NEONATOLOGY ON THE WEB

Premature and Congenitally Diseased Infants

by Julius H. Hess, M.D.

Part IV
The Outlook for Prematures
Chapter XIX
Prognosis

In estimating the outlook for an infant born before the natural termination of the normal period of pregnancy, one must consider the prenatal and the postnatal factors before arriving at a conclusion. Of prenatal influences the most important is: (1) The absolute age; (2) the physiological development and absence of constitutional anomalies; (3) transmitted parental conditions; (4) the presence of malformations. Of postnatal conditions the occurrence of any of the various diseases of the new born affects the prognosis unfavorably as a rule while the temperature and general behavior are of the utmost value in judging of its chances for life. In addition to these, the time at which the infant is received for treatment, and the character of the treatment it receives, go far in determining the probable outcome. While all factors must be taken into consideration, yet those of the most practical value relate to the child's behavior. Ability to nurse and swallow, coupled with strong muscular movements and a good cry, are the principal indications that the infant possesses a fair degree of vitality and resistance to disease, and that with proper care and nourishment it stands an excellent chance of resisting the enemies which threaten its existence during the first few weeks of its career, namely, cold and infection. At first doubtful, the prognosis becomes better as time passes in proportion to the care the child receives with respect to its hygiene and feeding. The secret of success in raising the premature lies in avoiding cold and infection, and in the proper selection of food as regards quality, quantity and method of administration.

There is not the slightest doubt but that the premature infant born of healthy parents, who is without congenital deformity and who survives the first few days of life, is entirely capable of complete and perfect development. The various factors that affect the outlook may be considered in detail.

Age. -- The prognosis of the premature infant depends in the first place chiefly upon the actual (fetal) age, or in other words upon the length of time it has remained within the uterine nest (Pfaundler); the infant born before the twenty-seventh week of pregnancy having but a slight chance of living. Other things being equal, those who are not too young can be raised.

The influence of the age on the mortality is well shown by the figures of Potel:

Age	No. of children	Number dying	Per cent.
6 1/2 fetal months	56	45	80.4
7 fetal months	131	76	58.1
7 1/2 fetal months	53	17	30.1
8 fetal months	110	39	35.5

Sherman quotes the figures of several observers and includes those of his own experience in the Children's Hospital, Buffalo:

Incubator. Saved at:	Tarnier Per cent.	Charles Per cent.	Sloane Hospital Per cent.	Gilbert Per cent.	Sherman Per cent.	Cook Per cent.
6 months	30	10	--	20	0	17
6 1/2 months	--	20	66	--	--	20
7 months	63	40	71	35	50	50
7 1/2 months	--	75	89	--	66	--
8 months	85	--	91	85	--	74
8 1/2 months	95	--	--	--	100	--

Sherman's table shows the fallacy of the popular belief that more children are saved at the seventh month than at the eighth. All things being equal the older the premature the better its chance of life.

Great confusion exists in a study of various statistics because of the misapplication of the term "months"; the latter should apply to lunar months (twenty-eight days) and not calendar months or better the age should be stated in days or weeks to avoid all confusion.

The Germans have usually considered one hundred and eighty-one days as the minimum period after which life may be sustained, while the French laws regard one hundred and eighty days of uterine life as necessary to viability. That one hundred and eighty days (six and one-half lunar months or nearly twenty-six weeks) are necessary to existence is disputed by many.

The exact age of an infant is not easy to determine. In fact, it is most difficult, due to the uncertainty as to the beginning of pregnancy. As previously stated, the statement of the mother as to her last menstrual period or as to the time that life was first felt are notoriously uncertain, and weight, length, and other head and body measurements are uncertain factors in determining the degree of unripeness of the premature child. The most accurate method at hand today to determine the age of the premature infant is by roentgenograms of the skeleton, since the osseous development is more regular and offers more factors for consideration than determining the age based on length and other measurements (see "Skeletal Development," p. 101).

Weight. -- This is a much less dependable factor than age in estimating the outlook for the premature child. All conditions being equal, a small older child has a better chance of living than a younger one who weighs more. Nevertheless, a decrease in the death-rate accompanies an increasing birth weight. The prognosis is better, on the face of it, in a child of 2000 gm., but on the other hand, the 2000-gm. child may have a poorer chance of life because of debility (Pfaundler).

Credé reported a mortality of 83 per cent for children weighing 1000 to 1500 gm. and 11 per cent for those of 2000 to 2500 gm. weight. Here the healthy and debilitated prematures have not been discriminated between. Separating these two classes, as François did, one finds that of 81 children born of diseased parents, 30 to 37 per cent died, while of 386 apparently well premature babies, only 12.5 per cent died.

Carlini gives as the lowest figures compatible with viability, a weight of 1000 gm. and a length of 31 cm. These figures are high as attested by an examination of the literature, where several cases are on record as surviving with either a weight or a length smaller. (See list of smallest prematures saved.)

Sherman [1], of Buffalo, published the following table showing the number of children saved according to weight in his institution:

Weight	Percentage saved
2 to 2 1/2 pounds	25.0
2 1/2 to 3 pounds	50.0
3 to 3 1/2 pounds	42.8
3 1/2 to 4 pounds	50
4 to 4 1/2 pounds	75.0

Cook's [2] results were as follows:

Weight	No. of cases	Percentage saved
Under 1500 gm.	17	53
1500 to 2000 gm.	20	55
2000 to 2500 gm.	20	75
Over 2500 gm.	5	100

The smallest infant to survive in this series weighed 1250 gm. and was 38 cm. long. The initial loss was 130 gm.; it began to gain on the fourth day and had regained its birth weight on the fifteenth day. At the age of two months, which otherwise would have been at term, it weighed 2000 gm.

These figures indicate that the heavier the child at birth, the better its chances of surviving the first few weeks or months of life. What bearing the natal weight has on the future of the child we shall see later.

The smallest prematures recorded in the literature that were saved showed the following body weights and measurements:

Author	Weight, gm.	Length, cm.
Oberwarth	500
J. H. Hess (71 days)	690
J. H. Hess (72 days)	740
Oberwarth	750	35.3
d'Outrepont	750	37.0
Meyer	750
Roth	750	31.0
Heller	800
Heller	840	32.0
Ylppö	840
L. E. Frankenthal	850
Pfaundler	860	35.5
Waegeli	860	31.0
Klinker	895
Ahlfeld	900	34.0
Pizzini	900	30.0
Jardine	907
Villemain	950	38.0
Maygrier and Schwab	970
Heiberg	975
Rommel	980
Ahlfeld	980	37.0
Tissier	990	31.0
Schmid	1000	35.0
Kopp	1000
J. H. Hess	1070
Reber	1120

Martha and Augusta were two of triplets born of a Greek family at six and a half months, and were delivered by a midwife. The mother visited the children at the hospital on the fourth day after their birth and on the following, the fifth day, gave birth to a third, still-born fetus with a second placenta, and was again out on the ninth day. No less interesting were some of the deformities in the case of Baby Martha of the interesting group of triplets. She had but two fingers on one hand, and both knees and elbows were ankylosed in extension; in fact, there seemed to be an absence of the joint surfaces; while Baby Augusta had freedom of motion in all of her joints. Considering their prematurity, six and a half months, their weight at birth, 740 and 690 gm., respectively, together with the deformities in Baby Martha, it is surprising to find them surviving to seventy-two and seventy-one days, when both succumbed during attacks of cyanosis, due in all probability to overfeeding.

Because of Baby Augusta's better development, she was fed greater quantities from the start and although she did not have as great an initial fall in weight, both continued to lose until the twentieth day, Baby Augusta losing a total of 200 gm. and Baby Martha 230 gm. in this time. The records are rather incomplete as to the food given in Case II during this period. In Case I the estimates run from 65 to 89 calories per kilo. From the twentieth day on both infants showed almost stationary weight with food values below 120 and the greatest gain on an energy quotient between 130 and 140; and death in both cases with an energy quotient of over 200.

Temperature. -- In order to correctly estimate the power of resistance of a premature infant it is necessary to consider the degree of depression of the temperature and with it the weight of the child. The figures of Budin show that the lower the temperature the more serious any further reduction will be, and the less the weight the more easily the child succumbs. In weaklings in whom the temperature was 32° C. or less (89.6° F.) the mortality was 98 per cent when they weighed 1500 gm. or less; 97.5 per cent when they weighed between 1500 and 2000 gm.; 75 per cent when they weighed more than 2000 gm. When the rectal temperature fluctuated between 32° and 33.5° C. (89.6° and 92.3° F.), the mortality of the first group was 97.3 per cent; of the second group 85.6 per cent; and of the third group, weighing 2000 gm. or over, 69.2 per cent. Thus it is necessary to consider both the weight and the degree of hypothermia. The most striking contrast is seen in comparing the figures of the Maternité and the Clinique Tarnier, Paris. To the former are often brought infants with a temperature lowered to 32° C. (89.6° F.); the mortality among these neglected weaklings of a weight of 2000 gm. or less ranged from 90 to 98 per cent. At the Clinique Tarnier every precaution is taken to conserve the body warmth and here the mortality of infants of the same weight is only 23 per cent.

Sherman's experience is comparable with that of Tarnier. Of 10 babies having a rectal temperature of 35.5° C. (96° F.) or less, all but 2 died.

Porak and Durante estimated the lowest degree to which the body temperature may sink, with reparation still possible, as follows:

Infants with weight less than 1100 gm., 34° C. (93° F.)

Infants with weight 1100 to 1300 gm., 30° C. (86° F.)

Infants with weight 1300 to 1750 gm., 29° C. (84° F.)

Infants with weight above 1750 gm., 28° C. (82.4° F.

Ylppö disagrees with the French observers in that his belief is that the mere cooling of the body surface does not result in death, but that many of these infants with subnormal temperature are the victims of birth injuries or brain hemorrhage, the latter factors resulting in fatality.

Apert reported a premature with a temperature of 30° C. (86° F.) which lived. Ylppö states that he has seen a series of infants who in spite of a temperature of only 27° to 28° C. (80.6° to 82.4° F.) at birth, remained alive. If the subnormal temperature does not persist too long, with resulting capillary damage and edema, especially of the lungs, recovery is possible. To show the relation between mortality and subnormal temperatures, Ylppö summarizes his material in a table.

	37-35° C. (98.6-95° F.)			34.9-33° C. (95-91.4° F.)
	No.	Death at:		No.	Death at:
		5 days	1 month		5 days	1 month
Group I 600 to 1000 gm.	3	2 66.60%	--	12	8 66.60%	11 91.60%
Group II 1001 to 1500 gm.	40	10 25.00%	15 37.50%	46	15 32.82%	19 41.30%
Group III 1501 to 2000 gm.	76	7 9.12%	16 21.05%	40	3 7.50%	8 20.00%
Group IV 2001 to 2500 gm.	85	4 4.71%	5 5.88%	19	1 5.26%	5 26.32%
	32.9-31° C. (91-87.8° F.)			30.9-29° C. (87.6-84° F.)
Group I 600 to 1000 gm.	5	4 80.00%	5 100.00%	6	5 83.30%
Group II 1001 to 1500 gm.	27	7 25.90%	13 48.10%	12	7 58.30%	10 83.30%
Group III 1501 to 2000 gm.	20	5 25.00%	10 50.00%	12	2 16.60%	7 58.30%
Group IV 2001 to 2500 gm.	8		2 25.00%	1
	28.9-27° C. (84.2-80.6° F.)			26.9-25° C. (80.4-77° F.)
Group I 600 to 1000 gm.	6	5 83.30%	6 100.00%	1		1 100.00%
Group II 1001 to 1500 gm.	7	3 42.80%	6 85.70%	1		1 100.00%
Group III 1501 to 2000 gm.	5	2 40.00%	3 60.00%
Group IV 2001 to 2500 gm.	5		1 20.00%	1	1 100.00%

Our experience has been that unless the child with subnormal temperature is soon placed in surroundings more favorable, the prognosis is grave. If, when placed in an incubator, the resulting rise of temperature is retarded, it is an unfavorable sign. An abrupt rise after a previously stationary hypothermia is also unfavorable. If the body rises to 37° C. (98.6° F.) and remains there, one may say that the nervous system is doing its work properly.

Body Measurements. -- Other measurements beside those of weight are of assistance in estimating the viability of the premature.

Ostrcil gives figures which show a rapid lessening of mortality in infants weighing over 2000 gm. and of a length greater than 44 cm.:

Weight, Grams	Viability, Per Cent
1400	0
1500	0
1600	17
1700	27
1800	21
1900	33
2000	47
2100	50
2200	43
2300	49
2400	58
2500	54
2600	62
2700	59
2800	63

Length, Cm.	Viability, Per Cent
40	21
41	20
42	25
43	28
44	51
45	50
46	55
47	58

Similarly, Pfaunder demonstrated the decreasing mortality with increasing birth weight:

Age in fetal months	Body weight		Body length, cm.	Mortality in first weeks of life, per cent	Surviving, per cent
	Normal fetuses, gm.	Prematures, gm.
6	1300	1000	35	95	5
6.5	---	1200	37	82	18
7	1800	1500	39	63	37
7.5		1800	42	42	58
8	2500	2200	45	20	80

The Cause of Labor. --

Generally speaking, in those infants whose early birth depends on the induction of labor, the outlook is better than when it results from spontaneous delivery. The following percentages are given as saved after induced labor:

Author	Born alive, per cent	Saved, per cent
Hahl	75.0	59.5
Raschkow	84.8	78.6
Heymann		71.2
Ahlfeld		90.9
Lorey	74.0	60.0
Hunziken		83.5
Ostrcil		56.9

That there are exceptions to the above statement cannot be doubted. For example, the occurrence of albuminuria may lead to the induction of labor, the child being not only premature but a weakling of low weight and vitality. On the other hand the infant born as a result of the shock attendant upon operative interference in non-suppurative appendicitis would in all probability possess excellent vitality. The artificial induction of premature labor with its associated trauma to the infant plays a very important part in the mortality. The foregoing figures are to be seriously questioned as there is no record of the birth weight, which in many instances was undoubtedly well above 3000 gm. and therefore not strictly applicable to the premature infant.

Prenatal Influences. -- The health of the mother during the period of gestation is of the utmost importance in prognosticating the immediate future of the premature and the weak. The occurrence of syphilis, tuberculosis, alcoholism, eclampsia, nephritis, severe heart disease, or other conditions producing faulty nutrition of the fetus -- all have their effect on the well-being of the infant. Of special importance is the occurrence of syphilis or nephritis. Though necessarily the age and weight of the child have a direct bearing upon its physiological development, yet the occurrence of constitutional diseases in the child is even of greater importance. Despite the greater age and the comparatively good development of a premature, the existence of a prenatal syphilitic infection or of an inherited predisposition to tuberculosis greatly jeopardizes the prognosis. If constitutionally well, the infant under 1000 gm. weight can live, providing sufficient attention is paid to the three conditions governing the survival of these infants. On the other hand, prematures or even full-term infants, the victims of parentally derived disease, often do not survive, regardless of the care they receive.

Francillon attempted to group the prematures in relation to the cause of prematurity and to show the death-rate for each group. He considers as premature all infants born with a weight below 2900 gm. Of 2271 births, 832 were premature, a proportion of about 36 per cent. Of these 832 prematures the number born dead was 76, a still-born death-rate of 9.1 per cent. Of these 76 born dead, 59 died in utero. The rest died during labor either as the result of accident or of mutilating operations. Of 756 born alive, 39, or 5.1 per cent, died during their stay in the maternity department, that is, during the first three weeks of their existence. In grouping them according to the cause of the prematurity, Francillon finds that:

Because of obstetrical intervention: 6 out of 28 cases died (21.4 per cent).

Because of twins: 5 out of 49 cases died (14.2 per cent).

Because of albuminuria: 3 out of 23 cases died (13 per cent).

Because of syphilis: 8 out of 75 cases died (10.6 per cent).

Because of heart disease: 1 out of 13 cases died (7.7 per cent).

Because of unknown causes: 13 out of 499 cases died (2.7 per cent).

Ylppö, discussing the various factors which are concerned with the etiology and mortality of prematurity, presents the table below.

Etiology	No.	Not followed up	Followed through.	Death by:
				5th day	1 month	1 year	Over 1 year
1. Diseases of the mother
(a) Lues	26	--	26	4 = 15.38%	10 = 38.46%	18 = 69.23%	19 = 73.08%
(b) Tuberculosis, spontaneous labor	9	3	6	---	1 = 11.11%	2 = 22.22%	2 = 22.22%
Tuberculosis, artificially induced	3	1	2	1 = 33.33%	1 = 33.33%	2 = 55.57%	2 = 66.67%
(c) Other infectious diseases (influenza, scarlatina, pneumonia, grippe)	7	1	6	1 = 14.29%	1 = 14.29%	2 = 28.57%	3 = 42.86%
(d) Eclampsia, spontaneous labor	12	2	10	--	--	4 = 33.33%	4 = 33.33%
Eclampsia, artificially induced	9	1	8	3 = 33.33%	3 = 33.33%	4 = 44.44%	4 = 44.44%
(e) Chronic or subacute albuminuria (nephritis), spontaneous labor	13	--	13	3 = 23.08%	5 = 38.46%	7 = 53.85%	8 = 61.54%
Chronic or subacute albuminuria, artificially induced	3	--	3	1 = 33.33%	1 = 33.33%	2 = 66.67%	2 = 66.67%
(f) Heart disease, diabetes	13	1	12	3 = 23.08%	5 = 38.46%	5 = 38.46%	7 = 53.85%
2. Habitual familial premature birth	4	--	4	1 = 25.00%	1 = 25.00%	1 = 25.00%	1 = 25.00%
3. Premature birth because of anomalies or diseases of the sex organs -- passages	3	--	3	--	--	2 = 66.67%	2 = 66.67%
(a) Small pelvis -- Caesarean section	2	--	2	1 = 50.00%	1 = 50.00%	1 = 50.00%	1 = 50.00%
(b) Myoma uteri or other anomalies of the uterus	8	1	7	2 = 25.00%	2 = 25.00%	3 = 37.50%	4 = 50.00%
(c) Placenta previa	9	--	9	3 = 33.33%	4 = 44.44%	4 = 44.44%	4 = 44.44%
(d) Diseases of the uterus, i.e. adnexa, endometritis, gonorrhea	8	--	8	2 = 25.00%	5 = 62.50%	6 = 75.00%	6 = 75.00%
4. Premature birth following trauma, fall, blow, etc.	30	5	25	4 = 13.33%	5 = 16.66%	7 = 23.33%	7 = 23.33%
5. Twin pregnancy [spontaneous labor?]	128	12	116	20 = 15.63%	28 = 21.88%	43 = 33.59%	48 = 37.50%
6. Twin pregnancy [artificially induced?]	12	--	12	3 = 25.00%	4 = 33.33%	6 = 50.00%	8 = 66.67%
7. Unknown causes	369	43	326	66 = 17.89%	127 = 34.42%	178 = 48.24%	188 = 50.95%
	668	70	598	118 = 17.66%	204 = 30.54%	297 = 44.46%	320 = 53.53%

Deformities. -- Certain deformities affect very materially the well-being of the premature child and not infrequently are important factors in the causation of labor before term. One of the most important compatible is cleft palate, either with or without hare-lip.

There are some features which are especially noteworthy. Of the 668 cases, more than half, 369, were due to unknown causes, which probably could have been explained by mild disorders or malpositions of the uterus. The prognosis in tuberculosis is much better than in lues -- a mortality of 33.33 per cent as contrasted with 73 per cent in the latter. Acute infections of the mother do not often appear in the premature, but are very important in bringing about premature delivery. Infants born of eclamptic and nephritic mothers have a very high mortality because of the fact that labor is shortened and often artificially induced, so that death most often results from the damage incidental to delivery. Diabetes and cardiac decompensation have a very deleterious effect on fetal development. The birth of twins is closely linked with prematurity and in Ylppö's series this class was 19.2 per cent of the total (128 of 668 cases).

Interference with the proper taking of nourishment complicates an already difficult problem, that of feeding, and impairs the child's chances of living. Of the other deformities, atresia of the digestive tract are not uncommon and generally speaking offer an absolutely bad prognosis unless limited to the rectum and anus.

Illegitimacy. -- Bakker paid attention to this phase of the birth of premature infants born at the Eppendorfer Hospital, Hamburg, from 1907 to 1912. Of one group weighing from 2000 to 2500 gm., 80 per cent of the legitimate children survived for at least one year, while of the illegitimate only 61.3 per cent lived that long. Thus, the mortality in the illegitimate is seen to be almost twice as high as in the legitimate of the same weight. Of those weighing from 1500 to 2000 gm. the mortality among the legitimate was 30 per cent, among the illegitimate about 47 per cent. Of a group of 75 weighing from 1000 to 1500 gm. only 10 lived to leave the institution. Four of these were followed up, of which only one, a legitimate child, was alive at the end of the year.

Thus we see that the death-rate among the illegitimate born ranges from half again to twice as high, or even higher, than in the legitimate, depending upon the weight at birth. This difference is accounted for largely by the inferior care the illegitimate infant receives at the most critical period of its existence, the first few days after birth.

Infectious Diseases. -- The secret of success in raising premature infants lies in three directions: (1) In the prevention of chilling of the body surface with the production of a subnormal temperature; (2) in the administration of the proper diet; (3) in the prophylaxis against infectious diseases.

Of the commoner infections erysipelas results fatally in the majority of cases. It is usually violent in its course in the very young and is frequently accompanied by signs of cardiac failure. The prognosis of tetanus neonatorum, fortunately now very rare, is generally unfavorable, even worse than with older children. In ophthalmia neonatorum the outlook is good when proper treatment is instituted sufficiently early. In sepsis the prognosis is bad, varying in direct proportion with the age and the immaturity of the infant attacked. The greater the number of organs involved the poorer the child's chances. In gastro-intestinal and other visceral hemorrhages as well as in other varieties of bleeding in the premature new born, the outlook depends upon the underlying cause or disease; sepsis, syphilis, asphyxia, etc.; but in general, it is grave, even more so as a rule than the underlying condition when uncomplicated.

Other Diseases of the New-born Premature. -- Icterus of the new born, unless due to atresia of the biliary passages, offers a favorable prognosis and is not followed by complications. Recovery usually occurs from moist gangrene of the cord unless the infection spreads to adjacent parts. Only in the very weak are umbilical ulcers followed by extensive tissue destruction. Inflammations of the umbilical cord, usually seen in the very feeble, of necessity offer a poor prognosis. Arteritis has a comparatively favorable outlook, but umbilical phlebitis is almost invariably fatal.

General Conditions. -- Of all prognostic signs, the study of the general condition of the premature infant offers the best evidence of the child's viability. If it cries strongly, exhibits vigorous movements, tends to stay awake and possesses well-developed ability to nurse, its viability may be considered as established and its opportunity for maintaining life good. On the other hand, if there is a tendency to deep sleep, to apathy, to asphyxia and cyanosis or to hypothermia, if the nursing ability is poor and there is difficulty in swallowing, the outlook is bad for the infant. Sometimes several days of observation are necessary in order to pass judgment upon the viability.

The condition of the turgor of prematurely born infants is of considerable importance as a prognostic sign. Absolutely flabby prematures with a poor turgor and a poor tonus prove to be lost in almost all cases. Prematures with a good turgor and a good tonus, even with a low weight, almost always live up to expectation. It is highly probable that the tissue turgor is conditioned by the mode in which the water is held. Where the water content is diminished the turgor decreases. The presence of water is closely connected with the presence of alkalies in the tissues and, therefore, it might be correct to state the hypothesis that the alkali deficiency of the prematurely born leads to a poor tissue turgor and therefore to inability to live (Langstein).

The greatest number of premature children die in the first few days of life. This is because of birth trauma, the unfinished condition of the organs, or the result of postpartum conditions or constitutional diseases or lack of facilities for proper care. At autopsy the cause of death is often not to be found, although the unripeness of the infant is evident.

Although 1000 gm. is accepted as nearly the low weight compatible with life, exceedingly small babies may live and thrive as is attested by the cases previously listed on page 44 (Physiology).

General Mortality

A consideration of the preceding factors, prenatal and postnatal, forms the basis for the mortality statistics which have been compiled by Ylppö in a series of over a thousand premature infants.

The above figures are quite accurate to the first year. Beyond this it was difficult to follow the patients. However only about 70 of the series could be followed. Of the 668 prematures 320, or 53.5 per cent, died. About 50 per cent survived to one year. An interesting feature is the fact that the mortality after the first year fairly well approximates that of full-term children. In the first to the fifth day of life the greatest death-rate is noted and is linked with the damage to the infant in the course of labor.

	Number	There perished.								Not followed up.
		On 1st day.	Up to 5th day.	In 1st month.	Up to 6th month.	In 1st year.	In 2nd year.	In 3d year.	In 5th year.
Total number	668	62 9.28%	120 17.96%	206 30.84%	275 41.17%	301 50.33%	315 52.67%	319 53.34%	320 53.51%	70
600 to 1000 gm.	37	14 37.84%	27 72.90%	31 83.80%	33 89.20%	34 94.40%				1
1001 to 1500 gm.	183	28 15.30%	57 31.10%	88 48.10%	111 60.60%	114 65.10%	117 66.80%		118 67.40%	8
1501 to 2000 gm.	240	16 6.70%	26 10.80%	56 23.30%	83 34.50%	96 44.90%	102 47.70%	103 48.10%		26
2001 to 2500 gm.	208	4 1.90%	10 4.80%	31 14.90%	48 23.10%	58 33.50%	62 35.80%	65 37.50%		35

Because of the fact that the etiological factors in the birth of twin prematures differs greatly from those of single birth (usual absence of infectious and constitutional disorders in the mother), Ylppö considers this class separately:

	Number	There perished.								Not followed up.
		On 1st day.	Up to 5th day.	In 1st month.	Up to 6th month.	In 1st year.	In 2nd year.	In 3d year.	In 5th year.
Total number	128	11 8.59%	19 14.84%	30 23.43%	38 29.68%	43 37.07%	47 40.52%	48 41.38%		12
600 to 1000 gm.	4	2 50.00%	3 75.00%	4 100.00%		4 100.00%
1001 to 1500 gm.	36	5 13.89%	12 33.33%	16 44.44%	18 50.00%	19 52.78%	20 55.50%
1501 to 2000 gm.	51	4 7.84%	4 7.84%	6 11.76%	11 21.57%	15 31.91%	16 34.04%			4
2001 to 2500 gm.	37			4 10.81%	5 13.51%	5 13.51%	7 24.14%	8 27.59%		8

The table shows that at the end of the first year the total mortality was 37.07 per cent, considerably less than with single births.

Footnotes

[1] Sherman, D. H.: Buffalo Med. Journal, 44:653; New York Medical Journal, 82:272, 1905.

[2] Arch. Ped. 33:201, 1921.

References

1. Jahrb. f. Kinderh., n.f., 60, 377 and short reports.

2. A study of the caloric needs of premature infants, Am. Jour. Dis. Child., 1911, 2, 302-314..

3. Oberwarth: Ergebn. d. inn. Med. u. Kinderh., 1911, 7, 191.

4. d'Outrepont: Abhandlungen und Beiträge geburtshilflichen Inhalts, Part I, p. 167.

5. München. med. Wchnschr., 1912, No. 47, p. 2596.

6. Roth: Ztschr. f. Kinderh., 1913, 5, 134.

7. Heller: München. med. Wchnschr., 1912, No. 47, p. 2596.

8. München. med. Wchnschr., 1907, No. 29, p. 1417.

9. Gynaecologia Helvetica, 1917, autumn edition, p. 199.

10. Allgemeine deutsche Hebammenzeitung, 1903, p. 289.

11. Lehrbuch der Geburtshilfe, 3d edition, 1903, p. 214.

12. L'arte ostetrica, November, 1908.

13. Cited by Mansell: British Med. Jour., 1902, 1, 773.

14. Nouvelles Archives d'Obstetrique et de Gynecologie, 1895, Répertoire, No. 2, p. 50.

15. Bulletin de la Société Obstétr. de Paris, 1907, p. 216.

16. Monatsschr. f. Geb. u. Gynäk., 17, 369.

17. München. med. Wchnschr., 1903, No. 37, p. 1603.

18. Lehrbuch. d. Geb., 1903, 3d edition, p. 214.

19. Zentralb. f. Gynäk., 1912, No. 19, p. 626.

20. Allgem. Deutsche Hebammenzeitung, 1911,No. 11, p. 235.

21. Schmidt's Jahrbücher, 3, 128.

22. Unreported case.

23. The Prematurely Born, Cor.-Bl. f. schweiz. Aerzte, Basel, 1918, No. 27, 48, 897.

	Fig. 181. Two of Greek triplets weighing 690 and 740 gm.
	Fig. 182. Weight and food curves of first of Greek triplets. Birth weight, 690 gm.
	Fig. 183. Weight and food curves of second of Greek triplets. Birth weight, 740 gm.