Gentlemen,
To-day I should like to finish what I have to say with regard to weaklings.
You recollect we studied the disastrous effects of the lowering of their temperature. I showed you that their feeding must be directed with the greatest care, for, underfed, they are liable to attacks of cyanosis; and, overfed, to digestive troubles and diarrhoea. We have yet to consider, however, the important question of the contagious diseases which attack weaklings placed together in a common ward.
A short time ago you had a demonstration of the facility within which infants can become infected in a hospital. Here, in the Clinique Tarnier, where we are without distinct isolation wards, two women suffering from sore throats were admitted and placed in the same general ward. The trouble spread among the other patients. We at once took all the precautions possible with our defective organisation. There were no fatalities among the mothers; all rapidly recovered.
It was otherwise, however, with the infants. They offered much less resistance, and the contagion, spreading to them, gave rise, in some cases with fatal results, to erysipelas and broncho-pneumonia. Here it was a question of healthy, full-term infants; but weaklings, puny little beings, who often are ill before they are brought to us, can still more easily be infected.
I have already alluded to what took place at the pavilion for weaklings at the Maternité. In 1895 all was going smoothly when, on a cold and damp winter afternoon, November 26, the wet-nurses, in spite of all remonstrance, went out with their infants. Next morning three were coughing and nine of the infants were ill. The following day the six remaining infants were also attacked.
Our great dread was lest this affection, which had broken out so suddenly, should spread to the weaklings. Apart from coryza, respiratory troubles had been relatively rare in the wards; we had had only one case of bronchitis from July 1 to November 27, for an infant that began to cough was always immediately isolated.
But how was the spread of the disease to be prevented? The wet-nurses, not having a special room in which to tend their infants, constantly brought them into that used for the weaklings. This practice was prohibited, and orders were given to the nurses to leave their infants in their own dormitory. Other precautions were taken, but notwithstanding, six days later, December 3, the epidemic broke out among the weaklings. At first 17 were attacked, but it gradually spread till nearly all were involved. On December 5 the wards were closed.
The epidemic was exceedingly fatal to these frail little creatures, scarcely able to exist outside an incubator: 34 were affected and 23 died. Congenital feebleness, as is shown by experience, greatly diminishes an infant's power of resistance. Among the weaklings 23 out of 34 died, a mortality of 67.6 per cent., whilst amongst the infants of the wet-nurses only 1 died out of 15, a mortality of 6.6 per cent. (Fig. 41).
After the epidemic was over the wards were reopened, and everything proceeded regularly once more. Towards the end of 1896 another epidemic broke out. On November 26 three infants of wet-nurses were taken ill. The affection spread to the others, and soon all fifteen were implicated, without, happily, any fatal results.
In spite of all our precautions the weaklings were attacked. We prohibited the infants of the wet-nurses from being taken into the dressing-room for the weaklings. We obliged every wet-nurse to wash her face and hands, and change her uniform each time she went to feed the weaklings, but nothing availed, and eighteen days after the first appearance of the epidemic two weaklings were affected. The disease gradually spread among the greater number of them, and on December 26 the wards had to be closed. Out of 25 seized with this influenzal bronchitis, 4 died, a mortality of 16 per cent. (Fig. 41).
In 1897 we had not one but two epidemics of bronchitis, the first in March, the second in November.
In March, 13 infants of wet-nurses were attacked, but all recovered; 28 weaklings were affected and 16 died, a mortality of 57.4 per cent.
In November a sick weakling seemed to be the starting point of the epidemic; 9 infants of the wet-nurses suffered without any fatalities, but out of 34 weaklings attacked only 16 survived; 18 died, which was a mortality of 52.94 per cent.
You see, gentlemen, how easily these affections can be contracted, not only by weaklings, but also by full-term infants. The latter, however, being stronger, resist better, and in the three epidemics to which I have referred, there was only one death among the children of the wet-nurses. What a contrast with the weaklings! Look at the mortalities among them: 16 per cent., 52.94 per cent., 57 per cent., and even 67.6 per cent.
Besides influenzal bronchitis there has also been chicken-pox. At the time of my entry into the Maternité in 1895, it was the custom, when a woman about to be confined arrived with her children during the night, to leave the latter in the wet-nurses' dormitory till next day. I ordered them to be immediately taken to "Les Enfants Assistés" without being allowed to enter our wards. But this precaution was too late: an infant of a wet-nurse had already contracted chicken-pox. Without delay it was sent with its mother to a hospital for contagious diseases. In order that the weaklings might by their night feeding inconvenience the wet-nurses as little as possible, it was then customary to carry them in their incubators from their mother's bedside to the dormitory of the wet-nurses. One of these little beings contracted chicken-pox among the wet-nurses, and a small epidemic ensued. The incubation period was thirteen days.
I have also observed a strange affection, characterised by bronzing of the skin, the precise nature of which is not yet known. In 1896 we had thirteen cases; all ended fatally. It is essentially a contagious disease, and any infant attacked by it ought to be at once isolated.
Among infants brought from outside we have had many cases of ophthalmia. At the Maternité we hardly ever saw it, for we treated the eyes with a few drops of silver nitrate, 1 in 150, immediately after birth. But infants born outside the hospital, in whom no preventive measures had been employed, very readily took conjunctivitis. It even seemed as if the temperature of the incubator favoured the development of this affection, so we made it a rule to put a few drops of a weak solution of silver nitrate in the eyes of every infant we admitted.
Ophthalmia is an annoying affection, it requires frequently repeated attention; it is dangerous and contagious, and moreover, it often gives rise to coryza, which may prevent the infant sucking, and necessitate feeding by spoon or gavage.
These facts demonstrate the numerous dangers of infection to which the newly born are exposed. The weaklings, especially, run great risks; in these epidemics the mortality among them from influenzal bronchitis was considerable and even appalling, whilst among the infants of the wet-nurses it was practically nill.
In your practice, therefore, you must immediately isolate any infant suffering from influenza, or all other children in the house will also take it. And, further, if you have to choose for a weakling a wet-nurse and her child, you must carefully examine the latter to ascertain if it has any contagious disease.
I told you that the department for weaklings at the Maternité was defective in its organisation; no provision had been made for the possibility of contagion.
The following is a description of it which I gave in 1896, together with the modifications which I then proposed:--
"The department for weaklings is, at present, constructed thus:--
"A. On one side there is a large ward containing the weaklings in their incubators and cradles; at one end of this ward there are four small rooms for isolation.
"B. On the other side there is the wet-nurses dormitory, at one extremity of which are the dining-room, dressing-room, pantry, lavatory, &c.
"Between these division is a ward, generally kept at a temperature of 24°-25° C., where the weaklings are undressed, washed, and fed. This ward, being unique, serves for all, so the infants of the wet-nurses are there constantly. If one of them has any contagious malady the weaklings can easily become infected. How can this be avoided?
"1. Wet-nurses could be taken without their infants, as is done at 'Les Enfants Assistés.' This would be a great advantage, inasmuch as it would get rid of the principal cause of infection. But it must not be forgotten that w have to deal with weaklings. If some, grown strong, can suck vigorously, others, still feeble, can scarcely suck at all, whilst others again have to be hand-fed, and the wet-nurse has to draw off her milk either by means of a 'breast-evacuator,' or by pressure of the fingers. Suckling maintains in a mother her milk production. What would happen if the wet-nurse was deprived of her own infant -- the physiological stimulus of her mammary secretion?
"And if, in spite of all precautions, an epidemic were to take place, so that during a certain time no weaklings could be admitted, the wet-nurses would be in danger of losing their supply of milk, and with it their chief means of living.
"2. If, then, the infants of the wet-nurses have to be allowed to stay with their mothers, they must be completely isolated. There ought to be, therefore, a pavilion specially reserved for the wet-nurses, so that under no pretext whatsoever shall their infants cross the threshold of the wards for the weaklings.
"But this is not all; there is a further possible source of infection in sick infants brought from outside. No matter what we did we could never restrict the wards for weaklings absolutely to infants suffering solely from congenital feebleness. Certainly, the majority admitted are infants born before term, premature but healthy; yet, many are brought, several days and even weeks old, suffering from gastro-enteritis, suppuration of the cord, conjunctivitis, erysipelas, &c. In 1895, 395 infants were received, of whom 117 had some pathological condition. They were feeble, puny, and weakly, but they were also ill. To receive only congenital weaklings, and to refuse those whose debility is acquired, are practically impossible. We tried it, but without success, and, meanwhile, those weaklings who are ill are a source of danger to the others.
"Hence, I believe it would be necessary to establish three divisions in the department.
"In the first would be placed the congenital weaklings, transferred from the wards of the Maternité or admitted immediately after birth, who did not present any symptoms of infection.
"The second would be reserved for weaklings who were either ill, or not free from suspicion of infection, such as those coming from the wards of other hospitals, or from midwives.
"The third, totally distinct from the other two, would consitute the pavilion for the wet-nurses.
"It remains for me briefly to indicate how I would proceed to organise each of these separate divisions.
"First Division -- Healthy weaklings.
"This would comprise the department as it at present exists -- a large ward for the cradles and incubators, four small isolation rooms, a room in which to dress and undress the infants, provided with balances, baths, hot and cold water, &c., and a small room for putting the linen of any infant whose dejections have to be kept for the doctor's inspection.
"Second Division -- Weaklings ill or suspected.
"This would comprise a certain number of rooms destined to receive only one or two infants.
"At one extremity of this division there would be a room in which all that is necessary for tending and feeding infants, such as baths, balances, breast evacuators, &c., would be kept, but each infant would be cared for in its own separate room. At the same end there would also be an apartment to serve as a dressing-room and lavatory for the wet-nurses, where, before ministering to any of the weaklings thus isolated, they could wash their hands and face and don an overall.
"Third Division -- Pavilion for wet-nurses.
"This would be quite dinstct from the other divisions, separated by an interval of 2 1/2 metres, covered in so as to protect the wet-nurses from rain. It would comprise one large common ward, containing sixteen beds for the wet-nurses and sixteen cradles for their children. A small passage at one end would lead to a large, airy apartment with cribs, balances, hot and cold water, &c., where the infants would be bathed and dressed. In a small room apart, sterilised milk would be heated for the infants, and food prepared for the older children. The bottles of sterilised milk would be kept in a cool place, and during summer a small ice chamber might be provided for them. There would also be a water-closet and other conveniences, with a small passage opening out into the yard, so that these rooms might be cleaned without refuse having to pass through the wet-nurses' dormitory. Lastly, there would be a dressing-room for the wet-nurses, and an apartment in which each of them would have a cupboard for keeping her clothes.
"Thus would be brought about --
"1. The grouping together of the healthy weaklings.
"2. The isolation of the sick and suspects.
"3. The absolute separation of the wet-nurses' infants from contact with the weaklings."
The public authorities were quite willing to permit the realisation of this programme. My successors, I hope, will now be freed from the difficulties I had to contend against, and able successfully to avoid the spread of any contagious affection in the department at the Maternité. This new organisation has been in existence one year so far without a single epidemic. Here, at the Clinique Tarnier, in spite of the defective system, there have been no epidemics among our weaklings, for no precaution is neglected.
What were my results at the Maternité? I do not wish to enter into a fastidious study of the figures, year by year, as I have already published the statistics for 1895, 1896, and 1897. I shall simplify the matter by grouping these three years together, and then I shall show you, for the sake of comparison, my results here, at the Clinique Tarnier, in 1898.
Let us first take the department for weaklings at the Maternité. By dividing the infants according to their weight on admission we get four categories--
I. The first category comprises infants who weighed less than 1200 grams.
II. The second category comprises infants who weighed from 1200 to 1499 grams.
III. The third category comprises infants who weighed from 1500 to 1999 grams.
IV. The fourth category comprises infants who weighed 2000 grams and more.
Here are the results in tabular form:--
Categories
Weight in Grams
Number of Infants
Dead Living Total
Proportion
per Cent.Total
Proportion
per Cent.I.
Less than 1200
40
38
95
2
5
II.
From 1200 to 1499
146
124
85
22
15
III.
From 1500 to 1999
432
265
61.34
167
38.6
IV.
2000 and over
212
69
32.55
143
67.45
Thus for 40 infants weighing less than 1200 grams the mortality was 95 per cent.; 5 per cent. were saved.
For 146 infants weighing from 1200 to 1499 grams, the mortality was 85 per cent.; 15 per cent. were saved.
For 432 infants weighing from 1500 to 1999 grams, the mortality was 61.34 per cent.; 38.6 per cent were saved.
For 212 infants weighing more than 2000 grams, the mortality was 32.55 per cent.; 67.45 per cent. were saved.
Considering all these infants together, 40 per cent. left the wards in good health.
Evidently we cannot say that these figures are extremely favourable; however, we succeeded in saving 38.6 per cent. of the infants who weighed between 1500 and 2000 grams, and 67.45 per cent. of those who weighed more than 2000 grams, usually between 2000 and 2500 grams. But the state in which these weaklings were so often brought to the Maternité must not be forgotten. A large number of them, 27 per cent., or almost a third, arrived with a rectal temperature of less than 33.5° C.; in addition, the majority of them were already suffering from digestive troubles, diarrhoea, sclerema, ophthalmia, &c.; and lastly, they were scourged by contagious diseases, for 61 died from influenzal bronchitis alone, in the three years.
I think I can safely assert that the results would have been vastly superior if we could have shielded the infants from their three chief maladies, cold, digestive troubles, and contagious maladies. Here is a proof of this.
I have made an abstract of the infants who were born at the Clinique Tarnier, with a weight of 2500 grams or less, between March 1898, when I took charge of the hospital, and December 31 of the same year. In order to render the figures comparable to those dervied from the department for weaklings, I have omitted all infants who died within forty-eight hours, for I did not count those brought to the Maternité who did not survive more than two days. Neither have I included those who at birth weighed more than 2500 grams and subsequently fell below that figure.
There were 1400 infants, and I shall, as before, separate them into four categories:--
Categories
Weight in Grams
Number of Infants
Dead Living Total
Proportion
per Cent.Total
Proportion
per Cent.I.
Less than 1200
1
1
100
0
0
II.
From 1200 to 1499
5
3
60
2
40
III.
From 1500 to 1999
30
4
13.3
26
86.7
IV.
From 2000 to 2500
108
7
6.4
101
93.6
For infants weighing less than 1200 grams, our mortality was 100 per cent., but as we only had one infant in this category the figure is without significance.
We had 5 infants weighing from 1200 to 1499 grams; the mortality was 60 per cent.; 40 per cent. were saved.
For 30 infants weighing from 1500 to 1999 grams, the mortality was 13.3 per cent.; 86.7 per cent. were saved.
For 108 infants weighing from 2000 to 2500 grams the mortality was 6.4 per cent.; 93.6 per cent. were saved. Among the 7 who died, 5 were syphilitic. Eliminating these, we lost 2 infants out of 103, a mortality of 1.84 per cent.
If we group together all these infants who weighed less than 2500 grams, we find that 129 out of 144, that is 89.5 per cent., left the Clinique Tarnier in good health.
On Fig. 43 the results obtained at the two hospitals are compared; the red columns represent the mortality among the weaklings at the Maternité; the yellow, at the Clinique Tarnier.
A considerable difference is seen to the credit of the Clinique Tarnier. Why?
It is not a question of the relative amount of care bestowed on the weaklings. I had charge of both institutions. A little hesitant at first, gradually experience gave me the confidence which I now possess. As for my staff, they were as intelligent, faithful, and perfect at the Maternité as they are at the Clinique Tarnier. So we must look elsewhere for the cause.
At the Maternité, infants were often brought with a considerable lowering of the temperature; at the Clinique, we took every precaution to avoid the exposure of our infants to cold.
At the Maternité many infants, on admission, were already suffering from digestive troubles; here by attentively supervising the feeding, all digestive troubles were avoided.
Lastly, at the Maternité there were several deadly epidemics of influenzal bronchitis, while at the Clinique we succeeded in protecting the weaklings against such calamities.
These are the reasons of the high mortality among the weaklings at the Maternité. The low death-rate among them at the Clinique Tarnier is the product of a wider experience.
I think I am justified in concluding that if every precaution was taken to avoid depression of temperature, digestive troubles, and contagious diseases, the great majority of weaklings would be saved.
What becomes of these infants when they leave hospital and return to their homes? What is their mortality then? How do they develop physically and intellectually? I have made a certain number of observations, of which I shall now give you the results.
I sought to ascertain what became of the infants who were cared for in the department for weaklings from January 1 to October 1, 1896. I commenced my inquiry on December 1; the infants had then left us at least two months, and at most ten. Many letters were undelivered, as the mothers had left their former addresses and could not be traced. For 73 infants we had 54 answers; we were therefore without information regarding 19.
Out of these 54 infants who, at the moment of their departure, weighed between 2800 and 3000 grams, 37 were living and 17 were dead; the total mortality was thus 31.5 per cent. These were infants for whom we had zealously cared; we had given them to their families in good health, and they had been allowed to die in a proportion of 31.5 per cent. Only 68.5 per cent. had survived, which was not a very encouraging result.
But let us go further, and see how these infants were fed. We had strongly recommended that they be breast-fed, but unfortunately our advice was not followed.
Among these 54 infants--
20 were exclusively breast-fed.
24 were exclusively bottle-fed.
3 were partly fed on the breast, partly on the bottle.
1 was breast-fed at first, and then bottle-fed.
6 were on a regime, concerning which no particulars were returned.
Out of the 24 bottle-fed, 10 died, which makes a mortality of 41 per cent.
Out of the 20 breast-fed, 3 died, so their mortality was 15 per cent.
The mortality among bottle-fed infants is therefore very much higher than that among those who are breast-fed. We have saved only 59 per cent. of infants reared on the bottle, but 85 per cent. of those reared on the breast.
But in order to form a correct estimate of these results, I required to know in what proportion full-term infants die, so I proceeded as follows:--
Infants born at the Maternité are fed by their mothers, and do not leave the hospital till she does; if they had to be put out to nurse, I authorised their departure before the mother's only if they were confided to a wet-nurse to be reared at the breast. During that same year, 1896, I noted the names of all such infants, together with the names and addresses of their wet-nurses. The following year, 1897, I asked the authorities to make an inquiry as to the fate of each of these infants. This was done with great thoroughness, and the following results were obtained: 91 women received infants to be breast-fed; two of them could not be traced; of the other 89, one had twins, and thus there was a total of 90 infants.
Four of these 90 had been taken home by their parents before the end of the second month. Of the remaining 86, 15 had died, which is a mortality of 17.4 per cent.
Hence, among well-developed full-term infants, in whom no congenital defect was found, and who were reared at the breast, there was a mortality of 17.4 per cent.
Our weaklings under similar circumstances, confied to wet-nurses to be breast-fed, died in the proportion of 15 per cent. Therefore these infants leaving the department for weaklings are quite viable; indeed they are as much so as infants born at full-term, for their death rate is less.
These infants were confided to breast wet-nurses, or rather to so-called breast wet-nurses. As one is very easily deceived, I took the trouble to ascertain from the State register of births, the age of the last child of each wet-nurse, and found a record of infants of one, seven, eight, nine, fourteen, nineteen, and even twenty years. But this fraud was short-lived, and only true breast wet-nurses, i.e. women several months delivered, were employed. This source of fallacy, therefore, does not materially affect the results; and besides, it applies equally to both weaklings and full-term infants.
We are thus justified in concluding that a weakling, when it is discharged from our wars, is as capable of existing as a full-term child.
I have been enabled still further to verify this conclusion. The philanthropy of M. Henri Bamberger has created at Versailles a very interesting organisation, called the Pouponnière, where infants are raised, at first exclusively on the breast, later on a diet of human and cows' milk combined. It is directed by ladies with the scientific aid of a medical committee. A certain number of infants are admitted, some of whom are received gratuitously; and there are, in addition, the children of the wet-nurses, for these are not alienated from their mothers. This institution consists of three pavilions, of which three are reserved for full-term infants, and one for those who, in due course, have been discharged from the department for weaklings at the Maternité. These continue to be breast-fed, and are kept till they attain a weight of about five kilograms. As I was not personally on the staff, I shall confine my remarks solely to the results obtained. Our last batch of weaklings was sent to the Pouponnière at the end of November 1897, and remained there until January 1, 1898. I left the Maternité about that time, to take up my duties at the Clinique Tarnier, so I have no later information.
What were the results from the point of view of the infants? What were the working expenses?
52 infants had been received at the Pouponnière. Of these, the history is known only until January 1, 1898; 9 died and 43 lived. Their mortality was therefore 17 per cent., which is exactly that of the full-term infants who were born at the Maternité and entrusted to breast wet-nurses. This rate is almost equal to the mortality of 15 per cent., among the weaklings who were discharged from the department in 1896, and confided to wet-nurses to be breast-fed.
What was the expense involved? This is an important consideration from a humanitarian point of view, for we must try to obtain the greatest possible return from all money consecrated to charity. The working expenses during 1897 were 2000 francs per month, 24,000 francs per year. As 43 children left in good health, each infant saved at the Pouponnière cost 558 francs, excluding the initial expenditure for building and furnishing. This is relatively a large figure. A breast wet-nurse costs 40 francs per month, and an infant could be nourished for a whole year on the smaller sum of 480 francs.
There is still another interesting result from a social aspect. I have pointed out to you that an infant treated at the department for weaklings is separated from its mother. To save their lives is our primary concern, but afterwards, their mothers, no longer able to furnish the milk necessary to their nutrition, confide them to paid breast wet-nurses. I have been grieved to see a certain number of women come more and more rarely to visit their child, and gradually lose all interest in it. At length, when they were notified that it was about to be discharged, they made no response, and the infant, thus abandoned, I had to hand over to "Les Enfants Assistés." At the Pouponnière 12 of these 43 infants, dismissed well, were abandoned -- that is to say, 28 per cent. Their parents, hitherto freed from all worry and expense with regard to them, were now unwilling to assume their responsibility. I do not dare to say that desertion has thus been made easy, or that a school to encourage it has practically been created, but this figure 28 per cent., is sad in the extreme.
This is the reason, gentlemen, why you have seen me insist so strongly in this Clinique on two points: first, save the infant, the essential point; second, save it in such a way that when it leaves the hospital it does so with a mother able to suckle it. So when a weakling has to be fed for a time by a wet-nurse I place a vigorous infant at the mother's breast. Her lacteal secretion is thus established. Soon she can nurse her own little one, and on leaving the Clinique, will continue to suckle it. You can see at our Consultation infants, once weaklings -- one of whom weighed only 1300 grams at birth -- who are nursed by their mothers, and are doing well.
What afterwards becomes of weaklings thus saved? It has been alleged that they remain puny and weakly all their lives, that many of them have Little's disease, and that they have a feeble intellectual development.
That is not so. During my three years at the Maternité, out of 1100 admissions I saw only one case of Little's disease, and it was consequent on a difficult intervention in a pelvic presentation, and not due to debility.
Due these infants remain puny and weakly? I think not, unless they have some inherited disease. I know several who have attained a certain number of years, and who in physical development cannot be distinguished from full-term children.
In 1877 I assisted at the birth of a premature girl infant. She was extremely difficult to save; for a whole month she had to be kept in a room the temperature of which was maintained uniformly at 25° C. She has practically never had a day's illness, and has grown to more than average height and strength. This is only one of several similar cases I could cite to you.
As for intelligence, there is a little friend of mine who three days after birth weighed only 950 grams. She is seven years old, and speaks French and German.
I think that these allegations regarding the permanent bodily and mental debility of weaklings, and the frequency of Little's disease among them, are entirely without foundation. Nevertheless, everything ought to be done to ensure that an infant be born at term, well developed, and in a healthy condition. During pregnancy women must live under proper hygienic conditions, and avoid all fatigue. But in spite of every care infants are born prematurely, as the cause of accidents, syphilis in the parents, and other causes. Are you to neglect the little weakling? Will you tell its mother it is far better not to try to rear it? Surely not. She will express in no uncertain fashion her wishes, especially if it be her first-born. She may not be free from fear lest this be her only hope of being a mother. Experience will teach you that the more an infant is dependent on a mother's care the more she cherishes it, so no effort should be spared to save the little one; and it can be saved. If the prematurity be due to an accident the infant is easy to rear. If, on the other hand, it be due to an inherited taint, such as syphilis, the task is much more difficult, although not impossible.
I showed you that here at the Clinique Tarnier during the year 1898, out of 30 infants born prematurely who weighed between 1500 and 2000 grams, 26 were saved, that is 87 per cent.; out of 108 weighing between 2000 and 2500 grams, 101 were saved, or 93.5 per cent.
Among the latter there were 5 syphilitics: therefore out of 103 infants free from congenital taint only 2 died; more than 98 per cent. survived. Therefore all that is humanly possible must be done on behalf of these little ones, and success will frequently attend your efforts.
There is one other point to be considered -- has one the right to provoke premature labor? Or should an infant always be allowed to go to full term, in order to give it the best chance of life, even although the mother must then incur the risks of operative interference? I believe the induction of premature labour to be absolutely legitimate.
In a recent paper Dubrisay has recorded the results of 8 cases of induction of premature labour. Seven infants left hospital in perfect health; 1 died of broncho-pneumonia three weeks after birth, but, as its initial weight was 3200 grams, its death could hardly be attributed to congenital debility arising from the premature labour.
In 1898, at the Clinique, here, I induced 7 premature labours; 7 infants and 7 mothers left the hospital living and well. This result was too good; I can scarcely expect again to have such fortune. I know how long and difficult such intervention often is, and how great are the risks to which the infant is exposed. Yet, considering the gravity of certain other operative procedures, such as symphysiotomy, which even in expert hands gives a mortality of 12 per cent. for mothers, and Caesarean section, which, although varying in fatality according to different authors, gives on an average a death rate of 10 per cent., I do not think we are justified in discarding induction. As the mother's existence is generally not compromised, and the result is usually a living child, it seems to me to be a most valuable method of obstetrical intervention. Further, infants thus brought into the world before term are often not weaklings; among my 7 cases only 2 could be described as congenitally feeble, 1 of which weighed 2110 and the other 2290 grams. The remaining 5 weighed 2800 grams or more (Appendix).
Having measured the pelvis as accurately as possible, and then estimated the dimaters of the foetal head by Perret's method, I waited till I found that the continuation of the pregnancy involved risk to the mother. Then, and not till then, did I induce labour.
In conclusion, gentlemen, when you are called to a weakling do your utmost to save it, and bear in mind three things in particular:--
1. Strive to prevent the weakling becoming cold, as a fall of temperature may prove fatal.
2. Carefully supervise its feeding; underfeeding means inanition and attacks of cyanosis; overfeeding, digestive troubles and diarrhoea. I have indicated to you how the quantities of milk are to be regulated according to the weight of the child.
3. Avoid absolutely all exposure to contagious affections.
If you take these precautions, and especially if the weakling has a good wet-nurse who, by also nursing her own child, conserves her supply of milk, or, better still, if the weakling be nourished by its own mother, in whom the mammary secretion has been established by one of the methods I have outlined, you will have the satisfaction of succeeding in the same proportion of cases as I have done. And surely my results are full of hope and encouragement.
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Fig. 41. Epidemics of bronchitis at the department for weaklings in 1895, 1896, and 1897. Red columns, percentage of deaths among the wet-nurses' children. Blue columns, percentage of deaths among the weaklings. |
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Fig. 42. Plan of the Department for Weaklings at the Maternité. |
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Fig. 43. On the left: comparison of the death-rate among weaklings at the Maternité (red columns) and at the Clinique Tarnier (blue columns). On the right: the description is placed above each figure. |
