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The Nursling

Lecture 1

By Pierre Budin, Professor of Obstetrics, University of Paris; Director of the Clinique Tarnier; Member of the Academy of Medicine, Paris, France. Authorized translation by William J. Maloney, M.B., Ch. B., 1907.


The first page of Lecture 1.


Gentlemen,

Medical interest in the welfare of infants is of comparatively recent development. Formerly, the birth of a child was an ordeal of life and death to the mother; and the accoucheur, engrossed in her safety, scarce spared a thought for the infant. Nowadays, thanks to asepsis, death has practically been banished from our maternity hospitals, and morbidity reduced almost to its minimum. Further, through the perfection of instruments and the advancement of operative technique, obstetrical interference has become much simpler and safer, so that the accoucheur, freed from anxiety as to the fate of the mother, can now devote his attention to the needs of the infant. Before parturition, he supervises the hygiene of the expectant mother so that she may arrive at term in a healthy; during delivery, he takes every precaution to ensure that the child will be born sound and viable, and throughout the first two years of life, he directs its feeding with the utmost care.

I intend, therefore, this year, in addition to the usual lectures on Practical Obstetrics, to devote a certain number of meetings to the consideration of the infant. I propose to study with you, successively --

  1. Infants born before term, i.e. congenitally feeble infants.
  2. Infants born at term and their care in the Maternité.
  3. Infants after they leave hospital.

In this connection I shall describe to you the constitution and function of Consultations for Nurslings which are being established throughout France. A considerable movement in this direction has taken place of late years, important results have been obtained, and great advances have been made. You will learn what practical experience has taught us relative to the feeding and weaning of infants, and the knowledge of these matters will prove indispensable to you as medical men.

We shall begin with the study of infants affected with congenital feebleness. They are classed as weaklings, and are, as a rule, the product of premature labor.

Infants born at full term weight on an average from 3000 to 3500 grams. Those born before term weigh less, and all between 1000 and 2500 grams are considered to be congenitally feeble. We shall not discuss infants of less than 1000 grams. They are seldom saved, and only rarely shall I need to allude to them.

We must not, however, base our estimate of an infant's vitality solely on its weight. Some born prematurely have quite a considerable weight, mainly accounted for by the excess of fat in their tissues. These infants do not, as a rule, live long; their pulmonary apparatus functions imperfectly and their digestive tube does not permit of assimilation. On postmortem examination their organs are found to be more or less incompletely. developed.

On the other hand, there are tiny, puny infants with great vitality. They seem never to rest. Their movements are untiring and their crying lusty, for their organs are quite capable of performing their allotted functions. These infants will live, for although their weight is inferior to that of those we have just mentioned, they have a greater power of resistance, for their sojourn in the womb was longer.

To appreciate the vitality of infants born born before term, it is necessary, therefore, not only to take into account their weight, but also the length of time they have remained in the uterine cavity.

Infants affected with congenital debility present certain external characters which I shall briefly recall to you.

The body is small and puny; the skin is soft and of a vivid red ; the dermis is transparent, allowing the blood vessels to be seen, and the circulatory network through the tissues can be clearly distinguished.

These infants breathe and they even cry, but their respiration is far from complete. As can be seen at the post-mortem examination, it is not really pulmonary, but only bronchial; the air may penetrate into the large, into the medium-sized and even into the small bronchi, but it does not reach the interior of the pulmonary alveoli.

Further, these infants show a most remarkable degree of muscular inertia: their movements are slow and lagging, their cry without force, and their voice wavering and toneless. Some make feeble and impotent efforts of suction; but they cannot suck, sometimes they seem not to have even the strength to swallow a few drops of milk trickled from a spoon into their mouths. It is then necessary to use various means, in order to ensure that the nutrient fluid will reach the stomach.

What should be your treatment of such an infant? In 1853 Hervieux published some interesting researches on what he called "The Progressive Algidity of the Newly Born." He showed that in them the temperature, the circulation, and the respiration became depressed, following a parallelism almost mathematical. Gueniot, in 1872, delivered some important lectures on congenital debility and its treatment. A little later, Tarnier and his pupils, Auvard, Berthod, &c., endeavoured to maintain these infants at a sufficient and uniform temperature by the use of the incubator. Through the influence of Madame Henry, formerly chief midwife at the Maternité, a special department for weakings was inaugurated at the end of the year 1893; of this I had charge from January 1895, till I was appointed to the Clinique Tarnier, in March 1898. During this time I made a special study of infants affected with congenital debility, and my interest in them has continued unabated.

Here, when an infant is born before term, we devote special care to it; we keep mother and weakling in hospital as long as possible, and allow them to leave only if the progress of the little one is satisfactory, in order to minimise its liability to disease. Unfortunately, mothers cannot always be persuaded to stay long enough for their infants to attain the development of a full-term child. It has occasionally happened that I have had to readmit to the wards, weaklings whose condition had become critical, after they had been taken home by obstinate mothers.

What I wish, then, to lay before you in this lecture, is the result of my personal observations and researches.

Authorities are agreed as to the essential importance of preventive medicine in early infancy. Hitherto, their efforts have been mainly directed towards two objects: --

  1. The care of the digestive tube.
  2. The prophylaxis of contagious diseases.

Infants enfeebled by premature birth should be guarded with special solicitude. Not only do they share to a greater extent than full-term children the ordinary risks of infancy, but they labour under a danger which in its intensity is almost peculiar to them. I refer to the great readiness with which they become fatally chilled.

With weaklings we shall then have to consider three points: --

  1. Their temperature and their chilling.
  2. Their feeding.
  3. The diseases to which they are specially liable.

To-day we shall study the temperature of weaklings.

At the moment of birth, the infant at term experiences a slight fall of temperature. If, in the case of a pelvic presentation, a thermometer be introduced into the anus of the foetus, the temperature is found to be the same as, or slightly higher than that of the uterine cavity; but from the moment of expulsion, the mercury falls: it passes from 38°to 37°, to 36°C., and sometimes even lower.

This may be due to evaporation from the surface of the body, but more probably, it arises from the fact that the processes of respiration and combustion are not yet fully established and adjusted.

In the case of the full-term child, under favorable circumstances the temperature quickly rises, but what happens to the premature ?

In 1870, Lépine wrote: "I have observed a most striking difference between infants born robust and infants born weak. If they are exposed for some time to the temperature of the labour ward (15°to 17°C.) before being adequately clothed, the temperature of the latter falls to about 33°C., whilst that of the former remains practically normal. This depression of temperature in weaklings is, however, only transient, as a few hours suffice for it to return to between 36°and 37°C. It is quite exceptional if at the end of twenty-four hours this figure is not attained."

The first part of Lépine's remarks is absolutely correct: the second, less so. If the infant be not placed under favourable conditions, the temperature not only falls considerably, but does not easily rise again.

Here is an instance which occurred yesterday. A woman in the wards was delivered at 6.50 P.M., of an infant weighing only 950 grams. As the vaginal temperature of the mother at the moment of delivery was 37.3°C., it is likely that the temperature of the infant, in the uterine cavity, was not less. But ten minutes after birth, at 7 o'clock, the thermometer, placed in the rectum of this weakling, did not register more than 35.1°C.; the infant was immediately put in an incubator at 32°C., which, during the night, was maintained uniform.

Time

Temperature

9 P.M.

35.6°C.

11 P.M.

34.2°C.

1 A.M.

34.0°C.

3 A.M.

35.2°C.

5 A.M.

35.9°C.

7 A.M.

36.9°C.

Here, then, is a weakling whose temperature fell to 34°C., in spite of its having been placed in an incubator at 32°C. How far would it have fallen if this measure had not been taken?

Formerly, a pathological condition, sclerema, was frequently observed. Today, we seldom see it, for we do not allow our infants to become chilled. It is characterised by an induration of the skin and subcutanous cellular tissue. The former is remarkable for its pallor and is cold to the touch; the tissues are hard and wax-like, and at the same time, the temperature is lowered.

This fall in temperature can be carried very far in the hours and days subsequent to birth. Instead of 37.5°, the thermometer, placed in the rectum, may show only 35°, 33°, 32°, 30°, 28°C., &c. Several years ago, in passing one morning through the wards, I saw a premature infant which showed signs of sclerema. I touched it; it was cold. I wished to take its temperature, but the mercury would not leave the bulb, to register the lowest point on the scale, 28°C. Having sent for another, I found the temperature was 25°C.

What had happened? The child was in an incubator, but just as the foolish virgins neglected to fill their lamps, so, during the whole night, had the attendant forgotten to renew the warm water. In the ward the temperature had been only 10° C., and the infant, in the incubator, had been frozen. Needless to say, it died during the day. Thus, even without being exposed to the outside air, a weakling may die, if precautions are not taken to prevent the temperature of the room in which it is from falling too low in winter.

When I entered the Maternité, in January I895, I was impressed by the fact that weaklings brought from outside were often in a lamentable condition. Having arranged that the temperature of an infant should be taken when it arrived, I saw how evil an omen was its fall in a premature child.

Many infants who presented a considerable lowering of the temperature died within twenty-four, or forty-eight hours; others lived a little longer, but, in spite of all our care, also succumbed. So, when a puny infant was admitted with a marked fall of temperature, I could, almost with certainty, foretell its death.

At the autopsy, we found the tissues of these little beings in a state of fatty degeration; it seemed as if the cold had laid a deadly grasp on them.

The carelessness of parents is most extraordinary. Infants scantily clad are often brought to the Maternité, not only from Paris, but also from the surrounding districts and even from the Departments. An infant was once sent over a hundred miles to me, and its only covering was a small piece of flimsy material. Such conduct borders on infanticide by neglect. On the other hand, an intelligent midwife, in the neighbourhood of Paris, has several times sent me weakly infants swaddled so warmly as to place me under the most favourable circumstances for saving them.

What proportion of these infants die when their temperature has been allowed to fall markedly?

I can give you the figures for the three years 1895, 1896, 1897, during which I was in charge of the Matemité.

Amongst the infants.having, on admission, a rectal temperature of 32°C. or less, I shall distinguish two categories: --

  1. Those weighing less than 1500 grams.
  2. Those weighing between 1500 and 2000 grams.

103 weighed less than 1500 grams: 101 died, only 2 were saved.

39 weighed between 1500 and 2000 grams: 38 died, 1 survived.

This makes a total of 142 infants, of which 139 succumbed.

The mortality, then, has been almost 98 per cent. This is truly appalling. Evidently other causes, such as syphilis and digestive troubles, ought to be taken into account, but the lowering of the temperature played the principal part and rapidly brought about the end.

We have proof of this in the results obtained at the Clinique Tarnier. From the moment of my entry, I insisted on the necessity of preventing the chilling of the newly born, and those congenitally feeble I immediately placed in incubators.

From March 1, 1898, to December 31 of the same year, we had 39 infants who weighed, at birth, 2000 grams or less, and who were, in consequence, from the point of view of weight, in the same position as those at the Maternité. Of these only 9 are dead, 30 have survived. The total mortality, all factors (syphilis, digestive troubles, &c.) being included, has thus been 23 per cent.

In the department for weaklings at the Maternité, among the infants admitted with a rectal temperature of 32°C. or less, the mortality was 98 per cent.; but, at the Clinique Tarnier, where the weaklings were not allowed to become chilled, the mortality of infants of the same weight was only 23 per cent.

But, you will say, this fall to 32°C. is considerable.

That is true; nevertheless, in three years, 142 infants were admitted in this condition.

Let us take a lesser fall. Let us consider, for example, those infants who had on admission a rectal temperature between 32°and 33.5°C.

72 weighed 1500 grams or less: 70 died, 2 survived.

83 weighed between 1500 and 2000 grams: 71 died, 12 survived.

Thus, out of 155 infants weighing 2000 grams or less, 141 succumbed, i.e. fully 90 per cent. (Fig. 1).

You must think that weaklings having such a marked depression of temperature are rare; the figures which I have just quoted prove the contrary.

I have shown you that 142 infants, weighing less than 2000 grams, had, at the moment of admission, a rectal temperature of less than 32°C., and that with 155 others the thermometer oscillated between 32°and 33.5°C. This makes a total of 297 infants.

If to these we add 21 who weighed more than 2000 grams, in whom the temperature was equally depressed -- 32°C. in 8, 33.5°C. in 13 -- we have, in all, 318 infants.

As during these three years 1114 weaklings were admitted, 28.54 per cent., that is, nearly one-third, had when they reached us a temperature which scarcely permitted their survival.

It is evident that not only must the degree of depression of temperature be taken into account, but also the weight of the infant. A very small and puny infant offers less resistance to cold than one better developed. This is proved by the figures obtained at the Maternité (Fig. 2).

For weaklings in whom, on admission, the rectal temperature was 32°C. or lower the mortality was --

98 per cent. when they weighed 1500 grams or less: 103 infants; 101 died, 2 lived.

97.5 per cent. when they weighed between 1500 and 2000 grams: 39 infants; 38 died, 1 lived.

75 per cent. when they weighed more than 2000 grams: 8 infants; 6 died, 2 lived.

Consequently, with a rectal temperature of 32°C., the mortality is higher, the smaller the infants.

For infants in whom the rectal temperature fluctuated between 32°and 33.5°C., the mortality was --

97.3 per cent.l for those who weighed 1500 grams or less: 72 infants; 70 died, 2 survived.

85.6 per cent. for those who weighed from 1500 to 2000 grams: 83 infants; 71 died, 12 survived.

69.2 per cent. for those who weighed 2000 grams and over: 13 infants, 9 died, 4 survived.

Thus, in order to appreciate the power of resistance of an infant, it is necessary to take together into account the degree of depression of its temperature, and its weight. The lower its temperature, the more serious will be a chilling; the less its weight, the more easily will it succumb. This I can conclusively prove by statistics and graphs.

What should be done to protect a newly-born infant from cold ?

This question has long exercised the minds of men. Sterne, in "Tristram Shandy," quotes the following passage: --

"The foetus was no larger than the palm of the hand, but the father, having examined it in his medical capacity, and having found that it was something more than a mere embryo, brought it living to Rapallo, where it was seen by Jerome Bardi and other doctors of the place. They found it was not deficient in anything essential to life, and the father, in order to show his skill, undertook to finish the work of nature and to perfect the formation of the infant by the same artifice as is used in Egypt for the hatching of chickens. He instructed a wet-nurse in all she had to do, and having put his son in an oven, suitably arranged, he succeeded in rearing him, and in making him take on the necessary increase of growth, by the uniformity of the external heat, measured of a thermometer, or other equivalent instrument."

In order to hinder weaklings from becoming cold, it used to be the custom, before swaddling them, to envelop the limbs and trunk in a bed of wool; under the bonnet also, there was placed round the head a sheet of wool. Their appearance caused the pupil midwives to dub them "the little woolies."

Two or three hot-water bottles, frequently renewed, surrounded them in the cradle, and their warmth was further added to by blankets, or a little eider-down quilt.

Sometimes they were kept in a room maintained at a uniform temperature of 25° C., but it was trying for the mother stay constantly in a place so overheated. However, in 1877, I thus reared the infant of a celebrated doctor. The grandmother stayed with the little one and tended it, and the wet-nurse entered the room only at the times when the child had to be fed.

In December 1857, Professor Denucé of Bordeaux devised a zinc cradle, with a double bottom and double sides; it was like two baths, a smaller inside a larger, separated from each other by an empty space in which it was possible to put water.

"These two baths," said Denucé, "are united together by their upper edges so as to complete a closed cavity in which water can be received. A funnel is placed at the top, and at the bottom there is a tap by which the apparatus may be emptied.

"The bedding is placed in the cradle; to avoid loss of heat the cradle itself is enveloped in a woolen covering. Hot water is put in the apparatus. Then, by the aid of a thermometer placed in the cradle, as it is easy to add or draw off water, the temperature desired in the interior can be readily established and maintained. Further, with the precaution I have mentioned of wrapping the cradle in wool, the loss of heat is not great; and in the case in which I employed this apparatus, it was sufficient, every six hours, to draw off half a litre of water, and to replace it by the same quantity of boiling water."

In 1878 I saw this cradle incubator in use at the "Enfants Assistés" in Moscow. Later, in 1884, Credé published the results he had obtained with it at Leipzig.

The idea occurred to Tarnier to utilise an apparatus similar to that which is used to obtain artificially the hatching of hens' eggs. In 1880, by way of a trial, his first incubator was installed at the Maternité. It has been described by Auvard, and has been working regularly since November 21, 1881. To the one which had been placed in my wards at the Charité, I adapted, in 1883, a Regnard regulator. A uniform temperature could thus be ensured, for if it rose a little too high a warning was immediately given by an electric bell.

But this apparatus was bulky and dear. Useful in maternities, where it could hold several infants, it was scarcely practical in private work. Tarnier then designed a smaller incubator, simply heated and easily transported.

It is composed of a plain wooden box, 65 centimetres long, 36 broad and 50 high (Fig. 3). The walls are 25 millimetres thick. The interior is divided into two by a horizontal partition, situated about 17 centimetres from the bottom. At one end this horizontal partition is incomplete, so that air passes easily from one compartment to the other.

In the lower division hot-water bottles are put, either of metal or stoneware.

The child is placed in the upper compartment, on a small mattress which rests upon the separating shelf (Fig. 4).

The air enters the lower chamber by a trap-door, more or less open, arranged so that it can never be completely shut. As the air passes over the hot-water bottles it becomes heated. Through the space left at the free extremity of the transverse horizontal partition, it gains the upper compartment, where the child is lying, and thence it leaves the incubator by an opening which is guarded by a small chimney.

A large pane of glass is inserted into the top of the box, allowing everything which occurs in the incubator to be seen. It is movable and can be raised or replaced at will when the infant needs to be taken out or put in.

The bottles are renewed as often as may be necessary.

These incubators have been still further perfected. It sometimes happens that infants born in a state of congenital debility have attacks of cyanosis which may rapidly prove fatal. Hence it is necessary to watch them very attentively, so the wooden walls of the incubator have been replaced by thick panes of glass fixed in iron frames. The weakling is thus wholly and constantly exposed to view. In the lower compartment, a large reservoir has been substituted for the water bottles.

Lastly, as these incubators of glass and iron are somewhat dear, they are made nowadays of glass and wood, which is relatively cheap, and allows them to be more easily moved from place to place (Fig. 5).

These last two varieties, iron and glass, and wood and glass, are in daily use in our wards. They are easily cleaned by burning sulphur in them and then washing them carefully with a solution of corrosive sublimate.

You may also have seen large incubators, the "Lion" incubators, exposed even on a Paris boulevard. Air is obtained from without and, after being heated with gas, circulates round the infant. This apparatus necessitates the installation of two complete sets of pipes, one to communicate with the outside air, and one to conduct the gas. This requires time, and is, moreover, a source of expense which cannot be borne by all families. Furthermore, on three occasions, at the Maternité, we were forced to transfer infants placed in them to other incubators. In winter the greater cold requires more gas to heat the outside air; the longer nights also involve a greater consumption in town and a fall of the pressur in the mains, so it may often happen, as on the three occasions referred to, that the supply will be inadequate to maintain the desired temperature in the incubator.

Diffre of Montpelier has devised a metallic cradle incubator closed at the top by glass panes. As it is heated by an oil lamp, it sometimes gives rise to a very disagreeable odor, especially if there are several incubators in the same ward. It is very simple, but it is also rather dear.

Professor Hutinel has constructed an earthenware incubator which he uses at "Les Enfants Assistés." It is very easy to render aseptic, but the infant can be seen only through the cover.

In 1885, Professor Pajot, in this Clinique, prepared a chamber as a giant incubator in which to place infants, congenitally feeble, so that they might not be exposed to cold when they were being fed or changed. The wet-nurses, however, were obliged to feed and tend them in this oven; and the mothers, separated from their infants, soon lost all interest in those whom they were unable to nurse or cherish.

It is better by far to put the little one in an incubator by its mother's bedside. The supervision which she exercises is not to be lightly estimated. We have not always a staff so zealous as the present; and if the nurse be negligent, the mother does not fail to remark that the incubator is being allowed to grow cold. Further, it is possible, as you will see, so to arrange that the mother feeds the infant herself, and thus on leaving the hospital not only will the weakling have been saved, but a suckling mother will also have been conserved to it.

At what temperature ought the incubator to be kept? It used to be said, between 30° and 32° C. For my part I consider this much too high, save in certain exceptional cases, such as that of the infant weighing 950 grams, which you saw in the ward. At the Charité, when we were placing infants in incubators at 30° C., we often saw them covered with sweat, crying and restless. Their movements were directed to getting rid of their clothing, and we frequently found them lying naked. The temperature was obviously too high, so I reduced it, and I no longer allowed it to rise to more than 25° or 26° C.

When I took charge of the Maternité, I was much astonished to see that the weaklings in the glass and iron incubators, although the thermometers registered 30° C., did not seem to be at all inconvenienced. On observing more closely I saw that each thermometer was placed directly above, and at a short distance from the hot-water reservoir; it was exposed to the action of radiant heat. On moving it to the other end of the compartment in which the infant is contained I found it registered only 25° or 26° C. This seems to me to be a temperature which is sufficient, except in rare cases, so I have adopted it as my standard for general use.

I consider that the function of an incubator is not so much to provide heat for the infant, as to prevent its losing in too great quantity, that which it, itself, generates.

When a nursling attains the weight of 2280 to 2300 grams, if the room in which it is kept be sufficiently and regularly heated, we allow the temperature of the incubator to fall gradually to 24°, 23°, 22°, 21°, and 20° C., after which we dispense with the incubator.

Ought weaklings in incubators to be clothed or not? One of my colleagues, having observed that by their movements they tend to rid themselves of their coverings, now leaves them quite naked. But if, perchance, the renewal of the hot water at the proper time be neglected, the infant would become very quickly chilled. It is preferable, while not restricting their movements by swaddling, at least to clothe them lightly, so as to conserve their warmth and yet leave them absolute freedom.

Further, it is beneficial, especially at the beginning, when infants are very puny, to try to increase their circulation by massage. The infant is undressed and placed in front of a bright fire; the fleshy parts of its limbs are lightly rubbed and kneaded, and its joints gently moved by hands previously immersed in hot oil, or moistened with alcohol. These manipulations are continued for about five minutes, and are repeated two or three times in the twenty-four hours.

When you are called to an infant whose temperature has fallen considerably, it is always sufficient to place it in an incubator? The first essential is to restore the temperature as quickly as possible; and if another fall takes place it must be rapidly counteracted. The use of hot baths, in these cases, is of the very greatest service.

These hot baths can be given in two different ways. In the one, the infant, having, let us say, a rectal temperature of 34° C., is plunged into water at 38° C., and left there for fifteen to twenty minutes: the rectal temperature is found to rise, attaining progressively 35°, 36°, 37°, and 37.5° C. The infant is then taken out of the bath and put in an incubator, and the rectal temperature is noted several times, to find the duration of the action of the hot water. In the other, the infant is plunged into water which has a temperature one degree higher than that of its body, that is, 35° C. The heat of the water is gradually increased until it reaches 38° C.; the temperature of the weakling, at the same time, is steadily rising, reaching ultimately 37.5° C. At the end of twenty minutes it is transferred to an incubator. It is found that the temperature of an infant remains much longer near the normal and falls much more slowly, when it is kept for twenty minutes, in water made progressively warmer up to a certain point, than when it is kept throughout in water of the same high temperature.

With newly-born infants in a state of congenital feebleness every precaution should be taken to avoid the lowering of their temperature. When weaklings are brought in from other hospitals, the city, or the surrounding districts, to the wards set apart for them at the Maternité, they generally arrive, especially in winter, very chilled. If they must be taken from one place to another, they should be carefully wrapped up, and one or two hot-water bottles should be placed beside them. They become chilled with astonishing rapidity. At the Maternité, when the mother of a weakling was quitting the hospital, she used to carry her infant to the office to enrol it, before we admitted it to the department for weaklings. As we often found in winter that they reached it with a considerable depression of temperature, a thermometer placed in the rectum sometimes not registering more than 34° C. or even 32° C., I had to insist on their direct transference from the mother's bedside to the department, and in cold weather I even moved them in their incubators.

Similar measures ought to be taken in private practice. Several years ago I had charge of the tiny daughter of one of our prettiest actresses, born prematurely at Nice, and brought to Paris in an incubator. The infant did not suffer from the journey, and was successfully reared. Yesterday, as one of the mothers here wished her child to be baptized, it was taken in its incubator to the room where the ceremony was to take place.

It is a vital necessity to avoid the exposure of premature infants to cold, as is amply proved by the results obtained at this Clinique, which I cannot too often recall to your minds. In the department for weaklings at the Maternité, among infants brought with a rectal temperature of 32° C. or less, the mortality was 98 per cent.: for those with a temperature oscillating between 32° and 33.5° C., it was 90 per cent.

On the other hand, at the Clinique Tamier, where the infants were not allowed to become chilled, the mortality was 23 per cent. for infants of the same weight -- that is to say, 2000 grams or less.

I might also cite to you the histories of two very instructive cases which occurred in my private practice, the one in 1892, the other in 1898.

In the former, the mother last menstruated during the first of November 1891. She felt quickening on March 6, 1892. The birth took place on May 14, and, the pregnancy having thus lasted barely six months, I did not consider the infant viable. The father, a doctor, from the first plunged it in warm water, and seeing it continued to live, he put it in a Darsonval stove which he found in the house. On May 17, the infant, a girl, weighed 955 grams. On May 20, she had fallen to 900 grams. She was fed on a little milk, which from time to time was made to trickle into her mouth from the breasts of a wet-nurse. With infinite care she was successfully reared, but so little did we count on her survival that the declaration of her birth at the town hall, demanded by law, had been neglected, and this gave rise to some trouble with the authorities.

In the latter case, the infant was born on April 21, 1898, with a weight of only 1270 grams. It was warmly wrapped up, and two hours after birth was placed in a wood and glass incubator. Ten days later, May 1, it weighed 1070 grams -- a loss of 200 grams. On May 31, it weighed 1550 grams, having gained 480 grams in thirty days. On December 22, 1898, it reached 4800 grams (Fig. 6 and Fig. 7).

There can be no doubt that these two little beings would quickly have perished if they had been exposed to cold. They did not experience any appreciable depression of temperature and they lived.

Infants born at term, although much more resistant, also become chilled very easily, especially in the days immediately following their birth, and the more readily then that they take so little nourishment.

Who has not heard of the numberless infants taken in old days from Paris to be reared in the country? The mortality among them was terrible, for those did that did not succumb on the way died rapidly after their arrival, chiefly, in winter at least, owing to cold.

Several years ago, at the instigation of M. Paul Strauss and myself, the authorities ordained that all wet-nurses transporting these little Parisians should not only travel in well-heated, second-class compartments of express trains, which they were not to be allowed to leave until their journey's end, but also, on alighting, be provided with all that was necessary for the warmth of their charges.

The same precautions and supervision should apply to all wet-nurses. They ought to able on leaving the train, especially when they still have a long journey to reach their village, to obtain a supply of hot water for use in hot-water bottles.

For some years it was compulsory in France to carry all infants to the town hall, there to make a declaration of the birth and sex. This was, during winter, another source of danger from cold, especially in country places where the town hall was sometimes a long way off. Nowadays, in Paris, a medical official visits each house to ascertain the necessary facts, and in the country, it is sufficient to present to the authorities a certificate from the doctor, or midwife, declaring the sex. It is only when the parents, desiring to remain unknown, wish to register the infant as the offspring of a father and mother unnamed, that it must now be taken to a public office.

Although it is no longer obligatory to carry infants to the town hall, they are still taken to church to be baptized. As churches in villages and small towns are often unheated, the risk thereby incurred, especially to weakly infants, is great, yet in their case the ceremony is usually performed earlier lest they should die unchristened.

I have endeavoured to impress upon you the grave dangers of chilling. The mortality among prematurely born infants when their temperature is allowed to become too much depressed is really appalling, and too great precautions cannot be taken to protect them.

But, however important the external temperature may be, it is not everything; the infant must, in addition, be enabled to maintain its animal heat by being fed.

The feeding of weaklings is a matter of much difficulty. We shall study it in the next lecture.

Figure 1. In blue: Mortality of infants weighing 2000 grams or less brought with depression of temperature to the department for weaklings in the Maternité. In red: Mortality of infants weighing 2000 grams or less, born at the Clinique Tarnier, where every precaution is taken to avoid exposure to cold.

Figure 2. The mortality varies according to the infant's weight and the degree of depression of its temperature.

Figure 3. Tarnier's incubator. 1. Air entry. 2. Hot-water bottles. 3. Sliding door. 4. Air exit. 5. Glass cover.

Figure 4. Section of Tarnier's incubator. 1. Air entry. 2. Hot-water bottles. 3. Horizontal partition on which the infant rests. 4. Chimney for exit of air. 5. Glass cover. 6. Thermometer. The arrows indicate the course taken by the air in the incubator.

Figure 5. Incubator of wood and glass. 1. Air entry. 2. Hot-water bottles. 3. Horizontal partition upon which the infant rests. 4. Holes by which the air escapes. 5. Glass cover. 6. Thermometer. The arrows indicate the course taken by the air in the incubator.

Figure 6. Daily curve of an infant weighing 1270 grams. The quantities of milk taken per day are indicated in blue at the bottom of the figure.

Figure 7. Weekly curve of same infant (see Figure 6). The blue columns represent the average daily quantities of milk taken in the course of each week.


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