Pathologists have recognized since late in the 19th century that pneumonia was responsible for the deaths of many newborn infants.1Since many who died were stillborn or died within the first few hours or days of life, it was obvious that a certain proportion must have acquired pneumonia in utero. Pediatricians have virtually ignored this observation. Pneumonia is seldom diagnosed; indeed, it is rarely considered as a possibility in the differential diagnosis of respiratory illness in the early neonatal period. In this report we shall attempt to demonstrate that this condition is recognizable, given a high enough index of suspicion, and that it is not invariably fatal. In addition, we suggest that some cases are preventable and that vigorous treatment may be lifesaving. There is a considerable percentage of stillborn and newborn infants in whom evidence of inflammation of the lungs has been discovered in large series of consecutive
THE physical design of and routine practices in neonatal units (especially nurseries for high-risk infants) are presently influenced almost entirely by considerations related to the risk of spreading infection in the nursery by fomites and personnel. The role of nursery design and specific routines in preventing epidemics is considered so important that the details are encoded in many local, state, and federal health laws or regulations. These are enforced by periodic inspections and conformity is made a prerequisite for official approval, allocation of funds, etc. Although there is little reason to doubt that these policies have had the effect of reducing the incidence of nursery epidemics, there is growing concern that official rigidity in these matters may interfere with optimal care of the very ill infant, as well as with research designed to improve care and find solutions to the overall problems of neonatal mortality and morbidity. Infections are an important and frequent cause of disease in the newborn. They are, however, clearly outdistanced by major non-infectious disorders that account for the majority of deaths and brain damage in the neonatal period (respiratory distress, asphyxia, acidosis, hypoglycemia, and hyperbilirubinemia). Some of the precautionary techniques used to reduce the risk of infections have the practical disadvantages of making it difficult (1) to approach the neonatal patient and (2) to apply modern diagnostic maneuvers and therapeutic aids in order to improve the neonatal patient's chances for intact survival. As a result the nursery-based infants in this country are, in general, quite well protected from the risks of nosocomial infections; but, they receive less than ideal management for cardiorespiratory disorders, a major cause of neonatal mortality. It is obvious that new solutions are required to solve the problem of hospital care of the sick neonate. Unfortunately, both the search for new approaches to neonatal care and the application of some newly established knowledge are now being impaired by rigid rules and construction codes which do not permit innovation. Although these rules cannot be completely abandoned until safe alternatives have been demonstrated, the Committee believes that public health administrators and hospital committees must permit cautious, responsible exploration and evaluation of new approaches to the multiple problems involved.
In the numerous articles that have been written on erysipelas, a great variety of therapeutic agents have been recommended, most of which have eventually been proved to be ineffectual. Local remedies, comprising all sorts of ointments, compresses, lotions, the collodion ring, the surgical "fence" and, more recently, intravenous antiseptics, have been tried and found to be of no avail. Following Fehleisen's1discovery ofStreptococcus erysipelatis,antistreptococcal serums and vaccines were widely used, only to be discarded later. Recently, a specific serum has been made which gives great promise of proving an effective aid in combating the disease (Amoss,2Rivers3and Birkhaug4). The interpretation of statistical data is likely to be particularly misleading unless one keeps clearly in mind the extreme variation in mortality in the different age groups. Between the ages of 5 and 50, the average mortality is considerably less than 4 per cent, whereas
PNEUMONIC changes can be found the lungs of a substantial proportion of the fetuses which die utero the late stages of gestation. Similar alterations found the lungs of percentage of liveborn infants who for only a few hours or day. In the first instance it is certain, the second it is generally assumed that the process had its origin within the uterus. In additional number of both stillborn and liveborn infants, it may be demonstrated by microscopic examination that there is excessive quantity of sac contents within the lungs. The pathogenetic factors responsible for both intrauterine pneumonia and for excessive aspiration of contents have never been definitely established. still exit profound differences of opinion on every aspect of the process of intrauterine respiration. The following represent expert opinions on the question as to whether the fetus breathes or not. Snyder and Rosenfeld state that in the full-term fetus sponataneous rhythmic respiratory movements occur which may continue many hours. Davis and Potter maintain that amniotic fluid is normally aspirated into lungs as part of intrauterine respiratoy activity and concluded that an adquatic existence for the fetus is normal during intrauterine Windle has arrived at the opposite conclusion. In 1939 he wrote,One is tempted to entertain the false assumption that respiration at birth is a continuation of respiratory-like phenomena indulged normally throughout fetal life. This is contrary to fact. Sir Joseph Barcroft came to the same conclusion. There is during the second half of fetal life inhibition of the nervous mechanism responsible for respiratory movements. If there were not the fetus would be drowned before it was born.
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