
 of marasmus in premature infants leads us to give great considera- 
 tion to the development of even the slightest nutritional disturb- 
 ances. It should become the rule to give even moderate disturb- 
 ances the same consideration that is given to athrepsia (ma- 
 rasmus) in the older infant, which is always regarded as making the 
 feeding of human milk imperative. As this also entails the feeding 
 of minimal amounts of food the body temperature must necessarily 
 in part be conserved by artificial heat. 
 
 I. Functional Insufficiencies of the Gastro-intestinal Tract 
 Wholly or in Part Dependent on Lack of Development: (a) Diffi- 
 cult Nursing. — The causes of difficult nursing are to be found either 
 on the part of the infant or mother or both. 
 
 The Infant.— Various factors may enter which may make nursing 
 difficult or even impossible. Some of these will be treated under 
 the chapter on "Methods of Feeding" (page 171). Of the mal- 
 formations, those offering the greatest difficulty are cleft palate, 
 hare-lip and nasal deformities due to lack of cartilaginous develop- 
 ment. The tendency to sleep constantly is often very perplexing. 
 General weakness and lack of muscular development in the poorly 
 developed premature are not infrequently sufficient to make nursing 
 impossible. Infections of the mouth resulting in thrush, stomatitis 
 and ulcerative processes are always of serious import. All condi- 
 tions interfering with proper respiratory functions, whether due to 
 lack of development, such as atelectasis or pulmonary infections 
 interfere with the proper taking of food. These are but a few of 
 the many complications which may be cited as impeding proper 
 nursing. 
 
 The Mother.— On the part of the mother the various pathological 
 conditions of the nipples and breast must be given due consideration. 
 
 (b) Anorexia.— Premature infants born in the seventh and 
 eighth months rarely show a disposition to feed spontaneously 
 during the first days of life, and in a large proportion of cases we 
 are forced to administer the food without the infant's taking active 
 part. Only a small portion of the infants weighing between 1000 
 and 1500 gm. are able to nurse without assistance, and very few of 
 them, unassisted, are able to suck with sufficient strength to take 
 food from either the breast or the bottle. A very interesting fact 
 which we have noted in premature infants weighing under 1500 
 gm., and occasionally in even larger infants, is a tendency to at 
 least attempt to nurse spontaneously during the first two or three 
 days of life, during which they, however, receive very little food. 
 This period is followed usually about the third day by a marked 
 somnolence, during which they show little or no inclination to 
 purse. This is usually associated with a rather rapid loss in body
 
 272 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 weight due to underfeeding. At later periods not infrequently 
 infants show a repugnance toward food, which may follow periods 
 of overfeeding or be seen in the course of the gastro-intestinal or 
 systemic infections. At whatever stage of the infant's develop- 
 ment anorexia is seen it must be given the gravest consideration 
 and every attempt made to administer food sufficient to meet the 
 demands of the organism. Gavage must be resorted to if the less 
 drastic methods of feeding are unavailing. It has been our experi- 
 ence that occasionally the omission of one or two feedings with 
 the administration of a one-half strength physiological salt solu- 
 tion per mouth will result in the further stimulation of the appetite 
 by producing thirst. 
 
 During this period the fluids should be given in sufficient quan- 
 tity to meet the infant's needs, about one-sixth to one-fifth of the 
 body weight daily. The addition of one to three drops of brandy 
 is often a beneficial stimulant. 
 
 (c) Inanition Fever.— Unquestionably hyperpyrexia as seen in 
 the first days of life and during the time when these infants are 
 receiving a minimum of food need not necessarily be due to inani- 
 tion. Many are undoubtedly due to infection or toxic products 
 which enter the circulation through the gastro-intestinal tract. 
 The products of decomposition as seen during the period of change 
 from the meconial flora to the milk flora can undoubtedly give 
 rise to hyperpyrexia, as is also true of the toxic products formed 
 by decomposition of milk. The effect of products absorbed from 
 the intestinal tract on the parenteral cells, as well as the by-products 
 due to the rapid changes seen in the body tissues, may, any and all 
 of them, following their absorption, give rise to increase in body 
 temperature. Occasionally one sees cases of hyperpyrexia in the 
 premature and in the new born in whom the high temperature 
 cannot be due to the surrounding artificial heat, and who make a 
 rapid recovery without after-effect by simply increasing the fluid 
 intake of milk or water. The most striking cases that are seen 
 are those in which water insufficient to meet the body needs has 
 been given. 
 
 Treatment.— This consists in the administration of fluids equal 
 to at least one-sixth of the body weight of the infant in twenty-four 
 hours and the administration of food as per the rules on "Feeding 
 of Premature Infants during the First Ten Days of Life." Of equal 
 importance is the prevention of overheating by application of exces- 
 sive external heat. When doubt arises as to the causative factor 
 in so-called "inanition fever" a small dose of castor oil (5 to 10 
 minims) together with a colonic flushing with a saline solution 
 shoukl be given in addition to the increase in the amount of water 
 and human milk administered.
 
 DISEASES OF THE GASTRO-INTESTINAL TRACT 273 
 
 (d) Vomiting. — In general the vomiting in the premature is of 
 greater or lesser importance depending upon its intensity, and the 
 result upon the general state of nutrition. Vomiting musl be 
 considered only as a symptom and not primarily as a disease, and 
 again as a symptom which in its development is influenced by 
 many factors peculiar to the premature infant. The relatively 
 vertical position of the stomach in the sixth, seventh and eighth 
 months, as described under the "Physiology of the Premature 
 Infant," is a factor of considerable importance, as is also the poorly 
 developed sphincter at the cardia. 
 
 Of equal importance is the fact that most of these infants are 
 fed mechanically in amounts theoretically correct for their weights 
 and ages. But these same quantities may not agree with Nature's 
 idea of sufficiency, thereby leading to a rapid overfilling of the 
 stomach through catheter and other mechanical means of feeding. 
 Again the tendency toward abdominal distention and the frequent 
 handling and manipulation of the infant all tend to promote 
 regurgitation. 
 
 Vomiting persisting beyond the first or second week, even when 
 varying in frequency and intensity, is likely to result in a consider- 
 able degree of undernourishment. There is also the added danger 
 in the case of premature infants with a minimal development 
 of reflex irritability, that due to the lack of proper response on the 
 part of the laryngeal reflexes, the regurgitated food may be aspirated 
 with resulting sequela?, such as cyanotic spells, asphyxia or even 
 pulmonary infection. 
 
 Because of the great danger of underfeeding in the presence 
 of small food intake there is the gravest danger of weight losses, 
 with the consequent development of inanition. 
 
 Etiology. — Previous to the taking of food the infant may vomit 
 the various fluids such as liquor amnii and blood, which may have 
 been swallowed during labor. These may easily be recognized 
 by their character. Following the intake of fluid many factors 
 must be considered, such as atresias in the digestive tract, excessive 
 feedings, which may be due to too free nursing from an easily 
 secreting breast by the older premature infants, or too rapid feeding 
 of large quantities mechanically given to the smaller infants. 
 
 The dangers of compression of the abdomen due to improper 
 holding or excessive handling of the infant are usually overcome 
 by feeding in the bed. The tendency to habitual vomiting is not 
 uncommon in the first months of life in the premature. This i> 
 not infrequently due to a general state of nervousness or a neuro- 
 pathic constitution. According to Alfred F. Hess, this can easily 
 be demonstrated by passing a catheter and exciting the pharyngeal, 
 cardiac and pyloric reflexes, which in the normal child are but 
 18
 
 274 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 slightly developed, while in the neuropathic individual the passage 
 of the catheter is easily noted by the reflex manifestations following 
 its passage. Undoubtedly many of these cases are true instances 
 of pylorospasm. That true cases of pyloric stenosis may occur 
 has been proven beyond doubt. The fact that these infants not 
 infrequently vomit quantities larger than a single feeding should 
 not lead to the diagnosis of a hypertrophic stenosis, as is proven 
 by the fact that the stools usually contain a considerable amount 
 of food residue. 
 
 The toxic vomiting as seen in the infants of eclamptic mothers 
 and in the presence of sepsis, as well as hematemesis, will receive 
 further consideration in the discussions on these topics. Vomiting 
 may at any time become of serious moment and should always be 
 given proper consideration. The relative loss of food as foretold 
 by the scale, by weighing before and after feeding, and after vomit- 
 ing, the weight curve and careful observation of the stools will give 
 the best indications for therapeutic interference. 
 
 Treatment.— In the majority of cases there is no indication for 
 active treatment. The occasional or even more or less regular 
 "spilling" in the presence of a normal gain in weight and general 
 well-being need receive little or no attention. However, when 
 vomiting is persistent and is attended by stationary weight, which 
 is equivalent to loss in weight in older individuals, or when it is 
 associated with nausea or is expulsive in character or contains bile, 
 blood and other matter foreign to the normal stomach content, 
 it should receive prompt and careful attention. No set rules for 
 treatment can be prescribed, as the etiological factors in each and 
 every case must be considered individually. The following general 
 principles of treatment will in a great number of cases prove 
 sufficient: 
 
 1. The infant should be subjected to a minimum of handling. 
 It should, whenever possible, be fed without being removed from 
 its bed, or where handling is necessary, all violence should be 
 avoided. 
 
 2. The recumbent position with the head and shoulders slightly 
 elevated assist in overcoming the tendency to regurgitation in the 
 presence of a weak sphincter at the cardia. 
 
 3. Regulation of feedings is primarily indicated. This should 
 cover first the number of feedings and the interval between feedings, 
 and the amount of the individual meal. Not infrequently an infant 
 who is receiving quantities too great for the stomach capacity will 
 cease vomiting upon simple reduction of the size of the individual 
 meal. Again it may be necessary to decrease the number of 
 feedings, thereby lengthening the intervals between feedings. 
 Furthermore large meals at long intervals may be replaced by
 
 DISEASES OF THE GASTRO-INTESTINAL TRACT 275 
 
 small meals at short intervals with a very beneficial result. Where 
 the infant is nursing at the breast, simply reducing the time allowed 
 for nursing in many instances will accomplish the desired end. 
 The same may he true as regards the slower administration of the 
 individual feedings in the bottle-fed. 
 
 4. In infants nursing directly at the breast where the shortening 
 of the period of nursing is insufficient to control the vomiting, 
 drawing the milk by expression or by breast pump and feeding a 
 measured quantity which can be retained, either by hand or catheter, 
 is often successful. 
 
 It is customary to start such feedings by giving 2 to 10 gm. at 
 short intervals, 10 to 12 if bottle fed, or 6 to 8 if fed by catheter, 
 in twenty-four hours, preferably, although not necessarily, of freshly 
 drawn milk, following this by gradually increasing quantities, and 
 as soon as the proper quantity for growth is retained, lengthening 
 the intervals, returning to direct nursing when the infant's general 
 condition allows of the same. In the more severe cases the human 
 milk may be boiled or a skimmed human milk should be used. 
 
 Under these conditions the milk supply should be protected 
 through the emptying of the breasts by expression to prevent their 
 drying up. 
 
 The question of even temporary starvation in the premature 
 infant is one of serious import and should only be practised after 
 the most careful consideration, because of the rapidly developing 
 apathy in this class of infants. The presence of so-called " hunger 
 stools/'consisting of a brownish, stringy mucous substance with 
 little or no food residue, is as a danger signal of almost equal 
 importance with loss in weight. 
 
 If the above suggestions fail to accomplish the desired end, 
 rather than to institute a starvation diet we prefer to empty the 
 stomach by careful lavage, using a weak sodium bicarbonate or 
 saline solution, and before withdrawing the catheter placing a 
 small feeding of human milk into the stomach. Lavage is practised 
 not so much with the idea of removing any decomposed food 
 content, but because of the sedative action on the mucosa. The 
 dangers of gastric irritation from repeated introduction of the 
 catheter in careless hands must, however, always lie remembered, 
 also the dangers of promoting cyanotic spells, through the careless 
 deposit of fluids in the pharynx and larynx. In the infants arti- 
 ficially fed the problem is far more serious, and offers for it- solu- 
 tion greater difficulties unless human milk can be obtained. In 
 our own experience a well-boiled milk, in which the casein has been 
 precipitated as a fine flocculent curd by the addition of rennet, has 
 given the best results when human milk was not to be obtained 
 (see Preparation of Chymogen Milk). Diluting the milk thus
 
 276 DTSEASES OF THE GASTRO-INTESTINAL TRACT 
 
 prepared before feeding, or skimming before boiling may also be 
 of benefit. Lactic acid milk mixtures may be used. 
 
 (e) Gastric and Intestinal Indigestion and Distention.— These may 
 be of very serious consequence in the premature through inter- 
 ference with the respiratory and cardiac functions, and the 
 precipitation of cyanotic attacks. Although frequently following 
 relative overfeeding this need not necessarily be the case. Most of 
 the factors which result in vomiting also predispose to indigestion 
 and distention. Abdominal distention is exceedingly troublesome 
 in the premature infant, but does not necessarily imply that indi- 
 gestion is present. It may result in restlessness, vomiting, colic, 
 borborygmus, increased respirations and cardiac action, hypo- 
 thermia, cold extremities and not infrequently cyanosis. 
 
 While we have seen abdominal distention result in hypothermia 
 it is equally true that when hypothermia is present it is almost 
 invariably associated with impaired digestion, and a tendency to 
 cyanosis and syncope. Owing to the tendency to abdominal 
 distention there is the danger of underfeeding due to low-food toler- 
 ance. Excessive external heat whether from the use of simple 
 heating devices or the more complex incubators often cause increased 
 body temperature and result in impaired digestion. I have not 
 infrequently seen death result from a relative overfeeding, due to 
 attempts to feed infants food sufficient for their needs; but even 
 more frequently do we see grave catastrophes from underfeeding in 
 the same class, with rapidly developing syncope due to inanition. 
 
 Indigestion may be followed by an increase in the number of 
 stools, and they become green and foamy and contain curds. 
 The inability of the infant to handle foods sufficient for its mainte- 
 nance without the development of functional derangement is a 
 very grave deficiency, directly dependent upon the fetal age and 
 factors predisposing to prematurity in the individual case. Less 
 dangerous are the cases due to absolute overfeeding following 
 early correction in the errors of diet, as are also the cases following 
 indiscretions on the part of the wet nurse or mother. In the first 
 few weeks of life severe indigestion is often fatal. This is especially 
 true in artificially fed infants. Improper hygienic surroundings 
 such as poor ventilation, oppressive humidity and lack of personal 
 cleanliness may be factors in the development of indigestion. 
 
 The role of intestinal and systemic infections will be considered 
 under their respective headings. 
 
 Treatment.— In the treatment correction of dietetic errors is most 
 essential, and this is especially true in the artificially fed premature 
 infants. It should always be remembered that the correction of 
 the mild forms of indigestion are the life-saving measures. Severe 
 indigestion has a high mortality. Stimulation of peristalsis and
 
 DISEASES OF THE GASTHO-I XTESTIXAL TRACT 277 
 
 thereby emptying of the intestinal tract is usually accomplished 
 by a low-pressure saline enema of 1 or 2 ounces. In some Instances 
 the addition of 1 gm. of glycerin to an ounce of water is of great 
 assistance. Warm baths with or without very gentle abdominal 
 massage may aid in increasing the peristalsis. Where the symptoms 
 are persistent 5 to S drops of castor oil, 1 to 5 grain- of sodium 
 phosphate, or 5 to 10 minims of milk of magnesia, together with 
 3 to 5 minims of essence of pepsin of good quality, after each feed- 
 ing, can occasionally be administered with great benefit. But 
 unless the hygiene and feeding of the infant are properly regulated 
 little permanent good can he expected. Correction of dietetic- 
 errors in the breast-fed is best accomplished by reducing the size 
 and lengthening the intervals between individual meals when the 
 stomach is very irritable. However, decreasing the size of the 
 feedings is always associated with more or less danger and where 
 the same results can be secured by simply lengthening the intervals 
 this offers the best solution. Starvation diet should under all 
 circumstances be avoided, although it may be necessary in extreme 
 cases to dilute the meals. While larger infants— those weighing 
 in the neighborhood of 2000 gm.— will stand the reduction of the 
 feedings to as low as 60 calories per kilogram, in the smaller infants 
 70 to 80 calories must be considered the danger zone for even a 
 short period of time. In the artificially-fed every attempt should 
 be made to obtain human milk and where this is impossible our 
 best results have been obtained by feeding boiled milk, in which 
 the curd has been finely precipitated. (See Artificial Feeding, 
 page 199.) 
 
 (/) Diarrhea.— Constipation is the exception; loose stools or a 
 tendency toward diarrhea in both the breast-fed and the artificially- 
 fed premature infants is the rule. Therefore, frequency of bowel 
 movements, especially in the breast-fed may be entirely physio- 
 logical and unassociated with fever, vomiting and other evidences 
 of gastro-intestinal disturbances. However, they may be due to 
 contaminated food or intestinal infection, and every case should, 
 therefore be carefully studied so that evidences of deep lesions 
 may be immediately observed. In the infant nursed by its mother 
 the colostrum will almost invariably result in frequent bowel move- 
 ments. This is one of the prime reasons in the selection of wet 
 nurses, who have passed at least two or more weeks of their puer- 
 perium. The early milk also has a tendency to be high in its 
 carbohydrate and fat content, either of which may be factors in 
 the causation of frequent stools. A gastro-intestinal infection 
 may be unassociated with fever and may, therefore, go unrecognized 
 and be of serious consequence. Changes in the mother's environ- 
 ment, when she is nursing her own infant, as is seen at the end of
 
 278 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 the puerperium when she leaves her bed and changes her mode 
 of living, seem to have a very beneficial influence on the quality of 
 milk secreted, and the mother and baby seem to adapt themselves 
 more readily to each other. This beneficial change is, of course, 
 not seen where the baby is fed by a wet-nurse. 
 
 At this point I desire especially to emphasize my experience 
 with both mothers and wet-nurses who are given a too liberal diet. 
 While the average mother can be allowed to select her own diet 
 during the nursing period of a full-term infant, eliminating such 
 foods as may cause colic, abdominal distention and diarrhea in the 
 infant, in the case of the premature such liberties must under no 
 circumstances be allowed as they may result in an early disaster, 
 cyanosis and death due to abdominal disturbances. Therefore, 
 every wet-nurse should be made to adhere strictly to the limitations 
 of diet as prescribed under the section on " Diet of Wet-nurses" 
 (page 121). So long as the infant is passing yellow stools of normal 
 odor, without symptoms of indigestion and is gaining in weight, even 
 though the stools may number five to eight daily, no alarm should 
 be felt, and the diet should be sustained. 
 
 The change of the yellow stool to a green color shortly after 
 passage is the normal process of oxidation. However, the green, 
 frothy stool containing small white curds and considerable mucus 
 should always be considered abnormal. Such stools usually lose 
 their normal acid odor, cause excoriation of the buttocks, and are 
 frequently associated with fever. This is not infrequently a finding 
 in the breast-fed premature. In the treatment of such cases, 
 while the care of the infant is of paramount importance, no less 
 important is the careful regulation of the mother's surroundings, 
 mode of living and diet and also her mental activity. Again every 
 precaution must be taken in reducing the infant's diet, and the 
 same dietetic measures which were instituted for the treatment 
 of indigestion apply to every case of diarrhea with abnormal stools, 
 as they are almost invariably attendant on an intestinal indigestion 
 or infection. 
 
 Dehydration of the body tissues through excessive water losses 
 must be met with sufficient water administration, so that a good 
 working rule should lead one to administer at least one-sixth of the 
 body weight daily in fluids, in all cases of diarrhea. Therefore, 
 when the quantity of the meals is reduced, or the interval lengthened, 
 water should be added to the feedings or be administered between. 
 The normal infant's stool will form a water margin about the semi- 
 solid mass about one-half to three-quarters of an inch in diameter. 
 When more water than this is lost with each stool, the infant must 
 be carefully weighed and its water losses noted so that they may 
 be compensated.
 
 DISEASES OF THE GASTRO-INTESTINAL TRACT 279 
 
 Tarry stools are always due to the presence of blood, and abrasions 
 of the intestinal mucous membrane are likely to lead to fatal 
 infections and must therefore always be given serious consideration. 
 
 (<7) Constipation.— The mechanical causes such as atresias in 
 various parts of the intestinal tract, or an imperforate anus, must 
 be considered as possible causes. As has been previously stated, 
 diarrhea is far more common than constipation. This, however, 
 does not mean that a sluggish lower bowel is uncommon in the 
 premature. In fact the lack of power of the muscular wall and 
 the minimal reaction of the mucous membrane to mechanical 
 and chemical stimulation are both important etiological factors 
 and are often associated with intestinal distention. The first 
 evidence of this lack of response is often noted in the inability of 
 the premature infant to evacuate the meconium which has accumu- 
 lated in the lower bowel, and this may require mechanical removal 
 by the aid of a small saline enema or further irritation with a soap 
 or glycerin suppository. If these means fail, a single dose of 5 to 
 8 drops of castor oil may be administered without too great delay, 
 as it is our rule to start feeding only after the first intestinal evacua- 
 tion, so that the presence of an atresia may have been noted, and 
 the meconium removed before it has become infected through 
 bacterial ingestion. The next stage of the infant's existence which 
 is associated with constipation is in the first few days of life when 
 food ingestion is insufficient and below the caloric requirements of 
 the infant. In such instances in the absence of other causes it 
 may be considered as a certain symptom of underfeeding, as is 
 the case at all times when "hunger stools" are present. Increasing 
 the food judiciously removes the trouble. 
 
 As the infant's digestive function improves and it utilizes its 
 food to the fullest advantage, constipation may result from the 
 minimal amount of food residue. The best evidence of such a 
 causative factor in the presence of sufficient feeding is the improve- 
 ment in general condition and gain in weight. In fact, utilizing 
 their food perfectly, they have a tendency to constipation so long 
 as their food intake is not in excess of their required caloric needs. 
 Therefore, feeding this class of infants moderately in excess of the 
 normal caloric needs usually overcomes the constipation. 
 
 In the treatment where the ability to digest food is minimal, 
 increasing the water intake is frequently beneficial. Even prema- 
 ture infants are creatures of habit, and where it is necessary to 
 assist them in the evacuation of their bowels, this should be practised 
 at a stated hour, once or twice daily, either through the use of a 
 saline or oil enema, non-irritating suppositories, or what is better, 
 the tip of a well-oiled catheter. Medication in the form of laxatives 
 administered to the mother in the hope of influencing the character
 
 2'80 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 of the milk, as well as drugs administered directly to the infant are 
 more or less dangerous agents and should be avoided whenever 
 possible. Ten to 15 drops of paraffine oil, 5 to 10 minims of milk of 
 magnesia or equal amounts of castor oil, may occasionally be 
 administered, but only after attempts at correction by mechanical 
 irritation. 
 
 (h) Underfeeding. — In order to consider this subject properly 
 we must first take into consideration the types of infants with 
 which we are dealing, that is: (1) Healthy premature infants, 
 and (2) congenitally debilitated infants, either premature or full- 
 term. We must again divide them into the classes of breast-fed 
 and artificially-fed, and lastly, as to whether the underfeeding 
 occurs during the first days of life during the period when we may 
 expect normally stationary weight, or weight losses, or at later 
 periods, during which we are more likely to see the development 
 of the completed picture of marasmus. 
 
 Before entering upon the details of this subject several factors 
 which tend toward the development of inanition and marasmus not 
 directly dependent upon underfeeding must be considered: (1) 
 The danger of an imperfectly developed digestive tract, which 
 even in the presence of sufficient food may soon result in a metabolic 
 bankruptcy. These infants rarely survive the first days of life. 
 (2) Improper hygienic surroundings of the infant, of which one 
 of the most important is the danger of overheating, thereby inter- 
 fering with heat regulation and associated with excessive evapora- 
 tion from the body surfaces. This is especially disastrous in its 
 effects in the presence of decreased humidity. Both of these 
 factors predispose to atrophy. Lessened immunity with the added 
 dangers of local and general infections and the secondary nutri- 
 tional disturbances are especially common in this class of infants, 
 as are the tendencies toward repeated nutritional disturbances 
 once they are established. All of these factors which may tend 
 to impair the general nutrition of the infant will but serve to empha- 
 size the need of careful observation. It will, therefore, be seen 
 that underfeeding may be a primary affair, or may result secondarily 
 following previous nutritional disturbances. 
 
 II. Underfeeding in the Healthy Breast-fed Premature Infant 
 During the First Days of Life.— This represents the dangerous 
 period through which most premature infants pass whose feeding 
 is delayed, awaiting the secretion of milk from the mother's breasts. 
 While the full-term infant may pass through this period with slight 
 disadvantages to its future development, the life of the premature 
 infant may be jeopardized beyond all hope of recovery. 
 
 It has been our experience that when feeding is too long delayed 
 the infants, unless very carefully fed in minimal quantities, are
 
 DISEASES OF THE GASTRO-INTESTINAL TRACT 28] 
 
 subject to repeated digestive disturbances and secondary infection, 
 the latter due probably to lowered resistance. In the premature 
 infant this is true even though the infant's food be human milk. 
 How much more important is the avoidance of long starvation in 
 those who are to be fed artificially, can easily be surmised. Whereas 
 the birth weight in the average premature infant is regained by the 
 second or third week, in those who have suffered great initial 
 weight losses through starvation the return to normal birth weight 
 is greatly delayed. It is surprising, however, to note what minimal 
 quantities of human milk alternated with water, with a total 
 administration of one-eighth to one-tenth of the body weight of fluid 
 in twenty-four hours, will tend to prevent great initial weight loss 
 during the first few days. (See Section on "Feeding during the 
 First Ten Days of Life.") 
 
 The removal to an institution supplied with wet-nurses or a wet- 
 nurse in the home are the ideal remedies. Small quantities of milk 
 obtained from other mothers to tide over the period of early lacta- 
 tion when secretion is delayed, as is not infrequently the case where 
 labor is considerably before term, will prevent a critical condition. 
 Where the prospects for human milk are much delayed, the anxiety 
 of the family, due to the decrease in weight, may often be relieved 
 by judicious artificial feeding, as suggested in the chapter on 
 Feeding. It is always the part of wisdom to impress the family 
 with the fact that stationary weight and fluctuating weight are 
 to be expected for a much longer period in the premature than in 
 the full- term infant, and that this stationary weight curve does 
 not indicate a bad prognosis. Artificial feeding, if instituted should 
 always be discontinued at the first opportunity. 
 
 In the congenitally debilitated infant, especially the premature, 
 human milk is a practical necessity for a low mortality. 
 
 Atrophy and marasmus as seen after the first days or weeks of 
 life are even more dangerous than the evidence of inanition during 
 the first days of life, because they are almost invariably secondary 
 to previous underfeeding, errors in diet, or gastro-intestinal and 
 systemic infections, and improper hygienic conditions, which are 
 unfortunately frequently neglected or overlooked, even when 
 attempts to overcome the conditions are made. In all late cases 
 of marasmus in the premature, while removal of the underlying 
 factors is an absolute essential, the furnishing of the proper diet 
 in the form of human milk is of equal important e. 
 
 III. Secondary Digestive and Nutritional Disturbances Accom- 
 panying Systemic Infections (Parenteral).— Just as digestive dis- 
 turbances result in lessened immunity to infection, so do we find 
 digestive troubles following the infections in the premature, such 
 as infections of the skin, lungs, genito-urinary tract, ears and the
 
 282 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 general septic infections, which are of common occurrence in these 
 individuals. These secondary conditions are also likely to run a 
 more severe course than the primary nutritional disturbances. 
 
 Where it is possible to keep up the baby's nutrition by the proper 
 administration of foods during the course of an infection, such 
 children may be subject to little or no weight loss in the milder 
 types. In more serious cases the food must be reduced both 
 qualitatively and quantitatively. However, even in these, to 
 avoid catastrophes, long-continued underfeeding or starvation 
 must of necessity be avoided, and only in exceptional cases with 
 resulting food intoxication must all food be withdrawn. Such 
 cases furnish us with every indication for early feeding with human 
 milk whenever possible. True alimentary intoxication is usually 
 early recognized by the toxic symptoms— facial expression, rapid 
 respiration, and marked drops in the weight curve. In these cases 
 temporary complete withdrawal of food in the absence of severe 
 infection results in disintoxication. In parenteral infections this 
 is not the fact, and starvation only leads to a further reduction in 
 fighting power and therefore should not be long continued. The 
 further treatment of these cases is the same as that to be described 
 under "Infection of the Gastro-intestinal Tract." 
 
 IV. Infections of the Gastro-intestinal Tract (Enteral).— No 
 subject with which we have to deal in the care of premature infants 
 calls for such mature judgment as the care and treatment of gastro- 
 intestinal infections. In fact the entire hospital unit is more 
 or less planned and constructed with the idea of prevention and 
 isolation of these cases. Our thought should all be centered on 
 their prevention, since once they become established their course 
 is associated with the gravest dangers. 
 
 Infections of the intestinal tract are secondary in importance 
 only to infections of the respiratory tract. It is well known that 
 infection of either of these systems is likely to run rampant through- 
 out hospital wards unless the individual cases are properly segre- 
 gated at the outset. The infection may be spread through care- 
 lessness in handling the infant's utensils or lack in the care of the 
 nose and mouth, through the nipples if nursing on the bottle, or by 
 lack of asepsis in the care of the maternal breasts. Again it may 
 be spread by the thermometer, unclean napkins, or it may be 
 transmitted by flies and insects. The food is in all probability the 
 most common source of transmission, and the milk may be infected 
 either in the breasts themselves or in the handling. In the past 
 before our wards were properly equipped to care for premature 
 infants, doubt as to the advisability of instituting hospital treat- 
 ment in preference to the home, even though the facilities for 
 general care were limited, existed in our minds with good reason.
 
 DISEASES OF THE GASfRO-iNTESflNAL TUMI 283 
 
 All intestinal disturbances must be considered serious because 
 at the outset it is impossible to decide whether we are dealing 
 with a simple indigestion or the first symptoms of an infectious 
 diarrhea. Again it is quite difficult to determine whether we are 
 dealing with the abnormal activities of the intestinal flora or with 
 pathogenic bacteria or their metabolic products. It is also a well- 
 known fact that the normal bacterial inhabitants of the bowels max 
 under suitable circumstances either form toxic products or pass 
 through the frail intestinal wall of the premature infant into the 
 general circulation. 
 
 That we may have serious intestinal symptoms without infec- 
 tion is not to be denied. On the other hand, however, we have 
 the findings of Schabort 1 who was able to isolate diplococci and 
 staphylococci from the stools of every infant which he examined 
 between the thirty-second and the ninety-sixth hour after birth. 
 He found that the sooner the staphylococci appeared, the sooner the 
 stools took on a dyspeptic character, and when the intestinal 
 symptoms were at their height, these organisms dominated the 
 bacterial flora. He believes that every infant has a staphylococcus 
 enteritis in the first days of life. The etiological significance of 
 these cocci is, however, questionable. 
 
 Von Reuss 2 states that he has not infrequently seen, usually 
 toward the end of the first week of life, even temporarily, muco- 
 hemorrhagic stools, dysenteric in character, which did not, however, 
 impair the general health. He also states that the entrance of 
 staphylococci into the oral cavity of the infant and from there 
 into the intestine cannot be avoided, even with the most extreme 
 care on the part of the attendants, because the cocci may come from 
 the milk ducts or the genital canal of the mother. While the 
 milder types of enteritis are brought about by the irritation of the 
 bacteria or their products of decomposition of the normal intestinal 
 content, they are distinguished with difficulty clinically from the 
 forms of enteritis which are caused by pathogenic microorgani-m-. 
 
 Although in most instances the important element of time and 
 lack of laboratory facilities precludes the making of a diagnosis ;i- 
 to the specific causative organism, in the light of the more modern 
 work of Passini 3 in his studies of the new born, and Kendall and 
 Day 4 and others in older infants, the results of their studies are 
 equally applicable to infections in the premature. Passini found 
 that with the introduction of human milk into the lower part of 
 the intestinal tract the meconial flora consisting largely of the 
 
 1 Monatschr. f. Geb. u. Gyniik., 1900, 24, 29. 
 
 2 Die Krankheiten des Neugeborenen, Berlin, 1914. 
 
 3 A Study of the Anaerobic Intestinal Bacteria, Jahrb. f. Kinderh., 1911, 73, 1011. 
 
 4 Boston Med. and Surg. Jour., 1913, 169, 753.
 
 284 DISEASES OF THE GASTRO-lNTESTlNAL TRACT 
 
 speculating forms of the gas bacillus were changed to the fermenta- 
 tive, aerogenous forms, which were capable of forming irritative 
 products which frequently resulted in an increase of stools more 
 or less foamy, containing increased quantities of mucus. These 
 stools are frequently seen during the first days of nursing and are 
 the so-called " transitional stools." However, these products of 
 food decomposition may reach a considerable degree of intensity 
 and be associated with morbid manifestations (von Reuss). 
 
 Having thus described the mild types of irritation of the first 
 group due to the ingestion of staphylococci and of the second group 
 due to the transformation of the gas-forming flora of the meconium 
 into the aerogenous organisms, as seen after the ingestion of milk, 
 with the resultant irritation due to the fermentative action on the 
 milk sugar, we come to the large class of cases which may be due 
 to one of many types of organisms. Those due to streptococcus 
 infections through the maternal circulation before birth (which in 
 itself may be the cause of premature birth), or the secondary 
 infections through the mother's milk, lochia or other products 
 entering the gastro-intestinal tract by way of the mouth, are 
 among the most virulent. 
 
 The Streptococcus enteritis may, therefore, make its appearance 
 very early in life depending upon the time of infection. In prema- 
 ture infants it has a very high mortality. The various bacillary 
 infections of the intestinal tract due to the colon bacillus, dysentery 
 bacillus, typhoid, paratyphoid bacillus, etc., with the exception of 
 the colon bacillus, are rarely seen during the first days of life, 
 unless the mother is suffering with an infection due to one or the 
 other organism. The clinical symptoms are dependent upon the 
 fetal age and stage of development of the individual infant and upon 
 the type and virulence of the infecting organism. The general 
 health of the infant suffers in all cases. Weight has a tendency 
 to become stationary or show a loss. The temperature curve varies 
 directly with the influencing factors and the reaction on the part 
 of the infant, in the milder types being dependent to a great degree 
 on the absorption of the toxic products. Vomiting is an almost 
 constant factor, and the stools which are at first frequent, con- 
 taining food material when developing after the first few days 
 of life, or meconium if the infection be very early, show mucus and 
 often gas, depending upon the infecting organism, and in the severe 
 cases sooner or later blood. Even the premature infant will give 
 evidence of pain and tenesmus as seen by its facial distortion, its 
 low whining cry, and drawing-up of the lower extremities. In the 
 great majority of cases the abdomen is sunken rather than dis- 
 tended. The skin soon becomes dry. The body fat is burned up 
 and collapse becomes imminent. The prognosis is in each case
 
 DISEASES OF THE GASTRO-IXTESTIXAL TRACT 285 
 
 dependent upon the exciting factors, the degree of resistance, bul 
 in all cases, however mild, the outcome remains- in doubt. 
 
 Treatment.— The therapy of these cases offers one of the mosl 
 
 difficult problems confronting the pediatrician, because of the 
 danger of marasmus following even short periods of starvation, 
 and because of the limitations of dietetic treatment. Human milk 
 is indeed the only food which can be given with any degree of 
 safety, and this at the same time because of its high sugar content 
 offers a splendid culture medium for the gas-forming organism. 
 The frequent, somewhat foamy, mucous stools which are seen 
 during the transitional period, that is, in the change from the 
 meconial stools to the normal breast-fed stools as well as the fre- 
 quent stools of similar formation as seen after this period, when 
 unassociated with temperature, loss in weight, and other symptoms 
 indicative of serious trouble, should not lead to dietetic changes, 
 but breast nursing should be continued as long as there is an absence 
 of all signs of beginning general disturbance. When the infant 
 is feeding on the milk of its mother similar but physiological stools 
 are very commonly seen during the period in which she is secreting 
 colostrum and are not to be confused with intestinal infection. 
 Evidence of more serious infection should lead to a short period 
 of feeding on inert fluids of proper volume. This period of starva- 
 tion in most eases should not be continued over six, or at the most, 
 twelve hours, and should be followed by gradual feeding of smaller 
 quantities of human milk than has been previously given. Where 
 there is question as to the mother's milk being the source of infec- 
 tion, wherever possible, the milk should be obtained from another 
 source, or the mother's milk should be sterilized before feeding. 
 This latter is easily accomplished because in most cases premature 
 infants are hand-fed during the first few days of life. These 
 measures should be carried out until bacteriological examination 
 is completed. 
 
 The intestinal tract may be cleansed by the administration of a 
 single dose of castor oil, varying from 10 to 30 minims, depending 
 upon the age of the infant and the conditions at hand. The large 
 bowel may be emptied by irrigations of normal saline solution, 
 which later may also be given as small repeated nutritive enema ta 
 after the intestinal tract is once thoroughly cleansed. Vomiting 
 may be allayed by very careful gastric lavage, small quantities of 
 saline solution being left in the stomach after the washing. Lavage 
 must be rapidly and dexterously performed to avoid attack- of 
 cyanosis. Brandy (1 to 5 minims), or aromatic spirits of ammonia 
 (1 to 2 minims), at regular intervals are the best forms of stimula- 
 tion for oral administration. Minimum doses of paregoric (| to 2 
 minims) will frequently allay the intestinal peristalsis and relieve
 
 286 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 tenesmus, both of which add to the dangers of the intestinal infec- 
 tion. Intestinal antiseptics are to be avoided. Hypodermic 
 stimulation must be very carefully given because of the dangers 
 of toxic effects and of local irritation. Small doses of camphor in 
 oil (1 to 5 minims) are the best. In the artificially fed infant 
 every effort should be made to obtain human milk. 
 
 DISEASES OF THE LIVER AND BILE PASSAGES. 
 
 Icterus Neonatorum.— Two varieties must be distinguished — 
 icterus simplex and icterus gravis. 
 
 While the simple form of icterus is, as a rule, a very benign 
 condition usually running its course without severe systemic 
 manifestations, the grave type is especially fatal in premature 
 infants in whom it is usually a clinical manifestation of sepsis, 
 syphilis, hemorrhagic diathesis, or some grave form of liver insuffi- 
 ciency or bile-passage obstruction. 
 
 Frequency.— The incidence of icterus neonatorum in premature 
 infants varies with the observer from 15 to 100 per cent. This 
 variation probably depends upon what the individual observer 
 considers to be jaundice. If a yellowish tinge to the nose and 
 cheeks is regarded as sufficient to make the diagnosis then the 
 percentage will be high; should staining of the conjunctiva? only 
 be taken as evidence the number will be low. The term "true 
 icterus" can be applied only to those cases in which the yellow 
 discoloration of the skin is caused by a staining of the bile pigments. 
 
 Pathology.— Autopsy in moderate cases shows that the intima 
 of the arteries, the serous membranes and the various body fluids and 
 the interstitial tissues are stained yellow, but the brain, the cord, 
 liver, spleen and kidneys are usually only slightly stained, if at 
 all. In severe types, however, deposition of bilirubin crystals 
 may be found in the cells of the skin, in the capillaries and lym- 
 phatics and also in the renal pyramids, blood, adipose tissues, 
 brain and other organs. 
 
 Etiology.— The recent work of A. Ylppo offers the most plausible 
 solution for the occurrence of jaundice in the new born, and his 
 experiments are well worth quoting in detail. His experiments 
 were conducted through spectroscopic analysis of the blood for its 
 bilirubin and biliverdin content. He found that biliary pigment 
 secretion is small until the late fetal months are reached. Shortly 
 before birth the secretion is rapidly increased, and this increase is 
 intensified after birth. 
 
 This biliary pigment content of the blood increases up to the 
 third to the tenth day and on the whole continues for a longer time 
 in the premature than in the full term, He found that blood
 
 DISEASES OF THE LIVER AND BILE PASSAGES _'s7 
 
 from the umbilical vessels averaged from 13,0 58,2'10 ' per LOO 
 cc of blood and that this increased from the third to the tenth. In 
 those cases which passed 12o,0 - 10 _5 gm. per 100 cc of blood, icterus 
 developed, while it remained absent in those containing less than 
 this amount. lie also found that there was a direct parallel between 
 the blood content of biliary pigment and the intensity of the icterus: 
 Clinical manifestations due to the icterus were absent in the mild 
 cases, while in the severe ones the cholemia resulted in somnolence. 
 He found little evidence that syphilis, sepsis and traumata influem e 
 the development of the jaundice. From his studies he concluded 
 that icterus neonatorum is hepatogenous in origin and is due to 
 the fact that for some days after birth the liver continues to secrete 
 bile into the blood stream by the same routes that this occurs in 
 fetal life and that due to the fact that there is an intensified se< re- 
 turn of bile pigment shortly before and after birth, the blood content 
 of bile is increased, and that these findings result in the development 
 of the icterus when in excess. He therefore believes that it is a 
 physiological process which, however, may become pathological 
 when the blood content becomes excessive. 
 
 The earlier explanation of Knopfelmacher offers a closely related 
 explanation. He describes two factors as concerned in production 
 of jaundice in the new born, a hypersecretion of bile and a dis- 
 turbance of excretion. The richness of the blood supply to the 
 liver immediately after birth is responsible for a greatly increased 
 production of bile at this time, while during the first few days of 
 life there is only a rudimentary functioning secretory mechanism. 
 Accordingly the tenacious and stagnated bile passes from the 
 overfilled bile capillaries into the blood capillaries. 
 
 The increased viscosity of the bile during the first days of life 
 is explained by Pacchioni as being due to the loss of water sustained 
 by the infant at this time, leading to a greatly slowed biliary current 
 with absorption into the blood and lymph stream. 
 
 A hematogenous origin of the bile in icterus neonatorum may be 
 excluded by the experiments of Minkowski and Nyuyn, who 
 demonstrated that the liver is essential for the formation of bile 
 and that without this organ jaundice cannot be induced. The 
 connection of icterus with a stasis of bile, the result of the closure 
 of the ductus choledochus by meconium (Franck), by desquamated 
 epithelium (Cruse), or by a plug of mucus (Virchow), is not sup- 
 ported by the facts; neither is Birch-Hirschfeld's theory of edema 
 of the capsule of Glisson, Bouchut's theory of a hepatitis, or 
 Epstein's explanation that the cause is a catarrh of the small bile 
 ducts. 
 
 Freirichs explained the jaundice by a marked anemia and decrease 
 in pressure in the liver capillaries, which in turn lead to a lessened
 
 288 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 pressure in the bile capillaries and an overflow of bile into the 
 blood stream. The great degree of congestion of the hepatic capil- 
 laries at birth precludes this belief, however, while the fact that 
 the blood-pressure is raised in asphyxia neonatorum, in which 
 condition icterus is especially intense also nullifies this theory. 
 
 Symptoms. — In very mild cases the yellow color may appear 
 only on the face, chest and back, the conjunctiva 3 being but faintly 
 tinted and the urine and feces normal in appearance. In severer 
 forms the urine may be high colored enough to stain the linen, 
 and the jaundiced hue may extend to the arm and abdomen. Some 
 infants present a yellowish discoloration of the whole body, with 
 typical clay-colored stools. In most cases the jaundice has dis- 
 appeared by the eighth or tenth day. It may persist for several 
 weeks. In rare cases, after having much diminished, it reappears 
 with renewed intensity. The liver and spleen are usually 
 unchanged, however; in the severer types liver changes are the 
 rule and it is usually found enlarged. 
 
 An early type often seen from six to twelve hours after birth 
 is not infrequent in small prematures. These are usually severe 
 cases and although not of the septic type are slow in disappearing. 
 
 While most of the simple cases are unassociated with gastro- 
 intestinal and febrile disturbances the severer types even of the 
 simple form are associated with symptoms of indigestion which is 
 always of grave import in the premature. They are also subject 
 to febrile disturbances and are slow in overcoming their initial 
 weight losses. 
 
 Diagnosis. — Icterus neonatorum being a physiological condition, 
 it must be differentiated from jaundice due to causes other than a 
 mere disturbance of interrelation between formation and excretion. 
 There must be excluded septic, syphilitic and familial jaundice, 
 that due to deformities or obliteration of the biliary passages, and 
 three or four rarer conditions characterized by icterus. 
 
 Septic Jaundice. — Gessner believes that many instances of 
 so-called benign icterus neonatorum are dependent upon umbilical 
 infection, and DeLee agrees with him. Other cases are thought 
 to be due to intestinal infection. 
 
 In these cases the child is ill, the temperature is elevated and 
 the skin shows a marked degree of icterus, which in the severer 
 cases becomes a bronzing. Hemorrhages are often present, some- 
 times a foul-smelling pus exudes from the umbilicus, there is ano- 
 rexia and the abdomen may be distended and tender. Blood 
 cultures sometimes reveal the causative organisms or they can 
 be demonstrated in the septic foci. The outlook for these children 
 is poor, the younger and less mature the infant, the less is its chance 
 of recoverv.
 
 DISEASES OF THE LIVER AND BILE PASSAGES 289 
 
 Syphilitic Jaundice. -This form of jaundice is usually present at 
 birth or appears a few days later. It is generally rather intense 
 and may persist, though sometimes it improves, only to recur again. 
 Hemorrhages under the skin are not at all uncommon. It should 
 be suspected if other signs of syphilis are present, especially a 
 positive Wassermann reaction. 
 
 Family Acholuric Jaundice — This is a chronic condition charac- 
 terized by jaundice of long duration, the presence of bile pigments 
 in the stools and their absence in the urine. The spleen is usually 
 but not always enlarged, there is, as a rule, more or less anemia 
 present and some enlargement of the liver. The affection is com- 
 patible with life but occasionally there occur slight rises in tem- 
 perature with malaise, diarrhea, abdominal pain and an increase 
 in icterus. This jaundice has been explained on the basis of a 
 simple cholemia, biliary cirrhosis, splenomegalic jaundice, or it 
 may be that all the conditions are but different stages of the same 
 affection. 
 
 Prognosis. — It must be kept in mind that icterus neonatorum 
 may he of prolonged duration and yet be only due to disturbance of 
 bile secretion and excretion, and not dependent on malformation, 
 sepsis or other disease. An increase in the intensity of the icterus 
 during the second week should make one suspicious of some causa- 
 tive condition more serious than that responsible for a simple 
 icterus neonatorum. 
 
 Treatment.— There is no treatment for simple icterus of the new 
 born, nor is any needed though small doses of calomel with sodium 
 bicarbonate and sodium phosphate have been recommended. 
 
 Affections of the Excretory Bile Ducts. — (a) Stenoses and Atre- 
 sias.— The common, hepatic or cystic ducts, one or all, may he 
 affected in congenital stenoses. The more common etiological 
 factors are as follows: (1) One or more of the ducts and even the 
 gall-bladder may be totally absent; (2) fetal inflammatory pro- 
 cesses of obscure origin may result in atresias; (3) pathological 
 development at the distal end of the common duct with a valve- 
 like formation may result in atresia (similar formations may be 
 present in the mucous membrane at other locations in the bile 
 passages); (4) hereditary syphilis may result in a perihepatitis, or 
 cholangitis; and (5) occlusion may be due to inspissated bile or 
 concretions. 
 
 Symptoms.— Acholic stools are present where there is an involve- 
 ment of the hepatic or common duct or both. This may or may 
 not be evident in the meconium depending upon the causative 
 factor. Progressive icterus is an almost constant finding. I rinary 
 findings correspond to the degree of stenosis, and there is undigested 
 fat in the stools when fat is contained in the infant's food. 
 19
 
 290 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 Prognosis.— Death soon follows in the cases where the stenosis 
 is the cause of premature birth. However, in other cases where 
 it is simply a part of the general picture of congenital lues, or 
 occlusion is less complete, the infants may survive for a consid- 
 erable time, depending upon the degree of systemic involvement. 
 Death is usually due to intercurrent infection, which is not uncom- 
 monly through the gastro-intestinal tract, or inanition due to lack 
 of fat digestion or to cholemia. All cases of complete occlusion 
 are fatal in the premature. 
 
 Treatment.— In all cases except those due to inspissated bile 
 and lues the treatment would be surgical, but such interference 
 is practically hopeless in this class of cases and is rarely to be 
 advised in premature infants. The medical treatment of congenital 
 syphilis is far from hopeless. A much poorer prognosis is offered 
 in stenosis of the ducts than in those cases where jaundice is due 
 to a hepatitis. 
 
 (6) Gall Stones.— Cholelithiasis due to fetal inflammatory pro- 
 cesses has been described by Bland-Sutton 1 and Cautley states 
 that they are more frequent during the fetal age and early infancy 
 than at any other period of childhood. 
 
 (c) Inflammations of the Bile Passages.— Although they are rare 
 they may be due to ascending infection, but are more commonly 
 subacute conditions as seen in congenital syphilis. 
 
 Affections of the Hepatic Vessels.— Phlebitis and thrombosis 
 of the portal vein may result from an ascending infection through 
 the umbilical vessels. 
 
 Congenital lues may be associated with a periphlebitis of the 
 portal vein, or its intrahepatic branches, or gummatous infiltration 
 about the hepatic vessels. When the portal vein is the seat of con- 
 siderable obstruction, ascites, gastric and intestinal hemorrhages, 
 enlargement of the liver and splenic tumor usually result. 
 
 • BIBLIOGRAPHY OF ICTERUS NEONATORUM. 
 
 Minkowski-Nyuyn : Arch. f. exper. Pathologie, 21, 1. 
 
 Franck, J. Peter: De curandis hominum morbis Epitome, 1805, 55, 183. 
 
 Cruse, P.: Arch. f. Kinderheilk., 1, 353. 
 
 Virchow, R.: Gesammelte Abhandlungen, s. 847. 
 
 Birch-Hirschfeld, F. V.: Virchow's Arch., 1882, 87, 1. 
 
 Bouchut (quoted from Marcel Delestre) : Etude sur les infections chez le pre- 
 mature, Paris, 1901. 
 
 Epstein: Volkmann's Sammlung klin. Vortrage, 1880, Nr. 180. 
 
 Freirichs: Klin. d. Leberkrankh., 1858, p. 1. 
 
 Quincke: Arch. f. exper. Pathol, u. Pharmakol., 1885, 19,34; Virchow's Arch., 
 1884, p. 95. 
 
 Meckel, H.: Charite-Annalen, alte Folge 4, 1853. 
 
 DeLee: Principles and Practice of Obstetrics, Philadelphia, 1913. 
 
 1 Gall Stones and Diseases of the Bile Ducts, 1911.
 
 DISEASES OF THE LIVER AND BILE PASSAGES 291 
 
 Knopfelmacher, W.: Jahrb. f. Kinderhoilk., 1898, p. 47; 1908, p. 67. 
 Hess, A. F.: Am. Jour. Dis. Child., 1912, p. :304. 
 Abramow, S.: Virchow's Arch., 181, 201. 
 Pacchioni: Rivista di clinica pediatr., 1911, 9, 333. 
 Ylppo, A.: Ztschr. f. Kinderheilk., 1913, 9, 208. 
 
 Affections of the Hepatic Parenchyma. -Although the liver is 
 readily influenced by toxic and infectious products, which easily 
 pass through the permeable gastro-intestinal wall, nevertheless, it 
 
 is exceedingly difficult to recognize the part which this great organ 
 plays. 
 
 Among the most common affections of the liver is the predis- 
 position to icterus, which appears especially early in prematures. 
 Besides the physiological jaundice, icterus may accompany a 
 variety of disorders. In the later life we see different types of 
 icterus, aside from obstruction of the gall ducts, as: Septic 
 icterus, Winckel's disease, catarrhal icterus, toxic jaundice and 
 acute atrophy. 
 
 Parenchymatous and fatty degeneration of the liver is present 
 in all septic diseases. Degenerative liver processes are, however, 
 seen where there is no focus of infection and these are probably due 
 to toxins, which are absorbed from the placenta, as in the cases 
 of infants born of eclamptic mothers, perishing shortly after birth. 
 In some such instances there may be no gross change but micro- 
 scopically a high-grade degeneration exists. In addition, as 
 previously mentioned, subcapsular liver hemorrhages occur quite 
 frequently. Ylppo 1 was able to demonstrate such lesions in almost 
 80 per cent of the prematures under 1000 gm. birth weight, and 
 only in 5 per cent of those weighing between 2000 to 2.100 gm. At 
 times the hemorrhages may be very extensive and with rupture 
 of the liver capsule result fatally. Parenchymatous liver hemor- 
 rhages may also be found, but they are small and are not of much 
 significance. 
 
 In the literature one finds mention of cases of acute yellow 
 atrophy of the liver with the finding of tyrosin and leucin in the 
 urine, coagulation necrosis and hemorrhages into the parenchyma. 
 
 Septic icterus is characterized by a marked acute interstitial 
 and parenchymatous hepatitis. In some cases there have heen 
 noted cyanosis, convulsions and digestive disturbances, which 
 either disappeared in a few days or led to death. In these i ases 
 the liver symptoms are cloaked by those of general sepsis. 
 
 Icterus catarrhalis is often associated with duodenal catarrh 
 and cholangitis, and is characterized by jaundice, acholic stools, 
 bilirubinuria, and the prognosis is on the whole good. 
 
 1 Pathologisch-anatomische Studien bei Fruhgeburten, Ztschr. f. Kinderh., L919, 
 20, 329.
 
 292 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 Cirrhotic processes in the liver are usually associated with con- 
 genital syphilis or deformities of the gall tracts. One sees a diffuse 
 interstitial luetic hepatitis under the picture of hypertrophic 
 cirrhosis. With anomalies of the gall ducts there is a biliary 
 cirrhosis. 
 
 Congenital Tumors of the Liver. —These in themselves may be 
 the cause of premature birth. However, most of the cases of 
 malignant tumors described in the literature are those which have 
 developed after birth in infants either born in seeming health at 
 full-term, or those congenitally debilitated, but who did not give 
 evidence of tumor formation until some time after birth; while 
 the cases giving evidence of tumor formation at birth have been 
 commonly angiomata or cystic degenerations. 
 
 DISEASES OF THE PERITONEUM. 
 
 Fetal Peritonitis.— Intra-uterine peritonitis is usually chronic in 
 character, and in premature infants usually results in death shortly 
 after birth, if not already the cause of still birth. 
 
 Etiology and Pathogenesis. — 1. Malformations in the digestive 
 tract with emptying of the contents into the peritoneal cavity. 
 It is also quite possible that some of the malformations described 
 previously may result from secondary changes due to fetal peri- 
 tonitis. 
 
 2. Malformations of the genito-urinary tract may likewise 
 cause fetal peritonitis owing to the extravasation of urine into the 
 abdominal cavity. 
 
 3. Spontaneous rupture of any of the hollow abdominal viscera 
 with extravasation of their contents may result in peritonitis. 
 
 4. Congenital syphilis is frequently associated with fetal perito- 
 nitis (Simpson. 1 ) Maceration of the peritoneum, as frequently 
 seen in still births in congenital lues, should not be mistaken for 
 true peritonitis. 
 
 5. True congenital tuberculosis may be a causative factor and 
 Mya 2 believes that the toxic bodies circulating in the blood of a 
 tuberculous mother may in themselves cause peritonitis without 
 the presence of the specific organisms. 
 
 6. Various septic infections may pass through the placental 
 circulation into the fetal body and may among other lesions cause 
 peritonitis. 
 
 Symptoms.— The symptoms depend upon the degree of peritoneal 
 involvement and the nature of the cause. In living infants where 
 the process is localized, there may be but few symptoms at birth, 
 
 1 Cases of Intra-uterine Peritonitis, Zentralbl. f. Gynak., 1S77, p. 4S. 
 
 2 Monatsscbrift f. Kinderh., 1906, 4, 341.
 
 HERNIA 293 
 
 l>ut such a process usually results in the formation of adhesions 
 and the development of intestinal obstruction in surviving infants. 
 More commonly the process is generalized, the abdomen distended, 
 containing more or less effusion with resulting dyspnea and cyanosis 
 
 and the early development of ileus. 
 
 Prognosis. — Premature infants with fetal peritonitis rarely sur- 
 vive the first days of life and even the cases of localized peritonitis 
 usually result in early death because of the inability of the individual 
 to withstand surgical interference. 
 
 Acute Peritonitis.— Etiology.— It rarely occurs as a localized 
 affection in the premature. The most common sources of infection 
 are: 
 
 1. Hematogenous, either through general sepsis or local infection 
 in some distant part. 
 
 2. Infections through the umbilical cord. 
 
 3. Infections through the intestinal canal either through rupture 
 of the intestines due to trauma (this is usually located in the region 
 of the sigmoid flexure), or the passage of bacteria into the peritoneal 
 cavity, either through the uninjured intestinal wall, or through the 
 inflamed, ulcerated or gangrenous bowel wall. 
 
 Symptoms.— Violent vomiting, abdominal distention with either 
 diarrhea or obstipation, usually temperature, although it may remain 
 subnormal, rapid respirations and pulse, not infrequently marked 
 icterus, and early collapse are the usual findings. The diagnosis 
 is often impossible before death owing to the rapid development 
 of similar findings in the premature from other causes, unless 
 there is evidence of transmission from some localized source of 
 infection, as about the umbilicus. 
 
 Prognosis. — Entirely unfavorable. 
 
 HERNIA. 
 
 Congenital Diaphragmatic Herniae. —These hernias are described 
 as true and false. The true diaphragmatic hernias are covered 
 by the peritoneum and there is no direct communication between 
 the pleural and the abdominal cavities. In the latter or false 
 type there is really an extrusion of the abdominal organ, and 
 therefore a direct communication between the abdominal and 
 pleural cavities. The latter are by far the more frequent type 
 and the left side is more commonly involved than the right. The 
 diagnosis offers considerable difficulty in the premature and because 
 of the commonly associated cyanosis they are usually diagnosed 
 as congenital atelectasis, a diagnosis which is not greatly in error 
 as the lung on the side involved is not infrequently entirely undevel- 
 oped. In contradistinction to full-term infants who may live to 
 considerable age, premature infants usually succumb during the
 
 294 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 first hours or days of life with symptoms of asphyxia and cyanosis, 
 usually due to gastric or intestinal distention within the chest 
 cavity (Figs. 154 and 155, pages 256 and 257). 
 
 Ventral (Lateral) and Lumbar Herniae.— Etiology.— They are 
 usually due to defects or arrested development of the lateral 
 abdominal or lumbar muscles. They may, however, result from 
 increased intra-abdominal pressure. 
 
 Prognosis.— This depends on the extent of the hernia and the 
 general development of the infant. Three cases which I have 
 seen in premature infants who survived resulted in spontaneous 
 recovery. 
 
 Treatment.— During the first months of life treatment must 
 necessarily be limited to abdominal bandages or adhesive strips. 
 
 Umbilical and Inguinal Herniae.— Navel and inguinal hernise are 
 especially common in the premature. Ylppo 1 found hernia? of one 
 or both varieties in 84 per cent of the premature infants with a 
 birth weight of less than 1500 gin. before the third month. 
 
 Umbilical and Inguinal Hernle (Ylppo). 
 
 Weight in grams. No. of Hernia Per 
 
 cases. present. cent. 
 
 1000 1 1 
 
 1001 to 1500 50 42 84.0 
 
 1500 to 2000 81 31 38.3 
 
 2000 to 2500 73 15 20.5 
 
 Inguinal her nice are rarely observed at birth, usually developing 
 when the infant is several days or weeks old, following intra- 
 abdominal distention or severe crying in stronger infants. They 
 are most frequently bilateral and are fairly common. The testicles 
 are often undescended, leaving a direct communication with the 
 abdominal cavity which is followed by rupture of the processus 
 vaginalis communis through the canal. This is rather interesting 
 when we note that the processus vaginalis is open at birth in the 
 majority of infants prematurely born. The tendency to meteorism, 
 which so commonly exists, enhances the development of hernias 
 under these conditions. While incarceration is rare, and reduction 
 usually easy due to the elastic walls, strangulation does occasion- 
 ally occur and is always dangerous if neglected. 
 
 Treatment.— Operative interference is usually out of the question, 
 and we of necessity have recourse to conservative treatment. Steel 
 trusses almost invariably cause trauma and erosion, with the 
 dangers of infection which are of graver importance than the 
 dangers of strangulation due to the hernia. Conservative treat- 
 ment by the use of yarn trusses as first devised by Fiedler 2 or by 
 
 1 Ztschrft. f. Kinderh., 1919, 24, 1. 
 
 2 Zentralbl. f. Chir., 1906, 33, 1161. Deutsch. med. Wchnschr., 1907, p. 105.
 
 HERNIA 295 
 
 the simple truss designed by Dr. Andrew A. (lour oilers the simplest 
 and best methods of treatment, and in the majority of cases results 
 in spontaneous eure (Fig. 157). 
 
 Fig. 156. — Illustrating the application in inguinal hernia. A pure wool, white 
 yarn -i-ply is wound into a skein of fifteen to twenty strands, from 15 to 20 inches 
 in length, depending upon the size of the infant to which it is to be applied. To 
 prevent tangling it is knotted by a single strand at six points. A single loop is 
 made which is passed around the body at the level of the crests of the iliac bones, 
 with loop coming directly over the hernia. Fixing the loop at this point with the 
 finger, the free end is now passed from above downward between the strands, mak- 
 ing a snug knot which is fixed over the hernia. The free end is then passed between 
 the thighs where it is fastened to the main loop over the back by tying with tape 
 or by the use of a narrow rubber elastic to which snap fasteners are sewed. They are 
 made to meet the needs of each individual case. Such a truss should be worn for 
 two or three months or longer. The strand passing between the legs can be protected 
 from excreta? by a cigarette made from oiled silk which can be slipped over the free 
 end before fastening. Six skeins should be kept on hand. They can be washed 
 in gasoline and soap and water. They should be stretched while drying. 
 
 The average mother or nurse can easily be taught to make the 
 bandage from a good quality of poplin and of such size as will
 
 296 
 
 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 meet the infant's needs. It is usually necessary for the infant 
 to wear the above improvised truss over a period of from one to 
 three months. 
 
 Fig. 157. — Inguinal hernia bandage with small oval metal pad inserted on left side. 
 
 (Dr. A. Gour.) 
 
 Fig. 158. — Pad designed by author for use with hernia bandage. An elliptical 
 piece of fine pore rubber sponge is glued to a slightly larger piece of sole leather. 
 The leather is perforated at four points so it can be stitched into the bandage. The 
 rubber pad insures close approximation and elasticity to the bandage. 
 
 Umbilical herniee are usually not extreme, most commonly devel- 
 oping during the first month increasing up to the third month. 
 With proper care they often disappear completely by the end of the 
 first year with the development of the recti and the other abdominal 
 wall muscles. 
 
 This seems to be hastened when the child reaches the age of
 
 HERNIA 
 
 297 
 
 walking where the cases are not already healed. The chief factors 
 in the causation of navel hernia' arc the weak abdominal walls, the 
 tendency toward rectus diastasis and the delayed healing and falling 
 off of the cord, which averages eight to ten days in the premature 
 as compared with five to seven in the full term. The diaphragmatic 
 respirations are also a factor. Although we may have hernia of the 
 umbilical cord proper, that is, true congenital umbilical hernia, the 
 condition more commonly described as navel hernia is the acquired 
 hernia of the umbilical ring due to deficient closure, resulting in the 
 protrusion of the omentum, or the intestines or both through the 
 ring resulting from increased intra-abdominal pressure. With 
 proper conservative treatment operative interference is rarely 
 necessarv. 
 
 Fig. 159. — Umbilical hernia bandage; j-inch cotton cigarette and strip of adhesive 
 
 plaster. 
 
 The method as illustrated usually results in cure in from one 
 to three months, and if a good grade of zinc oxide adhesive 
 plaster is selected, there is usually little excoriation of the skin 
 even in the premature, if the bandage is not applied until the 
 umbilical wound is entirely healed and all granulation tissue has 
 disappeared. It is, therefore, necessary to treat the umbilical 
 wound by the open method until thoroughly dried. A small 
 "cigarette-like" roll is made of cotton about h inch in length and 
 from | to I inch in diameter, depending upon the size of the hernia 
 and the elasticity of the abdominal wall. This small cotton cigar- 
 ette is then partially or entirely buried between the overlapping
 
 298 
 
 DISEASES OF THE GASTRO-INTESTINAL TRACT 
 
 skin lateral to the hernia, and while it is being held by the operator 
 (doctor, nurse or mother) a strip of adhesive plaster about 3 inches in 
 length and If inches in width is applied directly over the umbilicus. 
 
 Fig. 160. — Umbilical hernia bandage. Cotton cigarette in place. The next step 
 consists in burying the cotton by folding the skin over it. 
 
 Umbilical hernia bandage. Adhesive strap in place. 
 
 We have found the short strip of adhesive plaster preferable to 
 the longer strips encircling the entire body, as it causes less irrita- 
 tion, allows greater motor activity on the part of the intestines, 
 and is equally efficient in the treatment of these cases.
 
 CHAPTER XII. 
 
 DISEASES OF THE URINARY TRACT. 
 
 Smaller or larger hemorrhages in the kidney capsule are frequent, 
 but extensive extravasations are rare. Minute hemorrhages oe 
 the renal surfaces are common. In the kidney substance hemor- 
 rhages arc most commonly found at the apex of the pyramids and 
 
 in the medulla. Besides this zone of predilection there is another 
 at the junction of the cortex and the medulla. Here there are not 
 always hemorrhages but markedly engorged vessels (vena? et 
 arteriae arciformes). Hemorrhages occur more often between the 
 urinary tubules than in them. 
 
 Uric-acid infarcts are found as yellowish granules in the kidney 
 pyramids of prematures, still-born or perishing after a few days 
 of life. Hemorrhages are usually present also in the same regions. 
 Bile pigment is precipitated in the kidney in the same areas in 
 which there is the predilection for hemorrhage. 
 
 That cylindruria and albuminuria may be present without gross 
 demonstrable pathological change was mentioned before. The 
 transition from physiological to pathological albuminuria is not 
 abrupt and the instance of severe albuminuria is infrequent. 
 
 Observations have been so few in the cases of nephritis in newly 
 born prematures that an exact clinical picture has not been e>tal>- 
 lished. Quite frequently one finds parenchymatous or fatty degen- 
 eration of the kidneys following toxic or infectious conditions. 
 Perhaps the most outspoken form of nephritis in the new born is 
 the syphilitic. An interesting question is the influence of nephritis 
 and eclampsia in the mother on the kidneys of the infant. One 
 commonly sees cases where the infant is unaffected and the urine 
 retains its normal character, sometimes even when the premature 
 shows eclamptic symptoms. At times there may be the findings 
 of a well-marked hemorrhagic nephritis which clears up within 
 a few weeks. Infrequently the infant may show congenital edema 
 and ascites. The presence of "hydrops fetus universalis" has been 
 shown to have some relation to the presence of nephritis during 
 pregnancy, with well-marked renal pathology, causing still birth 
 or premature birth with death in a few days. 
 
 Shrunken kidneys have been demonstrated in the infant following 
 chronic nephritis in the mother. 
 
 A relatively large portion of the cases of nephritis in the new
 
 300 DISEASES OF THE URINARY TRACT 
 
 born have been ascribed to infections processes. Thus Mensi 1 
 examined 17 nephritic infants, ten to fourteen days old, and based 
 the condition on infections secondary to the diseases of the respira- 
 tory and alimentary tracts. 
 
 ECLAMPSIA NEONATORUM. 
 
 The analogue of classical eclampsia in the mother is very seldom 
 seen in newly born infants. These inay show no untoward symp- 
 toms or may be prematurely born dead, or if alive succumb in a 
 few days from degeneration of the organs, hemorrhages or nephritis. 
 Convulsions in infants born of eclamptic mothers are quite rare. 
 Esch, 2 in 1910, was able to collect only 32 cases from the literature 
 and his own experience. The convulsions appear in the first days 
 of life, sometimes a few minutes after birth, usually before the 
 end of the second day. Involvement of the eye muscles is usually 
 first noted, then cyanosis appears, followed by tonic and clonic 
 spasms of the body musculature. The convulsions last but a 
 few seconds, sometimes several minutes. The severity of the 
 eclampsia in the mother seems to have no influence on the frequency 
 of appearance of convulsions in the infant. If the children survive 
 the first few days the prognosis is relatively good. The treatment 
 is to force fluids by mouth, per rectum, subcutaneously or intra- 
 venously, in order to dilute the circulating toxins. 
 
 We have experienced severe toxemia, as evidenced by stupor 
 and other nervous manifestations, in both premature and full-term 
 infants fed on eclamptic and nephritic mothers' early breast milk. 
 To avoid this catastrophe it has become our rule to examine the 
 infants very carefully for toxic symptoms and in their presence 
 to feed all such prematures human milk obtained from healthy 
 women, during the first days or weeks of life. 
 
 PYELOCYSTITIS. 
 
 The appearance of an infectious process in the urinary tract, as 
 pyelocystitis, is as possible in the newly born as in older nurslings. 
 Although general infections appear relatively easily in the first days 
 of life, nevertheless, clinical symptoms are often lacking. The 
 presence of chills, fever and sweats, as noted in older children, is 
 seldom observed in the first days of life, so that the diagnosis is 
 only made by urinary examination, disclosing blood, albumin, pus 
 cells in large numbers and not infrequently colon bacilli. 
 
 Pushing of fluids and the administration of potassium citrate 
 to the point of positive alkalinization of the urine are the only 
 therapeutic measures applicable to the premature. 
 
 1 Rev. di clin. Ped., 1903, No. 8. 2 Arch. f. Kinderh., 1909, 88, 60.
 
 CHAPTER XIII. 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 MENTAL AND NERVOUS DISTURBANCES. 
 
 The frequency of mental disturbances and other phenomena on 
 the part of the central nervous system in premature infants has 
 been variously estimated. Finkelstein states that mental dis- 
 turbances and spastic phenomena are not more frequent in pre- 
 matures than in full-term infants, but Ylppo strongly contests 
 this statement. The attempt to express the frequency of perma- 
 nent mental defects and other cerebral disturbances in percentages 
 is only rarely possible before the end of the first year of life, with 
 perhaps the exception of the typical Mongolian idiot. Demon- 
 strable mental defects, either complete idiots or imbeciles, were 
 found in 7.4 per cent of Ylppo 's cases. 
 
 Mental defects in premature infants are frequently accompanied 
 by other symptoms on the part of the central nervous system. 
 The most common are the spastic paraplegias and diplegias. These 
 are present in prematures with demonstrable mental defects in 
 at least 75 per cent of all cases. However, mental development 
 may be complete in the presence of spasticity of the extremities 
 dependent upon cerebral irritation. In most instances this is 
 secondary to intracranial hemorrhage. Paraplegia or diplegia was 
 present in 3.1 per cent of all Ylppo's cases. These figures would 
 certainly be much higher, had all the prematures remained alive, 
 since most of the infants suffering from injury to the brain die very 
 early. The cerebral affections occur the more frequently, the 
 smaller the infant at birth. 
 
 In our experience mental disturbances and defects on the part 
 of the central nervous system have been confined largely to those 
 infants who survived from among the class of so-called weaklings. 
 These are the infants who have suffered from intra-uterinc disease 
 or congenital malformations, traumata at birth, or postpartum 
 dietetic errors and infection. Among the more mature that arc 
 normal for their fetal age the prognosis for a full mental develop- 
 ment is good. 
 
 Treatment. — In the postmortem examination of infants dying 
 of cerebral hemorrhage, Rodda 1 found over 50 per cent followed 
 
 1 Am. Jour. Dis. Child., 1920, 19, 268.
 
 302 DISEASES OF THE NERVOUS SYSTEM 
 
 non-instrumental deliveries and many followed normal and easy 
 births. In these cases the blood was found slightly or not at all 
 coagulated. Cerebral hemorrhage was by far the most frequent 
 cause of death in the new born in his group of cases. In many 
 cases at postmortem, no torn veins were found in the cerebrum 
 or cerebellum to account for the hemorrhage, and multiple hemor- 
 rhages were found in portions of the body where it was incon- 
 ceivable that they could be explained by trauma. Over 25 per 
 cent of all infants dying of cerebral hemorrhage showed this picture 
 of multiple hemorrhages. An analysis of cases reported in the 
 literature deepened the conclusion that these hemorrhages were 
 due to factors other than trauma. Further study led to the con- 
 clusion that there was a disturbance in the coagulation time of 
 the blood in the new born. It was found that the average coagu- 
 lation time in the new born was seven minutes. In icterus, melena, 
 jaundice, syphilis and non-traumatic cerebral hemorrhage, the 
 coagulation time of the blood was prolonged. In melena it might 
 be delayed to ninety minutes. The subcutaneous injection of 
 normal blood was effective in cases in which there was delayed 
 or slow bleeding. 
 
 The further treatment in those cases with a diagnosis of intra- 
 cranial hemorrhage is symptomatic and expectant. There is 
 always the possibility that there may be spontaneous cure. The 
 infant must be kept quiet and warm. For the motor hyper- 
 irritability and convulsions narcotics may be employed, before all 
 chloral hydrate (0.12 to 0.5 gm. per day per rectum), also bromides 
 (0.25 to 1 gm. per day) or calcium lactate (1 to 2 gm.) or calcium 
 bromide (0.3 to 0.5 gm. per mouth) per day. 
 
 Where the infants do not swallow well, feedings must be given 
 per catheter or subcutaneous infusions must be used for emerg- 
 ency. 
 
 Lumbar puncture, although primarily a diagnostic measure, 
 may have a beneficial therapeutic action. It is of diagnostic value 
 when the hemorrhage is below the tentorium. 
 
 In the full term, cranial decompression when employed early 
 has yielded favorable results, however little can be expected from 
 such surgical interference in the premature. 
 
 Schulze's swingings and other violent measures for artificial 
 respiration are distinctly contraindicated in the treatment of 
 asphyxia in the premature. 
 
 For the paraplegias and diplegias, corrective measures should be 
 undertaken early in order to prevent marked deformities. Massage 
 and active and passive movements should be practised regularly 
 beginning to advantage in the first year.
 
 HYDROCEPHALUS; MEGACEPHALUS 303 
 
 Muscle training in walking, climbing and other activities should 
 be instituted under the supervision of a trained assistant. 
 
 Orthopedic appliances are frequently indicated. 
 
 Surgical procedures may be necessary later. 
 
 Another group is made up of premature infants with more or 
 less serious mental defects in whom typical epilepsy gradually 
 develops, often of the Jacksonian type. It is very difficult and 
 often impossible to make a differential diagnosis between epilepsy 
 and spasmophilia in the first attacks, and especially in those cases 
 where the convulsions appear very early. Fortunately, ;i- ;i 
 general rule, the epileptic convulsions do not occur in the Grsl 
 year of life in prematures, while on the other hand electric hyper- 
 irritability and spasmophilic convulsions are quite frequent in this 
 period of life. This makes the differential diagnosis somewhat 
 easier. 
 
 On the other hand, however, in connection with febrile diseases 
 of later life, convulsions occur very frequently in premature infants. 
 Only the further course of the disease will show whether the con- 
 vulsions are of epileptic or spasmophilic nature. 
 
 HYDROCEPHALUS ; MEGACEPHALUS. 
 
 True congenital hydrocephalus is usually of the internal type 
 with enlarged ventricles. The external form is very rare. Mega- 
 cephalus must be differentiated from hydrocephalus, the two often 
 being confused in the premature, as previously mentioned in the 
 discussion of Pathology and Rachitis (pp. 104, 336). Internal 
 hydrocephalus results from a transudation or exudation. Obstruc- 
 tion to the outflow may be the cause as in the case of intracranial 
 hemorrhage or cerebellar cysts. However, most of the case- arc 
 probably due to an intra-uterine serous meningitis or meningo- 
 encephalitis of unknown origin. Syphilis is frequently the cause of 
 congenital hydrocephalus, 
 
 The inflammatory process bringing about hydrocephalus may be 
 at end by the time of completion of pregnancy, but usually persists 
 thereafter. Most of the infants show enlargement of the head 
 soon after birth or the enlargement becomes apparent at a later 
 period. When the process begins early, intra-uterine, it may bring 
 about a marked retardation in brain development. The head need 
 not necessarily be enlarged; indeed the head may he small a- in a 
 microcephalic. The brain in these cases is really a large cyst. ( )l'ten 
 the skull is enlarged at birth, and it may hinder labor to such an 
 extent that perforation or puncture of the head become> acces- 
 sary.
 
 304 
 
 DISEASES OF THE NERVOUS SYSTEM 
 
 Where the head has the classic hydrocephalic configuration the 
 diagnosis is, of course, easy. In many instances there are also 
 
 Fig. 162 
 
 Fig. 163 
 Figs. 162 and 163.— Megacephalus. Baby P. H. at four months. Baby P. H. 
 
 at six months. 
 
 the following symptoms at birth: Hypertonus and spasms of the 
 muscles, increased reflexes, convulsions, psychic disturbances and 
 apathy.
 
 HYDROCEPHALUS; MEGACEPHALUS 
 
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 306 
 
 DISEASES OF THE NERVOUS SYSTEM 
 
 Measurements. 
 
 Age, 23 days. 
 
 Dates April 23 
 
 Weight 725 gm. 
 
 Length 31.0 cm. 
 
 Occipitofrontal . . 
 
 Diameters: 
 
 Biparietal .... 7.5 " 
 Bitemporal . . . 6.5 " 
 Occipito-mental . . 7.0 " 
 Suboccipito bregmatic 6.5 " 
 
 Circumference: 
 
 Occipto-frontal . . 
 Occipito-mental . . 
 Shoulders .... 
 Hips 
 
 May 13 
 922 gm. 
 36.5 cm. 
 
 8.75 " 
 
 8.0 
 
 7.5 
 
 10.0 
 
 6.0 
 
 27.0 
 28.0 
 20.0 
 16.5 
 
 June 20 
 
 1200 gm. 
 
 38.0 cm. 
 
 9.5 " 
 
 8.75 
 7.0 
 11.5 
 8.0 
 
 30.75 
 33.0 
 25.75 
 20.0 
 
 August 28 
 1720 gm. 
 43.5 cm. 
 11.0 " 
 
 10.5 " 
 
 9.75 " 
 
 12.5 " 
 
 9.25 " 
 
 35.0 " 
 
 37.0 " 
 
 28.0 " 
 
 22.0 " 
 
 ^Yhere the characteristic head is not seen and only slight enlarge- 
 ment of the fontanelle areas is noted, the diagnosis is difficult. 
 Intracranial hemorrhage and meningitis must be ruled out. Lum- 
 bar or ventricular puncture is of great assistance. 
 
 Fig. 165. — Hydrocephalus. First signs when infant was four weeks old. 
 
 The prognosis is usually difficult to make early. The only 
 early therapeutic measure is lumbar or ventricular puncture with 
 drawing off of cerebrospinal fluid. Late surgical interference may 
 be indicated.
 
 H YDROCEPHALUS; MEGA CEP II A L US 
 
 307 
 
 Fig. 166. — Oxycephalus (Tower skull). Usually associated with other congenital 
 defects and stigmata of degeneration. The skull is dome shape with bulging tem- 
 poral regions. The deformity was present at birth. It is generally associated with 
 exophthalmos, proptosis and frequently with other ocular abnormalities. Some 
 children arc mentally normal. Others subnormal. 
 
 The term megacephalys is applied to the conditions in which the 
 head develops out of proportion to the other body measurements 
 and length. It is characterized by an abnormally large head, with 
 a relatively larger brain. This condition is a characteristic finding in 
 a high percentage of infants prematurely born and is seen in inverse 
 proportion to the fetal age and birth weight. Rosenstern, 1 in a 
 series of sixty-one prematures observed over a period of at least 
 three months, noted megacephalus in forty-four. lie concluded 
 that the lower the birth weight of the premature the more likely is 
 megacephalus to develop, 
 
 RELATION OF BODY WEIGHT TO MEGACEPHALUS (ROSENSTERN 
 
 Birth weight. 
 
 
 Present . 
 
 Absent 
 
 
 Severe. 
 
 Moderate 
 
 Mild, 
 
 Total. 
 
 In 1000 gm. . . 
 
 1 
 
 
 
 1 
 
 it 
 
 1 
 
 n 
 
 1001 " 1500 " . . 
 
 12 
 
 5 
 
 (i 
 
 1 
 
 12 
 
 
 
 L501 " '-'()()() " . . 
 
 21 
 
 3 
 
 14 
 
 1 
 
 1^ 
 
 ;; 
 
 2001 " 2500 " . . 
 
 27 
 
 1 
 
 9 
 
 3 
 
 13 
 
 14 
 
 Total 
 
 61 
 
 
 
 
 44 
 
 17 
 
 1 Rosenstern, J.: Ztschr. f. Kinderh., 1922, 22, 129.
 
 308 
 
 DISEASES OF THE NERVOUS SYSTEM 
 
 It usually occurs before the age at which rachitic changes are 
 noted in the long bones and chest. However, as rickets occurs 
 much earlier in premature infants than in full-term infants, I do not 
 believe that we are at present in a position to dissociate these two 
 conditions. There is therefore great probability that the same 
 etiological factors underlying the development of megacephalus 
 in the first months may be the cause of rachitic manifestations in 
 the bones and other organs at later periods. 
 
 TIME OF OCCURRENCE OF MEGACEPHALUS (ROSENSTERN) . 
 
 Age in 
 months. 
 
 Cases. 
 
 Age in 
 months. 
 
 Case 
 
 1 . . . 
 
 . . . 9 
 
 6 . . . . 
 
 . . . 
 
 2 
 
 . . . 11 
 
 7 . . . . 
 
 . . . 1 
 
 3 . . . 
 
 . . . 11 
 
 8 . . . . 
 
 . . . 1 
 
 4 . . . 
 
 . . . 
 
 9-11 . . . 
 
 . . . 
 
 5 . . . 
 
 . . . 4 
 
 12 ... . 
 
 . . . 1 
 
 It is most frequently first seen during the second and third months 
 of life and reaches its maximum between the sixth and eighth 
 months. It then gradually becomes less manifest. There is usually 
 an increased spinal fluid pressure in which it resembles hydro- 
 cephalus. The brain, on section, is found to be abnormally large 
 but in true cases there is a complete absence of hydrocephalus. 
 
 Associated with the large skull and wide-open fontanelles and 
 sutures, exophthalmos is frequently seen. The latter probably 
 results from the lack of skull capacity, the eyes being protruded, 
 with prominent cornea and, not infrequently, dilated pupils. Further 
 characteristics of the head are a broad face, and mouth, nose and 
 eyes which appear closely set together : the nose is stumpy and small 
 and rises but little above the face; the tongue is often large and 
 protruded. 
 
 ENCEPHALITIS. 
 
 The subject of encephalitis of the premature and full-term new 
 born is still very much in the dark. The etiology is obscure and 
 a clinical picture for the encephalitic processes has not yet been 
 described. 
 
 Encephalitis interstitialis congenita was described by Virchow, 1 
 with changes in the medullary substance of the cerebrum, as a 
 diffuse infiltration with fatty granular cells. Later, other observers 
 declared that this was not pathological (Jastrowitz, 2 Limbeck 3 ). 
 Brain defects (porencephaly) have been linked with congenital 
 
 1 Virchow's Arch., 1867, 38, 129. 
 
 2 Arch. f. Psych., 1870, vol. 2 and 1871, vol. 3. 
 
 3 Prague Ztschr. f. Heilk., 1885, 7, 87.
 
 MENINGITIS 309 
 
 encephalitis. Septic encephalitis is either a metastatic condition 
 or a meningoencephalitis, the difference between the two being 
 almost impossible to define. The medullary substance shows 
 clumps of bacteria and leukocytes, and later there appears a sup- 
 purative inflammation on the brain substance. Not infrequently 
 in prematures the meningo-encephalitis is a distinctly luetic process 
 (see Syphilis in Prematures, p. 330). 
 
 MENINGITIS. 
 
 The meningitic processes are as little understood as the encepha- 
 litic. They may be acute or chronic. Serous meningitis which is 
 not well understood is supposed to be intimately related to con- 
 genital hydrocephalus. Pachymeningitis hemorrhagica interna 
 seems to be a luetic process entirely (see Syphilis of Prematures, p. 
 330). 
 
 Purulent meningitis follows suppurative conditions in the mid- 
 dle ear, accessory nasal sinuses or is metastatic. Sometimes one 
 sees typical meningeal symptoms as: Convulsions, rigidity of the 
 neck, hypertonus, protruding fontanelles. However, meningitis 
 may be present without any characteristic signs. The infants are 
 flaccid, exhausted, and dried out. The diagnosis is verified by 
 lumbar puncture. Fever is often absent or only present terminally. 
 
 The prognosis is absolutely poor. Death usually follows in 
 twenty-four hours, but some linger eight to fourteen days. The 
 inception of the process is difficult to fix because of the uncertainty 
 of the symptoms. 
 
 Sinus thrombosis following middle-ear infections or phlebitis after 
 navel infections sometimes are responsible for the meningitis. 
 
 Epidemic cerebrospinal meningitis is not an uncommon compli- 
 cation in premature infants during the first year. A spinal puncture 
 should be made in every case showing marked evidence of cerebral 
 irritation. In positive cases serum should first be administered 
 intravenously through the longitudinal sinus, because of the ten- 
 dency to generalization of the infection in this class of infants. 
 Intraspinal administration of serum must always be made by the 
 gravity method after withdrawal of as much fluid as is to be admin- 
 istered. 
 
 Finally we find among the prematures a number of idiots that 
 have to be classified as "degenerative idiots." These are the 
 infants that at birth already show stigmata of Mongolism or other 
 malformations. These children are prematurely born with special 
 frequency, and it follows therefore that a considerable number of 
 children with Mongolian idiocy are prematures. After all, it is a 
 known fact that children with various congenital malformations,
 
 310 DISEASES OF THE NERVOUS SYSTEM 
 
 be they congenital bone diseases, bone anomalies, congenital 
 heart disease, malformations of the brain or spinal cord, etc., are 
 born in an immature condition. This circumstance, as previously 
 mentioned, is the reason that prematures have been very generally 
 but erroneously regarded as congenitally inferior. 
 
 SPASMOPHILIC CONVULSIONS. 
 
 With reference to spasmophilic convulsions we must not regard 
 them as purely functional convulsions; on the contrary the readi- 
 ness with which they occur and their frequency in premature 
 infants speaks very strongly for organic lesions, probably most 
 frequently among these being cerebral hemorrhage occurring 
 during labor. Naturally certain extra-uterine noxse, as anemia 
 and rachitis, are of importance as determining factors that make 
 the spasmophilic disturbances manifest. Numerous roentgeno- 
 logical examinations of the long bones of premature infants have 
 shown that the rachitic changes are not confined to the skull, but 
 that the other bones are also early affected, as early as the second 
 and third months of life. (See p. 347.)
 
 CHAPTER XIV. 
 SEPSIS. 
 
 The term sepsis may be defined as an invasion of the system by 
 pyogenic cocci or other equivalent organisms. These bacteria 
 may attain entrance through various atria and may spread by 
 means of the blood stream or may remain at the point of invasion 
 and from there discharge the products of their activity into the 
 blood of the infant. 
 
 Bacteriology.— The bacteria occupying the first place among those 
 causing sepsis are the pyogenic cocci, the streptococcus and staphylo- 
 coccus, both albus and aureus. With them may be included the 
 pneumococcus and colon bacillus. The colon group includes the 
 paracolon and paratyphoid varieties. Of other bacteria there 
 are found more rarely the Bacillus pyocyaneus, Bacterium laetis 
 aerogenes, Bacillus enteritidis (Gartner), proteus bacillus, the 
 gonococcus, the influenza bacillus and the meningococcus. Infec- 
 tion with Treponema pallidum is treated as a specific disease. 
 
 Blood examination during life and immediately after death in 
 cases of sepsis in the premature gave the following results: 1 
 
 Blood culture positive 15 
 
 Blood culture negative 4 
 
 Percentage positive 75.3 per cent 
 
 Streptococcus 6 times 
 
 Colon bacillus 5 
 
 Staphylococcus 1 
 
 Pneumococcus 1 
 
 Influenza bacillus 1 
 
 Colon bacillus and influenza bacillus 1 
 
 Ylppo, 2 in a small series of prematures, found: 
 
 BACTERIA IN BLOOD OF PREMATURES 
 
 Age, No. of Bacteria 
 
 days. found. 
 
 to 1 8 
 
 2 to 3 7 2 
 
 4 to 15 14 10 
 
 1 Delestre: Infections chez le pr&nature, Paris, 1901. 
 
 - Pathologiach-anatomischi Studien bei Fruhgeburten, Ztschr. f. Kinderh., 1919, 
 
 20, 371-372.
 
 312 SEPSIS 
 
 In 70 per cent of the infants perishing between the fourth and 
 fifteenth day of life, Ylppo was able to demonstrate bacteria in 
 the blood. In 12 cases the following organisms were noted: 
 
 Bacillus coli 6 times 
 
 Staphylococcus 3 " 
 
 Streptococcus 1 " 
 
 Not identified 2 " 
 
 The frequency of Bacillus coli, he believes, speaks for an internal 
 basis for the infection. 
 
 The Time of Infection.— This may be either intra-uterine, intra- 
 partum or postpartum (extra-uterine). Intra-uterine infection may 
 occur either through the placenta, or by way of the liquor amnii. 
 Should the mother be suffering from a septic infection, the causative 
 organisms may pass through the injured placental wall, which 
 ordinarily is sufficient to exclude bacteria from the fetus. 
 
 Infection of the liquor amnii may occur before or after the 
 rupture of the membranes. Before rupture the infection may 
 occur by contiguity of tissue, the organisms coming from the 
 peritoneal cavity, rectum or bladder. Infection through the 
 vaginal canal with unruptured membranes probably does not 
 occur, the cervical opening being obstructed by what Delestre 1 
 calls the "gelatinous stopper of pregnancy." Vaginal infection, 
 therefore, usually stops beneath the internal os. But once the 
 membranes rupture, infection can occur by the ascension of bacteria 
 from the vagina. This, however, is uncommon. 
 
 Our knowledge of infection through the liquor amnii is more 
 definite. Lehmann 2 states that bacteria can pass through uninjured 
 membrane and reports cases in support of this statement. 
 
 Intrapartum infectio?is occur during the passage of the infant 
 through the maternal birth canal. Local infection occurs first 
 and this may be followed by general sepsis. The atrium of infec- 
 tion may be the mouth, the digestive tract, the lungs after aspira- 
 tion of infected vaginal mucus or amniotic fluid, or wounds of the 
 skin. The eyes especially are subject to infection at the time of 
 birth, but fortunately infection there remains local. 
 
 Post partum, the most important sources of entrance of infection 
 are the umbilicus, the skin, the gastro-intestinal tract and the respi- 
 ratory apparatus. As compared with intra-uterine and intra- 
 partum infections those of extra-uterine origin are much the most 
 important. 
 
 Umbilical infections through the physiological wound made at 
 the time the cord is severed are the most frequent of all infections 
 
 1 These, A Study of the Infections of the New Born, Paris, 1901. 
 
 2 These, De l'infection amniotique et de ses consequences pour 18 enfants, Paris, 
 1899.
 
 THE TIME OF INFECTION 313 
 
 after birth and this forms the most common portal of entry for 
 sepsis. At birth the most important structures found in the 
 umbilical cord are the two umbilical arteries which conduct the 
 blood from the fetus to the placenta, and which arise from the 
 common iliac arteries, and the umbilical vein which carries blood 
 from the placenta to the inferior vena cava via the left branch of 
 the portal vein and the ductus venosus arantii. Immediately 
 after birth the cord is ligated and cut, there remaining a stump a 
 few centimeters in length which undergoes desiccation during the 
 first few days of life and which separates on the fourth to the ninth 
 day with a slight inflammatory reaction. In the premature and 
 debilitated the falling off of the cord and subsequent cicatrization 
 of the base often occurs later. Ordinarily the base is covered 
 by epithelium by the end of the third week or a little before, but 
 infection of the umbilical wound may occur at any time up to the 
 moment of healing, and is especially common in prematures. 
 
 Of second importance as a gateway for the entrance of patho- 
 genic bacteria is the shin. .The frequent abrasions which occur 
 during birth, erosions from too severe efforts at mechanical cleans- 
 ing, the pemphigus lesions and the intertrigo so common in the 
 neglected weaklings, all form portals of entry for bacteria. In 
 the premature especially the skin is delicate, lacking the horny 
 layer which in the better developed tends to prevent the occur- 
 rence of abrasions. Furunculosis and abscess formation are often 
 the precursors of a general infection. 
 
 The respiratory tract is a frequent means of entry through the 
 occurrence of a simple or suppurative rhinitis, otitis media, bron- 
 chial infection with epithelial necrosis or bronchopneumonic inflam- 
 mation. It must be remembered that pulmonary inflammations are 
 prone to develop secondarily in sepsis and unless evidence of pul- 
 monary affection can be shown early in the course of sepsis, it 
 may be difficult to say whether it was primary or secondary. 
 
 Of nearly equal importance is the gastrointestinal tract as an 
 atrium of infection. The buccal mucosa may be the seat of mucous 
 patches, of Bednar's aphthae on the palate, of thrush, of stomatitis, 
 or gingivitis, of ulcerations from too vigorous cleansing, or of 
 abrasions due to the passage of the tracheal catheter. The intestinal 
 wall of the premature and even the full- term newly born weaklings 
 may be permeable to bacteria which cannot pass through the 
 intestinal wall of better developed infants. 
 
 We believe that though the gastro-intestinal tract is frequently 
 the seat of ulceration in the stage of atrophy in infants, a condition 
 more rapidly developing in the prematures than in full-term infants, 
 and therefore offering numerous portals of entry for systemic infec-
 
 314 SEPSIS 
 
 tion, every attempt should be made to exclude all other atria 
 before accepting the gastro-intestinal tract as the source of infection. 
 
 Genito-urinary infections are of importance as the source of 
 sepsis in the premature newborn. 
 
 Susceptibility. —The premature is especially receptive to infection 
 with the organisms of sepsis, seemingly possessing an extremely 
 low resistance. The organs in which the leucocytes are formed are but 
 imperfectly developed and the leucocytes themselves are deficient 
 in phagocytic power; other organs are incomplete, the individual 
 cells are immature and the lymph glands are of little importance 
 in these infants, and fail to enlarge in the presence of infection. 
 
 The frequent subnormal temperature of these weaklings 
 encourages this ease of infection, experimental evidence showing 
 that to lower the temperature of an organ is to lower its resistance, 
 and diminish phagocytic activity and the bactericidal energy of 
 the blood. Without doubt there is also a deficient formation of 
 antibodies in these premature infants (Pfaundler. 1 ) 
 
 Artificially-fed prematures possess a relatively greater suscepti- 
 bility to septic infection than do breast-fed infants, a fact which 
 may in part be explained by the fact that human milk is rich in 
 protective substances in contradistinction to cow's milk. 
 
 In sepsis the difference between the infants born of healthy 
 parents and those of diseased parents is marked. The healthy 
 premature is formed of young cells, full of vitality and only requir- 
 ing growth to perfect themselves, and capable to some degree of 
 resisting the organisms of infection with which they are continually 
 surrounded. The others are already affected by the toxemia of 
 the parental disease, or are themselves directly involved, and 
 thus their cells have their vitality reduced and so offer a medium 
 already prepared for infection. 
 
 The frequency of sepsis among the new born is today very much 
 less than it was in preaseptic days. Proper care of the hands 
 and the conduct of labor, sterilization of instruments and dressings, 
 has greatly reduced the incidence of this condition. The fact that 
 infants tend more often to become septic in a hospital or asylum 
 than in the home is to be accounted for by the greater frequency 
 of infecting organisms in the former, where many sick are con- 
 gregated, and by the fact that one attendant often cares for several 
 infants in the same hospital or ward (Meyer 2 ). 
 
 General Manifestations.— The onset of sepsis may occur at any 
 time during the first days of life or the infant may be born with an 
 infection present. The course varies, some almost without any 
 
 1 Die Antikorperiibertragung von Mutter auf Kind, Arch. f. Kinderh., 1908, 47, 
 260; 1908, 48, 245. 
 
 2 Hospitalismus, Berlin, 1913; Ges. f. Gynak., 1911.
 
 GENERAL MANIFESTATIONS 315 
 
 symptoms which can be interpreted as involving any one set of 
 organs, death occurring suddenly after collapse. 
 
 Local symptoms, if present, are dependent upon the situation 
 of the primary infection or of secondary metastatic foci, while 
 the general symptoms are those of a septicemia. 
 
 The septic fever in the premature infant does not possess those 
 characteristics found in older children. The center for heat regu- 
 lation lacks stability and the reaction to toxic influences is slight. 
 The more robust infants may show a rise of temperature which 
 may reach 105° F. or even higher, and which may run a more or less 
 regular course. In those born considerably before term, and in 
 the weaklings there may be little or no temperature reaction, in 
 fact in these latter a subnormal temperature is the rule, (hills 
 do not occur in these weaklings. 
 
 Loss of weight is likely to be rapid and great, depending upon 
 the ability to take food and the degree of intestinal involvement, 
 being due to disintegration of tissue, to loss of water, and to ina- 
 bility to take food and fluids. The pulse-rate is rapid and the 
 quality is usually poor. Respirations are often irregular. Cere- 
 bral symptoms are common during the final stages, the infant has 
 a prostrated appearance and is apathetic. The cry becomes more 
 feeble and the movements less frequent than usual. The skin 
 loses its turgor; anemia becomes evident and the skin color becomes 
 grayish or, if icterus exists, yellowish. Occasionally there is a 
 cyanotic tinge to the entire body surface. Hemorrhages are very 
 common during the course of sepsis, occurring from the mouth, 
 bowel, navel or into the skin. 
 
 Shin.— Icterus is a very frequent finding in the first few days 
 or weeks of life and is especially frequent in premature infants and 
 in the victims of sepsis. Particularly with umbilical infections is 
 the icterus of marked degree. Edema of the feet and legs occa- 
 sionally occurs and expecially in premature infants scleredema, or 
 even sclerema, may occur toward the end of the disease. Hemor- 
 rhages into the skin are common in sepsis, being seen over the 
 trunk and extremities, usually as petechia 3 . In some instances 
 they may be purpuric, or effusive in character. Pemphigus-like 
 blebs with bloody contents are a frequent complication. 
 
 Inflammation of the umbilical vessels is a frequent primary pro- 
 cess in a general sepsis. Most often the umbilical arteries are 
 involved, and less frequently the vein. The amount of involvement 
 varies, occasionally extending just a short distance within the 
 abdominal wall, sometimes the entire length of the vessel, in which 
 latter instance the thickened vessel cannot infrequently be palpated 
 through the abdominal wall. Septic thrombi or pus may be 
 present in the umbilical vessels, and pus can often be squeezed out
 
 316 SEPSIS 
 
 from the stump of the cord. Inflammation of the umbilicus or of 
 the abdominal wall in its immediate neighborhood may be present. 
 
 Omphalitis alone is sometimes seen. The usual termination of 
 this infection is in abscess formation, but occasionally an inflamma- 
 tion of an erysipelatous character spreads to the abdominal wall 
 (Holt 1 ). 
 
 Nervous symptoms are many. They may depend solely upon 
 the toxemia, or be due to an intercurrent meningitis, encephalitis 
 or edema of the meninges. Most often the infant lies quietly in 
 a stuporous condition, at other times there are restlessness, tremors, 
 spasms, jactitation, dilated pupils, bulging fontanel, spasticity of 
 the muscles with rigidity of the neck, and in cases of meningitis 
 and encephalitis, paralyses. 
 
 G astro-intestinal manifestations are practically always present. 
 In the mouth are seen ulcers, fissures, stomatitis and purulent 
 inflammations of the salivary glands. Not infrequently sepsis 
 will run its course with clinical pictures of dyspepsia with secondary 
 anhydremic intoxication, with vomiting and diarrhea as marked 
 symptoms. The vomiting and diarrhea are manifestations of the 
 toxemia, emesis being frequently cerebral in origin. The mesenteric 
 glands are infiltrated and the gastric and intestinal mucosa are the 
 seat of hemorrhages and frequently show evidence of inflammation. 
 
 Peritonitis is a rather frequent complication, either general or 
 local. Oftentimes it is accompanied by an umbilical inflammation. 
 Many cases are purulent, fluid being present. Adhesions of intesti- 
 nal coils to each other or to the abdominal wall occur. The symp- 
 toms of this condition are abdominal distention and rigidity with 
 tenderness, vomiting, umbilical protrusion, thoracic respiration and 
 flexion of the thighs. Diagnosis of the condition is not at all easy 
 as the presence of fluid is difficult to demonstrate. Probably the 
 finding of greatest value in these infants is abdominal tenderness. 
 
 The spleen is usually enlarged. The liver shows evidence of an 
 acute hepatitis, and not infrequently there are multiple foci of 
 suppuration. 
 
 Involvement of the circulatory apparatus in sepsis does occur 
 but is not very frequent. Pericarditis is commoner than endo- 
 carditis. The former usually arises by extension from the pleura. 
 
 The myocardium is frequently the seat of parenchymatous 
 degeneration and hemorrhage. 
 
 The respiratory organs are involved very frequently in the picture 
 of sepsis. Pneumonia is the most frequent lesion met with, and 
 as usual in the weakling or premature, is difficult of diagnosis, 
 especially when the process in the lung is not extensive, with lesions 
 
 1 Diseases of Infancy and Childhood, D. Appleton and Company, New York, 191.3.
 
 GENERAL MANIFESTATIONS 317 
 
 small and multiple. The lungs show areas of bronchopneumonia, 
 areas of atelectasis, alveolar fatty degeneration, hemorrhages into 
 the alveolar walls of multiple abscesses. Effusion into the pleura 
 is uncommon. 
 
 Rapid respiration and cyanosis are about the only symptoms 
 which are seen in these cases of pneumonia. Occasionally the 
 rapidity of breathing may occasion the belief that the lungs are the 
 seat of a pneumonic process, when its presence is only the result 
 of severe intoxication. 
 
 The kidneys usually show parenchymatous degeneration and 
 hemorrhagic nephritis, with occasional necrosis of the epithelium 
 and pyelitis. The albumin which is found in the urine is either 
 the result of the action of the absorbed toxins on the kidneys or 
 is the expression of the nephritis or pyelitis. In nephritis there 
 will be found hyalin, epithelial or granular casts, and in pyelitis, 
 pus cells and epithelium. 
 
 Bones and Joint Inflammations. — Rarely the bones are involved 
 in an osteomyelitis and the joints are sometimes the seat of acute 
 suppuration, usually several being involved at the same time. 
 Immobility and swelling over the involved joints are the common 
 symptoms seen. Pain is present and crepitus can be elicited when 
 epiphysial separation has occurred. 
 
 Unfortunately the blood is of little value in completing the 
 diagnosis, because of the usual absence of leucocytosis. A positive 
 diagnosis is possible by finding the causative organism in the blood. 
 The difficulties to be met in making blood cultures in premature 
 infants must be remembered. The longitudinal sinus is the best 
 source for obtaining blood. 
 
 Course.— In the premature the course is usually acute. Often 
 the first symptom is loss of appetite; the child refuses to take 
 the breast, or if artificially fed, it vomits. Convulsions may 
 usher in the condition, followed by icterus which increases in 
 intensity and soon is accompanied by diarrhea. Cyanosis may 
 next make its appearance, the accompanying dyspnea being hard 
 to detect because of the slight amplitude of the respiratory move- 
 ments. It is sometimes revealed by movements of the alse nasi 
 or by an increased frequency of respiration, or by change in the 
 respiratory rhythm, consisting of short inspirations followed by 
 relatively long expirations. Occasionally the respiration is slow, 
 feeble and superficial, because of the impermeability of the lungs 
 involved by atelectasis. 
 
 Some cases of sepsis prove fatal in a few hours; the younger 
 the infant and the weaker the condition at birth, the shorter the 
 course as a rule. Symptomless sepsis is frequent in the premature.
 
 318 SEPSIS 
 
 Prognosis.— Septic infection in the very young is a fatal disease 
 and the more immature the infant, the worse the outlook. In the 
 lesser degrees it offers a grave prognosis and in the severer forms it 
 is practically always fatal. Involvement of a large number of 
 organs makes the lethal outcome almost certain. 
 
 Prophylaxis.— Since the treatment of sepsis in the premature 
 new born offers so little, it becomes of prime importance to prevent 
 the development of the disease, and sepsis may be considered as 
 preventable. The vulnerability of the new born and particularly 
 of the premature new born, who is deficient in vital functions, to 
 the invading organisms of disease is notable, and the fact that 
 sepsis occurs particularly in institutions makes the care of these 
 infants of great importance. 
 
 Infection which reaches the child before birth is beyond our 
 control, but subsequent to that time very much may be done to 
 prevent the disease. The care of the umbilical wound is of great 
 importance; instruments used in dividing the cord, the cord tape 
 and dressings must all be aseptic. In hospitals the infant should 
 be kept in a separate room from the mother, and the same attendant 
 should not look after both mother and infant. The hands of the 
 attendant and of the mother when she handles the child must be 
 cleansed thoroughly before the child is touched. The nurse should 
 wash her hands after the care of an infant before passing to another 
 in the nursery. All articles which come into contact with the 
 infant's mouth— nipples, feeders, spoons, gavage tubes, etc., must 
 be sterilized before use. All utensils should, so far as possible, be 
 individual. The mouth of the infant must not be traumatized and 
 all rough handling or other body trauma must be avoided. The 
 breasts of the nursing mother must be washed thoroughly before 
 each nursing and protected between the nursing periods by covering 
 them with thin, clean gauze. 
 
 Strict asepsis during delivery will do a great deal toward reducing 
 birth infection to the smallest amount, while care in internal 
 examinations before delivery will do much toward lessening the 
 infections of the amniotic fluid. Lochial secretions can become 
 the source of infections and their care is important. They should 
 be disposed of at once. 
 
 In private families where there is not sufficient help and one 
 person must attend to mother and child, the infant must be taken 
 care of first, and the mother later. 
 
 To facilitate cleanliness the new-born infant should be given a 
 a daily warm sponge, unless very weak, and the diaper should be 
 changed frequently to prevent the development of intertrigo. 
 The use of a dusting powder in the skin folds often acts as an 
 irritant.
 
 ACTIVE TREATMENT 319 
 
 The room in which the infant spends its time should be kept 
 at a temperature warm enough to meet the needs of its individual 
 development if it is hypothermic. The air of its room should 
 always be kept pure and fresh and light freely admitted. The 
 clothing of the infant should be warm enough, but not too heavy, 
 being suited to the surrounding temperature and to the individual 
 needs of the child. It should not fit so tightly as to prevent move- 
 ment of the arms and legs. 
 
 Only the greatest cleanliness of the skin and umbilicus will 
 prevent infection. The falling-off of the cord and the subsequent 
 cicatrization is, as a rule, delayed in prematures, and infection is 
 favored. Wet compresses not infrequently macerate the delicate 
 skin and so dry or alcoholic dressings are advised, best without 
 dusting powder which is likely to cake and prevent absorption of 
 the exudate. 
 
 The existence of an angina, rhinitis, bronchitis or any other 
 form of infection, in the mother or nurse, make the separation of 
 the infant from the mother or a change of nurses imperative. Masks 
 must be worn by all infected individuals coming in contact with the 
 infant. 
 
 Active Treatment.— This promises very little, as we possess no 
 specific and our efforts must be directed chiefly toward the treat- 
 ment of individual symptoms, as they arise. If abscesses occur 
 they must be opened and drained. The strength must be supported 
 by judicious breast-milk feeding if this be possible, and by the use 
 of stimulants in 1 to 5-drop doses of brandy or whisky every two 
 hours. In collapse stimulation must be resorted to, the most 
 useful being camphor-in-oil, 1 to 3 minims hypodermic-ally. Spiri- 
 tus ammonia 3 aromaticus, 1 to 3 minims by mouth, well diluted, 
 every three or four hours is often of benefit. Infusion of digitalis 
 or digalen in minimum doses may be used to support a failing 
 heart. 
 
 Fluids should be pushed by mouth in the endeavor to dilute the 
 circulating poison. Gavage feeding should be instituted without 
 too prolonged delay. The use of saline transfusion has found 
 great favor in recent years. Seven-tenths of 1 per cent sodium chlo- 
 ride solution may be injected subcutaneously beneath the breasts or 
 into the loose areolar tissue of the interscapular region in quanti- 
 ties of \ to 2 ounces (15 to 60 cc) and repeated if indicated. The 
 danger of infection must be remembered. Great elevations of 
 temperature, if present, are to be controlled by tepid baths but 
 care must be taken to avoid collapse. Often, these premature 
 infants do not react to infection with temperature, and in such 
 cases warm baths are indicated. Mustard baths or mustard 
 compresses are of value in collapse.
 
 CHAPTER XV. 
 SYPHILIS. 
 
 Among the most important factors producing premature birth 
 syphilis ranks high. It is even more frequently the cause of intra- 
 uterine fetal death. The greater the severity of the infection, 
 the greater is the likelihood of still birth; they represent an over- 
 whelming of the fetus by the spirochetes. Infants who show 
 signs of syphilis at birth have a very high mortality percentage and 
 in the case of those prematurely born, almost all die. The prog- 
 nosis is much better in those developing clinical evidence one or 
 more weeks after birth. 
 
 Jeans 1 found that (in his out-patient department) : 
 
 "From 10 to 20 per cent of adult males and about 10 per cent 
 of married women are syphilitic and a minimum of 10 per cent 
 of marriages involve a syphilitic individual. 
 
 "Seventy-five per cent of all the offspring in a syphilitic family 
 are infected. 
 
 "In a syphilitic family 30 per cent of the pregnancies terminate 
 in death at or before term, a waste three times greater than is 
 found in non-syphilitic families. 
 
 "Thirty per cent of all the living births in a syphilitic family die 
 in infancy, as compared to a normal rate of 15 per cent in the 
 patients coining under his observation. 
 
 "About 5 per cent of our infant population is syphilitic. 
 
 "According to St. Louis vital statistics, 3.5 per cent of all infant 
 deaths are ascribed to lues." 
 
 Premature infants do not necessarily show symptoms of lues at 
 birth. In fact, in the majority of cases syphilis becomes manifest 
 only after a latent period and this may vary from one week to one 
 or more months. The later the development of the manifestations 
 the more likely is the infant to be viable. Cutaneous manifesta- 
 tions are usually preceded by coryza, splenic enlargement and 
 retarded progress. While some of the infants, and this applies 
 more especially to the later pregnancies of syphilitic mothers, may 
 be well nourished at birth, more often the earlier pregnancies 
 present a characteristic picture, even in the absence of specific 
 cutaneous manifestations. The skin is flabby and wrinkled and 
 
 1 Am. Jour. Syph., St. Louis, 1919, No. 1, vol. 3.
 
 SKIN ERUPTIONS 321 
 
 the facial expression senile— approximating the picture of extreme 
 marasmus or athrepsia in older infants. This class usually perish 
 shortly after birth and the postmortem examination reveals marked 
 luetic, visceral changes. 
 
 Infants born with luetic eruptions usually evidence a more or 
 less marked degree of visceral change and they run a much more 
 serious course and give a worse prognosis. However, even in the 
 premature the appearance of the cutaneous lesions need not neces- 
 sarily be associated with marasmus. This is more especially true 
 in cases unassociated with deep-seated visceral changes, hence 
 the clinical picture of lues is enormously variable and all transi- 
 tions occur from the serious generalized syphilis up to the case 
 involving a single organ or set of organs. When lesions are present 
 at birth, one or more of the following are usually in evidence: 
 Coryza (snuffles), bulla? on the hands and feet and splenic tumor. 
 
 Mucous Membranes.— Coryza is most often the first symptom. 
 In its onset it resembles an ordinary cold but is soon characterized 
 by its severity and chronicity. The discharge is profuse, becomes 
 mucopurulent and often tinged with blood. Nasal obstruction 
 results from the formation of crusts. Mouth breathing follows 
 and nursing becomes difficult. Pharyngitis and laryngitis are 
 usually associated with a resulting characteristic hoarseness and 
 aphonia. 
 
 Mucous patches and ulcerations "develop on the mucous mem- 
 branes and at the mucocutaneous surfaces, especially at the mouth, 
 anus, vulva and scrotum. 
 
 Skin Eruptions.— When not present at birth the skin eruptions 
 usually follow the development of the coryza but they need not 
 necessarily be preceded by it. 
 
 The most common lesions, and which are very rarely seen at 
 birth, are of two types, a diffuse more or less generalized skin 
 infiltration. The skin becomes thickened and infiltrated and 
 loses its elasticity and often after a short period the superficial 
 layers crack. The skin in greater part has a waxy' appearance 
 with interspersed inflamed areas, more especially at the points 
 of Assuring. This characteristic skin change may involve the 
 entire body or appear in isolated areas, of which latter the face 
 and extremities, more especially the hands and feet, are more 
 likely to be the seat of changes. About the face, the region of 
 the mouth, nose and eyelids are the sites of predilection, with fre- 
 quently resulting rhagades in these regions. A massive involve- 
 ment of the face results in a mask-like appearance. Following 
 Assuring, there frequently results an exudate with later crust 
 formation. When the scalp is involved alopecia usually results 
 and the same may be true when the eyelids are deeply infiltrated. 
 21
 
 322 
 
 SYPHILIS 
 
 The soles of the feet and palms of the hands usually present a 
 diffuse infiltration and appear firm and shiny, sometimes more 
 reddish or bluish red, at other times a copper-red or brown. 
 
 A true paronychia, which is often accompanied by complete 
 destruction of the nails, is an almost constant complication in this 
 type of skin lesions. 
 
 The surface is either smooth or shows fissures in the uppermost 
 horny layers of the epidermis, which occasionally sloughs in large, 
 lamellous scales. 
 
 In the second type of rash lesions which are more circumscript 
 are noted. These lesions assume more nearly the characteristics 
 
 y" 
 
 V. 
 
 
 >\*» J 
 
 i 
 
 V, 
 
 
 '^jRtot , 
 
 Fig. 167 Fig. 168 
 
 Figs. 167 and 168. — Congenital syphilis. Secondary lesions on face, body and 
 hands and feet. Lesions first appeared during fourth week. 
 
 of the skin manifestations in acquired syphilis. The most fre- 
 quent type of lesions are macules usually circular and slightly 
 elevated, averaging 2 to 5 mm. in size. The face and the extensor 
 surfaces of the upper and lower extremities and more especially 
 the hands and feet are usually involved and they may cover the 
 entire body, but more often the chest and abdomen escape. At 
 first red, they soon become darker and assume a coppery hue. 
 More elevated papules similar in character and without an inflam- 
 matory base may be interspersed among the macules. A squamous 
 eruption is frequently seen upon the palms and soles and small 
 masses of scales may appear upon the surface of the macules. 
 The eruption may develop abruptly but more frequently it increases
 
 LYMPH GLANDS 
 
 323 
 
 progressively during a period of from one to three weeks and under 
 vigorous treatment disappears rapidly except for the remaining 
 pigmentation. 
 
 In the most severe types the bullous or pemphigoid lesions may be 
 superimposed upon the macular squamous syphilides or they may 
 be primary. They may lead to deeper ulcerations of the skin with 
 secondary infection and are always a source of danger to others 
 because of the likelihood of the presence of spirochetes in the 
 lesions. The possibility of the confusion of these lesions with 
 non-specific pemphigoid lesions which are of not infrequent occur- 
 rence in obstetrical wards should be remembered as the latter are 
 especially prone to affect the premature. This latter type of 
 pemphigus neonatorum is probably a staphylococcus infection. 
 Linear fissures and mucous patches are among the most charac- 
 
 i 
 
 BlL'l^'»:"lfc M 
 
 
 
 •Wf^^F^ ' mm 
 
 
 
 
 .' J 
 
 
 *** 
 
 
 _ 
 
 - 
 
 jpoi 
 
 #4^ 
 
 W***^ 
 
 
 "*"■*-" 
 
 Hp: 
 
 Fig. 169. — Congenital syphilis. Baby A. Fissures about mouth. Large liver and 
 spleen. Six weeks later. 
 
 teristic features. On account of the fragility of the skin these 
 rhagades easily occur, especially on the lips, nose, about the anus 
 and less frequently about the eyelids. The healing of these lesions 
 usually results in radiating cicatrices which result in the very 
 characteristic "purse-string" deformity. 
 
 Umbilical Cord.— The umbilical cord often heals slowly and the 
 stump has a tendency to become purulent and there is a tendency 
 toward infiltration about the umbilicus. A more or less deep- 
 seated ulcer may result which heals slowly unless constitutional 
 treatment is instituted or mercurials are applied locally. Hemor- 
 rhage from the stump and secondary infection, with resulting 
 syphilis hemorrhagica neonatorum are likely to result. 
 
 Lymph Glands.— Only exceptionally do they present a character- 
 istic generalized enlargement in the new-born syphilitic premature.
 
 324 
 
 SYPHILIS 
 
 In untreated cases the lymph glands become palpable and this may 
 be due to luetic infection or, again, isolated groups of glands may 
 become involved through secondary infection and go on to suppu- 
 ration. The small size of the glands makes them difficult of pal- 
 pation, more especially in well-nourished infants. 
 
 Fig. 170. — Osteochondritis syphilitica. 
 
 Osseous System.— Osteochondritis syphilitica ranks next in 
 importance to the skin and mucous membrane lesions and splenic 
 tumor in the diagnosis of syphilis. Pathological changes are most 
 frequently seen in the long bones, the junction of the epiphysis with 
 the diaphysis being the seat of predilection. 
 
 These lesions are usually bilateral although occasionally only a 
 single lesion can be defined in the living. Involvement of the 
 joints is far less common. While the long cylindrical bones are
 
 OSSEOUS SYSTEM 325 
 
 the seat of the lesions whieh can most easily be defined clinically, 
 any of the bones may be the seat of a diffuse involvement of the 
 bony structures or a periostitis. Such lesions are more commonly 
 found in cases resulting in early fetal death (Fig. 170). 
 
 Roentgenography oilers one of the best diagnostic methods for 
 syphilis in the fetus and new born. Shipley and his co-workers 1 
 found evidence of syphilis in the osseous system of 25 per cent 
 of 100 white fetuses ranging from six months of intra-uterine life 
 to nearly term. Fifteen of these showed advanced luetic osteo- 
 chondritis. The bone lesions in syphilitic new-born infants present 
 characteristic lesions when there is sufficient involvement to be 
 evidenced in the roentgenographic plates. While any of the 
 bones may suffer, those most commonly involved and easiest of 
 study are the lower end of the femur, upper and lower ends of the 
 tibia, radius and ulna and the metacarpals. In their studies they 
 found that the fetal type of reaction and the changes before birth 
 were to a large extent confined to the epiphyseo-diaphyseal region, 
 at which points there develops an abnormal arrangement and 
 distribution of osseous tissue. After birth the periosteal reaction 
 begins, possibly because of the increased demands made on this 
 tissue by the increased muscular activity, and in young infants 
 this may be the most marked skeletal lesion. The most character- 
 istic lesions described by them were the following: 
 
 "The beginning of the process as shown by the roentgen-ray 
 picture is an intensification of the shadow cast by the bone at the 
 epiphyseal line. This line becomes much broader and more homo- 
 geneous and seems to form a cap on the ends of the trabecular of 
 the spongiosa (Fig. 172). This is significant of the beginning of 
 abnormally heavy calcification of the provisional calcified zone. It 
 must be remembered that while the provisional zone of calcification 
 in the cartilage of the normal embryonic bone is, relatively speaking, 
 very narrow, in many cases only one or two cells deep, in the 
 syphilitic bone the calcified cartilage may show on section a width 
 of from 0.5 to 1.5 mm. 
 
 "In other bones, in which the osteochondritis is further advanced, 
 it can be seen that on the marrow side of the intensified shadow 
 of the provisional zone there is a band-like area where the shadow 
 is less intense than in the rest of the bone (Fig. 170), giving an 
 appearance of diminished density to the region of the epiphyseal 
 line. 
 
 "Bones may also be seen in which the dense shadow at the epiphy- 
 seal end of the bone is broken by the presence of one or more small 
 
 1 Shipley, P. G., Pearson, J. W., Weech, A. A., and Greene, C. H.: Bull. Johns 
 Hopkins Hosp., March, 1921, p. 75.
 
 326 
 
 SYPHILIS 
 
 Fig. 171. — Hand and forearm of 
 human fetus to show extreme excess- 
 ive calcification of the provisional area 
 with irregular prolongation of the pro- 
 visional calcified zone into the area of 
 proliferative cartilage. Note the pres- 
 ence of the same lesions in the meta- 
 carpals and phalanges. (Shipley.) 
 
 Fig. 172. — Radius and ulna from 
 human fetus showing beginning re- 
 sorption of the area of intense calcifi- 
 cation at the epiphyseo-diaphyseal 
 junction. Resorption shown by areas 
 of decreased density of shadow, each 
 resorptive area surrounding a small 
 nucleus of persistent trabecular tissue. 
 (Shipley.) 
 
 Fig. 173. — Roentgen-ray picture of 
 syphilitic osteochondritis of the bones 
 of the hand and forearm of a human 
 fetus showing a zone of rarefaction 
 between two lines of abnormal calci- 
 fication. Note the lesion in the pha- 
 langes and metacarpals. (Shipley.) 
 
 Fig. 174. — Syphilitic periostitis of 
 both bones of the forearm. Note the 
 longitudinal striation of the thick 
 periosteal shadow which is nearly in 
 contact with the shafts of the bone. 
 (Shipley.)
 
 OSSEOUS SYSTEM 327 
 
 areas of rarefaction so as to give an appearance of irregular density 
 to the end of the bone (Fig. 173). 
 
 "At other times the bone appears to end in a double line, so that 
 two lines of heavily calcified tissue are seen, separated each from 
 one another by a zone in which lime salts are less heavily deposited. 
 This zone is a region which histological preparations show to con- 
 tain a great deal of delicate granulation tissue. This picture 
 becomes more and more intensified as growth goes on. The areas 
 of dense shadow and the fine clearer band between them grow 
 wider and the surfaces bounding them become more and more 
 irregular and jagged until the end of the bone has an irregular 
 appearance (Fig. 171). During the course of the disease the calci- 
 
 Fig. 175. — Distal end of radius and ulna. This plate shows intense calcification 
 of the provisional zone with resorption areas on the marrow side of the epiphyseal 
 line. Both bones show syphilitic periostitis and there is separation of the cortex 
 from the spongiosa in the ulna. (Shipley.) 
 
 fication of the infected areas is not only abnormally heavy but also 
 most irregular, so that the epiphyseal border of the shadow cast by 
 the bone has a notched, saw- toothed or serrated appearance (Fig. 
 175). 
 
 "Periostitis, when it occurs near term in the severe cases of lues, 
 may be present throughout the length of the bone or only at the 
 extremities. It is shown in roentgen-ray plates by a more or less 
 wide, almost homogeneous, shadow or with longitudinal striations 
 separated from the external surface of the cortex by a narrow clear 
 area which bounds the bone (Fig. 174). 
 
 "One other feature of these pictures appears worth noting. It 
 may be seen that in many luetic bones the cortex is separated from 
 the spongiosa by a very narrow clear zone winch gives the cone
 
 328 SYPHILIS 
 
 of spongy bone the appearance of being suspended unattached within 
 the cortical cavity (Fig. 175). In the roentgen-ray picture the 
 trabecular of the syphilitic bone appear to be finer than those of 
 the normal bone. 
 
 "Two other conditions which are encountered in children may 
 give roentgen-ray pictures which closely resemble, and in some 
 cases are identical with, the pictures described above. Scurvy 
 and rickets, when the latter disease is healing under the influence 
 of cod-liver oil therapy, may be difficult or impossible to differ- 
 entiate by roentgenographic means from osteal syphilis of the 
 fetal type. Fortunately, however, in the early weeks of life neither 
 of these conditions need be seriously considered in diagnosticating 
 hereditary lues, since there is no good evidence to show that fetal 
 rickets ever occurs and it is agreed that scorbutus is rare before 
 the sixth month of life has been reached." 
 
 Liver.— It may be stated that not less than 50 per cent of pre- 
 maturely born, syphilitic infants show a distinct enlargement of 
 the liver. A fair percentage of the cases show a marked increase 
 in size and consistency to such an extent that the abdominal dis- 
 tention in its upper half is visible to the naked eye. These latter 
 cases are usually associated with marked jaundice, dilated veins 
 and an impairment of hepatic function and a high mortality. 
 Because of the relatively large liver of the premature new born 
 normally present, difficulty may be experienced in the diagnosis 
 of a moderate increase in size due to syphilis. It is also to be 
 remembered that many other factors predisposing to premature 
 birth have a direct influence on the size of the liver. The char- 
 acteristic pathological findings are interstitial infiltration of the 
 connective tissues between the acini and about the vessels. Small 
 gummata, often the seat of central necrosis are more exceptionally 
 found. The frequent involvement of the liver is readily explained 
 by the peculiarity of the fetal circulation. The placental blood 
 passing through the portal circulation by way of the umbilical 
 veins, conveys the spirochetes into the liver substance. 
 
 Spleen.— Enlargement of the spleen, while usually moderate, is 
 one of the most important confirmatory signs but is in itself of 
 lesser diagnostic importance than the skin and 'mucous membrane 
 lesions. An easily palpable and hard splenic tumor in the first 
 three months of life, that is, before the advent of rickets in the 
 premature, should always be looked upon with suspicion. The 
 enlargement is usually due to hyperplasia of the pulp, with occa- 
 sional presence of foci of myeloid cells. Cellular infiltration of 
 the interstitial tissue may be present. 
 
 Respiratory System. —The lesions of the nasal mucous membranes 
 have been described. Frequently there is a chronic catarrhal
 
 KIDNEYS 329 
 
 laryngitis and perichondritis, with involvement of the epiglottis. 
 In the fetus and in infants dying soon after birth the so-called 
 "pneumonia alba" or "white pneumonia" is often present. In 
 these cases a considerable portion of the pulmonary tissue appears 
 whitish-gray, airless and smooth on section, due to cellular infiltra- 
 tion of the interstitial tissue, filling of the alveoli and bronchi with 
 degenerated epithelium and proliferation of the intima of the 
 vessel walls. Not infrequently the pleura is the seat of small 
 gumma-like nodular infiltrations. Massive involvement of the 
 lungs is rarely compatible with life. Because of their lowered 
 vitality, syphilitic infants are subject to secondary bronchial and 
 pulmonary infection, pneumonia being a frequent cause of death. 
 
 Circulatory System.— Most characteristic lesions are found in the 
 small bloodvessels and careful examination shows the presence of 
 spirochetes in the vessel walls. These findings are most easily 
 demonstrated in the parenchymatous organs. The characteristic 
 lesions following such involvement are those of coagulation necrosis, 
 with secondary hemorrhages, following rupture of the vessel walls. 
 These lesions may result in more or less generalized or local hemor- 
 rhagic skin lesions and those from the various mucous membranes. 
 Intracranial lesions frequently result from degeneration of the 
 bloodvessels, even in the absence of trauma. 
 
 Digestive System.— Chronic catarrhal pharyngitis is a common 
 early symptom which may later be followed by ulcerations of the 
 pharynx, tonsils and fauces. Only rarely is the stomach involved 
 and the lesions of the intestines which are also infrequent are 
 usually seen as hyperplasia of the solitary follicles and Peyer's 
 patches which may become necrotic and result in hemorrhages. 
 Scattered areas of necrosis not associated with the lymphoid tissue, 
 but due directly to bloodvessel degeneration may be found through- 
 out the intestines. Peritonitis is a more frequent finding in the 
 still born than in viable infants. It may be of the acute type 
 but in most instances it is of the chronic type and may result in 
 formation of adhesions. Localized or generalized ascites may 
 result. 
 
 The pancreas, thymus gland, suprarenal bodies and thyroid gland 
 occasionally exhibit interstitial inflammation, gummata or other 
 syphilitic manifestations. Small cystic formations are frequently 
 found in the thymus gland, usually varying in size from 1 to 5 mm. 
 It is a question whether they are due to arrest of development or 
 necrosis. Purulent material with which they are filled contains 
 spirochetes. 
 
 Kidneys.— While all types of nephritis have been described, those 
 of greatest importance are the interstitial and hemorrhagic. Inter- 
 stitial nephritis is a serious complication because of the danger of
 
 330 SYPHILIS 
 
 late secondary contraction. It is frequently overlooked because 
 of the absence of marked urinary findings. The hemorrhagic types 
 are usually associated with hemorrhages from some of the other 
 mucous membranes. The dangers of overmedication with arsenic 
 and mercury preparations, in the presence of kidney lesions must 
 not be overlooked. Hecker 1 states that he has been able to demon- 
 strate microscopical changes in 90 per cent of his autopsies. 
 
 Nervous System.— Involvement of the brain and its meninges is 
 more frequent than that of the cord. The most frequent lesions in 
 the still born and those dying shortly after birth is a meningo- 
 encephalitis, involving the pia and cortex. The pia is infiltrated 
 and covered by an exudate composed of plasma cells and lympho- 
 cytes. Similar areas are seen in the cortex and the medulla may 
 be involved. The most frequent lesion in viable infants is a men- 
 ingitis serosa interna and externa, which is not usually noted 
 until after the first few weeks of life. It may develop acutely or 
 insidiously and usually results in a more or less marked hydro- 
 cephalus. Because of the late development in some infants and 
 the early appearance of rickets in the premature it should not be 
 confused with megacephalus so commonly seen in the latter. 
 Pachymeningitis hemorrhagica less frequently seen than the former, 
 usually develops after the first few weeks of life. Intracranial 
 hemorrhages are probably a more frequent cause of extra-uterine 
 death than is commonly supposed. Gummatous meningitis and 
 ependymitis are among the rare lesions. Increased intracranial 
 pressure, as evidenced by increased tension over the fontanelles, and 
 which is usually accompanied by hyperexcitability on the part of 
 the infant, should lead to a lumbar puncture for diagnostic purposes. 
 Increased pressure and an increase in the number of lymphocytes 
 in the spinal fluid are always suggestive but not positive evidence. 
 A Wassermann and Lange reaction when positive may usually be 
 considered as conclusive evidence. When these reactions are 
 negative, in the presence of other positive signs, a careful search 
 should be made for spirochetes. 
 
 Any of the lesions of the central nervous system may result in 
 retarded mental and physical development. 
 
 Eyes.— The most frequent lesions are choroiditis, optic neuritis, 
 iritis and parenchymatous keratitis. They are of frequent occur- 
 rence in the still born and may develop in the first weeks of life. 
 
 Ears.— The organs of hearing are occasionally involved by lesions 
 which may be described as specific. The most common is an 
 involvement of the eighth nerve. Involvement of the organs of 
 
 1 Beitrag zur Histologie and Pathologie der kongenitalen Syphilis sowie zur norm- 
 alen Anatomie des Fotus und neugeborenen, Deutsch. Arch. f. klin. Med., 1898, 61, 1.
 
 LABORATORY DIAGNOSIS 331 
 
 the internal ear early in life is difficult of proof. Otitis media as 
 usually seen is due to a secondary infection. 
 
 Laboratory Diagnosis.— "Whenever there is a suspicion of the 
 presence of syphilis during pregnancy the blood of both parents 
 should be examined so as to give both the mother and fetus the 
 benefit of treatment. This will be given further consideration. 
 
 In cases in which the diagnosis has not been made before labor 
 and the possibility of syphilis exists the placenta should be examined 
 histologically and the placental cord blood should be examined for a 
 Wassermann reaction. It is estimated that about 50 per cent of 
 placenta? will show more or less diffuse lesions upon microscopical 
 examination. Jeans and Cooke 1 found that 57 per cent of their 
 syphilitic infants gave a positive Wassermann reaction on their 
 cord blood. They found that in every instance in which the 
 placenta was noted as showing syphilitic changes the infant was 
 later found to have syphilis. While a positive Wassermann reaction 
 may be regarded as nearly specific, a negative reaction must not be 
 regarded as indicating an absence of the disease when made during 
 the first days or weeks of life, as a large group of infants show little 
 or no tendency to give a positive Wassermann before the end of the 
 second month of life. In fact, some of them do not react before 
 the end of the third or fourth month. Negative findings in the 
 presence of lesions or suspicion of infection on the part of the 
 mother should, therefore, lead to an examination of maternal and 
 paternal blood. The variability in the reaction of a new born to 
 the Wassermann test is best evidenced by the report of one positive 
 and one negative reaction in each of a pair of twins by DeBuys 2 
 and Gerstenberger. 3 
 
 The blood taken from the infant during the first week or two of 
 life shows a somewhat higher average of positive serum reaction 
 than examination of placental blood taken from the same cases. 
 In the premature the blood can be taken from the longitudinal 
 sinus, a scalp vein or by a small incision in the heel. The applica- 
 tion of the luetin test offers serious objection in premature infants, 
 because of danger of secondary infection. In full-term infants 
 it averages a higher percentage of positives than the Wassermann. 
 
 Demonstration of spirochetes in the open skin lesions and bulla? 
 as well as from the scraping of the mucous membrane ulcerations, 
 makes the diagnosis absolute when the Treponema pallidum is 
 found. 
 
 While spinal and ventricular punctures are to be avoided when 
 possible in premature infants, examination of the cerebrospinal fluid 
 
 1 Trans. Am. Pediat. Soc, 1920, vol. 32. 
 
 2 Jour. Obst. and Dis. Women and Child., January, 1913, p. 65. 
 
 3 Personal communication.
 
 332 SYPHILIS 
 
 may be necessary when other findings are negative in the presence of 
 possible clinical nervous-system syphilis. About 25 per cent of 
 new-born infants will show spinal fluid changes of sufficient import- 
 ance to have a diagnostic value. These changes consist of a positive 
 Wassermann, which when present, is usually associated with a 
 definite albumin and globulin increase. More often the cell count 
 reveals a moderate pleocytosis. 
 
 Prophylaxis.— It is almost needless to say that luetic individuals 
 should not be permitted to marry. With the improved methods 
 of laboratory diagnosis of today— luetin, Lange and Wassermann 
 tests— it is now possible in a relatively high percentage of cases to 
 discover if an individual has a latent or active syphilis. When 
 there is the slightest suspicion of a specific infection during preg- 
 nancy, the mother should be treated intensively. This offers the 
 only hope of preventing a similar infection of the infant with its 
 consequences, or of ameliorating the condition. It is noteworthy 
 that women with luetic histories do much better if under treatment 
 during pregnancy, so that prematurity and still birth may often 
 be avoided. In the absence of specific therapy the child, instead 
 of being born healthy, may show active syphilitic manifestations 
 or develop them later. 
 
 As in the prophylaxis of any infection of infancy, extreme care 
 must be exercised with reference to the sterilization of feeding and 
 bathing utensils and clothing. 
 
 Nursing. — Whenever a mother bears an infant evidencing lues, 
 if she is at all able, she should nurse her infant. It seems well 
 established today that the mother is syphilitic, whether or not her 
 history is positive, and even in the absence of clinical manifestations. 
 The older controversies as to the possibility of infection of the 
 mother by the child and vice versa consequently do not enter into 
 consideration. Where an adequate supply of milk is present it is 
 of the utmost importance that the premature infant be suckled. 
 If the mother objects to nursing her infant at the breast because 
 of nasal and mouth lesions a shield may be used or the milk expressed 
 and hand fed. 
 
 Where the mother is unable to nurse her child a wet-nurse should 
 not be employed to suckle the child at her own breasts because 
 of the obvious danger of infection of the nurse. Expressed milk is, 
 of course very desirable. 
 
 Active Treatment.— In syphilis neonatorum, which so fre- 
 quently is associated with serious visceral changes and so commonly 
 affects children born prematurely, the prognosis is in general serious. 
 Very commonly the infants with serious forms of pemphigus, even 
 with early instituted treatment and with human milk feedings, die 
 in the first days or weeks of life. An essentially better prog- 
 nosis is offered by the cases with maculo-papular or papulo-bullous
 
 ACTIVE TREATMENT 333 
 
 syphilides provided always that the internal organs are not seriously 
 damaged. 
 
 As soon as the diagnosis is made certain, antiluetic treatment 
 should be immediately instituted. Healthy infants and those free 
 from symptoms but born from luetic parents should be treated 
 prophylactically. 
 
 Certain facts already enumerated in the general care of premature 
 infants should be especially emphasized in the care of this same 
 class of infants born of syphilitic parents, even though they show 
 no manifestations at the time of their birth. Practically all of them 
 show more or less evidence of malnutrition and, therefore, in this 
 class of infants, as in no other, is breast-feeding indicated. Every 
 effort should be made to stimulate the breast-milk supply on the 
 part of the mother because of the difficulty encountered in obtain- 
 ing a sufficient supply from other sources, as well as the danger to 
 a healthy wet-nurse. 
 
 In the presence of a syphilitic history or positive laboratory 
 findings in the parents, or the findings of clinical manifestations 
 in the infant a vigorous course of treatment should be instituted 
 without regard to the presence or absence of a Wassermann reac- 
 tion. In every case in which treatment is instituted the fetal age 
 and general condition of the infant must be taken into consideration 
 and the effect of medication, whether mercurial or arsenic prepara- 
 tions, carefully noted. Early dosage with each form of medication 
 should, therefore, be small, however, maximum administration for 
 the given infant should be attained as early as possible. 
 
 Mercury Therapy. — Three routes of administration deserve con- 
 sideration: Oral, external and intravenous. 
 
 In the treatment of older infants and children many clinicians 
 of large experience advocate the use of the arsenic preparations as 
 of first importance and while mercurial preparations are considered 
 as absolutely necessary to effect a cure, they are given a secondary 
 place. In view of this tendency it is well that we recall our earlier 
 good results in the treatment of congenital syphilis before the 
 discovery of these newer preparations. It is our belief that mercury 
 should rank first in the treatment of syphilis in the premature and 
 that arsenic therapy should rank second in importance: (1) Because 
 of the lesser danger, and (2) because of the rapid improvement which 
 may be expected in a large majority of the cases. However, the 
 dangers of overmedication, both by mouth and injection with 
 mercury must also not be overlooked. These are usually evidenced 
 by a lack of progress on the part of the infant, diarrhea and evi- 
 dences of hepatitis and nephritis. 
 
 For internal use the favorite preparations are hydrargyrum cum 
 creta, 0.005 to 0.03 gm. (yV to \ gr.), or hydrargyrum iodidum 
 flavum in doses of 0.002 to 0.005 gm. (^ toyo gr.) three times daily.
 
 334 SYPHILIS 
 
 It is well to begin with small doses, preferably of the former and 
 increase rapidly to the maximum dose in the absence of diarrhea. 
 In the presence of diarrhea the dose should be reduced. The intra- 
 muscular treatment must be administered with even greater fore-, 
 thought. For this purpose 0.0005 gm. ( T ^ gr.) of bichloride in 
 0.2 cm. (3 mm.) of distilled water or oil, for each kilogram of body 
 weight (2-ij- pounds) are recommended. The injections are to be 
 given once or twice weekly and should be made deep into the 
 muscle. The gluteal muscles offer one of the best sites for injections. 
 The skin surface should be sterilized with a not too concentrated 
 tincture of iodine and the injection is made deep into the muscle 
 by the use of a short needle, preferably of about a 20 gauge (for 
 oil) and \ to f inch in length. Care should be used so that none will 
 be deposited in the subcutaneous tissues. A course of four to eight 
 injections, covering a period of four weeks, is recommended, these 
 to be followed by a rest period of four weeks, during which arsenic 
 injections are given. The oral administration of mercury should 
 be continued throughout this period. Sublimate baths may be 
 successfully used in all moist forms, especially in all exanthemata 
 associated with vesicle formation— 0.2 gm. (3 gr.) for a bath of 
 about 4 liters (1 gallon) of water. 
 
 Inunctions are applicable in infants in whom the skin is not too 
 sensitive and are one of the best forms of treatment. In the presence 
 of local skin irritation it becomes necessary to stop this form of 
 treatment. The clanger of overmedication with mercury must, 
 however, be borne in mind. Mercurial ointment is especially 
 valuable for local application to ulcerated lesions and may be 
 applied to the deeper seated lesions of the hands and feet by the 
 use of mittens and stockings. For these purposes the official 
 mercurial ointment should be mixed with 2 parts of lanolin. In 
 the more mature infants it should be carefully rubbed into the 
 abdominal wall, axillse or thighs and the same site used only at 
 infrequent intervals in order that cutaneous irritation be avoided. 
 For a local lesion 2 per cent of yellow oxide of mercury ointment 
 will do. In the presence of snuffles a 1 per cent yellow oxide of mer- 
 cury ointment should be used. The ointment is introduced into 
 each nostril directly from a small compressible tube. It may be 
 necessary to carefully remove any excessive secretions with a pledget 
 of cotton or by washing with a normal salt solution before applying 
 the ointment. 
 
 It is advisable to continue mercurial treatment for at least a year, 
 decreasing the dose in the second six months, and repeating three 
 months of such therapy during the second and third years, even in 
 the absence of symptoms. As in treating older infants, there should 
 be short periods when treatment is discontinued.
 
 ACTIVE TREATMENT 335 
 
 Arsenic Thera/py.—lt is indicated in most cases as an adjunct 
 to mercurial treatment. Neoarsphenamine is the preparation of 
 choice for use with the premature because of the fact that it can 
 he administered in more concentrated solution, its greater solu- 
 bility and the lack of necessity for neutralization. It can be 
 administered intravenously in water or by intramuscular injections 
 in a bland oil. 
 
 The average dose is 0.01 gm. for each kilogram of body weight. 
 The dose should be diluted with 2 cc of sterile, freshly distilled 
 water for intravenous use. It is advisable to give one-half of this 
 quantity per kilogram for the first treatment. A course of four 
 intramuscular, or, when possible, preferably intravenous injections 
 are given at weekly intervals to be followed by a rest period of four 
 weeks when the treatment is to be repeated. During the period 
 of administration of neoarsphenamine the mercurial injections 
 should be discontinued but the oral administration continued. 
 
 Complications following the intramuscular injection of neo- 
 arsphenamine, such as abscesses and infiltrations can, to a large 
 degree, be avoided by the use of special needles, which permit the 
 solution to be injected deep into the muscle. After injection, the 
 needle is rapidly withdrawn and a cotton pledget is pressed firmly 
 over the site of injection for a few minutes. 
 
 For intravenous administration the best sites are scalp veins 
 or the external jugular vein. For administration into the latter 
 site the infant should lie with the shoulders elevated and the head 
 extended and rotated. Only in very exceptional cases should 
 cutting down on a vein be practised. The longitudinal sinus route 
 for arsenic injection is not to be considered because of the danger 
 of passing through the sinus and extravasating the preparation over 
 the brain tissue. 
 
 The general plan of treatment should, therefore, be as follows: 
 One of the mercury preparations should be administered in suitable 
 doses three times daily per mouth, and once or twice weekly during 
 the first four weeks an intramuscular injection of one of the mercurial 
 preparations should be given. During the second month the oral 
 administration should be continued but the mercurial injection 
 should be replaced by neoarsphenamine, preferably intravenously, 
 once each week. Mercurial ointment as inunctions or local appli- 
 cations are to be used when indicated. 
 
 This plan of treatment should be continued throughout the first 
 year, in the absence of toxic symptoms and at least three months 
 of treatment should be given during the second and third years. 
 Treatment should be continued for at least six months after all 
 evidence of activity has disappeared. This includes a negative 
 Wassermann. At no time should a negative Wassermann in early 
 infancy be considered as sufficient evidence to interfere with the 
 general course of treatment as outlined.
 
 CHAPTER XVI. 
 TUBERCULOSIS IN PREMATURES. 
 
 The recorded cases of tuberculous affections during the first weeks 
 of life are unusually rare, and their clinical symptoms, even when 
 anatomically demonstrable changes are present, ordinarily are 
 not to any extent characteristic. While in comparison with the 
 acquired tuberculosis, the congenital form is almost a rarity, 
 nevertheless numerous authentic instances are on record. 
 
 M. Pehu and J. Chalier 1 have collected 51 cases from the litera- 
 ture, the authenticity of which has been established. While some 
 of these cases have resulted in premature birth, the majority have 
 been born at full term; and although some of the latter have been 
 well developed, most of them have suffered from congenital debility. 
 
 Planchu and Devin 2 describe 39 premature infants born of 
 tuberculous mothers. They believe that the morbidity and 
 mortality is greater in infants born prematurely from tuberculous 
 mothers than the average for those born prematurely of other 
 causes. 
 
 While infants born at full term of tuberculous mothers may 
 occasionally be well developed, the majority nevertheless, if infected 
 with tuberculosis before leaving the uterine cavity, show marked 
 congenital debility. As a case in point in evidence for the possi- 
 bility of good development, may be cited the infant of H. Rollet, 3 
 which died forty-eight hours after birth, but in whom large caseous 
 areas were found in the bronchial glands, lungs, liver and spleen. 
 The mother of this child died eighteen days post partum from 
 miliary tuberculosis, and on examination it was found that the 
 uterus still contained placental remnants from which numerous 
 tubercle bacilli were obtained. 
 
 In cases of intra-uterine infection the tubercle bacilli penetrate 
 into the body of the infant, either by way of the placental blood 
 or by the swallowing of liquor amnii. It is impossible for the 
 embryo to become infected unless the mother be tuberculous. 
 
 The transmission of the bacilli from the mother to the infant 
 
 1 Heredity in Tuberculosis, Arch, de med. des enf., 1915, 18, 1. 
 
 2 Le Premature de Mere tuberculeuse, Lyon rned., 1911, 116, 72. 
 
 3 Ueber intra-uterine miliare tuberculose, Wien. klin. Wchnschr., 1913, No. 31, 
 26, 1274-1275.
 
 TUBERCULOSIS IN PREMATURES 337 
 
 can occur at any time during pregnancy. This may result from 
 bacilli carried in the fetal circulation, from various parts of the 
 mother's body, or through organisms found in placental lesions. 
 The normal placenta is usually conceived to be a filter impermeable 
 to bacteria. Presumption for the passage of tubercle bacilli from 
 the blood of the mother to that of the infant is a lesion of this filter. 
 Tubercle bacilli can pass into the blood stream of the infant only 
 when a communication has been established between the inter- 
 villous spaces and the bloodvessels of the chorionic villi, or when 
 liquor amnii becomes infected with the organisms. Therefore, the 
 bacilli infecting the fetus must come either from a tuberculous 
 placenta or from the circulating blood. The transmission of 
 bacilli into the blood of the infant takes place when a bloodvessel 
 of the villus becomes eroded or ruptured. 
 
 Tuberculous changes in the decidua vera or in the chorionic 
 covering of the placenta may result in infection of the liquor amnii 
 by breaking through the amnion, and also in intestinal infection 
 with eventual general systemic distribution. 
 
 The intra-uterine infections above described may lead to advanced 
 tuberculous processes at birth. Such infants are usually born 
 premature or show great debility. Not infrequently the infant is 
 infected through the transmission of the organisms during birth, 
 when in the separation of the placenta the bloodvessels of the villi 
 become ruptured, and thereby passage to the blood of the infant, 
 either from the tuberculous foci of the placenta, or from the maternal 
 blood, is made possible. In these latter cases no specific changes 
 are found in the organs at birth, and these infants are likely to 
 be well developed. 
 
 Intrapartum infection may take place through swallowing 
 or more rarely through inhalation during the passage of the child 
 through the birth canal. 
 
 The infection may take place after birth (acquired tuberculosis) . 
 This occurs either by way of the respiratory tract through inhala- 
 tion, or by way of the digestive tract, or through other portals of 
 entrance, far less common. 
 
 It is of the greatest importance from the clinical point of view 
 to separate the infants who are born with tuberculous organic 
 changes from those who are born without such pathology. The 
 new-born infant in this situation is in the stage of incubation for 
 tuberculosis. 
 
 Unfortunately such clinical distinction is usually impossible 
 because of the absence of pathognomonic symptoms, and the 
 failure of specific tests during the first weeks of life. While the 
 cutaneous and intracutaneous reactions are rarely seen before the 
 fourth week of life, a few cases have been described. Among these 
 22
 
 338 TUBERCULOSIS IN PREMATURES 
 
 is that of Zarlf, 1 who reported a positive von Pirquet reaction in 
 a seventeen-day old infant, which was still living at the time of the 
 report, six weeks after birth. In the discussion of this case von 
 Pirquet remarked that this was the earliest age at which a positive 
 reaction had been reported to his knowledge, and that he believed 
 it to be proof of the congenital origin of the case, as his conception 
 was that at least four weeks must pass after the time of infection 
 before a positive tuberculin reaction may be obtained. 
 
 It should be remembered that prematurity and congenital 
 debility on the part of infants born of tuberculous mothers does 
 not necessarily mean that the child is suffering either from congenital 
 or hereditary tuberculosis. It should not be forgotten that infants 
 infected with tuberculosis, in whom there are only minor or no 
 tuberculous lesions, may be born at full term, seemingly robust. 
 
 Etiology.— The frequency of tuberculosis as an etiological factor in 
 premature births or general debility of full -term infants must be con- 
 sidered: (1) From the standpoint of the effect of tuberculosis on 
 the entire organism of the mother; (2) its influence on the genera- 
 tive organs of the mother; (3) its effect on the general development 
 of the fetus; (4) of a systemic infection of the fetus; (5) from the 
 viewpoint of the results as they affect the future development of the 
 infant, which may be born at full term, without manifest evidence 
 of congenital debility. 
 
 1. Effect of Tuberculosis on the Entire Organism of the Mother. — 
 While numerous authentic cases of congenital tuberculosis are now 
 on record, by far the majority of infants born of tuberculous mothers 
 do not show evidence of systemic tuberculosis at autopsy, and in 
 our own studies of such instances in the Cook County Hospital over 
 a period of several years, the only well-authenticated case which 
 has come under observation and which has proven to be one of 
 general tuberculosis on the part of the infant, was reported by 
 Grulee. 2 The infant died on the eleventh day after its birth, and 
 at autopsy showed a generalized tuberculosis, affecting most 
 markedly the abdominal organs and especially the periportal 
 lymph glands, liver and spleen. The tuberculosis was miliary in 
 type, but the stage of the tubercles suggested an intra-uterine infec- 
 tion. The mother was still living several months after the infant's 
 death. 
 
 In contradistinction to this case we have had occasion to observe 
 numerous instances in which infants born of tuberculous mothers 
 have survived, and have either progressed more or less normally, or 
 have died of infections other than tuberculosis— in whom at least 
 tuberculosis could not be demonstrated at autopsy. 
 
 1 Congenital Tuberculosis, Jahrb. f. Kinderh., 1913, No. 1, 67, 95. 
 
 3 Tuberculosis as a Disease of the New Born, Am, Jour. Dis, Child., 1915, 9, 322.
 
 ETIOLOGY 339 
 
 2. Effect on the Generative Organs' of the Mother. — Tuberculosis 
 can be transmitted through the uterus, either through local lesions 
 or without demonstrable lesions in the uterus and placenta. 
 G. Luenherger 1 contributes records of two interesting cases of pla- 
 cental and congenital tuberculosis, which illustrate the abo Yemen - 
 tioned possibilities. In the first instance the mother died of tubercu- 
 lous meningitis and miliary tuberculosis. Tubercle bacilli were found 
 in the fetal liver and numerous miliary tubercles in the placenta. 
 Injection of a small piece of liver extract and of the heart's blood 
 of the fetus into a guinea-pig gave rise to pulmonary tuberculosis. 
 
 In the second instance the mother suffered from pulmonary tuber- 
 culosis, and aborted. Neither the fetus nor the placenta showed 
 any tuberculous changes, but tubercle bacilli were found in the 
 intervillous spaces of the placenta. 
 
 From the study of these two cases Luenberger draws these con- 
 clusions: When the mother suffers from acute miliary tubercu- 
 losis, there can develop numerous miliary tubercles in the placenta, 
 and from these, tubercle bacilli can penetrate the fetal circulation. 
 It is also true that without tuberculous changes in the placenta 
 or membranes the bacilli can pass from mother to child, that is, 
 during birth there can be sufficient injury to the chorionic vessels 
 to allow the bacilli to pass from the intervillous spaces into the 
 fetal circulation. 
 
 A. Dietrich 2 reported a case which suggests the possibility of 
 congenital infection. A woman with general tuberculosis gave birth 
 shortly before her death to a premature infant. Tubercle bacilli 
 were demonstrated in the placenta. The baby was never in contact 
 with the mother. It developed well for the first two months, when 
 an abscess formed in the right groin. Following this there was 
 loss in weight and rales in the chest. The child died in the third 
 month. Autopsy showed many tubercles in the lungs, intestines 
 and spleen, a few in the liver and a large lesion in the portal vein. 
 
 Tuberculosis of the placenta has been described by many observ- 
 ers. This is of importance in relation to tuberculosis of the fetus 
 in proportion as the fetal or maternal portion of the placenta is 
 involved. It is certain that in many cases only the maternal portion 
 is infected, the fetal remaining uninfected. 
 
 3. Effect on the General Development of the Fetus.— hi a consider- 
 ation of this class of cases, theoretically it may be viewed from two 
 standpoints: (1) That of general debility, without reference to a 
 special predisposition to tuberculous infection; and (2) that of 
 congenital predisposition to tuberculous infection. The question 
 
 1 Contribution to Placental and Congenital Tuberculosis, Beitrage z. Geburtsh. 
 U. Gynak., 1909-1910, vol. 5. 
 
 2 Congenital Tuberculosis, Berl. klin. Wchnschr., 1912, 19, 877.
 
 340 TUBERCULOSIS IN PREMATURES 
 
 of the possibility of an inherited immunity against tuberculous 
 infection is one which is open to great speculation, and we have 
 not been able to satisfy ourselves that such an immunity may 
 exist. That many of this class of infants seem to have a predispo- 
 sition to tuberculous infection, which in all probability is, however, 
 at least in great part due to their constant exposure and repeated 
 infection with the organisms through contact with an infected 
 mother, cannot be denied. This class of infants without really 
 having tuberculosis often shows signs of malnutrition. Doubtless 
 many of them have a diminished resistance to all infections and 
 more especially to tuberculosis. They are below the average in 
 development. 
 
 4. Systemic Infection of the Fetus.— If tuberculous changes are 
 present in the body at the time of birth, if the infant is born alive, 
 the disease leads to early death in the majority of cases, generally 
 within the first week of life. 
 
 In a great number of cases in which tuberculosis is transmitted 
 in utero, more especially in the last days of pregnancy, or intra- 
 partum, the disease remains clinically latent during the first days 
 of life, and may not become manifest for two or three months. 
 The infection may, however, be entirely overcome. These cases 
 may be described as the latent forms of tuberculosis. Of the 28 
 instances of congenital tuberculosis of which we have definite records 
 at hand, 10 infants were born prematurely, and 2 of these were 
 still births. Two of the living premature infants survived for three 
 months, the other 6 living from one day to two months. Of the 
 infants born at full term all died before the fifth month of life. 
 
 5. Results as They Affect the Future Development of the Infant, 
 Which May be Bom at Full Term, Without Manifest Evidence of 
 Congenital Debility.— The future development of this class of 
 cases is dependent upon their freedom from congenital infection, 
 their protection against postnatal infection and their general 
 resistance. 
 
 Symptoms.— Clinical data of tuberculosis of the new-born pre- 
 mature or full term are so scant that no conclusions can be drawn 
 as to the symptomatology. The combination of enlargement of 
 the spleen, high, irregular temperature and enlargement of the 
 liver, together with tuberculosis in the mother is very suggestive. 
 The infants are usually below weight at birth, pallid and may 
 show a positive tuberculin reaction in the sixth to seventh week 
 of life. 
 
 Treatment.— It is, of course, of the utmost importance that very 
 careful hygienic and dietetic measures be instituted at the earliest 
 opportunity. There are no specific cures or worth-while medicinal 
 measures. The critical question is that of the advisability of 
 nursing.
 
 TREATMENT 341 
 
 In general nursing should under all circumstances be forbidden 
 in open pulmonary tuberculosis of the mother, and the same is 
 advisable also in every active tuberculosis. The prohibition of 
 nursing in these cases has for its purpose the removal of the infant 
 from the coughing mother— from the tuberculous environment— 
 and is done more because of the danger of inhalation tuberculosis 
 than because of the possibility of an eventual transmission of the 
 bacilli by the mother's milk. Marked tuberculosis of the mother 
 should in all events be a contraindication against nursing for the 
 benefit of both. In such a case it is the duty of the physician to 
 do all in his power to accomplish the removal of the infant from 
 the neighborhood of the mother as soon as possible, at least for the 
 first months of life. 
 
 In the cases of mothers proven to be tuberculous, who show no 
 manifest signs at the time of delivery and lactation, caution is 
 necessary. When the removal of the infant from the mother 
 encounters insurmountable opposition and the infant must remain 
 at home, then it is more advisable in such cases not to endanger 
 the infant any more by introducing artificial feeding but to put 
 it to the breast. If in the mother there are neither clinically nor 
 physically demonstrable tuberculous changes, and sputum exami- 
 nation is negative, and if the tuberculosis is not only latent, but 
 also inactive and is confined to mild apex findings, then, when the 
 infant remains with the mother, nursing should not only be recom- 
 mended but strongly urged. If feeding by a wet-nurse is possible 
 it is for all events and purposes the best method in doubtful cases. 
 This should in justice to the wet-nurse be carried out by hand- 
 feeding of expressed milk. The wet-nurse baby should not come 
 in contact with the infected infant.
 
 CHAPTER XVII. 
 EDEMA AND SCLEREDEMA IX PREMATURE INFANTS. 
 
 Besides asphyxia and hypothermia there is a tendency to edema 
 in small premature infants. This occurs, sometimes during birth, 
 but more frequently during the first days of life, as edema of the 
 extremities and the genitalia. In contradistinction to the general 
 view that these edemas and scleredema are to be regarded as 
 sequela? of subnormal temperature, it must be emphasized that 
 these edematous conditions are not uncommon in small prematures, 
 and that they may occur even in utero. In this connection atten- 
 tion may be called to congenital general dropsy and to other localized 
 edemas, that have been observed by others in premature infants 
 immediately after birth, or in the new born. (Ballantyne, Link, 
 Kirk, Oswald, Chiari.) 
 
 Special forms of edema are scleredema and sclerema. It is not 
 always possible to make sharp differentiations between these and 
 other forms of edema. Scleredema is designated that form of 
 edema in which the skin is hard and taut, while sclerema is that 
 condition in which the skin is hard and dried out. Many authors 
 emphasize that in an individual case the sclerema is not to be 
 distinguished from scleredema, since they are only quantitative 
 differences of the same process. Ylppo 1 believes that it depends 
 entirely upon the water richness of the tissues, whether the skin 
 feels pasty hard (scleredema) or wooden hard (sclerema). 
 
 Etiology.— As far as etiology is concerned we cannot make special 
 differences. According to experience, the skin upon the external 
 portion of the thigh, whenever edema of the feet is present, feels 
 always somewhat tougher and harder (scleredemic), in comparison 
 to soft edema of the genital region or of the inner surface of the 
 thigh and leg. Because these differences in consistency are demon- 
 strable in many premature infants a few hours after birth, we 
 have to consider special anatomical conditions as factors responsible 
 for their production. The younger the infant, the thinner is the 
 fatty cushion. On the external surface of the thigh it is several 
 millimeters thick even in the smallest prematures, while in other 
 regions the subcutaneous fatty tissue is not well developed. The 
 occurrence of hard edema on the external surface of the thigh with 
 
 1 Ztschr. f. Kinderh., 1913, 24, 53.
 
 SYMPTOMS 343 
 
 simultaneous occurrence of soft edema in other portions, forces 
 upon us the conclusion that besides the water richness it also 
 depends upon the richness of the subcutaneous fatty tissue, whether 
 or not an edematous portion of the skin feels somewhat harder. 
 
 Now, new-born infants, and also prematures, whose bodies are 
 especially rich in water, lose in weight during the first days of life, 
 and thus it is easy to understand that the water content of the skin 
 and of the subcutaneous fatty tissues gradually becomes less. 
 According to Langer 1 and Knoepfelmacher, 2 the subcutaneous fat 
 contains chiefly palmitic and stearic acids, and proportionately 
 only a small quantity of oleic acid. The fat of the new-born infant 
 is therefore even with ordinary body temperature somewhat harder 
 than the fat of the adult, which is rich in oleic acid. The usual very 
 high water content of the fatty tissue in the new-born infant makes 
 it of normal softness during ordinary temperature. It is easy to 
 understand that the oleic-acid-poor, fatty tissue begins to feel 
 hard when the water disappears from the interstitial spaces of the 
 fatty tissue. 
 
 Symptoms. — In small prematures that are observed carefully 
 after birth, we may notice that the legs, and especially the feet 
 and hands, may begin to swell in from five to seven hours after 
 birth. These swellings often occur no matter whether the infant 
 is transferred immediately after birth into a warming tub, or 
 whether it shows subnormal temperature. In infants with sub- 
 normal temperature edema occurs more frequently and is more 
 marked. If the child is put into a somewhat inclined position, so 
 that the hands and legs hang down, then very soon cyanotic swelling 
 may be observed in the dependent extremities. If we change the 
 position and allow the head to be lower than the legs then the 
 edema disappears in a few hours. 
 
 This simple experiment shows that the cause of the edema 
 occurring in the premature infant during the first days or hours 
 of life, may be looked for in circulatory weakness. Besides this, 
 the high water content of the tissues and the ready permeability 
 of the blood and lymph vessels in prematures is of great importance 
 in this respect. In these infants edema occurs not only in the skin, 
 or more properly in the subcutaneous tissues, but also in many 
 other tissues. The marked tendency to hydrops of the cavities 
 and the high-grade edematous swellings of the pelvic walls and 
 brain coverings is also a manifestation of this general property of 
 the body of the premature infant. It cannot be denied, of course, 
 that hypothermia and initial cooling of the premature infant are 
 of importance in the development of edema. If the cold easily 
 
 1 Mathem.-naturw. Klasse, 1881, 84, 94 (dritte Abtlg.). 
 
 2 Jahrb. f. Kinderh., 1897, 45, 177.
 
 344 EDEMA AND SCLEREDEMA IN PREMATURE INFANTS 
 
 damages the small capillaries of an adult it does it even more 
 easily in the premature infant, in whom the skin is rich in water. 
 The water evaporation, by producing heat loss, favors the develop- 
 ment of lesions of the capillaries. It is a mistake, however, to 
 designate edema in premature infants simply as a sequel of hypo- 
 thermia. 
 
 Treatment.— In the treatment of sclerema it is important to see 
 first that the water intake is increased. It is understood that 
 proper care must be taken of the temperature and other conditions. 
 In general, the prognosis in sclerema of the premature infant is not 
 as bad as has generally been supposed. If we succeed in preventing 
 early the marked desiccation of the infant, then it is still possible 
 to save the infant. 
 
 Fig. 176. — Case of erythroblastosis. 
 
 ERYTHROBLASTOSIS FETALIS. 
 
 Among the various forms of congenital dropsy, in which the 
 infants are often prematurely born, erythroblastosis, first described 
 by Schridde 1 and named by Rautmann, 2 is the least understood. 
 Congenital generalized edema may be the result of cardiac anoma- 
 lies and diseases, portal obstruction, syphilis of the liver, fetal 
 peritonitis, abnormality of the D. venosus Arantii, deformities of 
 the intestines and diseases of the kidneys. Schridde, in 1910, 
 pointed out a form of congenital general dropsy with hydramnios 
 associated with a pathological blood state. 
 
 The disorder is characterized by anasarca and fluid in the cavities, 
 
 1 Die angeborene allgeraeine Wassersucht, Munchen. med. Wchnschr., 1910. 
 
 2 Ueber Blutbildung bei fotaler allgemeiner Wassersucht, Ziegler's Beitrage, 
 1912, 54.
 
 ERYTHROBLASTOSIS FETALIS 345 
 
 tiydramnios and enlargement of the liver and spleen. The latter 
 two organs show the most marked changes, which consist of the 
 accumulation, both inside and outside of the bloodvessels, of large 
 numbers of erythroblasts and a smaller number of other marrow- 
 cells. The lymph follicles in the spleen are absent and the liver 
 cells are crowded out. Accumulations of erythroblasts in small 
 numbers may be found in the kidneys, adrenals and lymph glands. 
 Erythroblasts appear in the blood in greatly increased numbers 
 and they show very often mitotic processes. The heart is often 
 hypertrophied. 
 
 Because of the presence of hemosiderin in the spleen and liver, 
 Schridde was led to believe that the disease was due to a severe 
 anemia with compensatory hematopoiesis having no relation to 
 syphilis. Others have assumed that the extramedullary formation 
 of blood corpuscles was due to some form of unknown toxic action. 
 Chiari 3 described an infant in whom there was no blood pigment in 
 the liver or spleen, and consequently no indications of any ante- 
 cedent destruction of blood cells. Fischer, 4 in his examination of 
 the older literature, came to the conclusion that many of the cases 
 described as congenital leukemia were probably instances of erythro- 
 blastosis. 
 
 3 Ein Beitrag zur Kenntnis der sogenannten fotalen Erythroblastose, Jahrb. f. 
 Kinderh., 1914, 80, 561. 
 
 4 Die allgemeine angeborene Wassersucht, Deutsch. rned. Wchnschr., 1912, Xo. 9.
 
 CHAPTER XVIII. 
 DISEASES PECULIAR TO PREMATURE INFANTS. 
 
 RACHITIS IN PREMATURE INFANTS. 
 
 The early appearance of rachitic manifestations in premature 
 infants has been noted by many observers, especially associated 
 with spasmophilia and anemia. Most prematurely born infants 
 become rachitic— the lower the weight, the more certainly— and 
 even human milk is not an absolute protection against this. 
 
 Huenekens 1 was able to collect 70 cases of prematures and twins, 
 of which 58 developed definite signs of rachitis (82 per cent). The 
 time of occurrence was interesting, inasmuch as of 33 cases seen 
 for the first time at or before four months, 27, or 81 per cent, showed 
 evidence of rachitis at that time. The first symptom usually noted 
 was craniotabes, which in 3 instances was already present at six 
 weeks. Langstein 2 observed it frequently in the third to the fourth 
 month of life and not much less often was the tendency to con- 
 vulsions (hyperirritability of the nervous system of these infants) . 
 
 Ylppo 3 observed commonly a megacephalus in connection with 
 rachitis of the skull, which often left marks permanent for 
 all life. These have to be regarded as characteristics of the 
 prematures and not, as unfortunately is often the case, as signs of 
 special "constitutional degeneration." Along with this mega- 
 cephalus with its somewhat large, plump skull, there is asymmetry, 
 which is not congenital but is produced in a mechanical way by the 
 pressure of the infant's head in the first months of life and the 
 softness of the skull. 
 
 The narrow thorax with its more or less marked signs of rachitis 
 may also be regarded as a peculiarity characteristic of the smallest 
 prematures but not of those of greater weight. This is not to be 
 confused with the early functional, funnel chest which can be 
 demonstrated in the first weeks of life and is due to the softness of 
 the ribs in the smaller prematures. This leads to further deformity 
 of the thorax, as the marked contraction of the lower half, which 
 is the result of the congenital softness of the ribs and the rachitic 
 affections later developing. The constriction around the chest 
 is best seen about the insertion of the diaphragm. 
 
 1 Jour. Lancet, 1917, 37, 804. 
 
 2 Ztschr. f. Kinderh., 1916, 15, 49. 3 Ibid., 1919, 20, 212.
 
 kACHITIS IN PRE MATURE INFANTS 
 
 347 
 
 The rachitic rosary is very prominent in prematures and is 
 explained on the basis of the constant respiratory movements 
 leading to deformities and marked enlargement of the epiphyses 
 of the ribs. 
 
 The long cylindrical bones, however, only exceptionally show 
 enlargements of the epiphyses in prematures, although rachitic 
 
 Fig. 177. — Rickets — first stage. 
 
 changes appear in these bones very early. The process in these 
 bones results rather in bone absorption and fringing of the epiph- 
 yses than in marked proliferation, which is the rule in strong 
 full-term rachitic infants. The explanation of this feature in 
 prematures may be in the fact that the rachitis appearing very 
 early is already at end by the time the infant learns to walk, whereas
 
 348 
 
 DISEASES PECULIAR TO PREMATURE INFANTS 
 
 in the full-term infant the hyperplastic epiphyseal enlargement 
 occurs as a compensatory process in the period when the lower 
 extremities are called upon to support the weight of the body. 
 In the absence of special rachitic curvatures and epiphyseal enlarge- 
 ments of the long bones, we cannot therefore exclude rachitis in 
 
 Fig. 178. — Rickets — second stage. 
 
 the premature. Histological examination shows a characteristic 
 picture in the absence of marked external manifestations. 
 
 Etiology.— The etiology of rachitis in premature and full-term 
 infants has been the subject of much discussion. Huenekens 
 believes that the explanation may be found in that the chemical 
 constitution of prematures is abnormal. Their salt content is
 
 RACHITIS IN PREMATURE INFANTS 349 
 
 far below normal. Birk 1 found that a four-months fetus contained 
 14 gm. of ash, at six months 30 gin. at nine months 100 gm., show- 
 ing that two-thirds of the minerals were taken on during the lasl 
 three months of fetal life. In the new born fully 75 per cent of this 
 ash is made up of calcium and phosphate, the chief constituents 
 of the bones. Huenekens believes, therefore, that the more pre- 
 mature the infant, the greater will be the deficiency of calcium 
 and other minerals, so that by the third or fourth month of extra- 
 uterine life the supply is entirely exhausted and rachitis results. 
 
 Underfeeding is another factor in the development of rickets 
 in the premature. The low calcium content of human milk and 
 the difficulty of metabolizing even this food in sufficient quanti- 
 ties to prevent drawing on the inherited supply may be an active 
 factor. The artificially fed are especially prone to develop severe 
 rickets. If the diet contains sufficient milk the tendency to develop 
 the disease is less than when fed mainly on cereals and proprietary 
 cereal foods with only small amounts of milk. A diminished 
 calcium retention (negative calcium balance) exists in the florid 
 stage of rickets, even though the intake is ample. A deficiency of 
 calcium in the diet while important in itself is probably not the 
 precipitating factor. It has been shown experimentally in puppies 
 that a diet containing an abundance of calcium does not prevent 
 rickets when the diet is deficient in other factors. 
 
 The average normal inorganic phosphorus concentration in the 
 serum is about 5 mg. per 100 cc. Howland and Kramer 2 found 
 that in all patients in the active stage of rickets the concentration 
 of inorganic phosphorus in the blood serum was low and that in all 
 children under two and a half years of age, in whom an inorganic 
 phosphorus content of the serum of 3 mg. or less was found, active 
 rickets was present. With the healing of the process in the bones 
 that occurred after cod-liver oil medication, the phosphorus rose 
 gradually to normal. These facts led them to consider the presence 
 of a low percentage of inorganic phosphorus in the serum of a young 
 child as nearly conclusive evidence of active rickets. They Relieve 
 that there is constantly a marked and for the causation of the 
 pathological lesions, an important deficiency in inorganic phos- 
 phorus. To this deficiency they ascribe the failure of calcium 
 deposition. 
 
 The phosphorus content of the blood can be increased by feed- 
 ing phosphorus per mouth. Marriott, 3 working with artificial blood, 
 found that by small increases in the phosphorus content, a 
 precipitate resembling in composition the salts of bone was formed. 
 
 1 In'Monatsschr. f. Kinderh., 1910, 1, 644. 
 
 2 Jour. Biol. Chem., 1920. 43, 35. 
 
 ? Report of Thirty-second Meeting of Am. Fed. Sqc. Arch. Ped., 1920, vol. 37,
 
 350 DISEASES PECULIAR TO PREMATURE INFANTS 
 
 Phemister 1 applied these experiments to children and noticed by 
 roentgenogram studies that phosphorus affected the normal bones 
 of children as it did Wegner's 2 animals and that the accumulation 
 of calcium and overproduction of bone in the metaphysis continued 
 for some time even after the administration of phosphorus was 
 discontinued. He has more recently reported similar results in 
 rachitic infants. 
 
 McCollum and his associates, 3 4 in a study of the effect on the 
 growth and development in rats, came to the conclusion that the 
 etiological factor is to be found in an improper dietetic regimen. 
 Their experiments showed that the majority of young rats devel- 
 oped pathological conditions of the skeleton having a fundamental 
 resemblance to rickets when fed upon diets low in both fat soluble 
 vitamines and phosphorus. When they modified this diet so that 
 the deficiency in phosphorus is compensated for by the addition of 
 a complete salt mixture, containing the phosphate ion, the deficiency 
 in fat soluble factors still existing, no pathological changes of a 
 rachitic nature developed. They, therefore, concluded that a 
 deficiency in this vitamine cannot be the sole cause of rickets. In 
 summarizing, they state that the phosphate ion in the diet may be 
 a determining influence for or against the development of rickets, 
 but that these findings should not exclude the absence of fat soluble 
 vitamine from consideration as an etiological factor in the produc- 
 tion of rickets and kindred diseases, since the level of the blood 
 phosphate is, in all probability, determined in part by the amount 
 of fat soluble vitamine available for the needs of the organism. 
 
 Summarizing, it appears that rickets is a nutritional disturbance 
 especially affecting the osseous and muscular system, with resulting 
 lesions which prevent the bones and muscles from utilizing calcium, 
 thus leading to a diminished retention of this element, although 
 there is plenty of it in the food intake and in the blood. Phos- 
 phorus probably plays an intermediate role in influencing the forma- 
 tion and deposition of the lime salts in bone. Whether the diet 
 plays its role by directly interfering with the calcium and phos- 
 phorus metabolism due to lack of an antirachitic factor or indirectly 
 by causing an underlying nutritional disturbance is open to con- 
 jecture. 
 
 Hygiene is an important factor in that improper hygiene results 
 in impaired metabolism with a resulting inability to properly 
 utilize the dietetic constituents even when properly balanced. 
 
 1 Effects of Phosphorus on Growing Normal and Diseased Bones, Jour. Am. Med. 
 Assn., 1918, 70, 1737. 
 
 - Yirchow's Arch. f. Path. Anat., 1872, 55, 9. 
 
 3 McCollum, Simmonds, Parsons and Shipley: Jour. Biol. Chem., 1921, 45, 333. 
 
 4 Shipley and Park, McCollum and Simmonds: Johns Hopkins Hosp. Bull., 
 1921, 32, 160.
 
 ANEMIA OF PREMATURE INFANTS 351 
 
 Infections play a similar role. Impairment of the body functions 
 also directly affects the glands of internal secretion with secondary 
 disturbances folloAving such dysfunction. Therefore, "while an 
 impairment of mineral metabolism precipitates the clinical 
 symptoms, one or several of the secondary factors may have an 
 important relation to the utilization of phosphorus and calcium. 
 
 Treatment.— Our therapy is along the same lines as in full-term 
 children with special stress on the feeding of human milk. Fresh 
 air and sunshine in the older children and the observation of careful 
 hygiene for all are without doubt highly important. 
 
 Diet must receive very careful consideration. In the very 
 young the ideal food is, of course, mother's milk. Where artificial 
 feeding must be instituted the amount of cow's milk should be 
 minimal, and cereals and vegetables started early. Orange juice 
 diluted with water should be given in small amounts from the 
 second or third months (one to four teaspoonfuls daily). After, 
 the first month the diluent in the milk mixtures should be a cereal 
 water (one tablespoonful of whole barley or oatmeal to the quart 
 of water— and not the dextrinized cereal flours). From the third 
 month cereal should be fed. After the fifth month vegetable 
 soups should be given, substituting an ounce of soup for an equal 
 amount of bottle-feeding. By the sixth or seventh month a milk- 
 feeding should be replaced by a vegetable-soup meal. 
 
 Cod-liver oil with phosphorus in a preparation containing 0.0003 
 gm. (airo g r -) to each 4 cc (1 dr.) oleum morrhuse, is a most practical 
 mixture and can be administered to most infants by the fourth to 
 the sixth week, beginning with | cc doses twice daily and increasing 
 to 4 cc twice daily by the fifth month. The work of Schloss 1 has 
 shown that the addition of a calcium salt to cod-liver oil with phos- 
 phorus further enhances the value of the mixture. Such a prepara- 
 tion is the tricalcium phosphate C. P. (10 per cent) in emulsion of 
 cod-liver oil U. S. P. 
 
 ANEMIA OF PREMATURE INFANTS. 
 
 Closely associated with rachitis in premature infants is an anemia, 
 which develops quite regularly and strikingly during the first three 
 months of life. In our previous discussion of the physiology of 
 the blood we noted from the work of Kunckel, Lichtenstein, Lande 
 and others (p. 67, et seq.) that in contrast with full-term infants, in 
 the premature there is a greater number of nucleated red blood 
 corpuscles, a more frequent appearance of myeloblasts and myelo- 
 cytes during the first days of life, a lesser development of absolute 
 
 1 Zur Therapie der Rachitis, Jahrb. f. Kiaderh., 1914, 79, 194.
 
 352 DISEASES PECULIAR TO PREMATURE INFANTS 
 
 and relative leucocytosis, and a greater number of immature leuco- 
 cyte forms. There is also a distinct and very early hemoglobin 
 impoverishment of the blood, which reaches its maximum in 
 about the third to the fourth month. 
 
 Etiology. — Kunckel 1 believed that this anemia appearing regu- 
 larly in the first three months of life was physiological and was of 
 the chlorotic type. His children improved in the second half 
 year of life, but if infection was present any time the infants devel- 
 oped a severe secondary anemia much more readily than full-term 
 infants. His opinion was that the anemia did not rest on an 
 alimentary basis but was due to an insufficiency in hemoglobin 
 metabolism, beside a deficient iron storage. 
 
 Pfaundler 2 felt that the anemia was closely related to a lack of 
 fresh air and sunshine. 
 
 Lichtenstein 3 fixes the early anemia in the first three months of 
 life as a hypoplastic condition resulting through insufficiency of the 
 hematopoietic system. The later oligochromemia, after spon- 
 taneous retrogression of the oligocythemia, he considers as a sequel 
 of the impoverished iron storage. He opposes the hypothesis of 
 alimentary anemia of Czerny and Kleinschmidt. The theory of 
 the harmful action of milk on the hematopoietic apparatus he 
 asserts is disproved by the excellent results attending the feeding 
 of human milk and the administration of small amounts of ferrous 
 lactate. 
 
 Lande 4 is in accord with the opinions of Kunckel and Lichtenstein. 
 As evidence in favor of the importance of iron storage he em- 
 phasizes the fact that eighth-month infants in the course of the 
 second quarter year of life show a higher percentage of hemoglobin 
 and erythrocytes than do seventh-month prematures. 
 
 The examination by Lande of the bone marrow in ten prematures 
 disclosed no decisive picture except an insufficiency of the granulo- 
 cyte system. Thus he disproves the theory that the basis of the 
 anemia rests with a defective erythropoietic system. 
 
 Lichtenstein feels that there is no marked difference in the blood 
 picture of artificially and breast-fed prematures. Examination of 
 twenty-eight cases artificially fed, many of whom were born of 
 nephritic, anemic and tuberculous mothers, showed no great differ- 
 ences in the blood picture from those breast-fed. 
 
 Symptoms.— The most marked symptom observed by Lande was 
 pallor of the skin, which he saw with great regularity. It appeared 
 especially early as a fore-runner of icterus, which in prematures is 
 
 i Ztschr. f. Kinderh., 1915, 13, 101. 
 
 2 Verhand. d. Ges. f. Kinderh., Breslau, 1904, 21, 24. 
 
 3 Svenska, LaKaresa As Kapets Handlingor, 1917, No. 4, 43. 
 * Ztschr. f, Kinderh., 1918, 22, 299.
 
 ANEMIA OF PREMATURE INFANTS 353 
 
 constantly present. The question arises as to whether the anemia 
 is promoted by the icterus or both icterus and anemia are not 
 bound up with a third factor— the maturity of the infant. 
 
 One can differentiate various grades of pallor, which is earliest 
 and most clearly seen in the face and well agrees in general with 
 the degree of pathological blood change. The most marked form 
 of anemia gives the infant a bluish, transparent appearance, or a 
 waxen, yellowish color, somewhat akin to the infants with severe 
 congenital syphilis or chronic pyelitis. The picture is accentuated 
 by the outstanding bluish veins, especially prominent on the skull 
 and abdomen. The ears are transparent with hardly the vestige 
 of a rosy hue and the mucous membranes are very pale. 
 
 The pallor after open-air treatment has been noted to give way 
 to a rosy hue, but only in a few cases is there a parallel permanent 
 increase in hemoglobin. However, with the increase in hemoglobin 
 and erythrocytes in the fourth to sixth months, the color simul- 
 taneously improves. 
 
 In Lande's series the appetite of the infants was in general satis- 
 factory. There was no stupor, especially in the more anemic. 
 There were no elevations of temperature, as described by some 
 observers, present with the marked blood changes. 
 
 Marked glandular and splenic swelling was not observed by 
 Kunckel or Lande, but Lichtenstein states that splenic tumor was 
 present in two- thirds of his children. 
 
 Lichtenstein finds that the blood pictures in the well breast-fed 
 prematures and those showing alimentary disturbances are both 
 of the chlorotic type and differ mainly in degree. He also believes 
 that the clinical picture described as pseudoleukemic anemia is a 
 severe form of secondary anemia and is not a distinct clinical 
 entity. 
 
 Treatment.— For the general and hygienic treatment of primary 
 and secondary anemia, the suggestions made for general measures 
 in the care of rachitis should be followed. The infants must above 
 all be given the advantage of a good environment, plenty of fresh 
 air and sunshine. 
 
 Iron therapy for the purpose of increasing the iron content of the 
 tissues and the hemoglobin has met with individual success. It 
 should be started early. Among the iron compounds to be recom- 
 mended are ferri carbonas saccharatus 0.25 to 0.5 gm., ferri et 
 ammonii citratis 0.06 to 0.12 gm. or ferri Iactis 0.12 to 0.25 gm. 
 one to three times daily. 
 
 Small doses of liquor potassii arsenitis 0.03 to 0.0(5 cc may be 
 given one or two times daily for short periods. The infant should 
 be observed carefully for evidence of arsenic intoxication. 
 
 In the presence of congenital syphilis, mercurial therapy is impera- 
 23
 
 354 
 
 DISEASES PECULIAR TO PREMATURE INFANTS 
 
 tive and may be combined with the arsenic treatment to good 
 advantage. 
 
 Lande suggests the use of intramuscular injections of normal 
 human blood. The blood is drawn from the vein of a healthy adult 
 with a Wassermann needle and allowed to flow into a flask containing 
 small glass beads. It is shaken about five minutes and thus defibrin- 
 ated and before injection is passed through a double thickness of 
 sterile gauze. In individual cases the result may be very good, 
 however, in a series of thirteen cases he was unable to demonstrate 
 a marked increase in hemoglobin or red corpuscles. 
 
 It is of the greatest importance to bear in mind that, as in the 
 case of rachitis, the treatment for anemia should be started early. 
 It is our custom to begin the prophylactic treatment of both of 
 these conditions in the first weeks of life. 
 
 SPASMOPHILIC DIATHESIS IN PREMATURE INFANTS. 
 
 TETANY. 
 
 Besides anemia and rachitis, spasmophilia is one of the most 
 interesting clinical peculiarities of premature infants. The term 
 
 Fig. 179. — Spasmophilia. Infant in state of "tetany. 
 
 spasmophilia is used here in the sense of designating the mani- 
 festations occurring in the nursling, while tetany refers to the older 
 child. Typical tetany with all its characteristic symptoms, the
 
 SPASMOPHILIC DIATHESIS IN PREMATURE INFANTS 355 
 
 phenomena of Erb, Chvostek and Trousseau, carpopedal spasms, 
 tonic and clonic convulsions and laryngospasm, has rarely been 
 observed in the premature new born. While spasmophilia is by 
 no means rare in artificially fed, full-term infants, it is found quite 
 frequently in prematures, and not only in those artificially fed, but 
 also in the infants fed on human milk. With breast-feeding, 
 however, spasmophilic manifestations occur only exceptionally and 
 lead to convulsions usually only in connection with infections. 
 
 Etiology and Symptoms.— There are other predisposing factors 
 besides feeding in the development of spasmophilia in prematures. 
 We may not call these factors constitutional, since in all proba- 
 bility they depend on the various noxse of the extra-uterine life. 
 These lead to a hyperirritability of the nervous system. The 
 nervous system in all premature infants is extraordinarily lowered 
 during the first weeks of life against all possible stimuli, including 
 the electrical. 
 
 On the other hand, however, it is a fact that feeding plays a very 
 important role in the development of spasmophilia and above all 
 in the appearance of convulsions. Not uncommonly one observes 
 prematures in whom the spasmophilic manifestations remain latent 
 as long as breast-feeding is continued, but appear shortly after 
 the institution of artificial feeding. Langstein 1 reported a case of 
 twins in whom convulsions always appeared shortly after artificial 
 feeding was added to human milk. There were individual differ- 
 ences between the twins in the ease with which the convulsions 
 could be produced. In one infant they developed within seven to 
 twelve days after the addition of artificial food, in the other 
 within eighteen to twenty days. 
 
 If we systematically examine the electrical irritability in a large 
 number of prematures we can determine that in infants fed on 
 human milk the electrical irritability may increase to such an 
 extent as to be C.O.C. less than 5 milliamperes at the age of six 
 to ten weeks. Rosenstern 2 studied the spasmophilic diathesis in 
 premature infants and noted individual differences in the electrical 
 hyperirritability, which appeared very early and frequently in 
 breast-fed prematures. He was able to demonstrate spasmophilia 
 in the form of electrical hyperirritability in 76 per cent of the 
 prematures and debilitated infants that he examined. 
 
 In Ylppo's series the electrical hyperirritability was not as 
 frequent. Among the 42 premature infants in whom he was able 
 to determine the electrical reaction systematically during the first 
 three to six months of life, only 15 infants (35 per cent) showed 
 C.O.C. less than 5 milliamperes. In 3 cases electrical hyper- 
 
 1 Kassowitz, Festschrift, Berlin, 1912. 
 
 2 Ztschr. f. Kinderh., 1913, 8, 171.
 
 356 DISEASES PECULIAR TO PREMATURE INFANTS 
 
 irritability was already present in the second month. One infant 
 was on human milk-feeding and the other on mixed feeding. In 
 the third month electrical hyperirritability appeared in 3 additional 
 infants. It was most frequently present in the fourth month. 
 From this data it seems that spasmophilia appears earlier in pre- 
 mature than in full-term infants. 
 
 Ylppo 1 also noted the especially interesting fact that the great 
 tendency to electrical hyperirritability and convulsions, which he 
 determined in many artificially fed premature infants, three to 
 four months old, gradually disappeared in the fifth to sixth months 
 without any treatment, while the feeding remained the same. 
 In other children it often took months before the electrical hyper- 
 irritability disappeared. 
 
 In premature infants we frequently find very interesting devi- 
 ations from the generally recognized symptoms of spasmophilia. 
 It is not at all infrequent that the cardinal symptom of spasmo- 
 philia (Erb's symptom), the electrical hyperirritability of the 
 peripheral nerves, may be absent, in spite of the manifest signs 
 of the disorder. To know this is very important, because we know 
 that there exist conditions in premature infants in which the 
 electrical reaction remains increased for months, although no con- 
 vulsions occur. This lack of electrical hyperirritability in spasmo- 
 philic convulsions in prematures exists not only after convulsions 
 have taken place— which could easily be accounted for by exhaus- 
 tion of the nervous system— but also before the appearance of 
 convulsions. 
 
 In individual cases there may be pathologically increased elec- 
 trical hyperirritability, even when the electrical reaction does not 
 go below 5 milliamperes for C.O.C. Rosenstern called attention 
 to this fact and pointed out that the value below 5 milliamperes 
 for C.O.C, which is regarded as pathognomonic for the spasmo- 
 philic diathesis, was determined by Mann 2 and Thiemich 3 only for 
 the age of eight weeks. From this it follows that this value is not 
 to be regarded as a limit for younger infants, at least not for the 
 younger prematures. 
 
 In the majority of cases the disappearance of the spasmophilic 
 tendency in prematures occurs at the same time at which anemia 
 and craniotabes begin to improve. Thus it becomes more and 
 more apparent that the three symptoms, anemia, rachitis and 
 spasmophilia are in a certain interrelationship. It may very well 
 be that the same harmful factors that damage the activity of the 
 hematopoietic organs in the first months of life and also the growth 
 
 1 Ztschr. f. Kinderh., 1919, 24, 1. 
 
 2 Monatsschr. f. Psych, u. Neurol., 1900, 7, 14. 
 
 3 Jahrb, f. Kiaderh., 1900, 51, 99, 222.
 
 SPASMOPHILIC DIATHESIS IN PREMATURE INFANTS 357 
 
 and the normal calcification of the bones in such a high degree 
 produce in some manner unknown to us changes in the nervous 
 system. 
 
 Calcium Metabolism.— A calcium deficiency in the tissues has 
 been demonstrated by numerous investigators, more especially in 
 the brain and blood. The earlier investigations on the blood have 
 more recently been confirmed by Ilowland and Marriott, 1 who 
 found the calcium of the blood serum to be low in this condition, 
 averaging 5.(> mg. per 100 cc of serum in a group of 18 cases, the 
 lowest being 3.5 mg. per 100 cc of serum, the average normal 
 amounts being 10 to 11 mg. per 100 cc. They found a normal 
 calcium content in the serum in convulsive disorders due to other 
 causes. These same authors found the magnesium content in the 
 serum to be within normal limits even in the presence of active 
 spasmophilia. The relation of calcium to the symptoms of spasmo- 
 philia has been studied extensively, especially its influence on the 
 electric excitability. Physiologists have shown that certain 
 mineral ions exert a specific effect on muscle-nerve irritability. 
 Rosenstern 2 and Sedgwick 3 reduced the electric irritability in spasmo- 
 philic infants by administering large doses of calcium by mouth. 
 Loeb's 4 findings indicate that Na and K increases the threshold 
 for excitation, while Ca and Mg tend to decrease this. This 
 
 Ca + Mg 
 muscle nerve irritability is the function of the quotient -v? — . ^ 
 
 as designated by Reiss. 5 During a diarrhea Holt 6 has demonstrated 
 there is a much greater loss of Na and K than Ca and Mg in the 
 stools. Diuresis and catharsis often cause an improvement in the 
 spasmophilic symptoms. Consequently, there is much clinical 
 and experimental evidence that spasmophilia is much influenced 
 by the relationship between the Ca-Mg and Na-K group of ions. 
 
 Accidental removal of the parathyroid gland in humans and 
 experimental excision of these glands in animals have both resulted 
 in a tetany that resembles in its clinical manifestations the spasmo- 
 philia of infants. Following the animal experiments Howland 
 and Marriott 7 have demonstrated a diminution in the calcium 
 content of the blood. These findings have been verified by Mao- 
 Callum and his co-workers, 8 who also found a decreased calcium 
 content in the brain and an increased excretion. 
 
 1 Quarterly Jour. Med., 1917-1918, 11, 289. 
 
 2 Jahrb. f. Kinderh., 1910, 72, 154. 
 
 3 St. Paul Med. Jour., 1912, 14, 497-519. 
 
 4 Oppenheimer's Handbuch der Biochemie. 
 6 Ztschr. f. Kinderh., 1911, 3, 1. 
 
 6 Am. Jour. Dis. Child., 1915, 9, 213. 
 
 7 Trans. Am. Ped. Soc, 1916, 28, 200. 
 
 8 MacCallum and Voegtlein: Jour. Exp. Med., 1909, 11, 118.
 
 358 DISEASES PECULIAR TO PREMATURE INFANTS 
 
 Greemvald, 1 in his experimental studies, found that the phos- 
 phorus excretion in the urine of his animals was greatly decreased 
 (to as low as 8 per cent of the normal) shortly after operation. 
 He also found an increase of the phosphorus content of the blood 
 before the appearance of tetany. There was also a sodium and 
 potassium retention. He believes that following the extirpation 
 of the parathyroid there is a decreased excretion through the 
 kidneys and an abnormal retention in the tissues of the alkali 
 phosphates, which is followed by a decreased retention and an 
 increased excretion through the kidneys as soon as the spasms 
 develop. 
 
 There is, however, great question as to the relationship of para- 
 thyroid dysfunction and tetany in the infant. Pathological studies 
 lead us to believe that parathyroid lesions in infantile tetany are 
 the great exception. Parathyroid lesions have been described in 
 patients who have shown no evidence during life of the pathogno- 
 monic findings of tetany. 
 
 In summarizing the pathogenesis we may state that a diminution 
 of the calcium salts in all probability is the most important factor 
 in the development of this condition. However, the possibility of 
 an absolute or relative excess of the sodium and potassium salts, 
 especially the phosphates, playing an important role cannot be 
 overlooked. The relationship of disturbance in parathyroid func- 
 tions to the diminution of calcium tissue content must be made the 
 subject of further study before its importance can be fixed. 
 
 Diagnosis.— The differential diagnosis of spasmophilic convul- 
 sions in prematures is very difficult. Among the conditions to be 
 considered are hydrocephalus, congenital syphilis and tuberculosis, 
 epilepsy, infections, brain injuries, asphyxia and pulmonary atelec- 
 tasis. Tetanus neonatorum is rarely seen today. Meningitis and 
 encephalitis are the most important of the infectious processes, and 
 the primary focus often is unknown. Perhaps the best test after 
 careful history and physical examination is the determination of 
 the electrical reactions. 
 
 It must not be forgotten that given an injured brain and a marked 
 tendency to spasmophilia, this leads, in the premature, in the first 
 place to convulsions and other manifest phenomena of this diathesis. 
 
 There are only a few cases in the literature where special atten- 
 tion has been devoted continuously from birth to the later years 
 to the condition of the spasmophilic infants. Ylppo's material 
 enabled him to fill this gap to a certain extent. He was able 
 to show positively that spasmophilia in premature infants very 
 frequently occurred after a preceding injury to the brain, and this 
 
 1 Jour. Biol. Chem... 1913, 14, 370.
 
 SPASMOPHILIC DIATHESIS IN PREMATURE INFANTS 359 
 
 injury rather than spasmophilia, causes the later brain changes. 
 Spasmophilic convulsions may, however, produce extensive damage 
 to the brain, and may result in various defects of intelligence and 
 other cerebral disturbances. 
 
 Treatment.— The treatment of spasmophilia is largely prophylac- 
 tic and embraces the therapy of rachitis and anemia (see p. 351). 
 With the early institution and the continuation of these hygienic, 
 dietetic and medicinal measures, the development of spasmophilic 
 convulsions will be very unusual. 
 
 Fig. 180. — Spasmophilia — double fracture of both forearms following prolonged 
 carpal spasm. Premature, aged six months. 
 
 If convulsions appear the infant must be kept absolutely quiet 
 and warm. Narcotics are usually employed, the best being chloral 
 hydrate 0.25 to 0.5 gm. per rectum and calcium bromide 0.5 to 1 gm. 
 per day. 
 
 Lumbar puncture with the drawing-off of 5 to 15 cc of spinal 
 fluid may give relief from repeated convulsions. 
 
 The use of general anesthesia and morphine derivatives to control 
 convulsions is to be avoided except as measures of last resort. 
 
 Magnesium sulphate in sterile 8 per cent solution has been 
 used in subcutaneous injections, 5 to 15 cc repeated once or twice 
 within forty-eight hours, to control convulsions. Because of its 
 marked depressive action on the nervous system, the infant must
 
 360 DISEASES PECULIAR TO PREMATURE INFANTS 
 
 be very closely watched for collapse. Although this method has 
 been much used in some clinics our experience has not warranted 
 its use in preference to our preceding measures. 
 
 For the acute manifestations the calcium salts in maximal doses 
 (preferably calcium lactate, 0.3 to 0.6 gm., three times daily, in 
 solution or suspension) in our experience have been more valuable 
 than the magnesium salts. 
 
 Administration of cod-liver oil and phosphorus or tricalcium 
 phosphate in emulsion of cod-liver oil, as recommended in the 
 treatment of rachitis, should be started at the same time and con- 
 tinued indefinitely, in doses varying from | to 4 cc twice daily, 
 dependent upon the age and the indications. 
 
 Where feeding by mouth is difficult, catheter administration 
 must be resorted to together with inert fluids per rectum. If 
 human milk is not obtainable the best substitute is albumin milk, 
 which is poor in whey and rich in calcium. Where stimulating 
 treatment becomes necessary that which has been previously 
 mentioned may be employed. 
 
 In all our measures extreme gentleness must be used, as any 
 rough handling or violence, in case of asphyxia, has a very harmful 
 influence.
 
 PART IV. 
 THE OUTLOOK FOR THE PREMATURE. 
 
 CHAPTER XIX. 
 
 PROGNOSIS. 
 
 In estimating the outlook for an infant born before the natural 
 termination of the normal period of pregnancy, one must consider 
 the prenatal and the postnatal factors before arriving at a conclu- 
 sion. Of prenatal influences the most important is: (1) The 
 absolute age; (2) the physiological development and absence of 
 constitutional anomalies; (3) transmitted parental conditions; 
 (4) the presence of malformations. Of postnatal conditions the 
 occurrence of any of the various diseases of the new born affects 
 the prognosis unfavorably as a rule while the temperature and 
 general behavior are of the utmost value in judging of its chances 
 for life. In addition to these, the time at which the infant is 
 received for treatment, and the character of the treatment it 
 receives, go far in determining the probable outcome. While all 
 factors must be taken into consideration, yet those of the most 
 practical value relate to the child's behavior. Ability to nurse 
 and swallow, coupled with strong muscular movements and a good 
 cry, are the principal indications that the infant possesses a fair 
 degree of vitality and resistance to disease, and that with proper 
 care and nourishment it stands an excellent chance of resisting the 
 enemies which threaten its existence during the first few weeks of 
 its career, namely, cold and infection. At first doubtful, the prog- 
 nosis becomes better as time passes in proportion to the care the 
 child receives with respect to its hygiene and feeding. The secret 
 of success in raising the premature lies in avoiding cold and infection, 
 and in the proper selection of food as regards quality, quantity 
 and method of administration.
 
 362 PROGNOSIS 
 
 There is not the slightest doubt but that the premature infant 
 born of healthy parents, who is without congenital deformity and 
 who survives the first few days of life, is entirely capable of com- 
 plete and perfect development. The various factors that affect 
 the outlook may be considered in detail. 
 
 Age.— The prognosis of the premature infant depends in the first 
 place chiefly upon the actual (fetal) age, or in other words upon the 
 length of time it has remained within the uterine nest (Pfaundler) ; 
 the infant born before the twenty-seventh week of pregnancy 
 having but a slight chance of living. Other things being equal, 
 those who are not too young can be raised. 
 
 The influence of the age on the mortality is well shown by the 
 figures of Potel : 
 
 Age. No. of children. 
 65 fetal months 56 
 
 7 " 131 
 
 7| " 53 
 
 8 " 110 
 
 Sherman quotes the figures of several observers and includes 
 those of his own experience in the Children's Hospital, Buffalo: 
 
 Number dying. 
 
 Per cent. 
 
 45 
 
 80.4 
 
 76 
 
 58.1 
 
 17 
 
 30.1 
 
 39 
 
 35.5 
 
 Incubator. 
 
 Tarnier 
 
 Charles 
 
 SI 
 
 sane Hospital 
 
 Gilbert 
 
 Sherman 
 
 Cook 
 
 
 Per cent. 
 
 Per cent 
 
 
 Per cent. 
 
 Per cent. 
 
 Per cent. 
 
 Per cent. 
 
 Saved at: 
 
 
 
 
 
 
 
 
 6 months . 
 
 . 30 
 
 10 
 
 
 
 20 
 
 
 
 17 
 
 6| " 
 
 
 20 
 
 
 66 
 
 
 
 20 
 
 7 
 
 . 63 
 
 40 
 
 
 71 
 
 35 
 
 50 
 
 50 
 
 71 " 
 * 2 
 
 
 75 
 
 
 89 
 
 
 66 
 
 
 8 
 
 . 85 
 
 
 
 91 
 
 85 
 
 
 74 
 
 8| " 
 
 . 95 
 
 
 
 
 
 100 
 
 
 Sherman's table shows the fallacy of the popular belief that more 
 children are saved at the seventh month than at the eighth. All 
 things being equal the older the premature the better its chance of 
 life. 
 
 Great confusion exists in a study of various statistics because 
 of the misapplication of the term "months"; the latter should 
 apply to lunar months (twenty-eight days) and not calendar months 
 or better the age should be stated in days or weeks to avoid all 
 confusion. 
 
 The Germans have usually considered one hundred and eighty- 
 one days as the minimum period after which life may be sustained, 
 while the French laws regard one hundred and eighty days of uterine 
 life as necessary to viability. That one hundred and eighty days 
 (six and one-half lunar months or nearly twenty-six weeks) are 
 necessary to existence is disputed by many.
 
 WEIGHT 363 
 
 The exact age of an infant is not easy to determine. In fact, 
 it is most difficult, due to the uncertainty as to the beginning of 
 pregnancy. As previously stated, the statement of the mother as 
 to her last menstrual period or as to the time that life was first felt 
 are notoriously uncertain, and weight, length and other head and 
 body measurements are uncertain factors in determining the degree 
 of unripeness of the premature child. The most accurate method 
 at hand today to determine the age of the premature infant is 
 by roentgenograms of the skeleton, since the osseous development 
 is more regular and offers more factors for consideration than 
 determining the age based on length and other measurements 
 (see "Skeletal Development," p. 101). 
 
 Weight.— This is a much less dependable factor than age in esti- 
 mating the outlook for the premature child. All conditions being 
 equal, a small older child has a better chance of living than a 
 younger one who weighs more. Nevertheless, a decrease in the 
 death-rate accompanies an increasing birth weight. The prognosis 
 is better, on the face of it, in a child of 2000 gm., but on the other 
 hand, the 2000-gm. child may have a poorer chance of life because 
 of debility (Pfaundler) . 
 
 Crede reported a mortality of 83 per cent for children weighing 
 1000 to 1500 gm. and 11 per cent for those of 2000 to 2500 gm. 
 weight. Here the healthy and the debilitated prematures have not 
 been descriminated between. Separating these two classes, as 
 Francois did, one finds that of 81 children born of diseased parents, 
 30 to 37 per cent died, while of 386 apparently well premature 
 babies, only 12.5 per cent died. 
 
 Carlini gives as the lowest figures compatible with viability, a 
 weight of 1000 gm. and a length of 31 cm. These figures are high 
 as attested by an examination of the literature, where several 
 cases are on record as surviving with either a weight or a length 
 smaller. (See list of smallest prematures saved.) 
 
 Sherman, 1 of Buffalo, published the following table showing the 
 number of children saved according to weight in his institution: 
 
 Percentage 
 Weight. saved. 
 
 2 to 2\ pounds 25.0 
 
 2|to3 " 50.0 
 
 3 to3| " 42.8 
 
 3| to 4 " 50.0 
 
 4 to 4^ " 75.0 
 
 1 Sherman, D.-H.: Buffalo Med. Jour., 44, 053; New York Med. Jour., 1905, 
 82, 272.
 
 364 PROGNOSIS 
 
 Cook's 1 results were as follows: 
 
 No. of Percentage 
 
 cases. saved. 
 
 Under 1500 gm 17 53 
 
 1500 to 2000 " 20 55 
 
 2000 to 2500 " 20 75 
 
 Over 2500 " 5 100 
 
 The smallest infant to survive in this series weighed 1250 gin. 
 and was 38 cm. long. The initial loss was 130 gm. ; it began to gain 
 on the fourth day and had regained its birth weight on the fifteenth 
 day. At the age of two months, which otherwise would have been 
 at term, it weighed 2000 gm. 
 
 These figures indicate that the heavier the child at birth, the 
 better its chances of surviving the first few weeks or months of 
 life. What bearing the natal weight has on the future of the 
 child we shall see later. 
 
 The smallest prematures recorded in the literature that were 
 saved showed the following body weights and measurements: 
 
 Author.* Weight, gm. Length, cm. 
 
 Oberwarth 1 ... 500 
 
 J. H. Hess 2 (71 days) 690 
 
 (72 days) 740 
 
 Oberwarth 3 750 35.3 
 
 d'Outrepont 4 750 37.0 
 
 Meyer 5 750 
 
 Roth 6 750 31.0 
 
 Heller 7 800 
 
 840 32.0 
 
 Ylppo 840 
 
 L. E. Frankenthal . . 850 
 
 Pfaundler 8 860 35.5 
 
 Waegeli 9 860 31.0 
 
 Klinker 10 895 
 
 Ahlfeld 11 900 34.0 
 
 Pizzini 12 900 30.0 
 
 Jardine 13 907 
 
 Villemain 14 950 38.0 
 
 Maygrier and Scwab 16 970 
 
 Heiberg 16 975 
 
 Rommel 17 980 
 
 Ahlfeld 18 980 37.0 
 
 Tissier 19 990 31.0 
 
 Schmid 20 1000 35.0 . 
 
 Kopp 21 1000 
 
 J. H. Hess 22 1070 
 
 Reber 23 1120 
 
 1 Arch. Ped., 1921, 33, 201. 
 * References will be found on page 376.
 
 TEMPERATURE 365 
 
 Martha and Augusta were two of triplets born of a Greek family 
 at six and a half months, and were delivered by a midwife. The 
 mother visited the children at the hospital on the fourth day after 
 their birth and on the following, the fifth day, gave birth to a third, 
 still-born fetus with a second placenta, and was again out on the 
 ninth day. Xo less interesting were some of the deformities in 
 the case of Baby Martha of the interesting group of triplets. She 
 had but two fingers on one hand, and both knees and elbows were 
 ankylosed in extension; in fact, there seemed to be an absence of 
 the joint surfaces; while Baby Augusta had freedom of motion 
 in all of her joints. Considering their prematurity, six and a 
 half months, their weight at birth, 740 and 090 gm., respectively, 
 together with the deformities in Baby Martha, it is surprising to 
 find them surviving to seventy-two and seventy-one days, when 
 both succumbed during attacks of cyanosis, due in all probability 
 to overfeeding. 
 
 Because of Baby Augusta's better development, she was fed 
 greater quantities from the start and although she did not have 
 as great an initial fall in weight, both continued to lose until the 
 twentieth day, Baby Augusta losing a total of 200 gm. and Baby 
 Martha 230 gm. in this time. The records are rather incomplete 
 as to the food given in Case II during this period. In Case I the 
 estimates run from 65 to 89 calories per kilo. From the twentieth 
 day on both infants showed almost stationary weight with food 
 values below 120 and the greatest gain on an energy quotient 
 between 130 and 140; and death in both cases with an energy 
 quotient of over 200. 
 
 Temperature.— In order to correctly estimate the power of resist- 
 ance of a premature infant it is necessary to consider the degree 
 of depression of the temperature and with it the weight of the 
 child. The figures of Budin show that the lower the temperature 
 the more serious any further reduction will be, and the less the 
 weight the more easily the child succumbs. In weaklings in whom 
 the temperature was 32° C. or less (89.6° F.) the mortality was 
 98 per cent when they weighed 1500 gm. or less; 97.5 per cent 
 when they weighed between 1500 and 2000 gm.; 75 per cent when 
 thev weighed more than 2000 gm. AVhen the rectal temperature 
 fluctuated between 32° and 33.5° C. (89.6° and 92.3° F.), the 
 mortality of the first group was 97.3 per cent; of the second group 
 85.6 per cent; and of the third group, weighing 2000 gm. or over, 
 69.2 per cent. Thus it is necessary to consider both the weight 
 and the degree of hypothermia. The most striking contrast i- 
 seen in comparing the figures of the Maternite and the Clinique 
 Tarnier, Paris. To the former are often brought infants with a
 
 366 
 
 PROGNOSIS 
 
 Fig. 181. — Two of Greek triplets weighing 690 and 740 gm. 
 
 Juue July August 
 
 1J 20 23 2G 2D 2 5 8 11 14 17 20 23 2C 20 1 4 7 10 13 1G 19 22 25 
 
 700 
 600 
 
 WEIGHT 
 GM. 
 
 500 
 
 300 
 
 FOOD C.C. 200 
 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 - 
 
 
 
 
 
 
 
 
 
 q_ 
 
 
 
 
 
 
 
 -"- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 | | 
 
 u 
 
 
 
 
 
 
 
 
 CALORIES PER KILO. 
 
 
 
 
 
 1 W 
 
 it: + 113 1 u 
 
 
 
 13,6 | 1 
 
 8 
 
 
 
 
 i 
 
 6 
 
 
 
 Fig. 182. — Weight and food curves of first of Greek triplets. Birth weight, 690 grn. 
 
 June 
 1G 19 2 
 
 July August 
 2 25 28 1 4 7 10 13 1G 19 22 25 28 31 3 6 9 12 15 18 21 24 
 
 800 
 
 700 
 
 WEIGHT 
 
 GM. 
 
 COO 
 
 500 
 300 
 
 FOOD C.C. 200 
 
 100 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 — 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J-J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 i-- 
 
 P- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CALORIES PER KILO. 
 
 
 
 
 
 1 
 
 '• 
 
 8 
 
 ,| 
 
 I 
 
 
 
 1 
 
 H 
 
 
 
 1 
 
 8 
 
 1 
 
 JO 
 
 1 
 
 % + 1 
 
 7 
 
 
 
 Fig. 183. — Weight and food curves of second of Greek triplets. Birth weight, 740 gm.
 
 BODY MEASUREMENT 367 
 
 temperature lowered to 32° C. (89.6° P\); the mortality among 
 these neglected weaklings of a weight of 2000 gm. or less ranged from 
 90 to 98 per cent. At the Clinique Tarnier even' precaution is 
 taken to conserve the body warmth and here the mortality of 
 infants of the same weight is only 23 per cent. 
 
 Sherman's experience is comparable with that of Tarnier. Of 
 10 babies having a rectal temperature of 35.5° C. (90° F.) or less, 
 all but 2 died. 
 
 Porak and Durante estimated the lowest degree to which the 
 body temperature may sink, with reparation still possible, as 
 follows: 
 
 Infants with weight less than 110 gm., 34° C. (93° F.) 
 Infants with weight 1100 to 1300 gm., 30° C. (86° F.) 
 Infants with weight 1300 to 1750 gm., 29° C. (84° F.) 
 Infants with weight above 1750 gm., 28° C. (82.4° F.) 
 
 Ylppo disagrees with the French observers in that his belief is 
 that the mere cooling of the body surface does not result in death, 
 but that many of these infants with subnormal temperature are 
 the victims of birth injuries or brain hemorrhage, the latter factors 
 resulting in fatality. 
 
 Apert reported a premature with a temperature of 30° C. (86° F.) 
 which lived. Ylppo states that he has seen a series of infants who 
 in spite of a temperature of only 27° to 28° C. (80.6° to 82.4° F.) 
 at birth, remained alive. If the subnormal temperature does not 
 persist too long, with resulting capillary damage and edema, 
 especially of the lungs, recovery is possible. To show the relation 
 between mortality and subnormal temperature, Ylppo summarizes 
 his material in the table on page 368. 
 
 Our experience has been that unless the child with subnormal 
 temperature is soon placed in surroundings more favorable, the 
 prognosis is grave. If, when placed in an incubator, the resulting 
 rise of temperature is retarded, it is an unfavorable sign. An 
 abrupt rise after a previously stationary hypothermia is also 
 unfavorable. If the body temperature rises to 37° C. (98.6° F.) 
 and remains there, one may say that the nervous system is doing 
 its work properly. 
 
 Body Measurements.— Other measurements beside those of weight 
 are of assistance in estimating the viability of the premature.
 
 368 
 
 PROGNOSIS 
 
 TABLE SHOWING RELATION BETWEEN MORTALITY AND SUBNORMAL 
 TEMPERATURE IN PREMATURES. 
 
 
 37- 
 
 35° C. (98.6-95° F.). 
 
 34.E 
 
 -33° C. (95- 
 
 J1.4°F.). 
 
 
 No. 
 
 Death at : 
 
 No. 
 
 Death at: 
 
 
 
 
 
 
 5 days. 1 month 
 
 
 5 days. 1 month. 
 
 Group I 
 
 600 to 1000 gm. 
 
 3 
 
 2 
 66.60% 
 
 12 
 
 8 
 66.60% 
 
 11 
 
 91.60% 
 
 Group II . 
 
 1001 to 1500 gm. 
 
 40 
 
 10 15 
 25.00% 37.50% 
 
 46 
 
 15 
 32.82% 
 
 19 
 41.30% 
 
 Group III . . . . 
 1501 to 2000 gm. 
 
 76 
 
 7 16 
 9.12% 21.05% 
 
 40 
 
 3 8 
 7.50% 20.00% 
 
 Group IV .... 
 2001 to 2500 gm. 
 
 4 
 
 85 
 
 4 5 
 
 4.71% 5.88% 
 
 19 
 
 1 5 
 5.26% 26.32% 
 
 
 32.9 
 
 -31° C. (91°-87.8° F.l. 
 
 30.9° 
 
 29° C. (87.6-84.4° F.). 
 
 Group I 
 
 600 to 1000 gm. 
 
 5 
 
 4 
 80.00% 
 
 5 
 100.00% 
 
 6 
 
 5 
 83.30% 
 
 
 Group II ... . 
 1001 to 1500 gm. 
 
 27 
 
 7 
 25.90% 
 
 13 
 
 48.10% 
 
 12 
 
 7 
 58.30% 
 
 10 
 83.30% 
 
 Group III . . . . 
 
 1501 to 2000 gm. 
 
 20 
 
 5 
 
 25.00% 
 
 10 
 50.00% 
 
 12 
 
 2 
 16.60% 
 
 7 
 58.30% 
 
 Group IV ... . 
 
 2001 to 2500 gm. 
 
 8 
 
 
 > 
 
 25.00% 
 
 1 
 
 
 
 
 28.9°- 
 
 -27° C. (84.2°-80.6° F.). 
 
 26.9 C 
 
 -25° C. (S0.4°-77 o F.). 
 
 Group I 
 
 600 to 1000 gm. 
 
 6 
 
 5 
 83.30% 
 
 6 
 
 100.00% 
 
 1 
 
 
 1 
 100.00% 
 
 Group II ... . 
 1001 to 1500 gm. 
 
 7 
 
 3 
 
 42.80% 
 
 6 
 85.70% 
 
 1 
 
 
 1 
 
 100.00% 
 
 Group III .... 
 1501 to 2000 gm. 
 
 5 
 
 2 
 40.00% 
 
 3 
 
 60.00% 
 
 
 
 
 Group IV ... . 
 2001 to 2500 gm. 
 
 5 
 
 
 1 
 20.00%, 
 
 1 
 
 1 
 100.00% 

 
 CAUSE OF LABOR 
 
 369 
 
 Ostrcil gives figures which show a rapid lessening of mortality in 
 infants weighing over 2000 gm. and of a length greater than 44 cm.: 
 
 Weight. Viability. 
 
 Grams. Per cent 
 
 1400 
 
 1500 
 
 1600 17 
 
 1700 27 
 
 1800 21 
 
 1900 33 
 
 2000 47 
 
 2100 50 
 
 2200 43 
 
 2300 49 
 
 2400 58 
 
 2500 54 
 
 2600 62 
 
 2700 59 
 
 2800 63 
 
 Length. Viability. 
 
 Cm. • Per cent 
 
 40 21 
 
 41 20 
 
 42 25 
 
 43 28 
 
 44 51 
 
 45 50 
 
 46 55 
 
 47 58 
 
 Similarly Pfaundler demonstrated the decreasing mortality with 
 increasing birth weight: 
 
 
 Body weight. 
 
 Body 
 
 length, 
 
 cm. 
 
 Mortality in 
 first weeks 
 
 of life, 
 per cent. 
 
 
 Age in fetal 
 months. 
 
 Normal 
 
 fetuses, 
 
 gm. 
 
 Prematures, 
 gm. 
 
 Surviving, 
 per cent. 
 
 6 
 
 6.5 
 
 7 
 
 7.5 
 
 8 
 
 1300 
 1800 
 2500 
 
 1000 
 1200 
 1500 
 1800 
 2200 
 
 35 
 37 
 39 
 42 
 45 
 
 95 5 
 82 18 
 63 37 
 42 58 
 20 80 
 
 The Cause of Labor.— Generally speaking, in those infants whose 
 early birth depends upon the induction of labor, the outlook is 
 
 24
 
 370 PROGNOSIS 
 
 better than when it results from spontaneous delivery. The 
 following percentages are given as saved after induced labor: 
 
 Born alive Saved, 
 
 Author. per cent. per cent. 
 
 Hahl 75.0 59.5 
 
 Raschkow 84.8 78.6 
 
 Heymann 71.2 
 
 Ahlfeld 90.9 
 
 Lorey 74.0 60.0 
 
 Hunziken 83.5 
 
 Ostrcil 56.9 
 
 That there are exceptions to the above statement cannot be doubted. 
 For example, the occurrence of albuminuria may lead to the induc- 
 tion of labor, the child being not only premature but a weakling 
 with low weight and vitality. On the other hand the infant born 
 as a result of the shock attendant upon operative interference in 
 non-suppurative appendicitis would in all probability possess 
 excellent vitality. The artificial induction of premature labor 
 with its associated trauma to the infant plays a very important 
 part in the mortality. The foregoing figures are to be seriously 
 questioned as there is no record of the birth weight, which in many 
 instances was undoubtedly well above 3000 gm. and therefore not 
 strictly applicable to the premature infant. 
 
 Prenatal Influences.— The health of the mother during the period 
 of gestation is of the utmost importance in prognosticating the 
 immediate future of the premature and the weak. The occurrence 
 of syphilis, tuberculosis, alcoholism, eclampsia, nephritis, severe 
 heart disease, or other conditions producing faulty nutrition of the 
 fetus— all have their effect on the well-being of the infant. Of 
 special importance is the occurrence of syphilis or nephritis. 
 Though necessarily the age and weight of the child have a direct 
 bearing upon its physiological development, yet the occurrence of 
 constitutional diseases in the child is even of greater importance. 
 Despite the greater age and the comparatively good development 
 of a premature, the existence of a prenatal syphilitic infection or of 
 an inherited predisposition to tuberculosis greatly jeopardizes 
 the prognosis. If constitutionally well, the infant under 1000 
 gm. weight can live, providing sufficient attention is paid to the 
 three conditions governing the survival of these infants. On the 
 other hand, prematures or even full-term infants, the victims of 
 parentally derived disease, often do not survive, regardless of the 
 care they receive. 
 
 Francillon attempted to group the prematures in relation to the
 
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 372 PROGNOSIS 
 
 cause of the prematurity and to show the death-rate for each 
 group. He considers as premature all infants born with a weight 
 below 2900 gm. Of 2271 births, 832 were premature, a proportion 
 of about 36 per cent. Of these 832 prematures the number born 
 dead was 76, a still-born death-rate of 9.1 per cent. Of these 76 born 
 dead, 59 died in utero. The rest died during labor either as the 
 result of accident or of mutilating operations. Of 756 born alive, 
 39, or 5.1 per cent, died during their stay in the maternity depart- 
 ment, that is, during the first three weeks of their existence. In 
 grouping them according to the cause of the prematurity, Francillon 
 finds that: 
 
 Because of obstetrical intervention: 6 out of 28 cases died (21.4 
 per cent). 
 
 Because of twins: 5 out of 49 cases died (14.2 per cent). 
 
 Because of albuminuria: 3 out of 23 cases died (13 per cent). 
 
 Because of syphilis: 8 out of 75 cases died (10.6 per cent). 
 
 Because of heart disease: 1 out of 13 cases died (7.7 per cent). 
 
 Because of unknown causes: 13 out of 499 cases died (2.7 per 
 cent) . 
 
 Ylppo, discussing the various factors which are concerned with 
 the etiology and mortality of prematurity, presents the table on 
 p. 371. 
 
 Deformities.— Certain deformities affect very materially the well- 
 being of the premature child and not infrequently are important 
 factors in the causation of labor before term. One of the most 
 important compatible with life is cleft palate, either with or without 
 hare-lip. 
 
 There are some features which are especially noteworthy. Of 
 the 668 cases, more than half, 369, were due to unknown causes, 
 which probably could have been explained by mild disorders or 
 malpositions of the uterus. The prognosis in tuberculosis is much 
 better than in lues— a mortality of 33.33 per cent in the former 
 as contrasted with 73 per cent in the latter. Acute infections of 
 the mother do not often appear in the premature, but are very 
 important in bringing about premature delivery. Infants born of 
 eclamptic and nephritic mothers have a very high mortality because 
 of the fact that labor is shortened and often artificially induced, 
 so that death most often results from the damage incidental to 
 delivery. Diabetes and cardiac decompensation have a very 
 deleterious effect on fetal development. The birth of twins is 
 closely linked with prematurity and in Ylppo 's series this class 
 was 19.2 per cent of the total (128 of 668 cases). 
 
 Interference with the proper taking of nourishment complicates 
 an already difficult problem, that of feeding, and impairs the child's 
 chances of living. Of other deformities, atresias of the digestive
 
 OTHER DISEASES OF THE NEW-BORN PREMATURE 373 
 
 tract are not uncommon and generally speaking offer an absolutely 
 bad prognosis unless limited to the rectum and anus. 
 
 Illegitimacy.— Bakker paid attention to this phase of the birth 
 of premature infants born in the Eppendorfer Hospital, Hamburg, 
 from 1907 to 1912. Of one group weighing from 2000 to 2500 gm., 
 80 per cent of the legitimate children survived for at least one year, 
 while of the illegitimate only 61.3 per cent lived that long. Thus 
 the mortality in the illegitimate is seen to be almost twice as high 
 as in the legitimate of the same weight. Of those weighing from 
 1500 to 2000 gm. the mortality among the legitimate was 30 per 
 cent, among the illegitimate about 47 per cent. Of a group of 75 
 weighing from 1000 to 1500 gm. only 10 lived to leave the institu- 
 tion. Four of these were followed up, of which only one, a legitimate 
 child, was alive at the end of the year. 
 
 Thus we see that the death-rate among the illegitimate born 
 ranges from half again to twice as high, or even higher, than in the 
 legitimate, depending upon the weight at birth. This difference is 
 accounted for largely by the inferior care the illegitimate infant 
 receives at the most critical period of its existence, the first few 
 days after birth. 
 
 Infectious Diseases.— The secret of success in raising premature 
 infants lies in three directions: (1) In the prevention of chilling 
 of the body surface with the production of a subnormal tempera- 
 ture; (2) in the administration of the proper diet; (3) in the pro- 
 phylaxis against infectious diseases. 
 
 Of the commoner infections erysipelas results fatally in the 
 majority of cases. It is usually violent in its course in the very 
 young and is frequently accompanied by signs of cardiac failure. 
 The prognosis of tetanus neonatorum, fortunately now very rare, 
 is generally unfavorable, even worse than with older children. 
 In ophthalmia neonatorum the outlook is good when proper treat- 
 ment is instituted sufficiently early. In sepsis the prognosis is 
 bad, varying in direct proportion with the age and the immaturity 
 of the infant attacked. The greater the number of organs involved 
 the poorer the child's chances. In gastro-intestinal and other 
 visceral hemorrhages as well as in other varieties of bleeding in the 
 premature new born, the outlook depends upon the underlying 
 cause or disease; sepsis, syphilis, asphyxia, etc.; but in general, it 
 is grave, even more so as a rule than the underlying condition when 
 uncomplicated. 
 
 Other Diseases of the New-born Premature. — Icterus of the new 
 born, unless due to atresia of the biliary passages, offers a favorable 
 prognosis and is not followed by complications. Recovery usually 
 occurs from moist gangrene of the cord unless the infection spreads 
 to adjacent parts. Only in the very weak are umbilical ulcers
 
 374 PROGNOSIS 
 
 followed by extensive tissue destruction. Inflammations of the 
 umbilical cord, usually seen in the very feeble, of necessity offer 
 a poor prognosis. A rteritis has a comparatively favorable outlook, 
 but umbilical phlebitis is almost invariably fatal. 
 
 General Conditions.— Of all prognostic signs, the study of the 
 general condition of the premature infant offers the best evidence 
 of the child's viability. If it cries strongly, exhibits vigorous 
 movements, tends to stay awake and possesses well-developed 
 ability to nurse, its viability may be considered as established and 
 its opportunity for maintaining life good. On the other hand, if 
 there is a tendency to deep sleep, to apathy, to asphyxia and 
 cyanosis or to hypothermia, if the nursing ability is poor and 
 there is difficulty in swallowing, the outlook is bad for the infant. 
 Sometimes several days of observation are necessary in order to 
 pass judgment upon the viability. 
 
 The condition of the turgor of prematurely born infants is of con- 
 siderable importance as a prognostic sign. Absolutely flabby pre- 
 matures with a poor turgor and a poor tonus prove to be lost in 
 almost all cases. Prematures with a good turgor and a good tonus, 
 even with a low weight, almost always live up to expectation. It 
 is highly probable that the tissue turgor is conditioned by the 
 mode in which the water is held. Where the water content is 
 diminished the turgor decreases. The presence of water is closely 
 connected with the presence of alkalies in the tissues and, therefore, 
 it might be correct to state the hypothesis that the alkali deficiency 
 of the prematurely born leads to a poor tissue turgor and therefore 
 to inability to live (Langstein). 
 
 The greatest number of premature children die in the first few 
 days of life. This is because of birth trauma, the unfinished 
 condition of the organs, or the result of postpartum conditions or 
 constitutional diseases or lack of facilities for proper care. At 
 autopsy the cause of death is often not to be found, although 
 the unripeness of the infant is evident. 
 
 Although 1000 gm. is accepted as nearly the low weight compat- 
 ible with life, exceedingly small babies may live and thrive as is 
 attested by the cases previously listed on page 44 (Physiology). 
 
 GENERAL MORTALITY. 
 
 A consideration of the preceding factors, prenatal and post- 
 natal, forms the basis for the mortality statistics which have been 
 compiled by Ylppo in a series of over a thousand premature infants. 
 
 The above figures are quite accurate to the first year. Beyond 
 this it was difficult to follow the patients. However only about 
 70 of the series could be followed. Of the 668 prematures 320, or
 
 GEXERAL MORTALITY 
 
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 376 PROGNOSIS 
 
 53.5 per cent, died. About 50 per cent survived to one year. 
 An interesting feature is the fact that the mortality after the first 
 year fairly well approximates that of full-term children. In the first 
 to the fifth day of life the greatest death-rate is noted and is linked 
 with the damage to the infant in the course of labor. 
 
 Because of the fact that the etiological factors in the birth of 
 twin prematures differs greatly from those of single birth (usual 
 absence of infectious and constitutional disorders in the mother), 
 Ylppo considers this class separately: 
 
 The table shows that at the end of the first year the total mor- 
 tality was 37.07 per cent, considerably less than with single births. 
 
 REFERENCES. 
 
 1. Jahrb. f. Kinderh., n. f., 60, 377 and short reports. 
 
 2. A Study of the Caloric Needs of Premature Infants, Am. Jour. Dis. Child., 
 1911, 2, 302-314. 
 
 3. Oberwarth: Ergebn. d. inn. Med. u. Kinderh., 1911, 7, 191. 
 
 4. d'Outrepont: Abhandlungen und Beitrage geburtshilflichen Inhalts, Parti, 
 p. 167. 
 
 5. Miinchen. med. Wchnschr., 1912, No. 47, p. 2596. 
 
 6. Roth: Ztschr. f. Kinderh., 1913, 5, 134. 
 
 7. Heller: Munchen. med. Wchnschr., 1912, No. 47, p. 2596. 
 
 8. Munchen. med. Wchnschr., 1907, No. 29, p. 1417. 
 
 9. Gynaecologia Helvetica, 1917, autumn edition, p. 199. 
 
 10. Allgemeine deutsche Hebammenzeitung, 1903, p. 289. 
 
 11. Lehrbuch der Geburtshitfe, 3d edition, 1903, p. 214. 
 
 12. L'arte ostetrica, November, 1908. 
 
 13. Cited by Mansell: British Med. Jour., 1902, 1, 773. 
 
 14. Nouvelles Archives d'Obstetrique et de Gynecologic 1895, Repertoire, No. 2, 
 p. 50. 
 
 15. Bulletin de la Societe Obstetr. de Paris, 1907, p. 216. 
 
 16. Monatsschr. f. Geb. u. Gynak., 17, 369. 
 
 17. Munchen. med. Wchnschr., 1903, No. 37, p. 1603. 
 
 18. Lehrbuch. d. Geb., 1903, 3d edition, p. 214. 
 
 19. Zentralbi. f. Gynak., 1912, No. 19, p. 626. 
 
 20. Allgem. Deutsche Hebammenzeitung, 1911, No. 11, p. 235. 
 
 21. Schmidt's Jahrbiicher, 3, 128. 
 
 22. Unreported case. 
 
 23. The Prematurely Born, Cor.-Bl. f. schweiz. Aerzte, Basel, 1918, No. 27, 48, 
 897.
 
 CHAPTER XX. 
 THE FUTURE OF THE PREMATURE INFANT. 
 
 The early small, thin face with its mass of wrinkles in the presence 
 of proper feeding soon becomes rounded out by the deposit of layers 
 of fat, the skin becomes smoother and the face more nearly like thai 
 of a normal nursling. There, however, remains for a more or less 
 indefinite period a prominence of the sucking cushions greater than 
 that seen in the normal infant. The enlargement of the tongue may 
 be noted until toward the end of the first year. The same may be 
 true of exophthalmos. The small stumpy nose may also retain its 
 characteristic appearance until the end of the first year. The 
 "doll" type of face is also usually present until after the fourth 
 or sixth month of life. 
 
 The infants often show the adenoid appearance, due to the small 
 nose, with its tendency to the development of a posterior rhinitis, 
 and the large tongue. This appearance is lost as the megacephalus 
 disappears. 
 
 The other characteristic physical changes, which are evidenced 
 by a short neck, a long, broad trunk, with a deeply seated navel 
 and short legs, and which can usually be noted by the second to the 
 fourth month of life, gradually disappear during the second year. 
 
 The question is often asked as to what is the ultimate outlook 
 for prematurely born infants who live beyond the first year of life. 
 It is desired to know (1) if they suffer from a higher mortality in 
 early childhood than the full-term infant, and (2) are those that 
 survive normal mentally and physically. In order to answer these 
 questions in the proper way it is necessary to observe the children 
 over a period of years. With institutional children this is often 
 impossible and even in private practice difficult. Usually one 
 must satisfy himself with comparisons at the end of the first year. 
 For this comparison the full-term normal child is used as a basis, 
 but as Pfaundler says, only those who have been similarly fed 
 and raised under the same hygienic conditions can be fairly con- 
 trasted. 
 
 One observes with the premature as with the full-term child that 
 the breast-fed infants raised among good home surroundings have 
 a lower mortality than the same in institutions, and that the 
 artificially fed have a greater mortality than the breast fed.
 
 378 
 
 THE FUTURE OF THE PREMATURE INFANT 
 
 Ostrcil gives the statistics from the Prague Maternity. on 1542 
 illegitimate prematures. The total mortality of these infants was 
 52.7 per cent.- Of these cases 814 were followed for nine, ten and 
 eleven years. Of this series 86. G per cent are living, but these figures 
 include those in whom there was no indication of syphilis, those 
 who received breast milk after leaving the institution, and those 
 weighing up to 2800 gm. Those under 2500 gm. weight and 45 cm. 
 length, who left the institution alive and had, therefore, survived 
 the first weeks, were 86 in number, of which 38 were boys and 48 
 girls. Of these 51 were alive at the end of the first year, 23 boys 
 and 28 girls, a mortality of 40.7 per cent, or 39.5 per cent for males 
 and 41.7 per cent for females. 
 
 Oberwarth's results are shown in tabulated form below. He 
 followed for more than a year 12 infants who weighed less than 
 2000 gm. and who were, with 2 exceptions, illegitimate and raised 
 under poor hygienic surroundings. 
 
 Entrance. 
 
 Latf 
 
 >r examination. 
 
 General physical 
 development. 
 
 
 Length, 
 
 Weight, 
 
 Age. 
 
 W eight, 
 
 Length, 
 
 Mentality. 
 
 cm. 
 
 gm. 
 
 
 gm. 
 
 cm. 
 
 
 
 46.0 
 
 1880 
 
 17 mos. 
 
 10,750 
 
 79 
 
 Good; has eight teeth, 
 walked at fifteen mos. 
 
 Normal. 
 
 43.6 
 
 1890 
 
 17 " 
 
 10,250 
 
 77 
 
 Walks alone 
 
 Normal. 
 
 43.3 
 
 1960 
 
 24 " 
 
 9,700 
 
 75 
 
 Good ; has twelve teeth ; 
 walked at fifteen mos. ; 
 has a congenital hip 
 
 Very good. 
 
 
 
 
 
 
 dislocation 
 
 41.5 
 
 1460 
 
 30 " 
 
 9,750 
 
 77.6 
 
 Rachitis; anemia; con- Normal, 
 genital hip dislocation 
 
 40.0 
 
 1750 
 
 40 " 
 
 10,900 
 
 80 
 
 Severe rachitis; not Backward, 
 walking 
 
 44.0 
 
 1820 
 
 54 " 
 
 15,000 
 
 95 
 
 Very good Very good. 
 
 41.5 
 
 1710 
 
 60 " 
 
 10,900 
 
 86 
 
 Anemia; large head; Good. 
 
 
 
 
 
 
 convulsions 
 
 
 
 1250 
 
 66 " 
 
 13,900 
 
 103 
 
 Flat occipital region 
 
 Fair. 
 
 44.2 
 
 1980 
 
 6.5 yrs. 
 
 14,400 
 
 101 
 
 Anemic Nervous. 
 
 42.5 
 
 1710 
 
 6.5 " 
 
 17,000 
 
 106 
 
 Anemic for eleven mos. ; Normal, 
 now 100 per cent hem- 
 oglobin 
 
 41.0 
 
 1500 
 
 6.8 " 
 
 16,700 
 
 109 
 
 Rachitic deformities Backward. 
 
 45.5 
 
 1950 
 
 8.2 " 
 
 21,300 
 
 123 
 
 Good Normal. 
 
 A comparison of these results with those attained with a similar 
 group of full-term infants reflects with credit on the future develop- 
 ment of the premature. The tendency to anemia and the results 
 of rachitis, to both of which the premature is frequently subject, 
 are not uncommonly seen in the early years of childhood. Whether
 
 77/ E F VT l 'RE OF THE PRE M. \ T ( HE I X I •'. 1 .V T 379 
 
 the lack of resistance is a result of the shortening of the period of 
 intra-uterine nutrition, or whether it is due to extra-uterine factors, 
 more especially underfeeding and improper care during infancy 
 cannot be stated, but we are inclined to believe that the former 
 factor outweighs the latter. 
 
 According to Feer, many infants overcome their handicaps and 
 make good progress, so that by the end of the second or third year 
 their measurements are about the same as those of the normal child. 
 Some, however, do not do as well as this, showing tendencies to 
 rachitis, spasmophilia and especially anemia. The pallor develop- 
 ing toward the end of the first year depends in many instant es upon 
 the lack of iron deposits which are made in great part during the 
 last few months of intra-uterine life; in other instances it depends 
 upon a lack of development of the blood making organs. 
 
 Wallich and Fruhinsholz analyzed the previous history of older 
 children and adults and also ascertained the later history of the 
 prematurely born. Possibly the earliest instance of prematurity on 
 record is that of the Professor at Padua who was born at the end 
 of the seventh month and lived to be eighty. Other famous pre- 
 matures include Newton, Rousseau, Voltaire, Cuvier, Victor Hugo, 
 Lamartine and Renan. 
 
 The outlook for the future of the premature is shown to depend 
 in a large measure upon the degree of development at birth, as 
 evidenced chiefly by the weight. Of 17 infants weighing between 
 900 and 1500 gm., studied by Wallich and Fruhinsholz, 41.1 per 
 cent developed into normal adults, a similar percentage were 
 but slightly handicapped, while the balance were much below 
 normal. Of the 26 weighing between 1500 and 2000 gm., 52 per 
 cent were normal and 3G per cent slightly handicapped. Of the 
 36 between 2000 and 2500 gm., 75 per cent were normal and 22.2 
 per cent retarded. The last group comprised (15 weighing from 
 2500 to 3000 gm. of which 78.4 per cent were normal and 20 per 
 cent somewhat under the normal. 
 
 The same authors traced back to birth the history of 180 children 
 from Broca's surgical clinic and 620 inmates of the asylum for the 
 epileptic and feeble-minded. Twelve per cent of the former 
 and S per cent of the latter were known to be of premature birth. 
 Thus we see that a large percentage of the prematurely born develop 
 normally in both mind and body, while the balance exhibit varying 
 degrees of inferiority, hernias, club feet, enuresis, pavor nocturnus, 
 etc. These signs of degeneracy are seemingly the result of the 
 prematurity and of the trauma sustained at the time of delivery. 
 
 The studies of Ylppo on the development of the premature from 
 infancy to the school age led him to make certain generalization-.
 
 380 THE FUTURE OF THE PREMATURE INFANT 
 
 The growth of premature infants (those with a weight below 2500 
 gm.) discloses a considerable derangement in the first three to five 
 years of life. This discloses itself in that the weight, length, skull 
 and thorax growth in almost all this class is slower. This retarda- 
 tion in growth is the more marked, the less the body weight and 
 length. 
 
 Growth disturbances appear immediately after birth and are 
 proportionately more marked in the first six to twelve extra-uterine 
 months of life, t At the age of two to four years there begins a gradual 
 equalization, w T hich in most instances ends at about five or six years. 
 From this period on the curves of growth are parallel with those of 
 full-term children. Only in the case of very small prematures with 
 a birth weight of 1000 gm., the reparation does not seem to be 
 completed by the age of five to six years. The growth in length 
 is up to this time disturbed approximately to the same extent as the 
 mass growth. • 
 
 The chest, which is proportionately deficiently developed in 
 prematures, also shows on the average, until the age of three years 
 a retardation in growth. In the years following, the breast circum- 
 ference, however, reaches practically the same value as in full-term 
 children of a similar age.. The cross-section of the chest of the 
 premature approaches more the form of an ellipse than a circle. 
 The cross-section area is in the smallest prematures strikingly small 
 in comparison with the body length. The growth of the head is 
 the least disturbed or retarded. This is explained by the fact that 
 the brain growth in premature follows certain individual laws 
 without depending, as a rule, on the development of the body, 
 i The principal point of these growth disturbances in the prema- 
 ture is immaturity. The more immature an infant is born, the 
 more deficient is the function of the various organs in extra-uterine 
 life. Especially in the province of digestion are variations noted 
 in prematures, because of poor utilization, particularly of fat and 
 salts, a qualitative undernourishment results which favors the 
 development of growth disturbances. 
 
 Besides these and other exogenous factors, certain endogenous 
 factors probably play a passing but noteworthy part in the pro- 
 duction of growth disturbances. All these defects, however, gradu- 
 ally disappear or are overcome, so that reparation is completed 
 by the time the premature reaches the school age. From this time 
 on the growth again turns back to the paths which have been 
 designed for the hereditary body mass of the child. 
 
 Ylppo was able to follow up 89.52 per cent of his cases and thus 
 compiled his figures for the mortality and future development of 
 the premature.
 
 THE FUTURE OF THE PREMATURE INF AST 
 
 381 
 
 INFANTS WITH A BIRTH WEIGHT UP TO 2500 G.M. IN' THEIR 
 FIRST EIGHT YEARS. 
 
 Year of birth. 
 
 Total 
 No. 
 
 Not followed 
 
 up 
 
 per cent. 
 
 Followed 
 through. 
 
 In 1918 
 at end 
 
 of year 
 of life. 
 
 Of these 
 still alive 
 per cent. 
 
 Of these 
 
 dead, 
 per cent. 
 
 1918 . . 
 
 48 
 
 
 
 48 
 
 i 
 
 3 
 
 16 = 
 
 32.65 
 
 33 
 
 = 67.35 
 
 1917 . . 
 
 57 
 
 2 
 
 = 3.51 
 
 55 
 
 1 
 
 35 = 
 
 63.64 
 
 20 
 
 = 36.36 
 
 1916 . . 
 
 98 
 90 
 
 3 
 5 
 
 = 3.06 
 
 = 5.56 
 
 95 
 
 85 
 
 2 
 
 46 = 
 
 4^.42 
 
 49 
 43 
 
 = 51.58 
 
 1915 . . 
 
 3 
 
 42 = 
 
 49.41 
 
 = 50.59 
 
 1914 . . 
 
 101 
 
 11 
 
 = 10.89 
 
 90 
 
 4 
 
 40 = 
 
 44.44 
 
 50 
 
 = 55.56 
 
 1913 . . 
 
 85 
 83 
 
 13 
 10 
 
 = 15.29 
 = 12.05 
 
 72 
 73 
 
 5 
 
 30 = 
 
 41.67 
 
 42 
 43 
 
 = 58.33 
 
 1912 . . 
 
 6 
 
 30 = 
 
 41.10 
 
 = 58.90 
 
 1911 . . 
 
 57 
 
 16 
 
 = 28.07 
 
 41 
 
 7 
 
 19 = 
 
 46.34 
 
 22 
 
 = 53.66 
 
 1910 . . 
 
 48 . 
 
 10 
 
 = 20.83 
 
 38 
 
 8 
 
 20 = 
 
 52.63 
 
 18 
 
 = 47.37 
 
 
 668 
 
 70 
 
 = 10.48 
 
 598 
 
 278 = 
 
 46.49 
 
 320 
 
 = 53.51 
 
 These statistics show that only 40 to 45 per cent of the premature 
 infants lived to the school age. Twin prematures showed a some- 
 what better average— 50 per cent. 
 
 TWINS WITH A BIRTH WEIGHT UP TO 2500 GM. IN THEIR 
 FIRST EIGHT YEARS. 
 
 Year of birth. 
 
 Followed 
 through. 
 
 In 1918 
 at end 
 of year 
 of life. 
 
 Of these 
 
 still alive, 
 per cent. 
 
 Of these 
 
 dead, 
 per cent. 
 
 1918 
 
 9 
 
 1917 
 
 14 
 
 1916 
 
 26 
 
 1915 
 
 15 
 
 1914 
 
 18 
 
 1913 
 
 14 
 
 1912 
 
 11 
 
 1911 
 
 11 
 
 1910 
 
 10 
 
 128 
 
 5 = 27.7! 
 
 18.18 
 27.27 
 
 20.00 
 
 12 = 9.38 
 
 9 
 14 
 26 
 
 116 
 
 5 = 55.56 4 = 44.44 
 10 = 71.43 4 28.57 
 15 = 57.69 11 = 42.31 
 
 15 
 
 3 
 
 7 = 46.67 
 
 8 = 53.33 
 
 13 
 
 4 
 
 7 = 53.85 
 
 6 = 46.15 
 
 14 
 
 5 
 
 7 = 50.00 
 
 7 = 50.00 
 
 4 = 44.44 
 7 = 87.50 
 6 = 75.00 
 
 5 = 55.56 
 
 1 = 12.50 
 
 2 = 25.00 
 
 68 = 58.62 48 = 41.38 
 
 In concluding it may be said that the future of the prematures 
 who survive is on the whole good. They seem to be somewhat
 
 382 
 
 THE FUTURE OF THE PREMATURE INFANT 
 
 more subject to hydrocephalus and to psychic and nervous anoma- 
 lies, such as enuresis and night terrors, and to anemia, rachitis and 
 spasmophilia. Many are precocious, even original children. They 
 tend to remain light in weight and short in length, but this is usually 
 equalized by the time of entering school. 
 
 It is generally the case that in those infants who survive, most 
 differences between the premature and the full-term child have 
 disappeared by the time of puberty, and therefore every effort 
 should be made to preserve all perfectly developed premature 
 infants. 
 
 WALKING AND TALKING. 
 
 / It is well known that in premature infants we may not expect 
 the development of certain faculties, namely, speaking and walking, 
 at the same time as in full-term infants. iJVYall states that his 
 premature infants learned to talk seven and a half months later 
 and learned to walk six months later than full-term children. L He 
 also reports that certain speech defects, as'istuttering and stammer- 
 ing, occurred more frequently in his prematures. These differences, 
 however, became equalized later on. 
 
 In general, the smaller the premature at birth, the greater is 
 the delay in its learning to talk. It is rather an exception to the 
 rule when infants that have been born weighing 1000 to 1500 gm. 
 learn to talk before they are two years old. / The following table 
 shows when children of Ylppo's series learned to walk and to talk 
 a few words: 
 
 The age and number of children when they were able to speak: 
 
 9 months to 1 year 3 
 
 1 year 9 
 
 1 year, 3 months 48 
 
 1 
 1 
 
 2 
 2 
 2 
 3 
 
 4 
 Unknown 
 
 18 
 
 54 
 1 
 
 10 
 1 
 1 
 1 
 
 37 
 
 The age and number of children when they started to walk: 
 
 9 months to 1 year 3 
 
 1 year 15 
 
 1 year, 3 months 46 
 
 1 
 1 
 2 
 2 
 2 
 2 
 3 
 3 
 4 
 Unknown 
 
 52 
 28 
 25 
 
 4 
 1 
 
 1 
 26
 
 CONSTITUTIONAL INFERIORITY 
 
 383 
 
 The statements as to the time at which the child spoke the firsl 
 words, and when it started to walk var\- widely in individual 
 cases. Only intelligent mothers are able to make reliable state- 
 ments pertaining thereto. On the other hand the delay in learning 
 to talk and to walk depends in many cases not upon the docility 
 or development of the infants, but upon the efforts of its mother 
 or nurse. 
 
 From the preceding facts it follows that the small prematures 
 learn the first sounds and the first words on an average of one year 
 and six months. This occurs then about six months later than in 
 full-term infants. The age at which the child learns to walk is 
 about the same as that at which it learns to talk. This may be 
 regarded as a proof that learning to walk depends in a healthy 
 child upon its mental development. 
 
 CONSTITUTIONAL INFERIORITY. 
 
 The various lesions, either of traumatic nature, due to delivery 
 itself or extra-uterine life, brought on by deficient resistance or 
 deficient functional capacity of the different organs, result in various 
 clinical symptoms, which have been designated under the collective 
 
 Fig. 184. — Infant born at thirty-six weeks. Birth weight, 1500 gm. Intense 
 icterus, melena, double inguinal, lumbar and umbilical hernia. Photograph taken 
 at six months. Still showing evidence of megacephalus. 
 
 name " constitutional inferiority." Everything seems to point to the 
 fact that this constitutional inferiority in the strict sense of the 
 word does not occur in a much higher degree in premature infants 
 than in full-term children, if we do not include the various gross 
 anatomical malformations,
 
 384 THE FUTURE OF THE PREMATURE INFANT 
 
 Fia. 185. — Same child, aged two and one-half years. 
 
 Fig. 186,— Same child, aged, four and one-half years. Megacephalus has entirely 
 
 disappeared.
 
 CONSTITUTIONAL INFERIORITY 
 
 :;.s:> 
 
 We have reason to assume that main - prematures who remain 
 weaklings in their later life and show other signs of inferiority, 
 
 Fig. 187. — Infant born at thirty-four weeks. Complication, spastic paraplegia. 
 
 suffered from some constitutional anomaly, intra-uterine, or post- 
 natal trauma, or were born in a state of physiological immaturity. 
 
 Fig. 188. — Child shown in Fig. 187, showing standing posture. 
 
 This view seems to be especially strengthened by the fact that the 
 more premature and the smaller the infants come to the world, 
 
 25
 
 386 
 
 THE FUTURE OF THE PREMATURE INFANT 
 
 the more frequently they suffer with idiocy, Little's disease, serious 
 anemias, rachitis and other diseases based upon the condition of 
 deficient resistance. 
 
 The proportional diminution of various pathological symptoms 
 with increasing birth weight would be difficult to understand in 
 
 Fig. 
 
 189. — Child shown in two previous illustrations, showing good results following 
 tendon transplantation. Mental development in advance of age. 
 
 terms of congenital constitutional lesions. Also the frequent 
 disturbances of growth in premature infants, especially during the 
 first years of life, have some connection with this passing poor 
 condition of the premature. Later, strikingly good reparation of 
 the growth disturbances shows best that this state is not dependent 
 upon congenital constitutional factors.
 
 MENTAL DEVELOPMENT OF PREMATURE INFANT 387 
 
 THE MENTAL DEVELOPMENT OF THE PREMATURE INFANT 
 DURING EARLY CHILDHOOD. 
 
 In order to review this subject properly, it is necessary to divide 
 premature infants into two large groups: (1) Prematures without 
 pathological changes ; and (2) those born with pathological changes 
 due to constitutional diseases and congenital malformations. In 
 the well-developed fetus which has not been damaged during the 
 time of conception, and which is born at an age compatible with a 
 physiological development necessary to meet its needs for life 
 and which suffers no undue traumata during or following birth, a 
 normal mental development may be expected. External influ- 
 ences will affect its mental growth as well as its physical develop- 
 ment, therefore, it must be raised in a suitable environment and 
 be judiciously fed. It may be stated that the longer the intra- 
 uterine life of the fetus, the less the dangers of interference with 
 its normal mental growth. It is quite natural to expect, therefore, 
 that these immature infants are more subject to mental disturb- 
 ances and defects than the full-term infant. Abnormalities in 
 development need not be explained by anomalies in the embryo, but 
 rather may be due to direct external traumata of a mechanical, 
 dietetic and of an infectious nature. Thus, there remains no 
 other choice than to make the intra-uterine and extra-uterine 
 noxa? responsible for the frequent cerebral disturbances, be they 
 connected with spastic states or idiocy, with or without spasms. 
 
 It is our experience that the majority of premature infants bora 
 after the thirty-second week into a proper environment without 
 birth injuries, undergo a normal mental development. That these 
 individuals are more subject to rickets, anemia and spasmophilia 
 with their consequent effects on the nervous system is not to be 
 forgotten. But all of these conditions are amenable to therapeutic 
 procedures with only a limited after effect. 
 
 In the second group belong those suffering from constitutional 
 diseases and congenital malformations. These individuals cannot 
 be classified in groups as to their future development, but each 
 one must be considered individually. While congenital lues usually 
 leaves its mark in the full term, in the premature it is even more 
 grave in its consequences. However, much can be expected from 
 proper and early therapeutic measures. In those suffering from 
 hemorrhages into the cerebrum and spinal cord, it is easy to under- 
 stand that in the premature infant that has survived in spite of 
 these lesions sequela? may manifest themselves in later life. We 
 would especially impress upon the physician the fact that qoI all 
 infants with cerebral hemorrhages die in the first days of life but
 
 388 THE FUTURE OF THE PREMATURE INFANT 
 
 that many survive. Cerebral hemorrhage may not be suspected 
 until late mental and physical signs develop. 
 
 The prognosis in this group must always be made with con- 
 siderable reservations. 
 
 However, on the whole, it may be stated that mental develop- 
 ment goes hand in hand with physical development. To this 
 broad statement there are, however, many exceptions, and while 
 we do see a number of these infants with good physical development 
 who are of low-grade mentality, in our personal experience we have 
 come in contact with a larger group of premature infants with a 
 high grade of mental development, even to the point of precocity. 
 They tend to remain light in weight and short in length, but this 
 is usually equalized by the time of entering school.
 
 INDEX OF AUTHORS. 
 
 In the preparation of this volume the following authorities were consulted. 
 
 Abramow, S. 
 Ahlfeld 
 
 Ahlfeld and Hecker 
 
 Alexander 
 
 Auvard 
 
 Babak 
 
 Bade 
 
 Ballantyne 
 
 Billiard 
 
 Berthod 
 
 Birk 
 
 Bouchut 
 
 Brown, Alan 
 
 Budin 
 
 Camerer 
 
 Caspar 
 
 Chalier, J. 
 
 Chiari 
 
 Clementovsky 
 
 Cohnheim 
 
 Colerat 
 
 Coo, P. 
 
 Cragin, E. B. 
 
 Crede 
 
 Cruse 
 
 Czerny 
 
 Czerny-Keller 
 
 De Lee 
 
 Delmas 
 
 Diffre 
 
 Dubois and Dubois 
 
 Epstein 
 
 Escherich and Pfaundler 
 
 Eustache 
 
 Feer 
 
 Fischer 
 
 Franck 
 
 Frank 
 
 Freirichs 
 
 Friedenthal 
 
 Furmann 
 
 ( (anghofer and Langer 
 
 ( lartncr 
 
 Gundobin 
 
 Hartniann 
 
 II assel wander 
 
 Hearson 
 
 Hecker 
 
 Heller 
 
 Hess, A. J. 
 
 Hirsch 
 
 His 
 
 Hoeniger 
 
 Holt 
 
 Hougouneng 
 
 Howland and Dana 
 
 Buenekens 
 
 Hutinel and Delestre 
 
 Hymanson and Kahn 
 
 Ibrahim 
 
 Ibrahim and Gross 
 
 Jaeggis 
 
 Jaschke 
 
 Jastrowitz 
 
 Jeans 
 
 Jeans and Cooke 
 
 Kendall and Day 
 
 Kleinschmidt 
 
 Knopf elmacher 
 
 Krieber-Mall 
 
 Kunckel 
 
 Lambert z 
 
 Lande 
 
 Landois 
 
 Langer 
 
 Langstein 
 
 Langstein-Meyer 
 
 Lesage and Kuriansky 
 
 Lichtenstein 
 
 Limbeck 
 
 Link 
 
 Lion 
 
 Litzenberg 
 
 Lomer 
 
 Luenberger 
 
 Mall 
 
 McCollum 
 
 Meeh 
 
 Meeh and Lissauer 
 
 Mensi 
 
 Merkel, H. 
 
 Miller 
 
 Minkowski and Xyuvn 
 
 Molischott 
 
 Morse and Talbot 
 
 Nathan and Langstein 
 
 Nicoll 
 
 Nothmann 
 
 Nobecourt and Lemaire 
 
 Oberwarth 
 
 Oppenheimer 
 
 Ostrcil 
 
 ( )swald 
 
 Pacchioni 
 
 Pajot 
 
 Polanos 
 
 Parrot 
 
 Pasquad 
 
 Passini 
 
 Pehu, M. 
 
 Peiser 
 
 Pfaundler 
 
 Phemister 
 
 Pies 
 
 Planchu 
 
 Planchu and Devin 
 
 Poirier 
 
 Potel and Hahn 
 
 Quincke 
 
 Ramsay and Alley 
 
 Rauber-Kopsch 
 
 Reiche 
 
 Rodda 
 
 Rollet, H. 
 
 Rommel 
 
 Rusz 
 
 Salge 
 
 Samelson 
 
 Schabort 
 
 Schauta 
 
 Schloss 
 
 Schridde 
 
 Sehroeder 
 
 Schwegel 
 
 Sedgwick 
 
 Sherman 
 
 Shick 
 
 Ssytcheff 
 
 Stratz 
 
 Tarnier 
 
 Taylor 
 
 Theyson 
 
 Trumpp 
 
 Vierordt 
 
 Virchow 
 
 Von Reuss 
 
 Von Winckel 
 
 Wallich and Fruhinsholz 
 
 Weaver and Tunnicliff 
 
 Weldi- 
 
 Weissenberg 
 
 Ylppo 
 Zweifel
 
 GENERAL INDEX. 
 
 Acetone bodies, 73 
 Age, advantages of roentgenograph^ 
 methods of determining, 101 
 estimation, limitation of accuracy, 
 
 100 
 exact, difficulty of determining, 28 
 of parents a factor in premature 
 
 labor, 25 
 as shown by development of head, 
 
 79 
 sternum unreliable as index of, 101 
 as told by skeletal development, 77 
 Albumin as factor in causing induction 
 
 of labor, 370 
 Albuminuria, common in prematures, 
 
 73 
 Ammonia in atelectasis, 258 
 
 in cyanosis, 244 
 Anemia, 351 
 
 appetite in, 353 
 
 arsenic in, 353 
 
 in early childhood, holdover from 
 
 prematurity, 378 
 etiology of, 352 
 symptoms of, 352 
 treatment of, 353 
 Anomalous position of fetus cause of 
 
 premature labor, 24 
 Anorexia, 271 
 
 gavage in, 272 
 Anus, inspection of, in new born, 150 
 Arsenic in anemia, 353 
 
 therapy in syphilis, 335 
 Asepsis during and post delivery neces- 
 sary in preventing sepsis, 318 
 Aseptic condition necessarv for milk, 
 
 184 
 Asphyxia, 133 
 
 diagnosis of, 239 
 etiology of, 235 
 morbid anatomy of, 237 
 neonatorum, 235 
 oxygen in, 240 
 prognosis of, 239 
 sequelae of, 238 
 symptoms of, 237 
 treatment of, 239 
 violent measures for artificial respi- 
 ration contraindicated in, 302 
 
 Atelectasis, ammonia in, 258 
 diagnosis of, 253 
 
 differential, 254 
 oxygen in, 258 
 pathology of, 251 
 physical signs of, 253 
 prognosis of, 254 
 symptoms of, 252 
 treatment of, 255 
 
 Atrophy and marasmus, 281 
 
 B 
 
 Bacillary infections, treatment of, 285 
 Bacteria found in sepsis, 311 
 influence of diet on, 30 
 Bacteriology of gastro-intestinal tract, 
 
 64 
 Bath, mustard, in atelectasis, 256 
 in pneumonia, 264 
 value of, in collapse in sepsis, 319 
 Bed, heated, in home, 168 
 Bile-duet affections, causes of, 289 
 Blood, bacteria in, in sepsis, 311 
 cell content of, 67 
 changes in acidosis, 265 
 coagulating time in new born, dis- 
 turbance in, 302 
 coagulation and bleeding time of, 
 
 67 
 differential cell count, 68 
 hemoglobin content, 68 
 longitudinal sinus best source for 
 obtaining, for examination, 317 
 subcutaneous injection of normal, 
 in delayed or slow bleeding, 302 
 sugar determination, 71 
 transfusion of, in anemia, 354 
 Blood-pressure in mature infant, 67 
 Body surface, rules for estimation, 47 
 temperature of, 39 
 weight and measurement, 29, 31, 
 32 
 Hoi tic nursing for prematures, 172 
 Bowels, condition of, 28 
 Brain, weight of, 37 
 Breasl milk, average amounl required 
 during first twentv-one 
 days, lsi) 
 conditions influencing, 109
 
 392 
 
 GENERAL INDEX 
 
 Breast milk, conditions, quality of, 124 
 asthenia and anemia, 
 
 110 
 drugs, 110 
 fissures, 109 
 mastitis, 110 
 mental conditions, 
 
 110 
 menstruation, 110 
 simple engorgement, 
 109 
 Breast-feeding in infants with rhinitis, 
 247 
 methods, 171 
 Bronchial affections, 250 
 
 Calcium, deficiency of, in rickets, 351 
 in spasmophilia, 360 
 in tetany, 357 
 Carbohydrate ferments, 62 
 
 lactose, 62 
 Cardiovascular system, 66 
 Care and nursing, conditions of success 
 in, 131 
 immediate, of infants, 132 
 preparation for infant's birth, 131 
 requirements for hospital nursery 
 
 unit, 135 
 treatment of cord, 133 
 Castor oil in bacillary infections, 285 
 in constipation, 279 
 in inanition fever. 272 
 Catheter feeding in nervous and mental 
 disturbances, 302 
 number of feedings, 178 
 utensils for, 175 
 Causes of premature birth, 371 
 Cereal, 203 
 
 Characteristics deciding maturity, 17 
 Chronic affections as cause of prema- 
 turity, 22 
 "Cigarette" bandage in hernia, 297 
 Circulatory weakness, cause of edema, 
 
 343 
 Clinical features of prematures, 27, 28 
 Clothing outfit of infant, 153 
 essentials for, 157 
 necessity of warm, 169 
 Cod-liver oil in rickets, 351 
 
 in spasmophilia, 360 
 Colon flushing in inanition fever, 272 
 Congenital debility, causes of, 18 
 Congenitally debilitated infants, 17 
 Constipation, causes of, 279 
 
 increase water intake in, 279 
 Convulsions, spasmophilic, 310 
 Cord, treatment of, in delayed separa- 
 tion, 150 
 Cyanosis, 241 
 
 Cyanosis, administration of water in, 
 245 
 causes of, 242 
 
 danger of manipulation in, 245 
 diagnosis of, 243 
 hot bath in, 244 
 lavage in, 245 
 oxygen in, 244 
 prognosis of, 243 
 respiration in, 243 
 symptoms and treatment of, 243 
 
 Death, apparent, two forms of, 52 
 cerebral hemorrhage as cause of, in 
 
 new born, 302 
 due to poor intra-uterine develop- 
 ment, 34 
 fetal age as factor in, 262 
 meningitis as cause of, 309 
 refrigeration as cause of, 169 
 Deformity, effect of, on future of pre- 
 matures, 372 
 Developmental features by months, 29 
 Diabetes, cause of premature labor, 25 
 Diarrhea in indigestion, 277 
 Digestive disturbances accompanying 
 
 parenteral infections, 281 
 Diet, improper regimen in, factor in 
 rickets, 350 
 mixed, 203 
 no change in, unless well indicated, 
 
 180 
 in rickets, 351 
 
 too liberal in mothers, causeof indi- 
 gestion in infants, 278 
 Diseases of urinary tract, 299 
 
 pyelocystitis, 300 
 Dressing the baby, 156 
 Dropsy, congenital, 344 
 Ductus Botalli, closure of, 38 
 Dysenteric affections, medicinal treat- 
 ment of, 285 
 
 E 
 
 Edema, 342 
 
 etiology of, 342 
 
 symptoms of, 343 
 Electric hyperirritability in tetany, 355 
 Encephalitis, 308 
 
 interstitialis congenita, 308 
 
 septic, 309 
 Erepsion, 62 
 
 Erythroblastosis fetalis, 344 
 Etiology of prematurity, 19 
 Exophthalmic goiter, cause of prema- 
 ture labor, 24 
 Exophthalmos, occurrence of, in mega- 
 
 cephalous, 308 
 Eyes, 74
 
 GENERAL INDEX 
 
 393 
 
 Faulty nutrition of fetus, cause of pre- 
 mature labor, 25 
 Feeblemindedness as caused by prema- 
 turity, 379 
 Feeding after twenty-first day, 184 
 amount necessary in twenty-four 
 
 hours, 180 
 an individual problem, 179 
 artificial, 199 
 
 amounts to be fed, 202 
 boiling mixtures, 200 
 buttermilk and skimmed-milk 
 
 mixtures, 201 
 as increasing susceptibility to 
 
 infection, 314 
 quality and quantity of, 200 
 in atelectasis, an important prob- 
 lem, 257 
 cereal, 203 
 methods, 171 
 
 breast milk, 171 
 by catheter, 174, 178, 180 
 with infants too weak to 
 nurse, 172 
 mixed, 185 
 
 vegetable soup in, 203 
 Ferments, carbohydrates, 62 
 diastase, 62 
 erepsin, 62 
 hydrochloric acid, 61 
 invertin, 62 
 lipase, 62 
 maltase, 62 
 pepsin, 61 
 ptyalin, 62 
 rennin, 61 
 saccharose, 62 
 secretin, 62 
 steapsin, 63 
 trypsin, 62 
 Fluid administration in underfeeding, 
 281 
 intake, by mouth, to be pushed, in 
 sepsis, 319 
 in twenty-four hours, 151 
 Food, infants, 168 
 
 lack of, cause of insufficient heat 
 
 production, 41 
 requirements in calories, 182 
 Full-term infant, definition of, 17 
 
 newborn, body characteristics 
 of, 35 
 
 G 
 
 Gallstones, 290 
 
 Gastro-intestinal tract diseases, 266 
 anorexia, 271 
 bacteriology of, 64 
 
 Gastro-intestina] tract diseases, can- 
 crum oris, 269 
 constipation, 279 
 
 dysenteric affc cl io n b, 
 medicinal treatment of. 
 
 285 
 enteral infect ions, 282 
 inanition fever, 272 
 indigestion, 276 
 insufficiency dependent 
 on developmental lack 
 271 
 portal of entry for bac- 
 teria, in sepsis, 313 
 sprue, 266 
 
 stomatitis, etiology of, 268 
 of oral cavity, 266 
 prognosis of, 268 
 treatment of, 268 
 various types of, 267 
 Gavage in anorexia, 272 
 Genito-urinary system, 72 
 Growth, 41 
 
 fetal,inhibited by maternal disease, 
 46 
 
 H 
 
 Health of mother, important in future 
 
 of premature, 370 
 Heart disease, cause of premature labor, 
 
 24 
 Heated beds, dangers in use of, 221 
 
 home-made, 223 
 Hemorrhage present in septic jaundice, 
 
 288 
 Hepatic parenchyma, affection of, 291 
 
 vessels, affections of, 290 
 Hernia, cigarette bandage in, 297 
 congenital diaphragmatic, 293 
 umbilical and inguinal, 294 
 ventral and lumbar, 294 
 Hess bed, advantages of, 215 
 care of, 218 
 
 comparative measurements of 
 temperature in, 219 
 , construction of, 216 
 Home-made bed (Brown . 223 
 (Litzenberg), 224 
 specifications of, 22.5 
 temperature maintained by 
 hot-water bottles in, I'L'o 
 Hospital nursery, requirements of, 1M7 
 staff of, 146 
 records, 159 
 Hunger contractions, (il 
 Hydrocephalus, 303 
 Hydrochloric acid, presence of, in 
 
 stomach, 61 
 Hydrotherapy in pneumonia, 264 
 ELygiene of mother, 107 
 
 air and exercise, 108 
 care of bowels, 10S
 
 394 
 
 GENERAL INDEX 
 
 Hygiene of mother, care of breasts, 108 
 
 diet, 107 
 Hypothermia, cause and nature of, 40 
 
 Icterus catarrhalis, 291 
 
 frequent, in septic infant, 315 
 
 neonatorum, 286 
 
 pallor of skin, forerunner of, in 
 
 anemia, 352 
 stasis of bile, as cause of, 287 
 symptoms and diagnosis of, 288 
 treatment of, 289 
 Idiocy, Mongolian, prevalence of, 309 
 Illegitimacy, factor in survival of pre- 
 matures, 373 
 Immature infants, definition of, 19 
 Inanition fever, 272 
 Incubator room in Michael Reese Hos- 
 pital, 228 
 requirements of, 217 
 in University of California, 228 
 Incubators, 205 
 
 general requirements in care of, 222 
 history of, 205 
 relative humidity of, 217 
 requisites in, 215 
 room or giant, 226 
 transportation of, 229 
 De Lee, 231 
 Hess, 230 
 Indigestion, 276 
 
 dehydration in, 278 
 stools in, 276 
 treatment of, 276 
 medical, 277 
 Infection, intrapartum and postpar- 
 tum, in sepsis, 312 
 spread by carelessness, 282 
 Infectious diseases, cause of premature 
 labor, 24 
 effect of, on survival of prema- 
 tures, 373 
 Intestinal flora, cause of dysenteric 
 conditions, 284 
 tract, permeable to foreign pro- 
 teins, 63 
 Iron, important in anemia, 352 
 stored by fetus, 69 
 therapy in anemia, 353 
 
 Jaundice, family acholuric, 289 
 septic, 288 
 syphilitic, 289 
 
 Labor, preparation for, 169 
 Lavage in cyanosis, 245 
 
 Lavage in vomiting, 275 
 
 Life history of prematures, factors in, 
 
 18 
 Lipase, 62 
 
 Liver, acute yellow atrophy of, 291 
 congenital tumors of, 292 
 decreased size of capillaries of, as 
 cause of icterus neonatorum, 287 
 diseases of, 286 
 fatty degeneration of, 291 
 Lumbar puncture in megacephalus, 306 
 in nervous and mental disturb- 
 ances, 302 
 Lungs, congestion of, 258 
 
 infection of, bacilli in, 259 
 pathology of, 259 
 Lymphatic glands in syphilis, 323 
 system, 72 
 
 M 
 
 Mammary glands, 77 
 Maramus, danger of, 281 
 Measurements, 29, 31, 32 
 
 of assistance in estimating viabil- 
 ity, 369 
 Meconium, constituents of, 64 
 Megacephalus, 303 
 definition of, 307 
 
 differential diagnosis from occur- 
 rence in rickets, 330 
 lumbar puncture in, as diagnostic 
 
 measure, 306 
 occurrence of, in rickets, 346 
 prevention of, in prematures, 307 
 symptoms often appearing at 
 birth, 304 
 Meningitis, 309 
 
 Mental and nervous disturbances, 
 catheter feeding in, 302 
 spastic paraplegia in, 301 
 treatment of, 301 
 development of prematures in 
 early childhood, 387 
 Mercury therapy in syphilis, 333 
 Metabolism of prematures, 65 
 Milk, buttermilk and skimmed-milk 
 mixtures, 201 
 chymogen, 201 
 
 relative caloric values in, 202 
 stations, 143 
 Mineral content abnormal in prema- 
 tures, 348 
 Mixed diet, 203 
 Mortality, general, 374 
 Multiple pregnancy, cause of prema- 
 ture labor, 25 
 
 N 
 
 Nasal passage, diseases of, 246 
 treatment of, 246
 
 GENERAL INDEX 
 
 395 
 
 Nephritis, cause of premature labor, 22 
 Nervous disturbances, epilepsy in, 303 
 
 megacephalus, 303 
 
 system, 65 
 
 in syphilis, 330 
 Nitroglycerine in cyanosis, 244 
 Noma (cancrum oris), 269 
 Nursing axioms, 107 
 
 bottle for prematures, 172 
 
 daily routine, 146 
 
 hygiene of mother, 107 
 
 maternal, 111 
 
 in tuberculosis, 341 
 
 method of drawing milk, 125 
 
 regularity in, 42 
 
 requirements for, in home, 165 
 
 by syphilitic mother, 332 
 
 wet, hospital rules for handling, 
 129 
 
 Orange juice feeding, 203 
 
 in rickets, 351 
 Omphalitis in sepsis, 316 
 Organs, characteristics of respiratory 
 tract, 50 
 internal, weight of, in mature 
 
 infants, 37 
 stomach, 53 
 Osseous development, variations in. 99 
 Ossification of skeleton, head, 80 
 
 pelvic girdle and lower ex- 
 tremities, 83 
 ribs, sternum and upper ex- 
 tremities, 87 
 shoulder girdle, 80 
 vertebrae, 82 
 in weeks, (diagram), 77 
 eighth, 80 
 
 eleventh to twelfth, 84 
 ninth, 81 
 seventeenth to twentieth, 
 
 88 
 seventh, 79 
 tenth, 83 
 thirteenth to sixteenth, 
 
 87 
 thirty-seventh to fortieth, 
 
 96 
 thirty-third to thirty- 
 sixth, 96 
 twenty-fifth to twenty- 
 eighth, 92 
 twenty-first to twenty- 
 fourth, 90 
 twenty-ninth to thirty- 
 second, 96 
 Oxycephalus, 307 
 
 Oxygen consumption per gram body 
 weight, 41 
 
 Oxygen in asphyxia, 240 
 in cyanosis, 2 1 I 
 in pneumonia, 264 
 
 Paraplegia, corrective measures for. 
 
 302 
 Parathyroid dysfunction in tetany, 358 
 Parenteral infection accompanying di- 
 gestive disturbances, 283 
 Pathological processes in prematures, 
 
 103-104 
 Pepsin present in gastric mucosa, 6] 
 Peritoneal disorders, pathogenesis, 292 
 Peritoneum, diseases of, 292 
 Peritonitis, 293 
 
 Phosphorus concentration in serum, 349 
 role of, in osseous system, 350 
 in spasmophilia, 360 
 Pneumonia, 258 
 
 changes of position in, necessary, 
 
 265 
 collapse and cyanosis in, treatment 
 
 of, 264 
 diagnosis, prognosis, treatment, 
 
 262 
 general treatment of, 263 
 hygiene of, 264 
 hydrotherapy in, 264 
 lobular, symptoms in, 261 
 occurrence in sepsis, 316 
 physical signs of, 261 
 postnatal, 258 
 Porencephaly, 308 
 Premature birth, causes of, 371-372 
 definition of, 17 
 
 infants, classification of, 19, 103 
 constitutional inferiority of, 
 
 383 
 growth of, 364 
 outlook for, 377 
 prognosis of, in early child- 
 hood, 379 
 labor, causes of, 19 
 
 acute infectious diseases 
 
 in, 24 
 age of parents, 25 
 anomalous position of 
 
 fetus, 24 
 chronic affections, 22 
 
 nephritis, 22 
 diabetes, 25 
 exophthalmic goiter, 2 I 
 faulty nutrition of fetus, 
 
 25 
 heart disease, 24 
 multiple pregnancy, 25 
 season of year, 26 
 syphilis, 22 
 tuberculosis, 23
 
 396 
 
 GENERAL INDEX 
 
 Premature labor, causes of, uterine con- 
 ditions, 24 
 frequency of, 26 
 indications for induction of, 23 
 Prematurity, not mark of congenital 
 
 inferiority, 310 
 Prognosis of premature, 361 
 
 deformity in relation to, 372 
 factors affecting future, 370, 
 
 372 
 general conditions, 374 
 
 mortality, 374 
 illegitimacy factor in, 373 
 infectious diseases in, 373 
 Pulse-rate, 66 
 Pyelocystitis, 300 
 
 R 
 
 Rachitis, 346 
 
 definition of, 350 
 
 diet in, 351 
 
 in early childhood, holdover from 
 
 prematurity, 378 
 etiology of, 348 
 hygiene important in, 350 
 Rennet, casein precipitated by, in treat- 
 ment of vomiting, 275 
 Rennin, presence of, in stomach, 61 
 Respiration, artificial, violent measures 
 contraindicated, 302 
 in prematures, 51 
 Roentgen ray in stridor, 249 
 Roentgenograms, technic of, 102 
 Roentgenographic diagnosis in syphilis, 
 325 
 
 Saline solutions in intestinal difficul- 
 ties, 285 
 Scleredema, 342 
 
 Scurvy, differentiation from osteomye- 
 litis, 378 
 Secretin, 62 
 Skeletal development, 77 
 
 as basis for age, 77 
 Skin and adnexa, 74 
 
 care of, 150 
 Sepsis, active treatment of, 319 
 affections of skin in, 315 
 bacteria causative of, 311 
 course of, 317 
 
 general manifestations of, 314 
 infections in time of, 312 
 portals of entry for bacteria, 312, 
 
 313 
 prognosis for, 318 
 sterilization, reducing incidence, 
 
 314 
 susceptibility to, in prematures, 
 314 
 
 Skull, measurement of, 32 
 Spasmophilic convulsions, 310 
 diathesis of, 354 
 differential diagnosis of, 358 
 treatment of, 359 
 Spleen, enlargement of, in tuberculosis, 
 
 340 
 Stomach, capacity of, 55, 58 
 
 physiology of, 58 
 Stools, foamy, from gas bacillus, 284 
 
 in indigestion, 278 
 Stridors, congenital, 247 
 laryngeal, 247 
 roentgen ray in, 249 
 thymus, 248 
 
 thyroid gland enlargement in, 249 
 Subcutaneous infusions in nervous and 
 
 mental disorders, 302 
 Suffocation from external causes, 249 
 Syphilis, 320 
 
 abdominal organs in, 328 
 affections of eyes and ears in, 330 
 of mucous membranes and 
 skin in, 321 
 arsenic in, 335 
 circulatory and digestive system 
 
 in, 329 
 as cause of congenital hydrocepha- 
 lus, 303 
 factor in prematurity, 22 
 inunctions in, 334 
 kidneys in, 329 
 laboratory diagnosis in, 331 
 megacephalus in, differentiated 
 
 from that in rickets, 330 
 mercury therapy in, 333 
 nervous system in, 330 
 osseous system in, 324 
 
 roentgenographic diagno- 
 sis in, 325 
 percentage of, in parents, 320 
 prophylaxis of, 332 
 purse-string deformity in, 323 
 respiratory system in, 328 
 treatment, 332 
 
 Wassermann reaction not always 
 positive in, 331 
 
 Talking, age of, in prematures, 382 
 Temperature, how taken, 151 
 subnormal, cause of, 151 
 
 as factor in infection in prema- 
 tures, 314 
 Tetany, 354 
 
 electric hyperirritability in, 355, 
 
 356 
 etiology and symptoms of, 355 
 parathyroid deficiency in, 358 
 Trypsin, 62
 
 GENERAL INDEX 
 
 397 
 
 Tubercle bacilli, entrance of, into fetus, 
 
 337 
 Tuberculosis as cause of congenital 
 debility, 336 
 of premature labor, 23 
 effect of, on development of fetus, 
 339 
 on mother, 338 
 etiologic factor in prematurity, 338 
 results of, affecting future develop- 
 ment, 340 
 treatment, 340 
 
 U 
 
 Underfeeding, 280 
 
 factor in development of rickets, 
 349 
 Urinary diseases, 'eclampsia neona- 
 torum, 300 
 nephritis in mother causing shrun- 
 ken kidneys in infant, 299 
 Urination, delayed, measures in, 149 
 Urine, 72, 73 
 
 acetone bodies in, 74 
 albumin in, 73 
 in prematures, 28 
 Uterine conditions cause of premature 
 labor, 24 
 
 Variations in osseous development, 99 
 Vegetable soup, 203 
 
 Vomiting, 273 
 
 factor in dysenteric affections, 284 
 feeding in, 275 
 treatment in, 27 1 
 
 W 
 
 Walking, age of, in prematures, 382 
 Water administration by catheter, 1M 
 intake, increased, in constipation, 
 
 279 
 in sclerema, 344 
 requirements dependent on, 184 
 Weaklings, definition of, 17 
 Weight as factor in survival, 363 
 
 caloric requirement per kilogram of 
 
 body, 182 
 gain in, tabulated, 1 1 
 of kidneys, 39 
 of liver, 38 
 
 loss of, during first days, 152 
 initial cause of, 43 
 prevention of , by feeding, 13 
 rapid in sepsis, 315 
 of organs in mature new born, 37 
 of prematures, 27 
 in relation to body surface, 17 
 unreliability of, in estimating 
 fetal age, 363 
 Wet nurse, 114 
 
 diet of, 121 
 examination of, 116 
 hygiene of, 119 
 uniform, 120
 
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