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Pediatric Acute
Respiratory Distress
Syndrome
A Clinical Guide
Steven L. Shein
Alexandre T. Rotta
Editors
123
Pediatric Acute Respiratory Distress
Syndrome
Steven L. Shein • Alexandre T. Rotta
Editors
Pediatric Acute
Respiratory Distress
Syndrome
A Clinical Guide
Editors
Steven L. Shein, MD Alexandre T. Rotta, MD, FCCM
Rainbow Babies & Children’s Hospital Duke University School of Medicine
Case Western Reserve University Duke University Medical Center
Cleveland, OH Durham, NC
USA USA
ISBN 978-3-030-21839-3 ISBN 978-3-030-21840-9 (eBook)

https://doi.org/10.1007/978-3-030-21840-9
© Springer Nature Switzerland AG 2020

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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To my parents, Jeff and Diane, and brother, David, thank you for
all of your support growing up. To my countless teachers,
mentors, co-residents, co-fellows, and all the rest at CWRU,
RBC, and CHP, thanks for teaching me and being in the
trenches with me. To my wife, Monica, and my children, Jack
and Emily, thank you for your love, your support, your patience,
your understanding, your hugs, and your laughter. And to all of
the parents and families who have permitted me to care for their
critically ill loved one, thank you for the privilege of doing so.
Steven L. Shein
To my parents, Enio and Newra, for their contagious love for

medicine. To my brother, Francisco, for setting the bar so high.
To my mentor, Ashok, for showing me the way. To my teachers,
Brad and David, for all the knowledge. To my wife, Kristy, and
my daughters, Ashlynn and Valentina, for their encouragement,
support, sacrifices, patience, and unconditional love.
Alexandre T. Rotta
Preface
In 1967, Ashbaugh and colleagues described a group of predominantly adult

patients with various underlying conditions who developed a peculiar form of
respiratory failure. Regardless of the inciting etiology, these patients shared a
common rapid progression to respiratory failure with hypoxemia, diffuse
infiltrates on chest radiographs, decreased lung compliance, and decreased
functional residual capacity, requiring the application of positive end-
expiratory pressure (PEEP) to improve oxygenation. This condition, which
we now know as the acute respiratory distress syndrome (ARDS), was based
on somewhat vague diagnostic criteria and was not specific enough to exclude
other medical conditions with similar manifestations.
Our understanding of ARDS has increased greatly during the past five
decades. ARDS definitions and diagnostic criteria have also evolved over time,
including the Murray Lung Injury Score (1988), the American-European
Consensus Conference Definition (1994), and the Berlin Definition (2012) put
forth jointly by the European Society of Intensive Care Medicine (ESICM) and
the Society of Critical Care Medicine (SCCM). Each of these definitions repre-
sented a step forward in delineating this important diagnosis, yet the applicabil-
ity of these adult-centric definitions had significant limitations for children
since they did not consider ARDS factors germane to the pediatric patient.
The lack of a pediatric-specific ARDS definition, coupled with a rapidly
growing body of literature on children with acute hypoxemic respiratory fail-
ure, led an expert panel to assemble the Pediatric Acute Lung Injury Consensus
Conference (PALICC, 2015) and put forth the first definition of pediatric
ARDS (PARDS). This definition represented a major step forward for those
involved in PARDS diagnosis, treatment, and research. It provided the frame-
work that would allow for comparisons across multiple institutions, helped
define the actual worldwide prevalence of this condition, and clarified the role
of various treatment modalities and their impact on outcomes.
This textbook will provide a comprehensive review of the available and
emerging science related to PARDS, discuss state-of-the-art treatment modal-
ities and strategies, and reflect on clinical outcomes for this important condi-
tion. The various chapters were written by established experts in the field of
PARDS, many of whom participated in the original PALICC effort.
Cleveland, OH, USA Steven L. Shein

Durham, NC, USA Alexandre T. Rotta
vii
Acknowledgment
We are grateful for the diligent work and dedication of our contributors, with-
out whom this book would have never amounted to more than an idea. We are
also thankful to Sheik Mohideen, Andy Kwan, and the entire team at Springer
Nature for keeping us on track and for their expert assistance.
ix
Contents
1 The History of ARDS and the Need

for a Pediatric Definition �� 1
Howard Eigen
2 Pediatric Acute Respiratory Distress Syndrome:
Definition and Epidemiology�� 7
Fernando Beltramo and Robinder G. Khemani
3 Pathobiology of Pediatric Acute Respiratory
Distress Syndrome�� 19
Lincoln S. Smith
4 Risk Factors and Etiologies of Pediatric Acute
Respiratory Distress Syndrome�� 33
Joseph G. Kohne and Heidi R. Flori
5 Imaging and Monitoring in Pediatric Acute
Atsushi Kawaguchi and Philippe Jouvet
6 Conventional Mechanical Ventilation in Pediatric Acute
Aditya Badheka, Veerajalandhar Allareddy, and Ira Cheifetz
7 Nonconventional Mechanical Ventilation
for Pediatric Acute Respiratory Distress Syndrome:
High-Frequency Oscillatory Ventilation and Airway
Pressure Release Ventilation �� 73
Pauline de Jager, Robert G. T. Blokpoel, and Martin C. J.
Kneyber
8 Ventilator Weaning and Extubation Strategies
for Children with PARDS�� 89
Adrienne Randolph
9 Noninvasive Respiratory Support in Pediatric Acute
Omar Alibrahim and Katherine Slain
xi
xii Contents
10 Ancillary Pulmonary Treatments for Pediatric

Acute Respiratory Distress Syndrome �� 117
Andrew L. Beardsley
11 Analgesia, Sedation, and Neuromuscular Blockade
in PARDS�� 127
Christopher Heard and Joseph Tobias
12 Fluids, Nutrition, and Acute Kidney Injury
in Pediatric Acute Respiratory Distress Syndrome�� 141
Ayse Akcan-Arikan and Katri V. Typpo
13 Heart–Lung Interactions and Cardiovascular Support
in Pediatric Acute Respiratory Distress Syndrome�� 159
Saul Flores, Rohit S. Loomba, and Ronald A. Bronicki
14 Red Blood Cell Transfusion in Pediatric Acute
Kenneth E. Remy, Daniel A. Mannion, and Jennifer A.
Muszynski
15 Pediatric Acute Respiratory Distress Syndrome
in Immunocompromised Patients�� 181
Courtney M. Rowan
16 ECMO for Pediatric Acute Respiratory Distress
Syndrome (PARDS) �� 193
Jesse C. Bain and Doug Willson
17 Clinical Outcomes in Pediatric Acute Respiratory
Distress Syndrome�� 211
Nadir Yehya
Index�� 225
Contributors
Ayse Akcan-Arikan Sections of Pediatric Critical Care Medicine and Renal,

Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
Omar Alibrahim Division of Pediatric Critical Care Medicine, Department
of Pediatrics, Oishei Children’s Hospital, Jacobs School of Medicine and
Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
Veerajalandhar Allareddy Division of Pediatric Critical Care, Department
of Pediatrics, Duke University School of Medicine; Duke Children’s,
Durham, NC, USA
Aditya Badheka Division of Pediatric Critical Care, Department of
Pediatrics, University of Iowa Stead Family Children’s Hospital, Iowa City,
IA, USA
Jesse C. Bain Division of Pediatric Critical Care, Children’s Hospital of
Richmond at VCU, Richmond, VA, USA
Andrew L. Beardsley Department of Pediatrics, Indiana University School
of Medicine, Indianapolis, IN, USA
Fernando Beltramo Children’s Hospital Los Angeles, University of
Southern California Keck School of Medicine, Los Angeles, CA, USA
Robert G. T. Blokpoel Department of Paediatrics, Division of Paediatric
Critical Care Medicine, Beatrix Children’s Hospital, University Medical
Center Groningen, Groningen, The Netherlands
Ronald A. Bronicki Section of Critical Care Medicine and Cardiology,
Texas Children’s Hospital, Department of Pediatrics, Baylor College of
Medicine, Houston, TX, USA
Ira Cheifetz Division of Pediatric Critical Care, Department of Pediatric,
Duke University School of Medicine; Duke Children’s, Duke University,
Durham, NC, USA
Pauline de Jager Department of Paediatrics, Division of Paediatric Critical
Care Medicine, Beatrix Children’s Hospital, University Medical Center
Groningen, Groningen, The Netherlands
Howard Eigen Department of Pediatrics, Indiana University School of
Medicine; Riley Hospital for Children, Indianapolis, IN, USA
xiii
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xiv Contributors
Saul Flores Section of Critical Care Medicine and Cardiology, Texas

Children’s Hospital, Department of Pediatrics, Baylor College of Medicine,
Houston, TX, USA
Heidi R. Flori University of Michigan, Department of Pediatrics, Division
of Pediatric Critical Care, Ann Arbor, MI, USA
Christopher Heard Department of Anesthesiology and Division of Pediatric
Critical Care, John R. Oishei Children’s Hospital, University at Buffalo,
Buffalo, NY, USA
Philippe Jouvet University of Montreal, CHU Sainte-Justine, Department
of Pediatrics, Division of Pediatric Critical Care Medicine, Montreal, QC,
Canada
Atsushi Kawaguchi University of Montreal, CHU Sainte-Justine,
Department of Pediatrics, Division of Pediatric Critical Care Medicine,
Montreal, QC, Canada
University of Ottawa, Children’s Hospital of Eastern Ontario, Department of
Pediatrics, Division of Pediatric Critical Care Medicine, Ottawa, ON, Canada
Robinder G. Khemani Children’s Hospital Los Angeles, University of
Southern California Keck School of Medicine, Los Angeles, CA, USA
Martin C. J. Kneyber Department of Paediatrics, Division of Paediatric
Critical Care Medicine, Beatrix Children’s Hospital, University Medical
Center Groningen, Groningen, The Netherlands
Joseph G. Kohne University of Michigan, Department of Pediatrics, Division
of Pediatric Critical Care, Ann Arbor, MI, USA
Rohit S. Loomba Section of Cardiology, Division of Cardiology, Department
of Pediatrics, Chicago Medical School, Advocate Children’s Hospital, Oak
Lawn/Chicago, IL, USA
Daniel A. Mannion Saint Louis University School of Medicine, St. Louis,
MO, USA
Jennifer A. Muszynski Nationwide Children’s Hospital, The Ohio State
University College of Medicine, Columbus, OH, USA
Adrienne Randolph Boston Children’s Hospital and Harvard Medical
School, Boston, MA, USA
Kenneth E. Remy St. Louis Children’s Hospital/Barnes Jewish Hospital,
Washington University in St. Louis, St. Louis, MO, USA
Courtney M. Rowan Department of Pediatrics, Division of Critical Care,
Indiana University School of Medicine, Indianapolis, IN, USA
Katherine Slain Division of Pediatric Critical Care Medicine, UH Rainbow
Babies & Children’s Hospital, Case Western Reserve University School of
Medicine, Cleveland, Cleveland, OH, USA
Contributors xv
Lincoln S. Smith University of Washington, School of Medicine and Seattle

Children’s Hospital, Department of Pediatric, Seattle, WA, USA
Joseph Tobias Department of Anesthesiology & Pain Medicine, Nationwide
Children’s Hospital, The Ohio State University, Columbus, OH, USA
Katri V. Typpo Division of Pediatric Critical Care Medicine, Department of
Pediatrics, University of Arizona, College of Medicine, Tucson, AZ, USA
Doug Willson Division of Pediatric Critical Care, Department of Pediatrics,
Children’s Hospital of Richmond at VCU, Richmond, VA, USA
Nadir Yehya Department of Anesthesiology and Critical Care Medicine,
Children’s Hospital of Philadelphia and University of Pennsylvania,
Philadelphia, PA, USA
The History of ARDS and the Need
for a Pediatric Definition 1
Howard Eigen
The history of acute respiratory distress syn- This concept of IRDS remained predominant
drome (ARDS) is long, complex, and very inter- until the mid-1950s.
esting. It is one of the few conditions first named In 1959, James [5] contributed new observa-
in children, in this case neonates with infant tions of the clinical features of IRDS because of the
respiratory distress syndrome (IRDS), also then novel practice of caring for these infants,
known as hyaline membrane disease. The term unclothed in clear-walled incubators, which
was then applied to adults with acute respiratory allowed for the observation of the patient strug-
failure exhibiting clinical and pathophysiological gling through several hours of rapid and labored
features closely resembling those of the neonatal breathing with deep sternal and intercostal retrac-
counterpart. It is likely that the clinical entity we tions alternating with periods of apnea. This is
now know as ARDS has existed for centuries, yet similar to how the understanding of ARDS evolved:
its recognition as an organized syndrome did not the rudiments of the pathology and the clinical
occur until just over half a century ago. course were each identified separately, without a
The initial description of pulmonary hyaline full understanding of the links between them.
membranes is generally attributed to Hochheim Perhaps the earliest published description of
[1], who, in 1903, described 2 neonatal cases at ARDS came in 1821 when Laennec characterized
autopsy and attributed the presence of alveolar anasarca of the lungs and pulmonary edema with-
membranes to the aspiration of amniotic sac con- out heart failure in his book “Treatise on Diseases
tents. They were first described in the English- of the Chest.” The concept of ARDS as an
language literature in 1925 by Johnson [2], who unnamed clinical entity certainly was known
regarded hyaline membranes as a form of neona- early in World War I. A military medical textbook
tal pneumonia. The studies of Farber in the 1930s published in 1915 and used by Canadian armed
attributed pulmonary hyaline membranes to the forces during World War I contains a graphic
peripheralization by respiratory activity of aspi- description of ARDS in relation to a poison gas
rated amniotic sac contents – particularly ver- attack: “Edema of the lungs, with general
nix – into the distal airways of the lung [3, 4]. asphyxia. Livid cyanosis with great dyspnea is the
outstanding clinical feature. A yellow serous fluid
fills the air passages in such quantities that it may
drip from the mouth of the living patient when the
H. Eigen (*)
stretcher is tilted head downwards. Death in this
Department of Pediatrics, Indiana University School
of Medicine; Riley Hospital for Children, stage may occur at any time from the first to the
Indianapolis, IN, USA fourth or fifth day.” [6] Concomitantly, physicians
© Springer Nature Switzerland AG 2020 1

S. L. Shein, A. T. Rotta (eds.), Pediatric Acute Respiratory Distress Syndrome,
https://doi.org/10.1007/978-3-030-21840-9_1
2 H. Eigen
in World War I established the relationship course of 12 patients with acute respiratory fail-
between trauma and a sudden and severe respira- ure that did not respond to usual methods of
tory failure ultimately leading to death, then respiratory support. These patients had tachy-
termed “posttraumatic pulmonary massive col- pnea, hypoxemia, and loss of lung compliance
lapse.” [7] following a variety of insults, exhibiting clinical
A 1946 publication by Brewer and colleagues and pathological characteristics thought to be
[8] described the “wet lung” in the following “remarkably similar to the infantile respiratory
manner: “In handling this large number of casu- distress syndrome” [9]. In a follow-up publica-
alties it was found in the forward hospitals in par- tion in 1971, Petty and Ashbaugh [10] used the
ticular, that those cases with dry lungs gave us term adult respiratory distress syndrome, pre-
very little trouble. On the other hand, those show- sumably not to exclude children from the diagno-
ing a wet pulmonary tree were difficult to resus- sis, but in an attempt to distinguish it from the
citate from shock.” By the close of World War II, well-established IRDS. In fact, one of the patients
the syndrome of “wet lung” had been character- described in the original cohort was an 11-year-
ized further, in which life-threatening respiratory old with the ARDS clinical syndrome, and 4 oth-
distress complicated the progressive recovery ers were teenagers (18- and 19-year-olds) that
from hemorrhagic and traumatic shock incurred would have been routinely cared for by pediatric
during combat. intensivists in the current era.
During the Vietnam War, as the survival rate The incidence and recognition of the adult
following circulatory collapse on the battlefield respiratory distress syndrome increased dramati-
improved, the syndrome was frequently identi- cally after 1967, coinciding with the height of the
fied, but under various names. Thus, “wet lung,” Vietnam War. With the advent of better treat-
“shock lung,” “transfusion lung,” or “Da Nang ments in the field and rapid staged evacuations,
lung” became synonyms for severe acute respira- more casualties survived to reach higher-level
tory failure that followed successful resuscitation care and had time to develop ARDS, or before
from circulatory collapse. The sequence was sim- 1967, one of its synonyms (Box 1.1). Given the
ilar in all of those named syndromes: severe non- magnitude of the disease in morbidity, mortality,
thoracic injury, blood loss, and hypotension and cost, a clear, widely accepted, and clinically
acquired during combat, successful resuscitation useful ARDS definition was needed.
on the battlefield, and prompt evacuation to a Over the next couple of decades, ARDS con-
medical facility for further management. In a few tinued to be an important cause of morbidity and
days, there followed progressive respiratory dis- death. Nevertheless, the heterogeneous nature of
tress and failure. Although only a small fraction
of those who reached the hospital developed
“shock lung,” in those who did, the pattern of
evolution was consistent: insidious onset of rapid Box 1.1 ARDS Historical Synonyms
shallow breathing, crackles, refractory cyanosis, • Congestive atelectasis
radiographic appearance of enlarging interstitial • Wet lung
and alveolar infiltrates with the entire lung even- • Hemorrhage lung
tually enveloped in a diffuse haze, and a chest • Shock lung
radiographic “white out.” Administration of high • Pump lung
oxygen concentrations and assisted ventilation • Trauma lung
became less and less effective, followed by death • Transfusion lung
resulting from respiratory insufficiency often • White lung
complicated by circulatory collapse. • Da Nang lung
In 1967, Ashbaugh and colleagues [9] pub- • Adult hyaline membrane disease
lished a more detailed, systematic, and cohesive • Adult respiratory distress syndrome
description of the syndrome based on the clinical
1 The History of ARDS and the Need for a Pediatric Definition 3
Table 1.1 The American-European Consensus Conference definition of ARDS

Timing Oxygenation Chest radiograph Pulmonary artery wedge pressure
ALI Acute PaO2 ≤ 300 mm Hg Bilateral infiltrates seen ≤18 mm Hg when measured or
criteria onset (regardless of PEEP level) on frontal chest no evidence of left atrial
radiograph hypertension
ARDS Acute PaO2 ≤ 300 mm Hg Bilateral infiltrates seen ≤18 mm Hg when measured or
criteria onset (regardless of PEEP level) on frontal chest no evidence of left atrial
radiograph hypertension
PEEP positive end-expiratory pressure, ALI acute lung injury, ARDS acute respiratory distress syndrome
ARDS created great difficulty in determining its The AECC defined ARDS as the acute onset
true incidence and outcomes, especially in the of hypoxemia (arterial partial pressure of oxygen
absence of a clear definition. As an example, the to fraction of inspired oxygen ratio [PaO2/FIO2]
published ARDS mortality rate varied between ≤200 mm Hg) with bilateral infiltrates on a fron-
10% and 90%, and its reported incidence differed tal chest radiograph, with no evidence of left
vastly between European countries and the atrial hypertension (Table 1.1). The AECC did
United States [11]. This was due to, at least in not consider the type or intensity of respiratory
part, the lack of an agreed upon definition among support to be a requirement in defining ALI or
various countries, or even among different stud- ARDS because resources for ventilator therapy
ies within the same country. In an attempt to and physician practice patterns vary consider-
bring clarity and uniformity to the definition of ably. Also, there are many cases in which
ARDS, a series of meetings were held under the mechanical ventilation is intentionally withheld
auspices of the American Thoracic Society and because of patient request or a determination that
the European Society of Intensive Care Medicine aggressive support is futile. In general, it is best
in 1992. The American-European Consensus to keep disease definitions independent of the
Conference on ARDS (the AECC) was con- therapy used to treat them. Definitions of any dis-
vened with the charge of not only defining ease states suffer at the margins, usually at the
ARDS, but also to bring light to the issue of lower end of the severity spectrum.
incidence, focus on the emerging understanding Nearly 2 decades later, the Berlin Conference
of pathophysiologic mechanisms, and establish was organized to clear up multiple issues regard-
guidelines for the conduct and coordination of ing the reliability and validity of the AECC defi-
clinical studies. The AECC published its posi- nition. The ARDS conceptual model proposed by
tion paper in 1995, but the formal definition was the Berlin Conference stated that ARDS is a type
not easily arrived at, as some participants sug- of acute diffuse, inflammatory lung injury that
gested that the definition of ARDS should be leads to increased pulmonary vascular permea-
different for research, epidemiology, and indi- bility, increased lung weight, and loss of aerated
vidual patient care. Early on, it was decided that lung tissue. The clinical hallmarks are hypox-
there should be a return to the term “acute” emia and bilateral radiographic opacities. These
(rather than “adult”) respiratory distress syn- are associated with increased venous admixture,
drome in recognition of the fact that ARDS is increased physiological dead space, and
not limited to adults. Unfortunately, the AECC decreased lung compliance. The morphological
also introduced the term acute lung injury (ALI) hallmark of the acute phase is diffuse alveolar
to the definition, in an effort to characterize the damage (i.e., edema, inflammation, hyaline
less severe end of the ARDS spectrum. Later on, membrane, or hemorrhage). The Berlin
this simply caused confusion as the cutoff points Conference proposed three disease severity cate-
for ARDS and ALI became a topic for debate. gories and tested outcomes of these categories
More recently, ALI has been dropped from gen- against a validation dataset of previous cases
eral usage and termed “mild ARDS.” (Table 1.2). Using the Berlin definition, patients
4 H. Eigen
Table 1.2 The Berlin definition of ARDS the syndrome and show what elements are unique
Acute respiratory distress syndrome to the disease in children.
Timing Within 1 week of a known clinical In 2015, Pediatric Acute Lung Injury
insult or new worsening respiratory Consensus Conference (PALICC) published the
symptoms
much needed and long overdue first pediatric-
Chest Bilateral opacities – not fully
imaginga explained by effusions, lobar/lung
specific definition of ARDS [14]. In addition, it
collapse, or nodules put forth consensus recommendations regarding
Origin of Respiratory failure not fully therapies for pediatric acute respiratory distress
edema explained by cardiac failure or fluid syndrome (PARDS), defined a subset of patients
overload considered to be “at risk” for PARDS, addressed
Need objective assessment (e.g.,
echocardiography) to exclude PARDS in specific populations (i.e., cyanotic
hydrostatic edema in no risk factor heart disease, chronic lung disease, left ventricu-
present lar dysfunction), and delineated priorities for
Oxygenationb 200 mm hg < PaO2/ future research. The definitions and recommen-
Mild FiO2 ≤ 300 mm hg with PEEP or
Moderate CPAP ≥5 cm H2Oc
dations were developed over the span of 2 years
Severe 100 mm hg < PaO2/ by 27 experts in the field of PARDS representing
FiO2 ≤ 200 mm hg with PEEP or 21 academic institutions from 8 countries in 3
CPAP ≥5 cm H2O continents. The PALICC experts evaluated clini-
PaO2/FiO2 ≤ 100 mm hg with PEEP
or CPAP ≥5 cm H2O
cal issues on 9 topics related to PARDS and
developed and voted on 151 recommendations.
CPAP continuous positive airway pressure, FiO2 fraction
of inspired oxygen, PaO2 partial pressure of arterial oxy- Strong agreement (meaning that all experts rated
gen, PEEP positive end-expiratory pressure the recommendation 7 or higher on a scale of
a
Chest radiograph or computed tomography scan 1–9) was reached in 132 recommendations.
b
If altitude higher than 1000 m, the correction factor should
The PARDS definition was a central compo-
be calculated as [PaO2/FiO2 × (barometric pressure/760)]
c
This may be delivered noninvasively in the mild ARDS nent of the PALICC report [14]. Like the Berlin
group definition, PALICC determined that the onset of
PARDS must occur within 7 days of a known
with mild, moderate, or severe ARDS exhibited clinical insult and the respiratory failure must not
incremental mortality (27%, 32%, and 45%, be fully explained by cardiac failure or fluid over-
respectively), as well as increased median dura- load. Significant changes from the Berlin defini-
tion of mechanical ventilation in survivors [12]. tion included abandoning the PaO2/FiO2 ratio in
Compared with the AECC definition, the final the grading of PARDS severity (mild, moderate,
Berlin definition had better predictive validity for and severe) in favor of the oxygenation index
mortality and was rapidly accepted worldwide (OI) or the oxygen saturation index (OSI). Using
for its overall superiority. the OI or the OSI allows for a more precise appre-
Both the AECC and Berlin definitions of ciation of the role of mechanical ventilation sup-
ARDS were created without specific consider- port on oxygenation and severity of illness
ation to ARDS that occurs in children. If a case classification. The presence of bilateral pulmo-
were to be made for a separate pediatric defini- nary infiltrates is no longer a requirement in the
tion, it must have been made on the basis that the PALICC definition, since there is no evidence
current definition for adults does not properly that pediatric patients with unilateral pulmonary
characterize the disease in children. Unlike in involvement have different clinical courses and
adults with ARDS, the Berlin definition severity outcomes than those with bilateral disease.
stratification fails to show an incremental mortal- PALICC deliberately chose not to specify age
ity between children with mild and moderate criteria for PARDS, but it should be understood
ARDS at 6, 12, or 24 hours from diagnosis [13]. that the definition is intended to cover the demo-
Any new template proposed for PARDS should graphics generally cared for by pediatric
be carefully drawn so as to properly characterize intensivists and excludes neonates with perinatal-
1 The History of ARDS and the Need for a Pediatric Definition 5
related lung disease (e.g., meconium aspiration, 4. Farber and Wilson. The hyaline membrane in the
hyaline membrane disease, alveolar capillary lungs II. Exp study Arch Path. 1932;14:450–60.
5. James LS. Physiology of respiration in newborn
dysplasia). Chapter 2 covers the PALICC defini- infants and in the respiratory distress syndrome.
tion in detail. Pediatrics. 1959;24:1069–101.
ARDS has had a longer history than many 6. Montgomery AB. Early description of ARDS. Chest.
would think. Our understanding of this important 1991;99:261–2.
7. Churchill ED. Pulmonary atelectasis with especial
syndrome was built through thoughtful and astute reference to massive collapse of the lung. Arch Surg.
clinical observations with the ultimate goal of 1925;11:489–518.
making therapy more effective and improving 8. Brewer LA III, Burbank B, Samson PC, Schiff
patients’ lives. It is clear that the disease in chil- CA. The “wet lung” in war casualties. Ann Surg.
1946;123:343–61.
dren is distinct from that in adults, so although 9. Ashbaugh DG, Bigelow DB, Petty TL. Acute respira-
ARDS definitions have evolved over time, the tory distress in adults. Lancet. 1967;2:319–23.
recent development of a pediatric-specific defini- 10. Petty TL, Ashbaugh DG. The adult respiratory dis-
tion has been widely welcomed by the critical tress syndrome. Clinical features, factors influenc-
ing prognosis and principles of management. Chest.
care community. This much needed thoughtful 1971;60:233–9.
and relevant new PARDS definition provides a 11. Bernard GR, Artigas A, Brigham KL, et al. The
unifying language for those caring for critically American-European consensus conference on
ill children or advancing the field through ARDS. Definitions, mechanisms, relevant outcomes,
and clinical trial coordination. Am J Respir Crit Care
research. Med. 1994;149:818–24.
12. The ARDS Definition Task Force. Acute respira-
tory distress syndrome: the Berlin definition. JAMA.
2012;307:2526–33.
References 13. Khemani RG, Smith L, Lopez-Fernandez YM,
et al. Paediatric acute respiratory distress syndrome
1. Hochheim K, Geh H. Medicinabrat Dr. Johannes Orth incidence and epidemiology (PARDIE): an inter-
zur Feier seines 25 Jahrigen Professoren Jubilaums national, observational study. Lancet Respir Med.
Gewidmet. Berlin: Hirschwald; 1903. 2019;7:115–28.
2. Johnson WC, Meyer JR. A study of pneumonia in 14. Pediatric Acute Lung Injury Consensus Conference
the stillborn and newborn. Am J Obstet Gynecol. Group. Pediatric acute respiratory distress syndrome:
1925;9:151–67. consensus recommendations from the pediatric acute
3. Farber S, Sweet LK. Amniotic sac contents in the lung injury consensus conference. Pediatr Crit Care
lungs of infants. Am J Dis Child. 1931;42:1372–83. Med. 2015;16:428–39.
Pediatric Acute Respiratory
Distress Syndrome: Definition 2
and Epidemiology
Fernando Beltramo and Robinder G. Khemani
Introduction Histopathology is impractical for real-time

clinical applications, no definitive biomarker is
In 1821, Laennec described in his “Treatise on present in all cases, and there is a spectrum of
Diseases of the Chest” probably the first pub- the degree of injury. While elements of the
lished description of ARDS. Laennec described pathobiology continue to be established,
the gross pathology of the heart and lungs as idio- in vitro and in vivo models have improved the
pathic anasarca of the lungs – pulmonary edema fundamental understanding of the pathobiol-
without heart failure. By the 1950s, pulmonary ogy of ARDS. As such, our diagnostic criteria
edema had become a medical entity; however, no have sought to identify clinical signs and
distinction was made at that time between cardiac symptoms reflective of this pathobiology
and noncardiac causes. For a period of time, related to the diffuse albeit nonhomogeneous
ARDS went by the name of inciting injuries nature of the injury at both the alveolar epithe-
(shock lung, posttraumatic lung, Da Nang lung, lial and endothelial surface, inflammation, loss
etc.). It was not until 1967, in a landmark article of functional residual capacity and impairment
published in Lancet, that the term acute respira- in pulmonary compliance, hypoxemia, and ele-
tory distress syndrome (ARDS) was mentioned vations in alveolar dead space.
[1]. Ashbaugh and colleagues described a syn- In 1994, the American European Consensus
drome of tachypnea, hypoxia, and decreased pul- Conference (AECC) defined ARDS as a syn-
monary compliance in a series of 11 adults and drome of inflammation and increased permeabil-
one child with respiratory failure. The pathologic ity in the lungs that is associated with a
features included interstitial and intra-alveolar constellation of clinical, radiologic, and physio-
edema and hemorrhage, as well as hyaline mem- logic abnormalities that cannot be explained by,
brane formation. but may coexist with, left atrial or pulmonary
Like other clinical syndromes, ARDS lacks capillary hypertension [2]. For years, pediatric
a definitive gold standard for diagnosis. practitioners used the AECC definition of ARDS
for clinical care, research, and prognostication.
While this definition was used for nearly
F. Beltramo · R. G. Khemani (*) 30 years, there were several limitations of the AECC
Children’s Hospital Los Angeles, University of definition of ARDS related to the influence of venti-
Southern California Keck School of Medicine,
lator settings on hypoxemia, the timing of disease,
Los Angeles, CA, USA
e-mail: [email protected]; RKhemani@chla. use of noninvasive ventilation, defining a spectrum
usc.edu of hypoxemia severity in ARDS, and how to specifi-
© Springer Nature Switzerland AG 2020 7

S. L. Shein, A. T. Rotta (eds.), Pediatric Acute Respiratory Distress Syndrome,
https://doi.org/10.1007/978-3-030-21840-9_2
8 F. Beltramo and R. G. Khemani
cally handle left ventricular dysfunction. These In 2015, the Pediatric Acute Lung Injury
limitations were addressed by the Berlin definition Consensus Conference (PALICC) published spe-
in 2012. While some of these issues are common cific definitions for pediatric ARDS (PARDS)
between adults and children with ARDS, pediatric- (Table 2.1) and those gauged to be at risk for
specific considerations were not included in either PARDS (Table 2.2), as well as recommendations
Berlin or AECC definitions [3, 4]. Although there regarding management and suggested priorities
are similarities in the pathophysiology of ARDS in for future research [6]. PALICC was a two-year
adults and children, pediatric-specific practice pat- process that consisted of 27 experts from eight
terns, comorbidities, and differences in outcome countries on three continents. The group was
necessitated a pediatric-specific definition [5]. tasked with determining whether the Berlin crite-
Table 2.1 PARDS definition

Age: Exclude patients with perinatal-related Oxygenation
lung disease Noninvasive mechanical ventilation: Full-face mask bi-level
Timing: Within 7 days of known clinical ventilation or CPAP ≥ 5 cm H2Ob with PF ratio ≤300 or SF
insult ratio ≤ 264a
Origin of edema: Respiratory failure not fully Invasive mechanical ventilation
explained by cardiac failure or fluid overload Mild Moderate Severe
Chest imaging: Chest imaging findings of
new infiltrate(s) consistent with acute 4 ≤ OI < 8 8 ≤ OI < 16 OI ≥ 16
pulmonary parenchymal disease 5 ≤ OSI < 7.5a 7.5 ≤ OSI < 12.3a OSI ≥ 12.3a
Cyanotic heart disease: Standard criteria with an acute deterioration in oxygenation not explained by underlying
cardiac disease
Chronic lung disease: Standard criteria with chest imaging consistent with new infiltrate and acute deterioration in
oxygenation from baseline
Left ventricular dysfunction: Standard criteria with chest imaging changes and acute deterioration in oxygenation
not fully explained by left ventricular dysfunction
OI = oxygenation index = (FiO2 × mean airway pressure × 100)/PaO2
OSI = oxygen saturation index = (FiO2 × mean airway pressure × 100)/SpO2
a
Use PaO2-based metric when available. If PaO2 not available, wean FiO2 to maintain SpO2 ≤ 97% to calculate OSI or
SF ratio
b
For non-intubated patients treated with supplemental oxygen or nasal modes of noninvasive ventilation, see Table 2.2
for at-risk criteria
Table 2.2 At risk of PARDS definition

Age: Exclude patients with perinatal-related lung disease Oxygenation
Timing: Within 7 days of known clinical insult Nasal mask CPAP or BiPAP
Origin of edema: Respiratory failure not fully explained by FiO2 ≥ 40% to attain SpO2 88–97%
cardiac failure or fluid overload Oxygen via mask, nasal cannula, or high flow
Chest imaging: Chest imaging findings of new infiltrate(s) SpO2 88–97% with oxygen supplementation at
consistent with acute pulmonary parenchymal disease minimum flowb:
<1 year: 2 L/min
1–5 years: 4 L/min
5–10 years: 6 L/min
>10 years: 8 L/min
Invasive mechanical ventilation
Oxygen supplementation to maintain SpO2 ≥ 88%
but OI < 4 or OSI < 5a
a
If PaO2 not available, wean FiO2 to maintain SpO2 ≤ 97% to calculate OSI
b
Given lack of available data, for patients on an oxygen blender, flow for at-risk calculation = FiO2 × flow rate (L/min)
(e.g., 6 L/min flow at 0.35 FiO2 = 2.1 L/min)
2 Pediatric Acute Respiratory Distress Syndrome: Definition and Epidemiology 9
ria for ARDS, created by adult practitioners and to define PARDS and at risk for PARDS in infants
validated with data from adult patients with and children on noninvasive ventilation.
ARDS, was applicable in children. The Berlin
definition of ARDS was seen as an iterative
improvement, and although there is value in hav- Rationale for Age Criteria
ing a single definition applicable to all ages of
patients, pediatric-specific shortcomings of the PALICC specifically excludes children with
Berlin definition were identified in relation to (1) perinatal-related lung disease from the PARDS
whether age or stage of lung development affects definition, although there is no upper limit for
the definition of ARDS, (2) the importance and age. Although the pathobiology of acute lung
reliability of radiographic criteria, (3) respiratory injury caused by perinatal events such as aspira-
criteria for severity of disease and risk stratification of meconium or group B Streptococcus may
tion, (4) the increasing use of noninvasive respi- be similar to the diffuse inflammatory and injury
ratory support and noninvasive monitoring for mechanisms of PARDS, the unique pathophysi-
acute hypoxemic respiratory failure, and (5) the ology related to persistent fetal circulation,
ability to diagnose ARDS in patients with pediat- changes in perinatal pulmonary vascular resis-
ric pulmonary and cardiac comorbidities. Aspects tance, and the processes of care by neonatologists
of the Berlin definition related to (6) timing of as compared with pediatric intensivists made it
disease and (7) coexistence of cardiac disease important to consider this group of patients sepa-
and ARDS with methods to define left ventricular rately. In response to this, a similar consensus
dysfunction were likely to be similar across a conference was convened to create a neonatal
spectrum of age, with some pediatric-specific definition of ARDS, which has many similarities
modification. to the PALICC definition [7].
The PALICC definition has no upper limit of
age, because there was no clear break point in the
efinition of Pediatric ARDS
D incidence or mortality of ARDS, sepsis, or pneu-
(PARDS) by the Pediatric Acute monia between adolescents and young adults
Lung Injury Consensus Conference [8–12]. Furthermore, there is no clear break point
at which critically ill patients are no longer cared
The Berlin and PALICC definitions of ARDS are for by pediatric intensivists. Increasingly, there
similar in regard to the development of signs and are patients in their twenties cared for by pediat-
symptoms within 7 days of a clinical insult and ric practitioners, and many adolescents are cared
the development of pulmonary edema that is not for in adult institutions. As such, there is no clear
fully explained by cardiac failure of fluid over- age cut point at which a patient with ARDS
load. Unlike the Berlin definition, the PALICC should be considered “pediatric” versus “adult.”
definition does not require bilateral infiltrates on In order to reduce confusion and improve recog-
chest radiograph, incorporates pulse oximetry nition of ARDS, PALICC recommended health
metrics when PaO2 is not available, introduces care providers caring for adolescents and young
the use of oxygenation index (OI) and oxygen- adults should use the definition of ARDS with
ation saturation index (OSI) to stratify severity which he or she is most familiar.
groups instead of PaO2/FiO2 (PF ratio) with mini-
mum positive end-expiratory pressure (PEEP),
and creates specific criteria to define PARDS in Timing and Triggers
children with chronic lung disease and cyanotic
heart disease. In addition, no upper limit of age is Acute onset has been included in definitions of
defined for PALICC criteria, although children ARDS to differentiate ARDS from existing
with perinatal-related lung injuries are excluded. chronic lung disease. In the AECC definition,
Moreover, PALICC had pediatric-specific criteria acute onset was mandated but timing was not
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specified; in the Berlin definition ARDS onset Radiographic Findings in PARDS

was mandated to be within 1 week of a known
clinical insult or new or worsening respiratory Both AECC and Berlin definitions of ARDS
symptoms [2, 4]. Review of both the pediatric require the presence of bilateral pulmonary infil-
and adult literature identified key similarities in trates on chest radiograph. The primary argument
the timing of ARDS after an inciting event such to include bilateral infiltrates in the definition of
as sepsis, trauma, or aspiration, with most of ARDS is to allow for discrimination between
patients developing symptoms within the first localized processes such as lobar pneumonia and
24 hours and almost all within 7 days [13–19]. the diffuse inflammatory processes seen in both
Some subgroups of patients develop ARDS lungs with ARDS. However, PALICC removed
very quickly. For example, transfusion-related the requirement for bilateral infiltrates, instead
acute lung injury (TRALI) is defined as ARDS requiring patients had evidence of pulmonary
that develops within 6 hours of a transfusion [20, parenchymal disease. The main arguments for
21]. Similarly, neurogenic pulmonary edema the removal of bilateral infiltrates surrounded (1)
develops rapidly following intracranial insult, the lack of sensitivity of chest radiographs to
typically from traumatic brain injury or sub- detect all pulmonary parenchymal inflammation
arachnoid hemorrhage [22]. Likewise, ARDS and edema, (2) that opacification on chest imag-
usually develops promptly in the setting of pedi- ing often lags behind hypoxemia, and (3) that the
atric drowning-related lung injury [23]. presence of bilateral infiltrates on chest radio-
graph does not seem to impart additional risk for
poor outcome not otherwise captured with the
oexistence of ARDS with Left
C degree of hypoxemia. PALICC elected not to
Ventricular Failure/Dysfunction eliminate radiology altogether from the definition
to help differentiate other causes of acute hypox-
The issue of left ventricular (LV) dysfunction/ emic respiratory failure, which do not share the
failure is specifically addressed by both the pathophysiology of ARDS (i.e., asthma without
AECC criteria and the Berlin criteria. The goal is coexisting pneumonia). However, because there
to differentiate hydrostatic causes of pulmonary is some evidence to suggest that the presence of
edema from ARDS. In the original AECC crite- bilateral infiltrates may have prognostic relevance
ria, the presence of left atrial hypertension (pul- in certain subgroups of patients, radiographic
monary capillary wedge pressure > 18 mm Hg or data should be included in the design of research
clinical evidence of left atrial hypertension) was studies for enrollment stratification or subgroup
an exclusion criterion for ARDS. Berlin revised analyses based on the presence or absence of
this to allow ARDS to coexist with left ventricu- bilateral infiltrates.
lar dysfunction, as long as there are clear risk
factors for ARDS. If not, objective assessment to
exclude cardiac failure (echocardiography) espiratory Criteria for Disease
R
should be performed. PALICC concluded that Severity
these phenomena are similar in children. Varying
degrees of left ventricular dysfunction are fre- Unlike the Berlin definition, PALICC allows for
quently reported in children with ARDS and the use of pulse oximetry criteria when an arterial
may be associated with increased mortality [24, PaO2 is not available and recommends the use of
25]. Furthermore, echocardiography is widely oxygenation index (or oxygen saturation index)
used in pediatrics to quantify ventricular func- instead of PF ratio for those on invasive mechani-
tion and is a good predictor of cardiac symptoms cal ventilation.
and outcomes in children with left ventricular PALICC argued that pulse oximetry criteria are
failure [26]. crucial to define ARDS in children because arterial
lines are not used in all ventilated children. While some investigators recommend assess-
Increasingly, arterial blood gases or arterial line ing PF ratio on standard ventilator settings (i.e.,
monitoring are reserved for patients with hemody- PEEP of 10 cm H2O) [38], PALICC determined
namic instability or severe hypoxemia. Requiring that requiring specific ventilator manipulations
arterial blood sampling would lead to a significant may impair recognition of PARDS by clinicians.
underrecognition of children with PARDS and Instead, PALICC elected to use oxygenation
make the definition subject to selection bias based index (OI = [FiO2 × mean airway pres-
on provider preference in obtaining an sure × 100] ÷ PaO2) to account for the degree of
ABG. Investigators have highlighted that even ventilator support. Cut points were derived and
after stratifying for similar degrees of hypoxemia, validated using existing datasets and the risk of
mechanically ventilated children with ABGs are death nearly doubled for each successive cut
sicker, have higher severity of illness, and are on point: OI < 4 (at risk for PARDS), 4–8 (mild
more vasopressor support [27]. Furthermore, sev- PARDS), 8–16 (moderate PARDS), and > 16
eral studies have validated that SpO2-based criteria (severe PARDS) with a relatively equal distribu-
have a strong clear predictable relationship with tion of patients within the mild, moderate, and
PaO2-based criteria, validating both SpO2/FiO2 severe groups. Like the Berlin definition, PALICC
ratio and the oxygen saturation index. However, it developed PARDS severity groups to facilitate
is important to remember that theses metrics common definitions for future research and ther-
require that the SpO2 be ≤97% since the oxyhe- apies targeting children with different degrees of
moglobin dissociation curve is nearly flat when lung injury. Given clear differences in mortality
SpO2 is >97% [25, 28–32]. and outcome based upon disease severity, as well
as potential differences in pathophysiology, risk-
benefit profiles may differ based upon disease
OI Versus PF Ratio severity [39, 40].
The Berlin definition for ARDS accounts for dif-

ferences in ventilator management by requiring a Pulse Oximetry Versus PaO2
minimal PEEP of 5 cm H2O or CPAP of 5 cm
H2O for noninvasively ventilated adults. A mini- Fewer arterial blood gases are obtained in pediat-
mum PEEP of 10 cm H2O was considered to ric ICUs, and the use of noninvasive respiratory
define severe ARDS, but this requirement was support has resulted in increasing number of
removed from the definition because it did not patients with lung injury that are cared for out-
discriminate increased risk of mortality as com- side of ICUs [35, 41–43]. Therefore, it was
pared with a PEEP of 5 cm H2O. It is important to imperative to create a definition for PARDS that
note that most patients included in the validation did not rely upon the subjective decision to obtain
of the Berlin criteria were enrolled in ARDSNet an ABG [44]. Given the strong linear relation-
studies, and oftentimes PEEP management was ship between oxygen saturation index
protocolized with a PEEP/FiO2 table, with over [OSI = (FiO2 × mean airway pressure × 100)/
50% of patients having a baseline PEEP SpO2] and OI when the SpO2 is ≤97%, PALICC
>10 cm H2O [3, 4, 33, 34]. Pediatric intensivists established OSI cut points to correspond with the
generally use less PEEP than their adult col- OI cut points proposed earlier [31]. The SF ratio
leagues [25, 28, 35], are more variable in how also has a strong relationship with PF ratio [31,
PEEP is applied as a function of hypoxemia, and 32, 45], particularly for those on invasive
less frequently escalate PEEP above 10 cm H2O mechanical ventilation. It is unclear how well SF
[35, 36]. This may be important because observa- ratio performs in relation to PF ratio for children
tional data suggests that failure to escalate PEEP receiving noninvasive ventilation, given difficul-
as hypoxemia worsens is independently associ- ties in calculating delivered FiO2 and the poten-
ated with mortality in PARDS [37]. tial effect of modification based upon the degree
of ventilator support. For this reason, PALICC response to a known clinical trigger. This is
did not recommend applying SF ratios for non- important because at baseline these children may
intubated patients (or those not on full-face mask have evidence of pulmonary parenchymal dis-
noninvasive ventilation) to grade severity, but ease on chest imaging and may be on invasive or
rather created guidelines based on combinations noninvasive mechanical ventilation. Hence,
of SpO2 and minimal delivered oxygen to estab- PALICC recommends that patients with preexist-
lish who is at risk for PARDS. Unfortunately, ing chronic lung disease who are treated with
conventional methods of estimating the fraction supplemental oxygen, noninvasive ventilation, or
of delivered oxygen (FdO2) for those on nasal invasive ventilation via tracheostomy should be
modes on NIV may over- or underestimate FiO2 considered to have PARDS if they have acute
depending on the rate of flow delivered to the changes that meet standard PARDS criteria
patient, the patient’s minute ventilation, and (acute onset, a known clinical insult, chest imag-
whether the flow is warmed or humidified. The ing supporting new-onset pulmonary parenchy-
published guidelines for the calculation of FiO2 mal disease) and have an acute deterioration in
by the American Association of Respiratory Care oxygenation from baseline which meets oxygen-
(AARC) suggest that nasal cannula do not pro- ation criteria for PARDS.
vide a FiO2 greater than 40% [46–49]. Patients with cyanotic congenital heart disease
PALICC recommended that patients who are have not been addressed in either the AECC or
on full-face mask modes of noninvasive ventila- the Berlin criteria. In general, the presence of
tion with a minimum CPAP of 5 cm H2O who cyanotic congenital heart disease has been con-
have PF ratios ≤300 or SF ratios ≤264 be consid- sidered an exclusion criterion for the diagnosis of
ered to have PARDS. Patients who are on full- ARDS in children. This is understandable as
face mask CPAP or BiPAP but do not fulfill all intracardiac mixing or right-to-left shunting of
the criteria for PARDS should be considered at blood affects the PF ratio and other indices of
risk for PARDS. To apply SpO2 criteria to diag- oxygenation. However, it is clear that PARDS
nose PARDS, oxygen therapy must be titrated to can occur in children with cyanotic congenital
achieve an SpO2 between 88 and 97%. heart disease [50]. Hence, worsening hypoxemia
with pulmonary parenchymal disease on chest
radiograph in the absence of changes in the
efining PARDS in Children
D underlying cardiac disease may be consistent
with Existing Lung or Cardiac with a diagnosis of PARDS.
Disease The diagnosis of ARDS in these children
requires individual providers to exclude new
A number of exclusion criteria related to gesta- changes in intracardiac shunt/mixing or worsen-
tional age, preexisting chronic lung disease, cya- ing left ventricular dysfunction as the cause of
notic congenital heart disease, and coexisting left worsening hypoxemia. Unfortunately, there are
ventricular failure/dysfunction have been applied limited objective criteria to exclude new changes
in variable ways in previous PARDS investiga- in intracardiac shunt. Echocardiography has limi-
tions. PALICC sought to standardize criteria in tations, although it may be useful in excluding
these subpopulations to facilitate future research selected cardiac causes of acute deterioration in
and clinical care because these preexisting oxygenation (e.g., systemic-pulmonary shunt
comorbidities do not exclude the potential for thrombosis or narrowing, increasing right ven-
these patients to develop PARDS, and these tricular outflow tract obstruction, increasing pul-
comorbidities represent important at-risk patient monary hypertension). More invasive modalities
populations. such as cardiac catheterization, CT angiography,
The most important factor in the diagnosis of and magnetic resonance imaging (MRI), while
PARDS in patients with preexisting lung disease useful in defining intracardiac shunts, pose sig-
is the acute deterioration in oxygenation in nificant risks in children with ARDS. Hence,
PALICC chose a pragmatic approach, stating formity in the reporting of pulmonary and extra-
patients with cyanotic congenital heart disease pulmonary etiologies and mortality in ARDS
are considered to have PARDS if they fulfill stan- patients makes direct comparison difficult [59,
dard criteria (acute onset, a known clinical insult, 60]. The PALICC definition is likely to identify
chest imaging supporting new-onset pulmonary many more patients with PARDS, which will
parenchymal disease) and have an acute deterio- likely change both the incidence and mortality
ration in oxygenation not explained by the under- rates.
lying cardiac disease.
alidation of the PALICC Guidelines

V
Incidence and Epidemiology in Recent Publications
Using the AECC definition, the incidence of Parvathaneni et al. [61] compared the PALICC,
ARDS in US, European, Australian, and New AECC, and Berlin definitions among children
Zealand children is estimated at 2.0–12.8 per admitted to a single multidisciplinary PICU in
100,000 person·years [19, 24, 38, 44, 51]. A the United States. They found that the PALICC
series of observational studies in the 1990s and criteria nearly doubled the number of patients
2000s found that ARDS occurs in 3–6% of PICU diagnosed with PARDS, largely because of the
patients and between 5 and 8% of mechanically pulse oximetry–based criteria in PALICC. Nearly
ventilated PICU patients. ARDS mortality in all patients who met Berlin or AECC criteria also
children appears to be lower than in adults (18– met PALICC criteria. The overall mortality for
27% vs 27–45%) [8, 14, 52–54], although, there those who met Berlin or AECC criteria was
are some populations in which adult and pediat- approximately 30% compared to 22% for those
ric ARDS mortality appears similar (35%) [9, 15, who met PALICC criteria. Approximately 40%
25, 38, 55]. A recent systematic review and meta- of the patients who only met PALICC criteria had
analysis [65] has found that the overall pooled mild PARDS and 11% were on NIV, but 20% had
mortality (including the control arm of RCTs and severe PARDS, with 31% mortality. Furthermore,
observational studies) for PARDS was 24% (95% for patients in whom both PALICC and Berlin
CI 19–31) and has been improving over time. criteria were met, PALICC identified ARDS
Most pediatric studies report an increased approximately 12 hours earlier. Interestingly, it
incidence of ARDS in males versus females, but appeared as if those with severe PARDS had sub-
males do not seem to have increased mortality stantially higher mortality than those with mild to
from ARDS [9, 14, 24, 25, 35, 52–54, 57, 58]. moderate PARDS, with minimal mortality differ-
Preexisting comorbidities are common among ence between those with mild or moderate
PARDS patients (12–74%) and may be associ- PARDS.
ated with higher mortality [9, 16, 24, 35, 38, 53, Yehya et al. [62] conducted a prospective
54, 56]. Immunodeficiency is a common preex- study looking at variables associated with mor-
isting condition, and most studies show increased tality and ventilator-free days at 28 days among
mortality among immunodeficient patients who PARDS patients at a single tertiary/quaternary
develop PARDS [9, 14, 24, 53, 54, 57, 58]. ICU in the United States. This cohort was
PARDS triggers may contribute to differences in restricted to children who met criteria with an
outcome between children and adults or even arterial blood gas (PF ratio for AECC and Berlin,
among children, but pneumonia, sepsis, aspira- OI for PALICC) and similarly identified that
tion, and trauma account for 63–92% of ARDS in nearly all patients who met AECC or Berlin crite-
both adults and children [8, 9, 14, 24, 25, 35, 38, ria also met PALICC criteria. They found that
54]. Likewise, there may be differences in the neither Berlin PaO2/FiO2 nor PALICC OI catego-
rates of pulmonary and extrapulmonary sepsis ries at onset of PARDS could discriminate mor-
between children and adults, but the lack of uni- tality. However, 24 hours after PARDS onset,
there was a stepwise increase in mortality as was similar (approximately 15%) for those who
severity increased (with both PALICC and Berlin have noninvasive ventilation, mild, or moderate
groupings). PARDS, with significant higher mortality (>30%)
Rowan et al. [63] investigated whether for those with severe PARDS. A delayed measure
PALICC criteria discriminated mortality in of PARDS severity (6 hours after PARDS onset)
hematopoietic stem cell transplant (HSCT) recip- appears to better stratify mortality risk than ini-
ients requiring invasive mechanical ventilation in tial PARDS severity. The PALICC definition
multiple PICUs in the United States. Using intu- identified approximately 40% more children as
bated HSCT patients without PARDS as the having PARDS and diagnosed PARDS a median
reference population, there was no difference in 12.8 hours sooner than the Berlin definition
the OR of mortality between HSCT patients with within the first 3 days. PALICC definitions by use
no PARDS versus mild PARDS (OR 1.1, 95% CI, of oxygenation index or oxygenation saturation
0.3–4.2; p = 0.84) and no PARDS versus moder- index measurements seem to stratify mortality
ate PARDS (OR = 1.8, 95% CI, 0.6–5.5; p = 0.31) better than the Berlin PF-based severity groups.
group. The severe PARDS group had a signifi- Bilateral opacifications were identified in 75% of
cantly higher risk of mortality with an OR of 6.1 PARDS patients at the time of PALICC PARDS
(95% CI, 2.1–17.8; p < 0.001). The nonsurvivors diagnosis, and 87% of patients had bilateral infil-
were more likely to have multiple consecutive trates within 3 days of PARDS diagnosis.
days at moderate to severe PARDS (p < 0.001).
Most (70%) of the patients met PARDS criteria
by day 1 of mechanical ventilation and 89% met Where Do We Go from Here?
criteria by day 3. The moderate and severe
PARDS patients had longer PICU length of stay The PALICC definition was meant to be a starting
and longer course of mechanical ventilation. point to unite the PARDS community in establish-
Wong et al. [64] evaluated the PALICC crite- ing a pediatric-specific definition to be used for
ria in a multicenter study in Asia. They found that clinical care and research. Further external valida-
the PALICC criteria for stratification into mild, tion of this definition is crucial, which should con-
moderate, and severe groups were associated tinue to be a focus of investigation. Based on the
with a stepwise decrease in ventilator-free days validation studies conducted to date, it is clear that
and a stepwise increase in short-term and the PALICC definition is capturing patients who
intermediate-term mortality. The overall mortal- have met previous definitions of ARDS (often-
ity in this study was 30.3%, which is comparable times earlier than previous definitions), plus
with overall PARDS mortality reported in other another subset of patients. A substantial proportion
studies in Asia, although different than what is of these patients simply do not meet historical cri-
reported in the United States and Europe. teria because of changes in clinical practice with
The Pediatric Acute Respiratory Distress syn- regard to the use of arterial catheters. Interestingly,
drome Incidence and Epidemiology (PARDIE) the reported incidence of PARDS with the PALICC
study [66] prospectively evaluated PALICC crite- definition is comparable to historical studies using
ria in approximately 170 international intensive AECC definition, prior to practice changes related
care units, representing 27 countries. PARDIE to pulse oximetry and arterial blood gases. Hence,
found that using the PALICC definition, PARDS it is possible that the PALICC definition has now
occurs in approximately 3% of children admitted just better aligned to our evolution in clinical prac-
to the PICU, or 6% of those on mechanical venti- tice and has not fundamentally changed the epide-
lation. The incidence of “at risk for PARDS” is miology of the disease.
undoubtedly higher, and a substantial number of The elimination of bilateral infiltrates in the
these children (32% in one single-center study of PALICC definition is among the most controver-
children with bronchiolitis) will subsequently be sial changes and is a departure from both adult
diagnosed with PARDS. In PARDIE, mortality and neonatal ARDS definitions. Diffuse inflam-
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the shops of the guild, receives and turns over to the state the
articles made by the guild, certifies to the pay rolls, and to the cost
of the articles made. It determines the amount of material required
and the number of men that shall be employed, basing its regulation
on the requisition of the general board for the goods which in turn
gets its data from the store keepers who make requisitions on the
board according to the public demand for the goods. The guild board
determines the number of men it can employ and if it has too many
the fact is reported to the general board whose business it is to find
work for the surplus men in another trade. The guild board naturally
anxious to preserve the credit of its own guild, always selects the
least competent of their men for transfer. The general board is
constantly posted as to the demand for labor in the different guilds
and can usually assign the men to places suited to their capacity,
which commonly admits of more or less variety of employment, their
school education being conducted with that view. If the trades are
all full or if the men prove unfit to perform such skilled labor as is
required, they are furnished laboring work not requiring skill of
which there is always plenty in the procurement of raw materials for
food, minerals, agricultural products, building materials etc. As most
of the things produced including food can be kept an indefinite
length of time, there is no objection to a considerable accumulation
ahead. When this happens and it often does, the community is in a
prosperous condition for it has more than enough. It is a sign that
the workmen have saved their money instead of buying goods with
it. They may knock off work and take holiday till the stocks are
reduced. Sometimes the fashion changes, and the state has
something on hand it cannot sell. Like any other manufacturer it
must sell at a sacrifice for what it can get, and use better judgment
next time. The general board looks out for that. This board also
equalizes wages in the several trades, lowering the pay in those
trades into which there is the greatest tendency to crowd and raising
it in those that are deserted. Striking in a body is not allowed. But
many or all the members of a guild may give notice of an intention
to leave, and they are then allowed to do so, a small number at a
time. The general board inquires into the cause of the dissatisfaction
and rectifies it if possible. If the wages are high enough the fact will
be proved by other workmen coming from other trades or other
places to take the job, in which case the disgruntled men must take
such other work as the board can find for them or remain idle if they
prefer to. If they are not high enough the vacancies will remain
unfilled till the board raises them.
“When men are idle, by no fault of their own, but because all
places are filled, the state is bound to feed and clothe them. This is
the theory, but it is very rarely put into practice. Since they prefer to
let them work at something rather than be idle even if the work is
not in great demand.”
“They seem to have but little use for apothecaries and doctors,
how about lawyers and courts?”
“There is no such thing now as the practice of law as formerly
understood. In your day the lawyer was called an officer of the
court. But in reality he was a partizan of one of the litigants bent on
gaining a victory for his client regardless of the justice of his cause;
and he often gained it when he knew it was unjust. Each town or
district is supplied with a board of lawyers three, five or seven
according to population, and these comprise the court. They are
elected by the people from the law graduates of the state school, for
a definite term. Any small case is heard by either one of the lawyers
upon whom both litigants can agree, both sides being heard and
witnesses examined by him. If either litigant is dissatisfied with his
decision he may appeal to the full bench, whose decision by a
majority is final on questions of fact. But if a minority dissents on
points of law a further appeal as to the law is allowed to be made to
the Supreme Court of the state, the dissenting minority preparing
the case for the higher court, and the majority preparing the counter
case in defense of their decision. The defeated party pays the costs.
These, however, are comparatively light, lawyers receiving no higher
pay than mechanics. But as the position brings distinction there are
always enough candidates for it. They are only paid as lawyers for
the actual time spent by them, and often increase their income by
other employment; for there is but a small amount of litigation.
“The criminal procedure is almost as simple. A person accused of
a petty crime is brought before a single lawyer who examines the
witnesses for both sides and decides the case, if the accused is not
satisfied he appeals to the full bench, and the minority of that bench
may carry an appeal on questions of law to the Supreme Court. In
important cases the legal bench may summon the bench of a
neighboring town or district to sit with them in the case and share
the responsibility. There is no criminal class and crime of any sort is
very rare. It is regarded as an insanity and a family in which it is
developed is at once prevented from going further in the hereditary
transmission of it. There is no capital punishment.”
“Well,” said I, “they are an interesting people; they seem to have
things about the way they want them and I reckon they ought to be
happy.”
“Yes,” he said, “they ought to be, and they are; as much so as any
intelligent creatures can be. You may know they are good natured,
jolly and generous from the size of their mouths. The size of their
heads is a guaranty that whatever is knowable on earth they are
pretty sure to find out, if you give them time enough; and renders
probable the inference that they know that they are well off, and
know enough to be contented. And as a matter of fact they are; and
while they congratulate themselves, they never fail to call up in
grateful remembrance the ancestors through whose martyrdom they
have attained peace. Well we must now take our leave of this large
hearted and large headed posterity of yours and return to the
nineteenth century.
“Ah! here we are!”
CHAPTER XIII.
Mars and the Martians.
The Professor at this point turned about, took hold of the wire that
anchored his car and slowly pulled it to the ground. I saw I was
about to lose him, but felt that I ought not to try to detain him any
longer.
I thanked him cordially for the invaluable visit he had given me
and told him I hoped it might be repeated. He nodded his head in
acquiescence, by which I understood, I might expect him some time
again. I went on to congratulate him on the happy home he was
returning to and the long agreeable rest that awaited him there after
this fatiguing journey.
He smiled with his great eyes, and thanked me for my good
wishes, but said he was destined to no such rest as I wished him.
“From the moment I reach home,” said he, “I shall be as busy as I
can be for a week, preparing for my journey to Mars.”
“Your journey to Mars!” I exclaimed, “do you mean to say you go
to Mars?”
“I have been there only three times myself; but our people have
visited that planet for the last ten thousand years, and there is quite
a colony of Lunarians permanently settled there looking after our
interests.”
“So you have interests on Mars! Well now this is interesting. I wish
I had known this before. I would give anything for information about
Mars and the Martians.”
“Well it will take me a little time to arrange my car and I can talk
to you while I am doing it. You see our folks first went there about
10,000 years ago. They found the planet inhabited by two bitterly
hostile races that did little else than hunt each other.”
“They must be like our race then,” I observed.
“Yes,” he said, “in respect to their warlike instincts, but not as to
their forms. They are not human nor even vertebrate, but they are
built on the radiate plan. In short they are almost exactly like your
star fishes, but enormously bigger. I have seen them as large as
twelve feet across, though their more common size at maturity is six
to eight feet. The difference between the two races is that in one
there are six spokes or limbs radiating from the central body and in
the other there are but five. These limbs may be called either legs or
arms, for they serve as either and are sometimes one and
sometimes the other. There is a fleshy disc that forms the extremity
of each limb, around which like the petals of a flower are the fingers
or toes, about like so many thumbs. There are six of these in the six
legged race and five in the five legged. This disc with its thumbs
forms the foot when the individual walks on land. Two of them are
always on the ground when he is standing, while the other four are
free to be used as hands, these thumbs being opposable and able to
grasp tolerably well.
“When they move on land it is always in an upright position, and
they roll along edgewise like a wheel destitute of felloes rolling on
the ends of the spokes. The central piece or hub constitutes the
body including the stomach, heart, lungs etc., as well as the sense
organs, and brain. The shape of the body is like a short stout
cylinder tapering to a rounded point at each end from one and a half
to two feet in diameter, the legs radiating from the sides. At the
center of one end of this body is the mouth, and the brain is located
all round it in what we would call the cheeks. There is no neck.
There are six eyes immediately around the mouth corresponding
with the six legs, and just outside of the eyes are six ear holes with
closable lips, but no outside flaps or shells. Outside of these are six
breathing or blow holes leading into the lungs. The mouth is round
and the lips pucker together when closing. There is no up or down
to the Martian man, he stands equally well on any pair of his legs
and handles equally well with any of his hands, and this is one of his
greatest drawbacks. He has a thick horny skin which appears to
have been the only skeleton possessed by his ancestors, but in
addition, he has a light internal skeleton developed later by the
practice of standing and running on his limbs, which consists of a lot
of plates and hoop like ribs in the body, and what would pass for
thigh and leg bones in each limb. These last are hung with ball and
socket joints both at the articulation with the body and at the elbow
and wrist. The limbs are thus remarkably supple and when the
Martian has a mind to, he can walk extremely well sideways on two
legs, that is, the head or mouth going forward. And this is the way
he should walk as our people long ago pointed out to the Martians.
He can walk on the same two feet continuously edgewise as the
wheel goes, but to do this he must merely drag the rear foot up to
the front one, and then throw the front one forward again, or else
sling them around past each other alternately in an awkward
manner as a cow does, for the reason that they are all on the same
plane. They greatly prefer the rolling motion and roll off on their
spokes with surprising speed, twenty miles an hour being a common
gait on a good road while some of the gigantic twelve footers can if
necessary reel off forty or more.
“They are so extremely fond of traveling off in this manner, that it
is difficult for them to confine their attention to any sedentary
employment. In order to attain a high civilization people must be
settled, and occupy themselves in some definite and constant modes
of employment. We pointed out to them long ago that they could
never have well differentiated arms and hands, unless they set apart
certain of their limbs to be used exclusively as arms, and never allow
the hands thus set apart for handling, to be used as feet.
“They objected, that, to confine themselves to two legs for
walking would reduce their gait to five or six miles an hour. This
would be a great drawback in war, and give their undifferentiated
enemies the advantage over them. This objection no longer has
much weight, since war has entirely ceased among them, the five
legged race having long since been defeated and practically
exterminated, the few that are left being glad to accept the most
obscure positions that will secure them a bare existence.”
“They must have been terrific warriors.”
“I saw a regiment of the six legged men drilling once. They were
marshaled on a large plain in two ranks, and rolled backward and
forward fast or slow according to command with great precision.
They then were commanded to load and advance. Around the body
in the spaces between the limbs they had artificial leathern pouches
in which they carried their ammunition. When they received the
command to load they took out of these pouches six stones one for
each hand, and they advanced with them clasped between their
stumpy fingers. Then they were commanded to double quick and
discharge, upon which they advanced at terrific speed and at a given
signal let fly the stones one after another as the hand containing it
came to the proper position for the most effective throw. The
centrifugal force they acquired from the long revolving arms sent
them with tremendous force, some going at least a mile. In real war
they used cast iron bullets. They have plenty of iron on Mars and our
folks taught them how to smelt and work it. The regiment then
charged up to a hand to hand encounter with an imaginary enemy.
In this charge they were armed with a heavy circular iron disc in
each hand, the disc having a handle on the back side by which it
was held. Then they charged with terrific fury the discs flying around
like lightning, chopping into mince meat, (in imagination) any enemy
that dared stand before them.
“The government is a despotism, the king having about the same
authority as the emperor of Russia, although he has a council of
state whose advice he listens to, and then does as he pleases. Since
the subjugation of the five legged race this king is the supreme ruler
of the whole planet. In some districts the people have made
considerable advances in civilization, confining themselves to the use
of two legs, and walking sidewise instead of rolling edgewise. But
the king does not want all his subjects to adopt these innovations,
for he is very proud of his soldiers and thinks them more efficient on
six legs then two. Besides, for certain kinds of labor, especially
drawing wagons and carriages, the old way is the best.”
“Why don’t they use horses,” I inquired, “or haven’t they any?”
“There are no such animals on Mars, nor in fact any other sort of
animals except radiates. There are many genera of these, mostly
living in the water and all small, except the dominant race, which I
call the Martians.
“But there are great differences in the conditions of life amongst
the people of this race, some being fairly civilized while others are
only beasts of burden, and still others take the place of dumb
machines. They are specially adapted to act as wheels for light
carriages. The axles of the carriage are terminated at each end with
a six pronged fork, the prongs arranged in a circle or cylinder so that
when a man is to play the role of wheel, he is impaled on this fork
one prong of it fitting snugly between each pair of his legs. A vehicle
of this kind is specially adapted for soft roads as the broad disc like
feet prevent sinking.
“The king has a phaeton mounted on twelve foot specimens of
these lively wheels, in which he dashes around at a thirty or forty
mile gait when the fancy strikes him. He also has a royal barge
propelled by the same sort of wheels, the legs acting as paddles.
“The king is imitated in his fads by the nobility and gentry as far
as they are able, and so one may quite often see these live wheel
phaetons, and live-paddle boats moving about.
“On the public roads, vehicles are used having wheels such as you
use, and drawn by these creatures, yoked together in pairs by the
pronged shafts or axles like those I just described. From 5 to 10
pairs may sometimes be seen tugging at one of these heavy freight
wagons. They are tremendously strong and their strength counts for
vastly more on the planet Mars than it would on the earth, because
Mars being so much smaller everything weighs very much less. I
have seen some of those big fellows after rolling a few hundred
yards with great speed give a leap from the ground and fly whirling
through the air for two hundred feet before they lit.”
“They are a wonderful race,” said I, “but it seems difficult to
connect intelligence with a tribe of star fishes or to imagine they
could ever become highly developed. You know those we have on
earth are very low in the scale of existence.”
“Intelligence,” said the Professor, “does not depend on the form.
Any form on which it is possible for the forces of the environment
such as light heat contact etc., to make an impression, already has
intelligence; the ability to be impressed is intelligence. If any
organism can be impressed, then if you give it time enough it can be
impressed indefinitely, because each impression differentiates it and
adds to its sensitiveness, that is, its ability to be further impressed.
The reason why inferior races so generally remain inferior is the
jealousy and hostility of the superior. The dominant race is always
hostile to any other race that shows any intelligence, and proceeds
to kill it off for fear it will become a rival. It is thus that the race of
man has no rivals that compare with him in intelligence, no
“connecting links” between him and the monkeys. He was jealous of
them and exterminated them.
“On the planet Mars there were never any forms of animal
superior to the stars so they have received all the development.
Their differentiation would have advanced further if the planet itself
had not been so backward. It has a great deal more water on it in
proportion to its size than the earth. It is destitute of high
mountains, and very much of its surface is but little raised above the
level of the sea. A great deal of it is marshy. It is only in recent
geologic times that it has become well suited to life on land. When it
became so, the star fishes crawled out, and by degrees became
accustomed to that mode of life as well as their aquatic mode. If
there had been any land animals there to attack them when they
first ventured to leave the water, of course they would have been
prevented from ever rising. But there were no enemies and they
gradually developed lungs by which they were enabled to live
continuously out of water. At first they crawled about like spiders
with all their feet on the ground at once, but after awhile they
learned to raise themselves up on edge and finally to roll from one
foot to another, and so gradually adopted a new and wonderfully
advanced mode of locomotion.
“They are still semiaquatic and amphibious, and they have both
lungs and gills. They do not bring forth their young alive, but the
female lays eggs in the water, the wealthy families having little tanks
kept at a proper temperature. The females of the poor and rougher
classes simply go to the nearest pond and deposit their eggs and
leave them to their fate. Nine times out of ten, however, the warmth
of the water is sufficient to hatch out the tiny stars which swim
around in the water without any care or bother to their parents.
They then use only their gills for breathing, but in a few weeks their
lungs are developed enough to permit them to crawl out on land and
remain awhile. They do this daily and finally are able to remain out
continuously. Some of the lowest classes, the savages as the are
called, never lose their gills, but continue to be amphibious all their
lives. They spend their days on shore and mingle with the rest, but
at night retire to the water in which they sleep and eat, feeding
upon a tender and nutritious grass that grows in the water and in
marshy places. This grass also constitutes a considerable part of the
food of the better classes, but they generally cook it. In winter time
these savages burrow in the mud at the bottom of the ponds and
marshes and canals and go into a sort of torpid condition and
remain there till spring. The more advanced classes cannot do this,
they remain out of the water continuously after they are fairly
weaned from it, and lose the use of their gills so that they cannot
breathe under water at all. So there is almost as much difference
between different varieties of these strange people so far as
civilization is concerned as between men and some of their domestic
animals.”
“Professor,” said I, “a moment ago you mentioned the canals. Our
astronomers have seen these and puzzled themselves greatly in
regard to them, now you can tell me all about them I am sure.”
“Yes, I intended to tell you about them, I understand their history
well. That’s where we sunk our money, or at least a great part of it.”
“What, in the canals?”
“Yes—that is, in their construction.”
“Do you mean that the Lunarians went and dug those canals on
Mars?”
“I will explain. As I said awhile ago when our folks first visited
Mars the people were in a very barbarous state, but still seemed to
have some idea of bettering their condition. They were much
impressed by the superiority of the Lunarians and were anxious to
get their advice as to the best way of improving their own situation.
The inhabitants then all lived along the shores of the seas while the
interior of the continents were uninhabited and for the most part
unexplored. The Lunarians by the help of their wings and their
repulsio-gravitation cars were in a position to make the exploration
and in a short time gained a general knowledge of the topography of
the planet. They found high land over both the poles, but all the
middle parts are low. There were numerous ponds and lakes of fresh
water, with marshy outlets to the seas, which are very salty. There
were no rivers except a few small ones in the high lands. As the
Martians were amphibious and had always been accustomed to salt
water, the Lunarians doubted whether they could live in the interior
where the water was fresh. But they saw that it would be necessary
to scatter the people away from the sea shore, divert their thoughts
from war by finding peaceful occupations for them, and to create
artificial wants for them since their very few natural wants were all
bountifully supplied with little or no effort on their part. The climate
of Mars is much like that of the temperate parts of the earth, but its
polar regions are never so cold nor its equatorial regions so hot.
“In summer time these people had no use for clothes, for it was
warm enough without them. In winter they had always gone into
winter quarters under water remaining in a torpid inactive condition
till spring. When they found the Lunarians never did so, they were
anxious to imitate them. But they could not stand the cold without
clothes and houses artificially heated. So some rude clothing was
made of grass, and some huts built under instructions from the
Lunarians and the king and some of the better classes undertook to
keep alive, as they called it, all winter. They were quick to perceive
that they could thus add much time to their lives, for the winters of
Mars last some 300 days out of the 687 that constitute his year. At
first it was hard to work into the new way, but after one or two
generations had been kept from hibernating from childhood, it came
to be a second nature to their descendants, and now all the better
classes have outgrown it, only the savages, who are merely beasts
of burden continue to go into the torpid state and not all of these.
This change of nature in these people, made it essential to have
houses and clothes and also to secure food to be kept through the
winter thus creating the wants that would compel the people to
employ their muscles and brains, and so insure their cultivation and
development. The chief food of the people consisted of the grass I
have mentioned which grows only in water and at that time only in
salt water. It grows in thick pulpy stems and is very rich in sugar oil
and gelatine. This vegetable product was obtainable only along the
sea shore in shallow water and in salt-water marshes formed by the
sea. The new way of life demanded at least one half more food than
the old for each person, and it also led to a rapid increase in the
population. These causes made it essential to devise some way of
increasing the production of food, the most obvious way being the
increase of the area of shallow salt water. This the king undertook to
do, but made small progress, for neither he nor his council knew
anything about engineering, or the management of such works.
“The Lunarians who had been observing matters and things, and
studying the situation very closely and shrewdly, now came forward
with a proposition for a very comprehensive scheme of public works
—or rather several schemes in one.”
CHAPTER XIV.
The Canals.
“First was a plan for increasing the salt water area by means of a
system of broad channels or canals reaching inland from the oceans
with a view of extending them from ocean to ocean as soon as
practicable so as to enable the tidal currents to flow entirely
through, thus insuring sea water in the very interior. It was proposed
to make these narrow at first, but to widen them as the population
increased and greater area became necessary for cultivation. After
the main canals should have become well advanced it was designed
to build branches and intersecting lines in such directions as might
be deemed most advantageous.
“The Lunarians proposed to the king to have this work done by a
great stock company, one-half the stock to be owned by the king
and the other half by them. They were to make the surveys and
direct the work and handle the funds of the corporation making use
of their mechanical and executive ability and great experience in
finance and engineering. The government was to pay a bonus to this
company of 100 kiks[4] per acre for every acre made available for
cultivation. The capital stock was fixed at 200 kiks per acre to be
issued to the stockholders as fast as the work was completed, the
king to receive 100 kiks as his share and the Lunarians the other
100. As fast as the canals were completed they were to be turned
over to the state and become its property, and in payment for this
the state was to guarantee an annual dividend or interest of five per
cent on that portion of the capital stock owned by the Lunarians.
The king was not well informed on financial matters and inquired the
meaning of five per cent interest, and was told that it meant the
payment of half a kik to the owner of every ten kiks of stock which
such owner was to receive in lieu of all other profits and reward for
his labor and investment and which he the king as the head of the
government was to guarantee. The king was satisfied to do this—
more than satisfied in fact.
“He said: “Gentlemen, I am a great King! what care I for half a
kik.” Then with a prodigal wave of all his disengaged limbs he
exclaimed “make it a whole kik.”
“But our Lunarians were not to be outdone in liberality by the
king, and while admitting that five per cent was ridiculously small,
modestly declined to take any more. The king then inquired why
they did not include his stock in the proposed guaranty. “Why should
not I be guaranteed as well as you?” To this they replied that they
purposely left his out because, first, he was himself the government,
and so he would simply be guaranteeing himself; in the second
place, if his stock were not named in this guarantee he need not be
confined to 5 per cent, but could as well take 10 or 20. The king
having been satisfied on this point they cautiously unfolded their
next proposition which was that they should have security in the
shape of a mortgage for the payment of the 5 per cent interest, and
that in case of default on the payment of said interest it should
become a lien against the state and thence forward be entitled to
draw interest the same as the original stock. “O king,” said they, “we
sincerely wish you might live forever. If we were sure you would we
would never think of asking security. But Martians and Lunarians all
die when their time comes, while this great corporation will be
immortal. Some time in the future a king may arise who, while
enjoying the blessings and comforts of civilization will forget what,
they were due to and will refuse to carry out Your Majesty’s contract,
about paying this interest.”
“Well,” said the King, “what security do you want?”
“They said they would be contented with a mortgage covering
Faithless Jack and Blind Lucy, and the two frigid zones of Mars.”
I may say here that the frigid zones of Mars cover the polar ends
of the planet and extend 28°. 42´ from the poles. I understood this
much, but did not know who were meant by Faithless Jack and Blind
Lucy. The Professor proceeded to explain.
“Mars as you know has two funny little moons. Your Astronomers
have named them Deimos and Phobos. But the Martians call them
by names that are equivalent to Faithless Jack and Blind Lucy. These
names belong to an ancient mythical legend, which I will relate to
you. In very ancient times there were a pair of lovers named Jack
and Lucy. Lucy was reputed to be the most beautiful lady that ever
walked on six feet. Her six eyes were quite unique, being alternately
red and yellow—three of each color. She was over eight feet high
when she stood up and was noted for the grace and dignity of her
manners, and the captivating way in which she walked, her feet
coming down one after another in perfect time and with a rhythmic
pit-a-pat pit-a-pat almost inaudible from the softness of her tread,
but which was nothing less than inspired music. Her disposition was
as charming as her person. She had a kind word for every one, and
was always doing some one a favor.
“Jack on the other hand was exceedingly ill favored. It could not
be said exactly that he was the ugliest or the most disagreeable
young gentleman in the community, but a great many were his
superiors in every way, and how it happened that Lucy fell in love
with him could never be accounted for, but she did, to an excessive
degree. To look at the Martians you might not suspect them of being
very sentimental or affectionate, but they are, and their form in a
manner compels them to be demonstrative. When a couple walk
together they cannot lock arms or take hold of each other’s hands as
you do, since their limbs are all employed in walking. But if they are
friends they hold on to each others cheeks with their lips, which
have a suctorial force like an air pump and which would raise a
blister on a skin less tough than the integument of a Martian. When
lovers walk out with each other they apply their lips together in an
affectionate kiss of most uncommon adhesiveness. Jack and Lucy
they say could have been seen any day walking about glued
together in that manner. As this was common it was considered
proper, but under the circumstances was not altogether prudent, for
it roused the jealousy of Jack’s rivals to an almost murderous pitch.
Jack was not so tall as Lucy by a foot, being only a little over seven
feet high. This brought his mouth six inches lower than hers, and
made it necessary for him to elevate himself on his toes (or fingers)
as much as possible, and even then Lucy had to meet him half way
by bending the limbs that happened to support her at the moment in
a manner that detracted considerably from her natural grace. Some
of the disappointed lovers attempted to relieve their chagrin by
speaking of Jack contemptuously as “Tiptoes” and making ungallant
remarks about Lucy. But this was small comfort to them, while the
loving pair were so much devoted to each other as to be quite
heedless of the angry and jealous comment they were causing.
“At last Jack’s rivals entered into a conspiracy to “do him up.” They
would beat and tar and feather him at the very least and if he
provoked them by resistance they would do worse. So they planned,
and one summer evening when Jack and Lucy were taking their
usual loving promenade, these disappointed suitors took after them.
But the lovers stimulated by a panic of sudden terror made a
miraculous race and distanced their pursuers. The latter declared
that the lovers did not run at all in fact, but glided along in some
miraculous way not touching the ground, but gradually rising and
sailing off getting constantly higher and higher, they at last
disappeared behind a cloud. And they all declared that there could
not be the least doubt that they had been translated to the sky to
associate with the innumerable stars that had gone before them.
There was nothing at all incredible in this to the Martian people,
because it was a cardinal principle of their religion that their great
heroes in ancient times had all been transferred from Mars to the
sky. The proof was patent to anybody that had eyes, for there they
were to be seen without any change of form, some with six radiating
limbs and some with five. And these two hostile races carried their
resentments to heaven with them and often engaged in direful
warfare, hurling at each other thunderbolts, meteors and aerolites as
might be seen almost daily or nightly. The celestial history of the
lovers is tragic. They no longer had to walk, because there being
nothing much to walk on, the celestial mode of locomotion is a
delicious glide, consequently they were able occasionally to give
their lips a rest, and hand in hand to quietly slip along with the
glittering crowd thinking of nothing whatever unless it were of each
other. But this happiness at last came to a sad ending. They were
sauntering along as thoughtless and careless as children, when
suddenly and without the least warning, an immense aerolite came
dashing through the sky and before Lucy even perceived it, it
crashed into her face knocking out every one of her pretty eyes,
smashing her lips and disfiguring her in the most terrible manner. In
the confusion she was separated from her companion, and when she
sought him, distracted by pain and blindness she took the wrong
track, and from that day to this she skurries across the sky in the
most feverish haste, rising in the west sailing overhead and setting
in the east from two to three times a day, while all the other stars
including the sun, and Jack with the rest, rise in the east and set in
the west. As for Jack, when he found how changed and hideous she
had become—his love turned to aversion. When she sought him, he
avoided her, and passed by far on the other side. And now, although
they pass each other every few hours he always looks the other way
and she, poor thing, cannot see him. “There used to be a serious
dispute among the Martians as to the particular sort of star that
threw that rock. One sect of theologians stoutly maintained that it
was hurled with malicious intent by a malignant five legged star, and
struck the fair mark it was aimed at with terrible precision. Another
sect held that it was only an accident; the missile was probably fired
by a friendly six pointer, missed its mark and unfortunately struck
where it was not intended to. As there was not a particle of proof for
either side, affirmations and assertions took the place of argument,
and were dogmatically made and maintained with no little acrimony
on both sides. But they all agreed in rendering divine honors to Lucy
with their sympathies and condolences: Poor Lucy! Perfidious Jack!
“When the King learned what the Lunarians wanted him to give
them a mortgage on, he laughed heartily and thought it a good joke.
He could hardly be made to believe they were in earnest. “As for the
poles if there is anything there except snow and rocks,” said he,
“whoever gets them will earn them, I warrant you.
“As for the moons, I shall never undertake to deliver them in case
you foreclose on them, and your mortgage must distinctly state that
you are to take them running.”
“The King thought the idea of mortgaging his moons was
peculiarly comical; and after the deal was consummated and the
papers all signed, he would sometimes stand on the door step and
call out to Lucy as she rushed along overhead with the speed of a
cannon ball, and ask her how she felt to be mortgaged. In addition
to the scheme for the construction of the canals, the Lunarians
asked and easily obtained a charter or concession from the king for
an easement or right of way twenty miles wide, ten miles on each
side of the equator, and reaching entirely around the planet, for the
purpose of one or more lines of telegraph and cables for the
conveyance of electrical power and for railroads etc. This region was
entirely uninhabited, and not suited for the occupation of Martians,
but the Lunarians said they would have use for it in the course of
time and wished to have it understood so they could know what to
depend on.
“All the preliminary negotiations being at last concluded, and the
contracts signed, they went to work with a will. The bonus or
subsidy of 100 kiks per acre was raised by taxation, those who had
no money being compelled to work out their tax on the canal. The
route selected for the first line was across a low swampy country.
The work was light and much of it in the water where the Martians
were at home. The Lunarians had flat boats constructed on which
the excavated muck and earth were loaded and floated to the deep
places which they partially filled up or deposited on the dry land.
The canal was made 200 feet wide at first, one-half of which was
kept entirely clear, while the other half was planted to the sea-weed.
“It took several years to finish the first line, and as soon as it was
done they commenced the work of widening it, adding a strip 200
feet in width, which when completed made the canal 400 feet wide.
This process was then repeated and has been going on constantly
not only in the first canals but in all subsequent ones of which there
is an immense number. As much material was carried to the banks
and deposited there in the construction of each strip, a good deal
had to be moved more than once. When this accumulation became
too great to be profitably moved it was skipped and the next channel
constructed parallel with the main canal, but separated from it by
the strip of solid land on which this waste earth was piled from a few
rods to a quarter of a mile in width. On these strips are located the
villages of the working people that cultivate the sea weed, work on
the canal and are engaged in navigation etc.
“The total width of some of these canals is now as much as sixty
miles, but they generally consist in reality of numerous wide
channels separated by narrow strips of land. This plan of canal
making has been steadily adhered to for several thousand years.
Lines parallel to each other and several hundred miles apart have
been constructed, and many others connecting with these and
intersecting them at various angles. These canals not only constitute
the principal fields for the cultivation of their staple food, but also
furnish what was for a long time their best and chief mode of
transportation. Their chief commercial and manufacturing cities
sprung up at the intersections of the canals.
“The building of these canals had a wonderfully stimulating effect
on the development of the Martian people. The population promptly
increased in proportion to the increase of the means for its support
as it always does, on all planets. With the increase of population
came diversity of employment, new ideas, tastes, and wants, new
inventions, more culture and refinement.”
“How did the Lunarians come out on their contract?” I asked.
“They must have made a lot of money I reckon.”
“I was just coming to that,” said he. “Yes they made lots of money
if they could only have got it, but that was the rub. For a few years
while the amount of the acreage of the canals was small, it was
comparatively easy to raise and pay over the five per cent due the
Lunarians, but by the time the first great canal was completed
through at a width of 200 feet, their interest amounted to 375,000
kiks per annum. By this time the king had discovered a good many
new uses for money, and it went very much against the grain to pay
over this interest. He began to think the Lunarians were going to be
rather too well paid for the services and “investment,” they had
talked about; and he congratulated himself that they had not availed
themselves of his effusive offer, of ten per cent instead of five.
However while he grumbled, he paid; and continued to do so as long
as he lived, although towards the last the interest amounted to the
very handsome sum of 1,000,000 kiks per annum. But that is all,
after the death of that king who is yet affectionately referred to by
the Martians as the “father of the canals,” the Lunarians for 7,000
years never got a kik. However, what they had already received was
enough to make every member of the colony many times a
millionaire if they had divided it amongst them. But this they did not
do. The Lunarians are socialists and they regarded this money as
belonging to the whole Lunarian race, to those at home on the moon
as much as to themselves. They invested it to the best advantage in
various enterprises, consuming on themselves only what their simple
and modest personal wants required. The bonus or subsidy of 100
kiks per acre generally paid the entire cost of construction and the
Lunarians had their interest money. At the death of the king there
was one year’s interest due amounting to 1,000,000 kiks. The
successor to the throne was not satisfied with the contract to pay a
dividend on the stock the Lunarians held in the canals, and in fact
repudiated it all except the 1,000,000 kiks then due which he said he
would pay when he got around to it. But he never did, and the claim
continued to draw interest which was computed and audited at the
beginning of each subsequent reign, but always put off for some
reason or other and not paid.”
“Why didn’t they foreclose their mortgage?” I asked.
“Well they did not want to do that until they were ready to
improve the property so as to make it earn something. They
reasoned that the canal claim, as it was called, was making money
at a tremendous rate. The interest on it 2,000 years ago or, over
6,000 years after the work on the canals was commenced,
amounted to thousands of millions of kiks every minute, and they
had not been able to devise any plan by which they could make any
satisfactory use of the mortgaged property; and so they let the
money remain in the canal fund.”
“But,” said I, “suppose it was earning so many millions of kiks, I
don’t see what good it did them if they never got it.”
“Why you see,” he replied, “they got out of it in that shape, all
they could have got if the money had been in their hands. And it
was safe. It could not be stolen and nobody would be tempted to
assassinate the owners in order to get it. When people have such
enormous fortunes they can come into personal contact with only a
small portion of them. An individual owning many millions can only
use on himself a few hundreds or thousands, and the rest of it buys
him nothing but the respect homage, consideration, obsequiousness
and sycophancy of the crowd. For all this he does not have to pay a
cent, but must own or be supposed to own millions. The funds which
our Lunarians owned in canal stock made them the lions of Mars.
Their personal abilities, accomplishments and graces would have
done that anyway, with a certain class, but the addition of all that
wealth gave them an influence and consideration amongst the mass
of people who had no great appreciation of any other sort of merit.
“All sorts of odd stories concerning the wealthy foreigners found
circulation amongst the masses. Once it was reported that if the
canal funds were not paid before the next Christmas, the Lunarians
intended to fill up all the canals again. It was well known for ages
that there was not enough money on Mars to pay the canal debt, or
even its accumulation for one year. Not very long ago it became
reported that the Lunarians had sold their claims to capitalists on the
earth, and that the latter were going to get out an attachment for
Mars, bid it off at sheriff’s sale and take it for another moon to the
earth. The story even settled the route it was to run on—half way
between the earth and the moon.”
“That was a likely tale indeed!” said I. “They didn’t know our
capitalists very well or they wouldn’t have imagined them going into
a scheme that did not promise to pay pretty big.”
“O, but it was to pay well as they had it planned. First the
speculators were to sell short for future delivery all the gas and
standard oil stocks in the world: then they were to bargain with the
various great cities to furnish additional moonlight at so much for
each added moon power, measured by our moon. They calculated
that Mars placed 120,000 miles from the earth would reflect upon
the earth 16 times as much light as the moon does. This would
make the night about as bright as day. This would reduce the value
of oil and gas stocks almost to nothing and the speculators would
then buy them up for delivery on their sale contracts and make an
enormous sum. The most of the Martians were keen for the
enterprise to be consummated. They said that they would gain more
than the earth by the change, for both the earth and moon would
act as moons for Mars, and he would get four times as much light
from the earth as he would give it. He would also get far more light
and heat from the sun than he did where he was. When it was
announced that the story was a hoax many people were actually
disappointed. Others said they were glad to have escaped the
disgrace of being sold out at a bankrupt sale and degraded from a
full fledged planet to a mere satellite to be towed off to play second
fiddle to another world.”
“But how did they think Mars was to moved over to the earth?”
“O they supposed the Lunarians were going to see to that part of
it. They had got the idea the Lunarians could do anything.”
“But could they have accomplished such an undertaking as that?”
“That question was never settled; but they would not have done it
if they could. The Lunarians always felt very much mortified that the
moon is only a satellite and not a full planet. They have got some
little satisfaction, however, in the great amount of attention, the
moon has always received from the people of the earth. In old times
in fact the earthlings used to pay divine honors to our globe, as well
they might. But if Mars were to become a satellite of the earth it is
easy to see he would monopolize all the attention that has
heretofore been lavished on us. We wouldn’t like that. No it looks as
if you may depend upon it, the Lunarians would never lend
themselves to a scheme like that. But a hoax like that has wonderful
vitality.
“A little over a thousand years ago the Lunarians began to think of
foreclosing their mortgage. They had the polar regions of Mars
quietly explored, and were agreeably surprised to find large deposits
of coal, iron, gold, silver, tin, copper and many other metals and
valuable minerals. They were already posted as to the nature of the
little moons Jack-Deimos and Lucy-Phobos. It was a difficult and
perilous task to effect a landing on them, but after much effort it
was accomplished. It was found that Jack Deimos, which by the way
is about seven miles in diameter and twenty-two in circumference—
you could ride clear around it on a bicycle in four hours—is about
one-half iron, the rest rock containing gold, silver, lead and tin.
Deimos always has the same side turned toward Mars, and on the
opposite side is a lake about a mile in diameter and frozen solid to
the bottom, which melts down a few inches every day and freezes
up again at night. There is a little thin air, that does not extend more
than one or two hundred yards high. The mass of this little moon is
so small that its attraction for anything on it is very slight. An
ordinary man weighs less than an ounce. He is considerably lighter
on the side toward Mars than he is on the opposite side. One might
stand on that side and shoot an arrow toward Mars, and it would not
return to him, but continue its flight till it reached the planet.
“There is in several places quite a growth of a hardy plant
something like an alga, although the temperature on the shady side
is 40° below 0. It is hot on the sunny side. The difficulty of getting
on this little moon is due to its small attractive power. When we
approach a large body, such as the Moon or Mars its attraction draws
us after it and gradually brings us to its surface. But Deimos attracts
with so little force that we have to get up speed and force from
some other body and so run alongside and catch him. He flies
around his orbit at the astonishing speed of 3,610½ miles an hour
or more than 50 miles a minute. In order to get up such a speed as
that our folks had to go off a million miles from Mars in a direction
opposite to the sun and then allow themselves to fall toward Mars
until they were near the orbit of Deimos; then they turned on
repulsion which sheered them off and caused them to describe an
orbit around Mars in the same direction as that of Deimos. Deimos
passed them several times before they could get into his attraction
close enough to be pulled in by him.
“They afterwards boarded Lucy-Phobos in the same way. Her
attraction is a little stronger than Jack’s as she is over eight miles in
diameter. But her speed is still more terrific than his as she goes at
the rate of 4,777 miles an hour or more than 79.2 miles a minute.
She, too, always presents the same face to Mars.
“Having made up their minds how they would improve the
property when they got it, they informed the King that they desired
to foreclose the mortgage. He made no defense and instructed the
authorities to throw no obstacles in the way. The foreclosure was
advertised in the usual way and when the day of sale arrived there
was the usual crowd of loafers, but no bidders except the Lunarians.
They bid three million kiks for the whole outfit—one million each for
the two frigid zones and one million for the two satellites, and the
property was of course knocked down to them, considering the
importance of the sale it was a quiet, tame affair.—The King was not
a little displeased when he found they had bid in the property for
less than the billion, billion, billionth part of their claim, thus leaving
the debt practically unreduced. He supposed they would bid the face
of their claim and thus wipe out the debt. Still, however, he made no
attempt at redemption; in fact nobody would have given any more
for the property than was bid. The title was confirmed to them by
the court and they entered into possession.”
CHAPTER XV.
The Great Debt.
“The King began to be much concerned in regard to the great

debt. He called his bankers together and had them compute it down
to date. Then after brooding over the matter for some days he called
his council and the Lunarian claimants together and made them a
speech. He declared he was sick and tired of “paying interest.” True,
he had never paid any, but it constantly added to the already most
appalling debt to be found in the solar system. “In fact it is so great
(said he) that we have no single words to express it. It is written by
setting down 20 and then annexing to that a string of 153 ciphers.
The original debt left by my illustrious ancestor the father of the
canals was 1,000,000 kiks, at least that is all his successor assumed,
and it is that insignificant sum that has grown to such overwhelming
proportions.
“Take 20,000,000 septillions of kiks and multiply by 1,000,000
sextillions; multiply this product by 1,000,000 of quintillions and this
by 1,000,000 quadrillions; this by 1,000,000 millions; and finally
multiply this by 1,000,000. Now from this inconceivably great sum
subtract one kik. That kik is the principal; all the rest is interest.
As the whole principal was 1,000,000 kiks, our whole debt is
1,000,000 times the above sum.[5] I have for several days been
endeavoring to master the financial principle applicable to this case.
Our Lunarian professors have told us that the normal advance of
natural modes of motion is by undulation, or the progressive rising
and falling of one wave after another, as in the ocean, the
movement of heat and light, the ebbing and flowing of the tides etc.
I have observed that the same law holds in the accumulation of
wealth. It undulates. It is lively awhile, then dull. Business men
accumulate a pile, then lose it. It is the same with money engaged
in business, it sometimes gains, sometimes loses. A man may drink
twenty hogsheads of wine, but he cannot accumulate that much
inside of him at once.
“It may be possible for one little kik in the course of 7,000 years to
earn on Mars all the wealth both real and personal that there is on
all the planets in the solar system and much more besides. At any
rate it has done it on paper according to the figures and the claim of
our Lunarian friends, but evidently it could only be done by its
dropping a lot of it occasionally and earning it over again. So the
undulatory movement applies here as a physical necessity. But the
papers in this case so far, represent only the swelling of the wave
without the complementary sinking that completes an undulation,
and makes its continued movement a physical possibility. These
papers relate only to the ascending or crescendo half of the wave,
but fail to provide for the diminuendo side of it. This wave has been
swelling for 7,000 years. It is high time it had reached its culmination
or greatest amplitude and I think it has. Seven is a mystic number
and in this case evidently marks that epoch. Time alone was
competent to enable a little kik to pile up such an accumulation of
debt against us, and what time has done, time can undo.
“I propose now to issue a diminuendo bond that will in the course
of 7,000 years reduce this debt back to the level it started from.
Instead of bearing interest, this bond will bear discount. This
discount the first year will be precisely what the interest was the
last, and each year in the descending future the bond will be
reduced to the same amount to which it was increased in the year
as far in the past as it is in the future counting from the date of the
bond. So that 1,000 years hence the amount of it will be the same
that it was 1,000 years ago and so on. Coupons shall be attached,
representing the amount of the discount each year which the holders
of the bonds shall detach and present to the treasurer to be
cancelled. Thus the debt will be reduced every year and it will cost
nobody a kik.
“At the end of 7,000 years all the accumulation of interest will
have been dissipated and only the principal will be left. This if not
paid then will begin to draw interest again, because by the
undulatory theory, the wave having reached its lowest ebb must
thereafter rise.”
“This was the substance of the king’s speech, and it was highly
applauded by the whole assembly, except the Lunarians. They said it
looked to them like repudiation, and they told the king they feared it
would hurt his credit not only in the Moon, but on the Earth, and
Venus, Juno, Pallas, Ceres, Vesta and all the rest. The King replied
that he would be sorry to do anything that would impair his credit in
the other planets and for that reason would not on any account
repudiate. That was why he gave this bond. If he intended to
repudiate he would not need to give any bond. By this arrangement
they would get their million kiks in the course of time—would no
doubt have got them long ago—if that load of interest had not been
piled on top of them. The object of this bond was to remove this
interest. According to the undulatory theory of finance that he had
just announced, the total amount of loss of money employed in
business exactly equals the total amount of gain, since money does
not change in amount by being used. But in particular cases there
may be net gains at the expense of loss somewhere else. And he
said that the shrewdness of the Lunarians would have insured to
them a measure of net gain; but by no possibility could it have
amounted to many times itself even in the course of ages. “It is
labor, not money, that creates wealth. If you bury 100 kiks in the
ground and after a year dig them up you will not find that they have
increased to 105.”
“This talk of the king convinced the Lunarians that he did not
intend to pay the interest on their claim and as they could not afford
to quarrel with him, they proposed a compromise, and it was finally
settled that they should receive 1,000,000 kiks in addition to the
property they had taken on the foreclosure, and a bond for ten
million kiks to be paid at the option of the government without
interest or security. They did not regard this bond as very valuable,
and as a matter of fact it has not been paid off to this day, but still
constitutes a “claim.” After all, however, they did well enough
notwithstanding their astounding loss.
“They were now recognized as men who through no fault of their
own had sunk the most stupendous sum of money ever known to
exist in one fund, and this circumstance gave them as much
notoriety and almost as much influence and importance, as if they
still had to their credit the sum of
20,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,
000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,00
0,000,000,000,000,000,000,000,000,000,000,000,000,000,000,000,0
00,000,000,000,000 kiks.”
Deimos and the Great Cable.

These financial questions being settled the Lunarians went to work
to improve their new property. They commenced work on the south
polar region, opening extensive mines of coal and iron and starting
furnaces and rolling mills. It soon became known what they were up
to, which proved to be nothing less than the capture of Jack-Deimos
and setting him to work. The first thing to do was to construct a
cable long enough to reach from the pole of Mars to Deimos. Deimos
is 14,547 miles from the center of Mars and a little further from the
pole viz 14,690 miles. The cable was made about 25 miles longer
than that. It was composed of a vast number of strands of
tremendously tough steel wire and put together in the most
marvelous way, for they were in small bundles insulated from each
other as to the attraction of gravitation and also insulated by
sections of their length. By this construction a part of the strands
might be made to be subject to the attraction of gravitation, others
alongside of them to repulsion, also a strand might be made subject
to attraction in one part while in another it could be subject to
repulsion, and these conditions could be reversed, or all the parts
could be caused to be in the same state. The effect of this was very
remarkable. When the cable was completed it was stretched out a
section of one to two hundred miles at a time, and tested, an
alternating electrical battery being used to alter the gravitational
conditions. By proper manipulation, the cable could be made to rise
bodily from the ground, or it could be made to rise by sections, one
section on the ground and another humped up like the back of an
angry cat, or when lying down straight it could be made to roll over,
by causing one side to be attractive and the other repelling.
“This cable was eight inches in diameter. The lower end was
doubled on itself to form an eye five feet in diameter. The other end
for 25 miles was left free, the wires all being separate and loose with
balls of iron attached to their ends. When this end of the cable was
tested, a considerable section, by being subjected to repulsion, rose
from the ground and assumed a perpendicular position, the loose
ends of the wire parting and repelling each other like the hairs on
the head of an electrified person. This was what was required and
the test was pronounced a perfect success.
“Over the south pole of Mars is a mountain some 8,000 feet above
the sea level. They found the exact pole not far from the highest
part of this mountain which was a lucky circumstance. Here they
planted a great steel shaft deep in the hard rock, its end sticking up
so as to receive the eye of the cable. A good deal of grading and
leveling off of obstructions that stood up above the proposed sweep
of the cable, had to be removed. But the largest part of the work
was the construction of the circular railway. This railway was built in
a circle around the pole and 285 miles distant from it. The diameter
of this circle was 570 and the length of the road was 1,791 miles.
There were two purposes to be served by this road. A person
standing at the pole of Mars cannot see Deimos on account of the
bulge or convex surface of the globe. And it is only when he gets
285 miles from the pole that he can look over the bulge and see the
little moon. So a rope drawn taut from Deimos to the pole of the
planet, would drag on the ground for the 285 miles next the pole,
but outside of the 285 miles the line would gradually leave the
ground. A large heavy car was made to travel on the railroad to hold
up the cable as it swept around. Attached to this car there was to be

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Table 2.1 PARDS definition

Table 2.2 At risk of PARDS definition

specified; in the Berlin definition ARDS onset Radiographic Findings in PARDS

The Berlin definition for ARDS accounts for dif-

 alidation of the PALICC Guidelines

“The King began to be much concerned in regard to the great

Deimos and the Great Cable.

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