Jacob Sobel, M.D.
Attending Pediatrician, Hospital for Joint Diseases and Beth David Hospital; Assistant Attending Pediatrician, Metropolitan Hospital, New York.
Read at a meeting of the New York Physicians
Association, April 28, 1926.
Published in Archives of Pediatrics 43:448-465, 1926.
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| The first page of the original Sobel paper. |
A fitting introduction to my remarks this evening would be the words of Montaigne: "I have gathered a bouquet of other people's flowers and only the thread that holds them together is my own."
It has been said that the most hazardous occupation in the world is that of being a baby. Less chance to live a week than a man of ninety and a year than a man of eighty, six times more hazardous than the life of a soldier in the trenches, less likely to complete its first year than an aviator who makes ascensions daily for twelve months has of surviving at the end of that period, do you wonder that the infant's existence is a most precarious one? Public health authorities tell us that approximately forty per cent. of all deaths under one year take place during the first month of life, and that of this number about two-thirds occur during the first ten days. They state furthermore, that three quarters of all deaths during the first month, and nine tenths of all deaths during the first ten days are attributable to what has been termed broadly, even if somewhat inexactly, congenital diseases -- congenital weakness or debility, prematurity, convulsions, marasmus, malformations, accidents, and injuries -- to conditions which bear little or no relation to hygienic, dietetic, or environmental errors, but are dependent upon factors operative before, during or shortly after birth. Speaking numerically it is estimated that every year in the United States 100,000 infants die within the first four weeks of life, and that there are about 135,000 still-births in this country annually, half or more of which are due to natal causes -- to conditions associated with labor. Foote states that "the rate of deaths of infants attributed to birth injury has been steadily climbing upward over a considerable period of years. The vital statistics reports of the United States Census Bureau show a rate 6.1 per 100,000 population for 1906, 6.9 for 1910, 8.1 for 1913, and in 1921 10.1." He asks: "To what extent is the increasing tendency toward interference with labor, advocated all too frequently in high quarters, responsible for this increase?" Yes indeed, the first month of life is the most critical one of the child's existence, for it is at this time that antenatal, intranatal and neonatal causes are operative and "tend to unite in their attach upon the new-born infant" and because "physiologically he is still tinged with traces of the life before birth."
For many years we have been concentrating efforts upon the care of the baby after birth failing to realize as Jacobi said "that the baby's life and pathology begin nine months before its birth." There is something so interesting, so human, so tangible, so dramatic about the new-born baby that we sometimes fail to realize that the condition of the baby at birth depends in no small measure upon the care of the mother before its birth. Fortunately the pendulum is beginning to swing from babyhood to motherhood, and today we appreciate that the first aid to the infant, the first prevention against disease, accident and injury at birth or shortly thereafter, begins or should begin from the time the mother becomes pregnant. In fact we hear too much these days of first aid to the injured. Why wait until injured? First aid to the uninjured or in other words prevention is the more logical method of approach it seems to me. I emphasize here the term prevention, because in infancy, especially, the highest type of first aid is that aid which renders first aid in its limited and general sense unnecessary.
With this initial point of attack fixed in our minds and which embraces the antenatal, intranatal, and early postnatal or neonatal prevention and care of the infant, let us reflect upon the diseases, accidents and injuries which may occur at these periods and which may cause either serious illness, deformity of a passing or permanent nature, or death.
While at first though the prevention and care of deformities might be considered the province of the orthopedist, in the antenatal, intranatal and neonatal periods the responsibility of the accoucheur, the general practitioner and the pediatrician is of equal if not greater moment. The causes of disability and deformity are so varied and unrelated, and the defects of locomotion and manipulation are so frequently traceable to diseases and conditions far removed from the affected parts, that the responsibility rests upon all physicians, who care for children, to keep in mind the possibility of deforming and incapacitating conditions following in the wake of many diseases and conditions acquired before birth or in early infancy.
While we cannot state statistically the number of preventable diseases and deformities, either in early infancy or in later life, it is safe to assume that a large number could have been avoided entirely, or certainly rendered less severe, by the institution of prompt and effective measures or after-care -- especially early after-care. Surveys made in larger cities have shown that sixty per cent. of all cripples become such before their sixteenth year and that the origin of many deformities can be traced to the early months of life.
It is an orthopedic dictum that the amelioration or cure of many deformities depends upon early mechanical, educational, manipulative or operative intervention and that while deformities in the primary stage are often readily and easily corrected, the secondary defects render cure difficult or impossible. The moral of this is, get them early and treat them right.
Childhood offers its many predispositions and its susceptibilities to disease and deformities. At different periods of life, from the moment of birth, yes indeed in the antenatal period, during the progress through the parturient canal, throughout infancy, babyhood and later childhood, the child is exposed to insults and assaults -- congenital, hereditary, traumatic, environmental -- and to diseases and infections, which may cause injury to vital organs, to brain, spinal cord, nerves, bones, muscles and joints and which may result in temporary incapacity, or lasting injury with future physical and psychic deterioration.
It may sound trite and even bromidic to state that the prevention of disease and deformities in children should begin before birth. Nevertheless, very much in the way of prevention can be accomplished by the careful and systematized supervision and instruction of the expectant mother -- and of the expectant father -- and by skilful obstetrics. The mother should be given the advantages of proper personal, home and mental hygiene, maintenance of good health, care of the breasts and nipples, avoidance of accidents during pregnancy, especially to the abdominal wall, careful antepartum measurements of mother and child, oversight of position and presentation, periodic determination of blood pressure and weight, regular urine examinations, systematic Wasserman tests, analysis of previous pregnancies, inquiry into and examination for the social diseases and tuberculosis, and the institution of modern approved methods, as well as for epilepsy, nervous disorders, chronic or debilitating diseases; the prevention of prematurity whenever possible, the correction of malpositions, the induction of premature labor if necessary, and as near full term as possible, or the institution of operative interference, all of which have for their purpose the bringing into the world a healthy and vigorous viable child under the best possible conditions for the particular patient and with the minimum danger of disease, accident or injury to either mother or child. This seems a large program and yet each and all of these measures have a bearing upon the future of the mother and the new-born. Apart from being a provider of material goods and comforts and of proper medical and nursing care, the expectant father owes it to the community, to himself, to his wife and to his offspring to place himself in proper health before marriage. If he has erred in youth through transgression or ignorance, it is his moral obligation to place himself before marriage in the hands of competent and trustworthy physicians, and not to enter into a marriage contract until all modern recognized tests pronounce him free, insofar as human intelligence can say, from any transmissible condition. If he belongs to the "I'll take a chance kind" then by all means let him confide in his physician, because much can be done for the child by medication of the father before conception. The mental health of the mother is an important consideration during pregnancy. Therefore, the future father should help to maintain the wife's emotional equilibrium by avoiding arguments or bringing his troubles home. It was my custom to say to him, "Whether your wife is right or wrong, you are always wrong and she is always right" -- during pregnancy.
Maternal and infant prophylaxis at this period of life is the duty of the obstetrician, and carefully supervised prenatal care and labor are the first prerequisites for the prevention of many accidents and injuries and deformities in infants as well as for diseases which directly or indirectly may cause deformity or physical and mental ill health.
It is understood of course that the intricacies of nature will produce some congenital defects or deformities beyond the power of man to prevent. And yet, while some of these congenital conditions are non-preventable, there are many others which are partially or definitely preventable, or respond promptly and completely to early intervention.
On the other hand, there are a number of diseases, injuries and deformities which can be traced to neglect or indifference during the prenatal period or to untimely or unwarranted obstetrics and which are largely preventable.
In my opinion meddlesome obstetrics and haste are more often to blame than inefficiency of the attendant. If more accoucheurs would assume the attitude of "masterly inactivity" and wait on nature, I am confident many mishaps would be avoided. If some practitioners could see the results of their labors, they would take more time and give more thought during the labor of their patients. If they saw as I see almost daily the cerebral spastic paralyses, fractures, dislocations, etc. they would think twice before they conducted a labor in rapid transit fashion. Injuries and accidents to the mother and the child at the time of birth often mean invalidism for the mother, loss of breast milk for the babies and shattered lives for the new-born. The after-results of some of these obstetric accidents and injuries vary in kind from the mild and evanescent to the most serious, incapacitating and hopeless. Some of the latter are so deplorable that one cannot escape the thought that death at birth would have been more acceptable to both mother and child. I do not want to be understood as advocating any laisse faire policy when intervention is clearly and legitimately indicated, for often timely and judicious intervention skilfully applied, is a life-saving measure for both mother and child. But the fact remains that "many a good piece of careful prenatal work has been ruined by indifferent confinement service."
The causes of intranatal accidents, injuries, disease and death "represent a noncompatibility between the child about to be born and the powers by which its birth is to be effected. The causes of intranatal death can to a great degree be anticipated and in many cases they can be defeated by good obstetrics (Ballantyne)."
In the antenatal period there are three conditions which may be influenced by careful prenatal supervision and which may spare the newborn not only its life but future disease and deformity. These are toxemia of pregnancy in the mnother, and syphilis and prematurity of the newborn.
Toxemia of pregnancy apart from the danger to the life of the mother, her future well being, her lack of desirability to nurse, or her inability to nurse and administer to the infant with all that this implies, often leads to prematurity, hemorrhagic disease, convulsions or death of the infant and possibly may favor fetal malformations. Talbot believes that "acute or chronic infection during the prenatal period, principally chronic foci in teeth and tonsils, produce localized infections in the placental blood supply to the fetus. This may cause early partial separation of the placenta and consequent abortion. If the pregnancy progresses, however, and the infarction occurred at the time that some portion of the fetus is in active proliferation or budding, such part will be inhibited in its growth with a resultant malformation."
The problem of syphilis in the new-born must be solved in the antenatal period by prevention rather than in the neonatal period by treatment. Both Findlay and Williams are of the opinion that means exist at hand for its almost complete eradication in infants, the former stating that "the curative type of treatment is a failure, and our hope for its eradication lies in prophylaxis"; the latter that "if syphilis is recognized early in the pregnant woman and is intensively and appropriately treated, almost ideal results may be obtained so far as the child is concerned."
Prematurity subjects the infant to endless dangers. Syphilis and toxemia of pregnancy are frequent causes, while debilitating diseases, nephritis, trauma, over-exertion, acute infections, and local uterine disease add their share. Prematurity predisposes the infant to intracranial hemorrhage with all its dire consequences, because in the premature the blood vessels are more under-developed, more readily torn and more friable -- the greater the prematurity, the more friable the vessels -- the coagulation point is low and the bleeding time is prolonged. Prematurity, according to Browne, is "seven times more likely to cause hemorrhage than causes found in infants at term. Hemorrhage in premature infants is more frequent at 7 - 7 1/2 months of uterogestation and every effort should be made to limit the induction of labor to as near as possible to full term, to avoid difficult forceps, hasty delivery and asphyxia."
The premature infant is a susceptible infant, susceptible not only to septic infection, which may cause bone and joint disease and deformity, but also to asphyxia, atelectasis, pneumonia, convulsions, rickets, spasmophilia. While prematurity is frequently recorded as the cause of death, it is seldom the sole cause but is usually associated with something else which the death certificate does not show. Any decrease in the number of premature infants or a prolongation of intrauterine life would tend to lower the infant mortality and morbidity rate. The importance of preventing prematurity, whenever possible, is emphasized by statistical returns which show that about 60 per cent. of all deaths, classified under the international heading of congenital diseases, are recorded under premature births and congenital debility and weakness. Prematurity should be measured not only in terms of the period of uterogestation, but also by the yard stick of length, weight, development, musculature, tonus and function of vital organs, as well as by the proportion between different parts of the body -- head to shoulder circumference, length of upper to lower extremities -- and by the weight-length quotient. Apart from the treatment of syphilis in the mother, which is a frequent cause of prematurity in the infant, careful regulation of the diet and hygiene of the mother, care of focal infections, treatment of chronic or metabolic diseases, avoidance of toxemia, rest periods especially at the time of the usual menstruation, freedom from anxiety, and maintenance of good nutrition will be found helpful in its prevention.
A condition which claims as high a mortality as 50 per cent. in infants born dead or dying uring the first month of life (Warwick) and which when it does not kill maims a goodly number and dooms them to a life of physical and mental deterioration, to a veritable living death in many instances, must engage the thought, the attention, and the resourcefulness of all physicians. Such a condition is intracranial hemorrhage of the new-born.
Considering the predisposing factors existant in the infant and the mechanism of labor, the wonder is that it does not occur more frequently. At that, the probability is that its occurrence is far greater than reports indicate, for doubtless many mild cases are unknown, unsuspected, undiagnosed, and untreated and recover completely. On the other hand, the writings of Sharpe and Maclaire and many others quoted by them in an extensive bibliography (Jour. A.M.A. January 30, 1926) leave no doubt of the serious aftermaths of the condition in the form of spastic paralysis, imbecility, idiocy, epilepsy and many deforming and incapacitating conditions, so serious in fact that it becomes the bounden duty of all accoucheurs and others entrusted with the care of the new-born to institute every possible preventive measure or in the event of its occurrence to apply immediate measures for its relief and, if possible, for its correction.
What are the predisposing factors in the infant which expose it to cerebral hemorrhage. They are fragility of the blood vessels, change in the blood and circulation in the transition from intrauterine to extrauterine life, low blood pressure (Rucker and Connell), deficiency of prothrombin (Whipple), defective quality of the platelets and fragility of the red blood cells (Lucas), asphyxia, prematurity, syphilis. The mechanism and conduct of labor add pressure, over-riding of the cranial bones, instrumentation and manipulation. And yet cerebral hemorrhage has occurred in normal labor -- especially rapid and precipitate labor -- and Tauber has reported a case of Little's disease in a baby born nonasphyctic by Caesarean section, in a contracted pelvis in which pressure of the symphysis on the skull during expulsion or over-riding of the cranial bones was advanced as the cause.
It follows therefore that in every case of labor whether normal, precipitate, prolonged, instrumental or manipulative, the possibility of this condition should be kept in the foreground.
The symptoms in severe cases need no comment. Happily for the infant, the parents and the community, death as a rule soon follows. In the mild cases, the symptoms may be indefinite. Personally I place great stress upon difficult or ineffectual suckling especially if once established, intermittent cyanosis, somnolence and twitchings, either ocular or of the extremities. The history of labor is important. With a difficult labor the presence of symptoms suggestive of intracranial hemorrhage should lead one to take the benefit of the doubt or rather give it to the infant and consider it intracranial hemorrhage.
From a prognostic standpoint progression of symptoms is unfavorable, while retrogression of symptoms or a stationary status makes one more hopeful.
What is the treatment for intracranial hemorrhage of the new-born? There is no uniformity of opinion or action. There are extremists who advise decompression and conservatives who advocate absolute rest and quiet -- in other words expectant and symptomatic treatment. Sharpe and his school champion early and repeated spinal punctures, both for diagnostic and therapeutic effect, while injections of whole or citrated blood has many followers. Each must decide for himself in each case what he considers best. Certain it is that decompression seems a radical and dangerous procedure. Whether early and repeated spinal punctures will prove the method of choice, the future must decide. While applicable to hospital cases it is not so easy of being carried out in private practice. The objectors of this method claim that if there is a large amount of blood in the spinal canal its removal may result in renewed hemorrhage, and that if the hemorrhage has lasted 24 hours or more the damage has already been effected. Sharpe states that "lumbar punctures should be attempted in all but the very extreme cases of extensive intracranial hemorrhage under high pressure within the first week after birth." The actual loss of blood is a less serious factor than injury to the central nervous system from increased pressure and the formation of organized residual clot.
In the supratentorial type of hemorrhage, spinal puncture may not always disclose blood but rather increased pressure, while in the infratentorial type blood is almost always found, together with increased pressure as a rule.
The indications for all lines of treatment presuppose accurate diagnosis. Herein lies the difficulty with intracranial hemorrhage of the new-born, for the early symptoms are often vague, elusive and indefinite. Unfortunately, in many instances, by the time the symptoms are manifest the damage has been done. Then again, in a given case, if after lumbar puncture the symptoms improve we are likely to attribute the result to the procedure. But is our conclusion justifiable? Perhaps it is; perhaps not. My feeling in the whole matter is that if the symptoms are suspicious of or indicate hemorrhage, lumbar puncture, if performed early, is advisable because it is a comparatively simple and safe procedure, does no harm and may do some good.
The determination of bleeding and coagulation time in the newborn should be a routine procedure in all maternity institutions and all cases, which exceed normal limits of 3-5 minutes for the former and 5-10 minutes for the latter, should be suspected as potential subjects of hemorrhagic disease, even in the absence of symptoms, and treated with subcutaneous, intramuscular or intraperitoneal injections of whole or citrated blood taken from teh father -- 10-15 c.c. per kilo of body weight, and repeated as indications warrant, every 8 to 12 hours. Helmholz goes further and rightly so, when he states: "We have made it a routine procedure in cases of more severe labor and forceps delivery to give infants at the time of birth a prophylactic injection of blood."
All cases irrespective of other treatment should be given the benefit of a special nurse, absolute quiet and rest in a darkened room, warmth, ice cap or clothes to the head, elevated position, breast milk by medicine dropper or Breck feeder, and sedatives in the form of bromide of calcium, 5-10 grains in sweetened water every three hours.
Strange as it may seem, the parents' great concern in these cases is usually not so much whether the child will live -- for often enough they hope for death -- as whether the child will be spared from idiocy or deformity. The former question may not be so difficult to answer, but who is gifted with sufficient prognostic sense to answer the latter? Opinion must be guarded to say the least. And yet I have found it better, though not always wiser, to look upon the brighter and more hopeful side, even at the expense sometimes of being pointed at as a poor prophet. This hopeful attitude does no harm to the infant, kindles a spark of promise in the mother, and if it does effect your status as a pronosticator, I still hold that it is worthwhile. I have come to this conclusion because observation of a fairly large number of cases of spastic paralysis has shown me that in many mild or moderate cases there is no marked mental retardation and that decided improvement in locomotion and manipulation takes place with time, massage, educational exercises, mechanical or operative intervention.
I hold that in all difficult, prolonged and instrumental labors the pediatrician should be called in an advisory capacity to observe the infant for at least one year.
After all is said and done Abt is right in saying: "The kernel of the matter is that the baby should be more adequately protected against meningeal hemorrhage during delivery. Prophylaxis is the most important point and lies to a large extent in the hands of the obstetrician."
Of the local birth paralyses those of the brachial plexus and of the facial nerves are the most common.
Obstetrical paralysis is bad enough, when unilateral, but when bilateral, as I have had occasion to observe it in two instances, it is a calamity. Perhaps a sad commentary upon American obstetrical practice, is the rarity of Erb's paralysis in Austrian and German orthopedic clinics as compared with the frequency with which it is met in American institutions. In all forms of manipulative obstetrical work, examination of the arms and face for paralysis should be made, since mild forms may be overlooked. At times Erb's paralysis is not recognized until the first bath is given or even later. Treatment should be immediate. The arm should be placed over the head with the humerus at right angles to the body and the forearm at right angles to the humerus. Every effort should be made to prevent contractures of the adductors and subscapularis and toward correcting pronation. Massage and electricity are later considerations.
The above treatment presumes accurate diagnosis and differentiation from skeletal injuries and from early luetic pseudo-paralysis. Only recently I saw at the hospital two cases of fracture of the clavicle in the new-born diagnosed as Erb's paralysis. In injuries of and around the shoulder joint, the position of the extremity while resembling that of an Erb's paralysis is not typical, in that there is lacking the involvement of muscle grouping, there is some resistance instead of flaccidity, and often there is pain.
Since the same manipulative procedures which produce nerve injury may cause bone, joint, or epiphyseal injury, I maintain that an x-ray examination of the extremity affected should be made in all cases of Erb's paralysis or conditions simulating it, so that prompt and proper treatment may be instituted, if a concomitant or primary injury exists.
Quite recently (Friedman and Chamberlain, Jour. A.M.A. March 27, 1926) our attention has been called to the possibility of a concurrent injury to the phrenic nerve in these cases, or as an isolated phenomenon, with resultant cyanosis, respiratory embarrassment, or labored breathing, paralysis, incoordination or paradoxical movement of the diaphragm as evidenced by x-ray and fluoroscopic examination.
Facial paralysis is usually unilateral. The parotid in infants offers little protection to forceps or other pressure. In rare instances, a critical hemorrhage localized in the face area is the cause. The condition, when peripheral, as a rule is slight and recovery occurs spontaneously in a few weeks.
Parrot's paralysis is a pseudo-paralysis due to syphilitic epiphysisitis and is sometimes mistaken for Erb's paralysis. Such error is usually made when the symptoms appear during the first days of life rather than when they appear as is usual several weeks after birth. Parrot's paralysis, however, is usually tender and painful to passive and active motion and atypical in that there is lacking the characteristic position of the arm and the involvement of the muscle grouping -- the deltoid, biceps, brachialis anticus and supinator longus and brevis combination of Erb's. The diagnosis is easy when other syphilitic manifestations are present -- coryza, snuffles, rhagades, condylomata and eruption. When these are absent the x-ray examination of the long bones is of great assistance. Findlay states that "it may be taken as an axiom, that the loss of power in a limb of an infant under six months of age is due to syphilitic osteitis." Parrot's pseudo-paralysis is a preventable disease if anti-syphilitic treatment of the mother is instituted. Its prompt recognition is important because of the danger of epiphyseal separation and of constitutional debility or death of the infant, all of which can be prevented by the institution of antiluetic treatment. The results are rapid and pronounced.
Shortly after birth, sometimes alone, sometimes as part of a general septic infection of the new-born, sometimes without apparent cause, there occurs an infectious suppurative arthritis most frequently in the hip, shoulder, or knee. This is usually an osteomyelitic process and is known as septic arthritis of the new-born, although the suppuration may be periarticular, articular, or osseous. The portal of entry of the infection in some of these cases cannot be found. We know, however, that in the new-born the primary focus of pyogenic infection cannot always be located but that it is usually in the umbilicus, the skin or mucous membrane of the mouth or nose and often of insignificant size. One must not lose sight of the fact that the new-born, especially a premature, is susceptible to infection because of lack or imperfect development of cellular and humoral immunity, because the skin and mucous membrane are delicate, thin, and poorly developed, offering little protection as barriers to bacteria, which readily break through, because the lymphatic system -- the bacterial filters -- function poorly and because phagocytic action of the leucocytes is deficient.
The prevention of this condition is careful asepsis during delivery and the puerperuim, avoidance of mouth washing in the new-born and immediate attention to the slightest abnormality in the umbilical region and to even a suspicion of cutaneous irritation in the form of erythema, intertrigo, abrasions, vesicles, bullae, and postules.
Among the congenital conditions whose etiology has baffled investigation, the many types of dwarfism will usually first come to the attention of the family physician or pediatrician. Of these, mongolism, achondroplasia, osteogenesis imperfecta can often be diagnosed at birth or shortly thereafter. Infantile myxedema or cretinism admits of a diagnosis later, usually at the third month, but occasionally at an earlier period -- earlier in the artificially fed than in the breast fed infant.
The importance of diagnosticating these conditions lies not so much in what can be done for them as in what is very frequently done to them. I mean that in some quarters unfortunately parents are led to hope that by internal medication some of these conditions can be materially benefited.
Correct diagnosis and friendly but frank prognosis to the parents will spare them much needless expense, while measures can be instituted to ward off for a time the dangers of intercurrent disease or trauma to which these children are prone. In cretinism prompt recognition and early and continuous administration of thyroid gland, preferably with suprarenal and pituitary, will improve the physical and mental condition and maintain them satisfactorily although not at a normal level for age.
Cretinism usually affects the first child while mongolism as a rule occurs at the end of the line, so to speak. Multiple cases of both occur in families. If the first child is a cretin, special watch should be exercised over other births so as to detect the symptoms in their incipiency and to institute thyroid therapy at once. One mongol in a family is neither for or against the birth of subsequent ones.
Endocrine disturbances in the mother have been suggested as probable factors in the development of cretinism and mongolism. In the former it is said that there is in all likelihood a thyroid disturbance in the mother while in the latter the thought lies near that, where the mother is advanced in yhears or has given birth to many children, there is general endocrine exhaustion. In fact, Shuttleworth considers mongolism an "exhaustion product" while Herrman regards it as an anthropological condition.
Congenital clubfoot of the new-born in its many forms, calls for immediate treatment. One must be sure that the condition is not due to spina bifida, evident or occult, because prognosis here is different from ordinary talipes. Congenital talipes may be unilateral or bilateral, that due to spina bifida is bilateral. The early treatment of talipes exemplifies the orthopedic axiom that deformities in the primary stage are readily responsive to correction and cure. There is no excuse for any physician who sees these cases early and whose decision has been asked permitting them to exist in later childhood. Often manipulative treatment is sufficient. In other cases mechanical means are necessary. In any event treatment should be instituted as soon as the diagnosis is made, as soon after birth as possible, or sooner.
Cleft palate, with or without hare lip, is a serious condition because of the dangers of malnutrition, starvation, fatigue and infection, while prolonged and ineffectual suckling tends to exaggerate the palatal deformity. Treatment may be temporary, either in the form of a rubber obturator flap attached to the upper side of the nipple, or the method of Foote, "a simple strip of dental rubber dam about 2 inches wide and 4 inches long to which tapes are attached at each side in the longest diameter, is placed over the infant's nose and the tape tied so that the rubber is stretched with sufficient tightness to block off the nostrils, the lower end of the rubber dam lying over the lip and nipple. Air for respiration is given by gently lifting the upper edge over the nose between sucking contractions." By this method Foote obtained a larger fluid intake with less fatigue especially if hare lip is not present or after the lip has been surgically repaired.
As soon as the nutrition of the infant improves, and in any event as soon after birth as possible, operation should be performed -- within the first few weeks if the deformity threatens life and at the sixth to ninth month of life as a general rule.
There are a few general conditions which I should like to touch upon in closing. The care of the breasts and nipples with a view to the establishment and maintenance of breast feeding is of more than passing importance. In congenital syphilis, in prematurity with its many dangers, and in sepsis, breast milk acts not only as a supporting element which enhances the institution of other measures, but frequently turns the scale in favor of the infant.
Asphyxia neonatorum should, of course, be prevented if possible. When it occurs attempts should be made to resuscitate the infant with the minimum effort and maximum efficiency. Apart from the dangers of cerebral hemorrhage, due to the condition itself, the older attempts at artificial methods of resuscitation by indirect stimulation of the respiratory center have been responsible for no small amount of damage -- rupture and displacement of organs, fractures, inspiration and exposure pneumonia, etc. Today the method of choice is direct stimulation of the respiratory center Today the method of choice is direct stimulation of the respiratory center by alpha lobeline grain 1/20 which acts promptly and specifically. Ampules of this drug should be part of the armamentarium of all those who practice obstetrics.
Engorged breasts in the new-born, not uncommon in both sexes, and due to the pregnancy reaction of Halban, that is, to hormone action of the placenta, will be spared suppuration if one will only keep his hands off and see that the hands of others are not permitted to squeeze and massage them for the purpose of expressing what is superstitiously called "witches milk."
As a rule no serious consequences follow mastitis in the newborn, but occasionally a perimastitis with involvement of the connective tissue and of the muscles complicates the process resulting in induration and sloughing as far as the axilla and sometimes in general sepsis.
The pernicious habit of washing the baby's mouth, even to the point of attempting to remove the normal Bohn's pearls and other normal conditions of the mouth in infancy, is responsible at times for ulcerative oral lesions, the inability to suckle properly and occasionally for general sepsis. Fortunately this procedure is far less common these days than formerly.
While the new-born are usually spared from most infectious diseases because of placental immunity, they are on the other hand very susceptible to respiratory infections -- tuberculosis, whooping cough, coryza, common colds -- all of which may cause serious and fatal disease. "Words that kill" are a reality when the words carry with them droplets of bacteria into the infant's mouth and nose. (Moser)
We return then to our original thesis that proper prenatal care and good obstetrics are the best safeguards against many mishaps to the mother and the infant. I cannot escape the thought, however, that the accoucheur is in part responsible for a share of the morbidity and mortality of the early days of life because of his belief and his attitude that the care of the new-born is his province. Prenatal care and delivery of the mother are the duty and the responsibility of the obstetrician. The care of the infant after expulsion from the parturient canal belongs to the pediatrician or to the practitioner who is trained in the possibilities and the actualities of disorder and diseases of infancy and who can discern and evaluate signs and symptoms. In other words, the accoucheur should be responsible for two deliveries -- the delivery of the mother and the delivery of the infant post partem to the family physician or the pediatrician. Why some accoucheurs insist upon the supervision of the new-born, at times during the entire first year, is not quite clear to me, viewing it altogether from the standpoint of the infant. It is just as reasonable to argue that the pediatrician should deliver the woman and take care of her for one year as it is to argue that the obstetrician should bring forth the baby and take care of it for one year. If the mother and the new-born are to receive what is theirs by right, a proper appreciation of the place of accoucheur and pediatrician should be definitely understood.
Huenekens, quoting Sedgwick as saying that "the baby is the byproduct of obstetrics," remarks that "to the obstetrician the mother is the first consideration and his comparatively slight interest in the infant has caused many large teaching hospitals to place the new-born infant in the care of the pediatrician."
Many years ago Dr. Parry said: "It's more important to know what kind of a person has a disease than what kind of a disease a person has." This new-born is a kind of a person in whom diseases and disorders produce signs and symptoms which are puzzling and baffling at times, and which can be properly interpreted best by the trained eye of those who have devoted time and study to them. Let us then not return to the days when the child was as Foote says: "A relatively unimportant subsidiary of obstetrics," to the days when "in the Eber's papyrus, the oldest medical manuscript in existence, which was written when Moses was about 25 years old, the child was only referred to as an obstetrical problem." Let it not be said that as a pediatrician the accoucheur makes a good obstetrician even as it might be said that as an obstetrician the pediatrician makes a good babyologist.
It must be apparent from this sketch that the prevention and early care of diseases and deformities in the antenatal and early postnatal period is not altogether a one man's job. The accoucheur, the general practitioner, the pediatrician and the orthopedist, each in his own way and sphere has his responsibility clearly defined: the accoucheur to institute proper and systematic prenatal care, and to conduct the labor with the minimum of danger to mother and child, to make pregnancy comfortable, labor safe, and the puerperium uneventful; the general practitioner who, either acting as accoucheur or family physician, and who sees the patient at the outset of the disease or deformity, to supervise pregnancy and labor, to recommend and institute proper preventative and remedial measures; the pediatrician alone or in conference with the obstetrician and practitioner to pass judgment upon preventive or remedial measures, and finally the orthopedist who, seeing the patient when the deformity has been established, to apply modern mechanical, manipulative or operative measures as early and as effectively as possible so as to secure either a complete cure or render the deformity as incapacitating as possible.
Jacob Riis once said: "It is not the things we have done here, but the things that we have left undone that will give us the bitter heartaches at the setting of the sun." Because of the complex and ever advancing medicine and surgery of today it is not given to any one man to master all their phases. It therefore becomes the duty and responsibility of physicians to call to their aid in doubtful or puzzling cases, confreres who have made special or intensive studies or who have had experience in special fields. Taking a chance or treating cases expectantly is often fraught with great danger to the patient and often places him in a position where proper treatment is ineffective or hopeless. It is quite as much the province of the physician to know that a case is beyond his God-given powers as to know when he is capable of giving full and proper care and attention. A wise physician knows not only when to treat certain cases but when to leave them alone, or, to refer them to others. This is not to be understood as an intimation that a physician should act as a directory, a human switchboard or a central agency for transferring his patients to others, but, rather, as a plea for cooperation between practitioner and specialist, and for purposes of this paper, between the accoucheur, practitioner, pediatrician, and orthopedist.