BACKGROUND:We know little about how neonatal research changed at the Paris Foundling Hospital following the revolution. SUMMARY:The number of unwanted children rose, and 5,392 infants were admitted in 1826 - a quarter of all infants born in Paris; 26% of them died in the infirmary before transport. The infants' appalling mortality was associated with artificial nutrition, and transfer to mercenary nurses in the countryside was organized. In the 1830s sedentary nurses began to run short, and nearly all babies were fed artificially at some time. François Chaussier was director at the Maternity from 1804. He developed instruments to resuscitate newborns: mask-and-bag ventilation, silver endotracheal tubes, and oxygen tanks. He classified congenital malformations and described osteogenesis imperfecta. Marie-Louise Lachappelle trained midwives in forceps deliveries and the use of endotracheal intubation of newborns. Other researchers at the foundling hospital included Antoine Dugès, Jacques-François Baron, Gilbert Breschet, Louis Véron, Johann Heyfelder, Prosper-Sylvain Denis, and Charles Billard. The latter investigated neonatal cry in 1827 and associated expiratory grunting with poor prognosis in prematures. His Treatise on Diseases of the Newborn, based on many autopsies and meticulous clinical records, remained a neonatology standard for a century. It described peritonitis, megacolon, intestinal hemorrhage, pertussis, spina bifida, patent ductus, single ventricle, and various forms of tuberculosis. KEY MESSAGES:Physicians were permanently employed from 1821; their research developed from autopsies. The fusion of medicine and surgery into a single faculty moved obstetrics (and thus newborn care) from the barbers' domain to research-oriented science.

BACKGROUND:The Paris Foundling Hospital was a breeding ground for neonatal medicine, but little is known about its research. During the century preceding the Revolution, admission of newborns rose dramatically, making this institution the largest infant hospital in the world. A total of 3,162 infants were admitted in 1742, of whom 40% died in the hospice and another 20% with the nurses. During the Revolution (1789-1804), monasteries were transformed into jails or hospitals, and the foundling hospital became a teaching institute. Students flocked to the capital, and those believed to qualify for hospital positions were selected through competing publications. SUMMARY:A major research focus was trials of artificial nutrition, motivated by the fear of transmitting venereal disease to wet nurses via breastfeeding. Cows and goats were held on the premises, but milk was kept without refrigeration. A research branch of the foundling hospital was in Vaugirard, directed by François Doublet. In 1781, he treated syphilitic newborns by wet-nursing them from syphilitic nurses treated with mercury. Another approach requiring considerable logistics was sending thousands of infants to the countryside for wet-nursing. In 1769, Joseph Raulin analyzed the mortality at the hospice and found that thrush, diarrhea, marasmus, suffocation, and inflammation were the major causes of death. Foundling hospital surgeon Jean-Abraham Auvity published prize-winning treatises on thrush and sclerema in 1786. He related skin hardening (sclerema) to postnatal hypothermia and developed warming techniques for premature infants. KEY MESSAGES:During the Revolution and Terror, meaningful research was conducted at the foundling hospital but failed to lower mortality.

BACKGROUND:Sensory capacities of the fetus and newborn are still incompletely known. This paper delineates the history of understanding and evidence. SUMMARY:In the 2nd century, Galen propagated the tabula rasa theory comparing newborns to a blank writing tablet, without senses of sight, hearing, taste, or smell. Somatosensory: once the microscope was available, tactile receptors were identified in mid-17th century. But the tabula rasa theory persisted, and physicians maintained until the 1980s that neonates feel no pain. Auditory: the inner ear's development begins at 10 weeks of gestation at the cochlear basis and ends at its apex at 24 weeks. Researchers believed still into the 19th century that the fetus lacked auditory sensitivity. The uterus is not a quiet place, as the fetus hears uterine vessels, maternal voice, peristalsis, diaphragmatic movement, and heartbeat. In 1980, DeCasper proved that newborns preferred hearing their mothers' voice when compared to that of another mother. The evidence is weaker for sounds originating outside the maternal body. Despite little in utero stimulation, the newborn's visual apparatus functions from birth. Infants enter the world with innate perceptual knowledge of the human face. Olfactory: human infants are attracted by the smell of their mother's breast. It took 1,500 years to discard the tabula rasa theory and to grant the newborn full personhood in the 20th century. KEY MESSAGES:Fetal sensory organs are developed by mid-gestation. Neonates know their mother's voice and smell, which encourages maternal contact, prudent disinfectant use, and reduced noise in the nursery.

Background:Little is known about medical research at theVienna Foundling Hospital during the 18th and 19th cen-turies.Summary:The present article focuses on nutrition,medical care, and research concerning newborn infants. In1784, Emperor Joseph II merged obstetric and foundlinghospitals under common leadership with specific statutes.Admissions rose from 1,704 in 1785 to 9,797 in 1859. A thirdof all infants born in Vienna in the 1890s were"foundlings"-correctly: abandoned infants, illegitimatebirth was a prerequisite for admission. Differing from otherfoundling hospitals, the statutes obliged physicians to re-search, which focused on the great baby killers of the 18thcentury: smallpox, puerperal sepsis, connatal syphilis, tu-berculosis, and malformations. Researchers included AntonRechberger, Lucas Bo & euml;r, Ignaz Semmelweis, Carl Rokitansky,Alois Bednar, and Carl Friedinger. Major scientific achieve-ments were Rechberger's introduction of smallpox inocu-lation in Austria in 1768; Semmelweis'prevention of puer-peral sepsis in 1847, and Bednar's classification of congenitalheart malformations in 1852. Mortality statistics were doc-tored: deaths within 1 year were related to admissions fromseveral years, which yielded maximum"mortality rates"of76% in 1811, and a minimum rate of 13% in 1829. Actualmortality, however, per number of admissions, was over 90%in thefirst year of life. The institution persisted for 126 yearsbecause of the strict anonymity of extramarital birth, fakedstatistics deceiving supervisors, and esteem for the imperialinaugurator even beyond the end of the Austrian Empire.KeyMessage:Despite appalling mortality, successfulresearch was conducted at the Vienna Foundling Hospital.(c) 2024 S. Karger AG, Basel

Background: Although a major cause of infant mortality for centuries, little research was done on the causes of infants’ diarrhea. Artificial feeding, teething, and summer heat were believed to cause the severe disease that spared breastfed infants. Summary: Since antiquity, infants’ digestive disorders were termed dyspepsia, flux of the belly, diarrhea, gastroenteritis, watery gripes, the runs, dysentery, or cholera, without definitions. Alois Bednar discerned 3 grades (dyspepsia, diarrhea, and cholera) of the same disease. Infants’ neurologic symptoms were interpreted as alimentary toxicosis. Chronic diarrhea caused emaciation and dehydration. In 1950, Laurence Finberg found diarrhea with hypernatremia causing cerebral damage. Seasonal influence was known since Hippocrates. Baudelocque recommended obtaining infant milk fresh from the cow because it decomposes in the summer heat. In the cities, summer diarrhea caused a third of total infant mortality. Physicians debated whether heat acted directly on the infant or spoiled the food. The discovery of microorganisms in the 1860s revolutionized medical understanding. However, influential researchers such as Adalbert Czerny classified nutritional disturbances by assumed pathogenesis (“ex alimentation, ex infection, ex constitution”), but denied the possibility of bacterial infection via milk. Heating baby food, practiced for centuries, was introduced in Denmark, Sweden, and France, whereas in Britain and Germany, professional and public debate on pasteurization persisted. Key Messages: It took half a century to implement effective hygienic measures once the bacterial origin became known. Foodborne infection was rejected, and the prejudice that raw milk possesses essential “living” properties, adopted by influential scientists, contributed to delaying pasteurization.

BACKGROUND:Little is known about research in Foundling Hospitals during the 18th century.SUMMARY:The London "Hospital for the Maintenance and Education of Exposed and Deserted Young Children" opened in 1741, after fundraising by the former shipmaster Thomas Coram and a Charter by King George II. From 1741 to 1756, fewer than 100 infants a year were admitted by lot. With onset of the Seven Years' War in 1756, the House of Commons resolved and financed the admission of all deserted babies. The number of admitted babies rose to 4,000 per year, and their mortality increased. The Institution was not intended as a research and teaching facility but soon became a site for gaining knowledge of young infants. Appointed physicians included Richard Conyers, William Cadogan, William Watson, and William Buchan. Their research focused on frequent conditions in the hospital's infirmary such as scabies, fever, measles, chilblains and scorbutic eruptions, and set standards for infant care and nutrition in the English-speaking world during the 18th century. They described the dangers connected with tight swaddling, meconium purgation, artificial feeding, and the difficulty to obtain wet nurses in the big cities. A major topic was their fight against smallpox, then fatal for 80% if infected infants, and the development of an effective technique of inoculation.KEY MESSAGES:Research at the London Foundling Hospital differed from modern understanding of controlled clinical trials but revealed systematic, hypothesis-driven approaches in the mid-18th century. As in other Foundling Hospitals, absent parental interference facilitated innovations.

Abandoning infants was a heritage of the Roman Empire. Foundling hospitals were established in Italy earlier and in greater number than in other countries; their goal was to prevent infanticides. The Foundling Hospital in Rome, established in the Santo Spirito Church in 1204, paved the way toward modern hospital care and child protection. The Order of the Holy Spirit was appointed by Pope Innocent III to care for foundlings, and set up a network of infant nurseries all over Europe. Poor unmarried pregnant women received obstetric services free of charge. Infants were admitted anonymously by the ruota, a baby hatch or turning wheel. The Order's rule regulated infants' admission, care, nutrition by wet nurses, and boarding out to foster families in the countryside. Chief physicians of the Santo Spirito Hospital were often Sapienza University professors and/or personal physicians to the Popes. Among them were Realdo Colombo, Andrea Caesalpino, Giovanni Lancisi, Giuseppe Flajani, Domenico Morichini, and Tommaso Prelà. They made major scientific progress in anatomy and surgery: descriptions of the pulmonary blood transit, embryonic formation, fetal circulation, malaria transmission from mosquitos, and surgery for congenital malformations such as hydrocephalus, anal atresia, and cleft lip. Per year, 800-1,000 exposed infants were admitted. Despite sufficient funding and meticulous regulation of care and nutrition, mortality in the hospital during the first month of life was around 70%; the causes were neglected surveillance, cleanliness, and artificial nutrition. The institution persisted for more than 700 years due to numerous connections with the Vatican.

Abandoning undesired newborn infants was a Roman form of family limitation. They were exposed or given to foster mothers. Christianization alleviated their lot when in 374 CE, Emperor Valentinian's law provided some protection. The Milan Foundling Hospital was established in 787 CE. When the Carolingian Empire fell apart during the 10th century, monastic networks (the Holy Spirit Order and Daughters of Charity) took over social support for the poor, the sick, and the insane. Foundling hospitals proliferated in Italy between the 13th and 15th centuries, in France during the 16th and 17th, and in Germany and Austria in the 18th century. Metropolitan hospices admitted thousands of infants each year. Most were not "found" exposed but were admitted anonymously via a revolving box or registered in an open office. Soon after admission, they were transported for foster care to wet nurses in villages. Sick infants, especially those suspected of suffering from syphilis, were denied the breast, and artificial feeding was tried with little success. Official death statistics were falsified by relating infant deaths not to admissions but to the total number of children cared for. Over 60% died during their first year of life, mostly from pre-admission problems such as malformation, hypothermia, and disease; from poor hygiene in overcrowded wards; and from artificial feeding. Although not intended for that purpose, the hospices became medical research institutions when in late 18th century, physicians and surgeons were employed by maternity and foundling hospitals.

The 21st century's medicine is predominantly female: two thirds of medical students now are women. In 375 BCE, Plato argued for equal education for male and female professions, explicitly physicians. In Greece and Rome, tombstones testify for patients' gratitude to women physicians. Christianization opened an era of female subordination. When universities established faculties of medicine during the 13th century, women were excluded and had no place where they could study medicine. Since 1850, female medical studies have been debated. Zürich admitted women from 1864, Paris from 1866. Up until the 1920s, treatment of newborns - especially preterm infants - was in the domain of obstetricians. When pediatricians accepted responsibility for sick newborns, women founded hospitals and public health facilities for infants. After WW2, women took leading roles in research. Their share within pediatrics increased from below 10% to above 60%. But they achieved less than 20% of full professor or chair positions in Europe and less than 35% in the US. Female neonatologists reached fewer positions in editorial boards, authorships, h-factors, keynote lectures, and research grants than did male colleagues. Women pediatricians earned 24% less than did male colleagues. When adjusted for labor force characteristics, the pay gap was still 13%. Women can augment their career chances by setting targets, seeking mentorship, and strengthening self-confidence. Women's careers should be effectively accelerated by institutional support: research offers, part-time work, paid research time, maternity/paternity leave, and support for childcare. Research-oriented neonatology cannot afford to lose female talents.

This paper investigates causes and consequences of the prejudice towards extramaritally born infants. The main rationale for such defamation seems to have been religious teachings. However, rather than a matter of sexual morals, “illegitimacy” became an economic issue when infants were maintained on taxpayers’ money. Under most civil laws, “bastards” could not inherit. In German-speaking states, they were excluded from the guilds, which deprived them of professional training. They found refuge in “dishonest” professions and life in poverty. In the Late Middle Ages, a third of the population was probably born extramaritally. From 1400 to 1600, the illegitimacy ratio dropped markedly, but from 1650 to 1850, it seems to have gradually risen from around 5 to 9% in most European states. French authorities did not search for the putative father but offered the mother the possibility to abandon her child in a foundling asylum. In 1990, the term “illegitimacy” was replaced by “born out of wedlock.” After an extramarital birth, the infant mortality rate was elevated by 40–50% above that of maritally born infants. After 1960, effective contraception changed sexual morals, but marital fell more than extramarital fertility. Paternity was no longer uncertain. The Catholic church’s influence decreased; and legal reforms protected the infant. Today, half of all infants in Europe are born out of wedlock; that is no longer a proxy for poverty.

This richly illustrated book fills a gap in the literature. It is not another history of famous researchers, but a history of endangered newborns and their fate in medicine and society from the earliest days of human thought, investigating what remained in medieval and persists in modern life. Each chapter rests on exhaustive research in hospital archives, libraries, churches, or excavation fields. With a global perspective, the book identifies technical, medical, social, and political conditions that improved—or compromised—the infant’s quality of life. The newborn’s history has multiple cultural implications. It depended on maternal care, breastfeeding, and cleanliness. Legislation had to protect babies from infanticide and to define the viability of preterm or malformed infants. By tracing the history of legal, philosophical, and social ideas about the newborn, the book develops three overarching themes across societies and times: (1) the newborn was not regarded as a complete human being, but as unfinished and endowed with only partial personhood; (2) rites of passage evolved everywhere, aiming to ‘complete’ the newborn and accept it in family and society; and (3) abandonment and infanticide suggest that many newborns were greeted with ambivalence, and that their frequent death was largely accepted by parents and societies. The book embraces all aspects of the transition from fetal to postnatal life. It will be of major interest to scholars, professionals, and students specializing in obstetrics, midwifery, paediatrics, and neonatology. Medical terminology has been used cautiously and a glossary makes the text accessible outside the health professions.

In most human societies, ritualized and firm rules evolved for cutting the navel-string and handling the umbilical stump. These customs were not always beneficial, and contributed to umbilical infection, neonatal tetanus, and navel hernia. After prematurity, neonatal tetanus was the most frequent cause of death in poor countries up to the 19th century. It was caused by poor cord hygiene and by the age-old habit of severing the navel-string with biological products instead of man-made tools, which included palm leaves, blades of grass, mussel shells, crusts of bread, and other devices likely to be contaminated with tetanus spores. The navel-stump was covered with zinc powder, starch, oak-gall powder, grease, musk, clarified butter, and many other substances believed to protect the baby from evil, but actually creating anaerobic conditions in the umbilical wound. Care of the cord was associated with deep-rooted rituals and customs, and dangerous techniques persisted on islands well into modern times.

Remarkable insight into disturbed lung mechanics of preterm infants was gained in the 18th and 19th centuries by the founders of obstetrics and neonatology who both observed respiratory failure and designed devices to treat it. Pathological anomalies in the immature lung were described in Germany by Virchow in 1854 and by Hochheim in 1903. The Swiss physiologist von Neergard fully understood surfactant function in 1929, but his paper was ignored for 25 years. The physical properties of surfactants were identified in the early 1950s through research on warfare chemicals by Pattle in Britain and by Radford and Clements in the US. The causal relationship between respiratory distress syndrome and surfactant deficiency was established in the US by Avery and Mead in 1959. The Australian obstetrician Liggins induced lung maturity with glucocorticoids in 1972, but his discovery was not fully accepted for another 20 years.

Given the high rate of alcoholism throughout history, its effects on the fetus may have existed for millennia. But, the claim that Greeks and Romans were aware of fetal alcohol syndrome rests on incorrect citations. From 1725, maternal alcohol consumption was associated with retarded fetal growth and neurological anomalies. From 1809, scientists followed Lamarck’s theory that the disorders parents acquire during their lifetime are passed on to their offspring. Fetal effects were thought to be inherited mainly from the father. During the 19th century, parental alcoholism became associated with malformations. In 1915, Ballantyne distinguished genetic influence via germ cells from toxin’s effect on the embryo. Fetal alcohol syndrome was characterized by Rouquette [Influence de la toxicomanie alcoolique parentale sur le développement physique et psychique des jeunes enfants] in 1957 and Lemoine et al. [Ouest Medical. 1968;21:476–482] in 1968 as consisting of 4 features: (A) facial anomalies (narrow forehead, retracted upper lip, and cupped ears), (B) severe growth retardation (prenatal and postnatal), (C) malformations (limbs, cardiac, and visceral), and (D) central nervous system anomalies (hyperexcitability and mental retardation). But, their studies, written in French, remained disregarded. In 1973, Jones et al. [Lancet. 1973;302:999–1001] reported “the first association between maternal alcoholism and aberrant morphogenesis in the offspring.” The history of fetal alcohol syndrome reveals shortcomings in citation practice. Alleged quotations remained unverified, non-English publications neglected, and short quotations taken out of context. Prejudiced by religious and abstinence groups, reports on alcohol damage to the unborn were fraught with emotions, moralizing, social implications, and presentism, the interpretation of past events with present knowledge.

Industrialization and urbanization jeopardized infant nutrition during the 19th century. Cow’s milk was produced in the cities or transported long distances under suspect conditions. Milk was contaminated with bacteria or adulterated with water, flour, chalk, and other substances. When distilleries proliferated in the metropoles, their waste slop was fed to cows who then produced thin and contaminated swill milk. Following a press campaign in the US, the sale of swill milk was prohibited in 1861. Bacterial counts became available in 1881 and helped to improve the quality of milk. Debates on pasteurization remained controversial. Disposal of the wastewater of millions of inhabitants and the manure of thousands of cows was environmentally hazardous. It was not until 1860 and after several pandemics of Asiatic cholera, that effective sewage systems were built in the metropoles. Milk depots were established in the US by Koplik for sterilized and by Coit for certified milk. In France, consultation services named goutte de lait distributed sterilized milk and educated mothers. Efforts to improve milk quality culminated in the International Congresses for the Prevention of Infantile Mortality.

Since antiquity, cot death was explained as accidental suffocation, overlaying, or smothering. Parents were blamed for neglect or drunkenness, and a cage called arcuccio was invented around 1570 to protect the sleeping infant. Up to the 19th century, accidents were registered as natural causes of death. From 1830, accidental suffocation became unacceptable for physicians and legislators, and ‘natural’ explanations for the catastrophe were sought, with parents being consoled rather than blamed. Prone sleeping originated in the 1930s and from 1944 was associated with cot death. However, from the 1960s many authors recommended prone sleeping for infants, and many countries adopted the advice. A worldwide epidemic followed, peaking at 2% in England and Wales and 5% in New Zealand in the 1980s. Although epidemiological evidence was available by 1970, the first intervention was initiated in the Netherlands in 1989. Cot death disappeared almost entirely wherever prone sleeping was avoided. This strongly supports the assumption that prone sleeping has the greatest influence on the disorder, and that the epidemic resulted from wrong advice.

This chapter collects information on artificial infant feeding published before 1860, the date when commercial formula became available. There is extensive artefactual evidence from thousands of feeding vessels since the Bronze Age. Literature on the use of animal milk for infant feeding begins with Soranus in the 2nd century c.e. Literature evidence from the very first printed books in the 15th century proves that physicians, surgeons, midwives, and the laity were aware of the opportunities and risks of artificial infant feeding. Most 17th- to 19th-century books on infant care contained detailed recipes for one or several of the following infant foods: pap, a semi-solid food made of flour or breadcrumbs cooked in water with or without milk; gruel, a thin porridge resulting from boiling cereal in water or milk; and panada, a preparation of various cereals or bread cooked in broth. During the 18th century, the published opinion on artificial feeding evolved from health concern to moral ideology. This view ignored the social and economic pressures which forced many mothers to forego or shorten breastfeeding. Bottle feeding was common practice throughout history.

Poppy extract accompanied the human infant for more than 3 millenia. Motives for its use included excessive crying, suspected pain, and diarrhea. In antiquity, infantile sleeplessness was regarded as a disease. When treatment with opium was recommended by Galen, Rhazes, and Avicenna, baby sedation made its way into early medical treatises and pediatric instructions. Dabbing maternal nipples with bitter substances and drugging the infant with opium were used to hasten weaning. A freerider of gum lancing, opiates joined the treatment of difficult teething in the 17th century. Foundling hospitals and wet-nurses used them extensively. With industrialization, private use was rampant among the working class. In German-speaking countries, poppy extracts were administered in soups and pacifiers. In English-speaking countries, proprietary drugs containing opium were marketed under names such as soothers, nostrums, anodynes, cordials, preservatives, and specifics and sold at the doorstep or in grocery stores. Opium’s toxicity for infants was common knowledge; thousands of cases of lethal intoxication had been reported from antiquity. What is remarkable is that the willingness to use it in infants persisted and that physicians continued to prescribe it for babies. Unregulated trade, and even that protected by governments, led to greatly increased private use of opiates during the 19th century. Intoxication became a significant factor in infant mortality. As late as 1912, the International Hague Convention forced governments to implement legislation that effectively curtailed access to opium and broke the dangerous habit of sedating infants.