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Statistics concerning the death rate of premature infants from several sources are available. Only a few of these need to be given, and these are among the most recent. Before the introduction of modern warming methods, and especially the septic aseptic methods, the results were very uncertain. Several modern writers confess they have little success with premature infants. Hecker and Trumpp give the mortality from 30 to 50 per cent, according to the initial weight of the infant. A few years ago Voorhees (Archives of Pediatrics, 1900) published some interesting figures on this subject. In the second edition of his "Infancy and Childhood," Holt compares Voorhees' death rate with those of Tarnier. With the increased length of gestation, the mortality drops. At 6 months, only 16 per cent were saved by Tarnier. Excluding cases which died within a short time after birth, Voorhees saved 66 per cent; at 6 1/2 months, only 22 per cent, and at 7 months 41 per cent survived.
Altogether, it seems that the weight of the infant serves as a better basis for comparing the mortality. Budin's statistics are based on the weight. He gives two tables which are here reproduced (Tables 24 and 25).
It will be seen that the results at the Clinique Tarnier, in 1898 give a total mortality of 10 per cent only, which are truly remarkable figures; but, on looking at the table it will be seen that nearly all the infants weighed 1500 grams or more. The death-rate in infants of less than 1500 and more than 1200 grams is 60 per cent.
But even more remarkable results were obtained at the Clinique Tarnier (Perrett, Rev. de Hyg. et du Med. Inf., 1903; see also Rothschild, "Tratie de Hyg. et Path. du Nourrisson," 1893). He gives the death-rate in 1899 as 17.8 per cent; but in 1900, with 148 subjects, it fell to 7.4 per cent; and in 1901 the extraordinarily small mortality of 4.8 per cent was obtained in 144 subjects. In a total of 579 premature infants during four years' service, Budin lost only 59, or 10.2 per cent.
Category
Weight, Grams
Infants
Deaths, No.
Deaths, Per cent.
Living, No.
Living, Per cent.
1
Less than 1200
40
38
95
2
5
2
1200-1499
146
124
85
22
15
3
1500-1999
432
265
61.3
167
38.6
4
2000 or more
212
69
32.5
143
67.5
Showing death-rate of Premature Infants at the Debiles de la
Maternite,
Paris, France, 1895. '96 and '97. -- Budin.
Category
Weight, Grams
Infants
Deaths, No.
Deaths, Per cent.
Living, No.
Living, Per cent.
1
Less than 1200
1
1
100
0
0
2
1200-1499
5
3
60
2
40
3
1500-1999
30
4
13.3
26
86.7
4
2000 or more
108
7
6.4
101
93.6
Showing death-rate of Premature Infants at the Clinique
Tarnier,
Paris, France, 1898. -- Budin.
It is no wonder, therefore, that we must call him master and be very slow to criticise his methods. Of course, although I have not seen the exact figures for the last three years, these infants mostly weighed near 2000 grams. Nevertheless, the results are remarkable, and he obtained these by insisting that the infant's temperature should not be allowed to fall too low after birth, that it should not be kept too warm, that it should not be overfed but get food enough, and that it should not be infected.
Before discussing various factors that influence the death-rate I will give the death-rate of the infants at the Incubators on the "Pike." (Table 26)
April - December September-December
No.
Died.
Recoveries,
Per cent.No.
Died.
Recoveries,
Per cent.Sex
Boys
24
15
37.5
12
5
58
Girls
32
18
44
17
5
70
Total
56
33
41
29
10
65
Gestation, Months
Under 6
2
2
0
1
1
0
6
6
6
0
4
4
0
7
16
4
75
13
2
85
8
5
3
40
3
1
66.
8 1/2
2
1
50
1
0
100
Weight, Grams
Under 1000
6
6
0
4
4
0
1000-1200
5
4
20
2
1
50
1200-1500
4
2
50
2
0
100
Over 1500
13
4
69
12
3
75
Admission
April
2
0
100
May
9
3
66.6
June
9
8
11
July
12
8
33.3
August
8
6
25
September
8
3
62.5
October
7
5
29.5
November
1
0
100
On account of the imperfect data it will not be practicable to make a comparison of the mortality of the First Series -- May to August inclusive, with the figures of Budin. The death-rate during September to November (Second Series), when placed in the categories suggested by Budin, is shown in Table 27.
Category
Weight, Grams
Infants
Deaths, No.
Deaths, Per cent.
Living, No.
Living, Per cent.
1
Less than 1200
6
5
83.3
1
16.1
2
1200-1499
2
0
0
2
100
3
1500-1999
6
1
16.3
5
83.3
4
2000 or more
5
1
20
4
80
Showing death-rate of Premature Infants during the months of
September to November, 1904, inclusive.
I must admit that this table is not entirely valid, since a few of these infants were turned over to me from the First Series in the incubators. One infant I have excluded from this table, it was an infant weighing 3182 grams and suffering with atelectasis. It died a few hours after it was received and was never in the incubator.
The two deaths of infants weighing more than 1500 grams are scarcely pardonable. One was clearly an infection, the other died from multiple hemorrhages after a very long drive in the ambulance. Excluding infants weighing less than 1200 grams, our mortality from September 1st to December 1st, 1904, of premature babies placed in the incubator was about 15 per cent.
What has our experience taught in regard to the weight of the infant and its likelihood of living?
Infants weighing less than 12200 grams at birth rarely live with any form of treatment. The cause of death is an inadequate food absorption, so that signs of exhaustion soon appear (cyanosis and hypothermia).
Literature, however, records a few infants who weigh less than this and still survive for many months. Occasionally an infant, as in the case of twins, will not be born until 8 months' gestation and still weigh less than 1300 grams and will, consequently, have more resisting power. Undoubtedly infants born at 6 months' gestation, or less, weighing less than 1000 grams, may live in spite of its weakness.
Before dismissing the subject of the mortality, it is interesting to note that the inherent vitality of premature infants seems to differ; some apparently struggle through hygienic surroundings and thrive with very little care on the part of the mother. The case reported by Oberwarth (Berliner Klin. Woch., July 13, 1903) is instructive in this connection:
A male infant, prematurely born at 27 weeks' gestation, was wrapped in a newspaper and laid on a couch, where it remained for eight hours. It being still alive at that time it was placed in bed with its mother. Thereafter it was placed in a basket and surround by hot water bottles. For nineteen days its skin was very cold. On the tenth day it weighed 1 pound (about 455 grams). It was fed on cows' milk, 1 part to 3 parts of water, with cane sugar added. It was too feeble to nurse, so it was fed with a spoon, receiving about two teaspoonfuls every two hours. On the twelfth day in June, it was taken out of doors. When one month old it weighed 750 grams and was growing very well, in spite of a suppurative otitis that developed.
This infant was entirely under the care of the mother, only the midwife gave advice as to care and feeding. It received a daily bath.
In literature Oberwarth found seven cases of infants weighing less than 2 pounds (910 grams) who lived varying periods from 10 days to 11 years.
One remarkable example may be cited from our cases, First Series:
Case 31. -- Esther, born June 30th, gestation 5 1/2 months, weight 600 grams; entered with a rectal temperature of 104.4° (portable incubator too warm). Placed in incubator but the temperature was not recorded. She was fed on mother's milk in 20 drop doses every hour. Became cyanosed several times during the first twenty hours. Her rectal temperature remained above 102°. She was given whisky and oxygen for its cyanosis.
July 31. -- Rectal temperature 99 to 100°. No cyanosis recorded. Mother's milk 20 to 25 drops every hours. This milk was given diluted with water.
August 1. -- History about the same.
August 2. Rectal temperature 98°; defecation only on saline enema.
August 3. -- Rectal temperature 97 to 99°.
August 4. -- Rectal temperature fell to 96°, but was again raised to 100°. Mother's milk increased to 2 cc every hour.
August 7. -- The infant suddenly became cyanosed, with a rectal temperature of 103.6° (infection or incubator too hot?), and died in a few hours.
This infant lived one week and its maintaining life so long gives hope that with greater care some may be saved who are even of less than 6 months' gestation.
With infants weighing more than 1500 grams the death-rate should be small. In the case of infants weighing more than 2000 grams the death-rate should approximate that of infants born at term.
As to the cause of death in our cases, little need be said. Infection played a most important part during the First Series, and even later was not entirely absent. As mentioned, the infants weighing less than 1200 grams usually died of cyanosis.
The time of death is important. If it lives as long as three days infection must always be considered as a possible cause. Of our babies who died:
The number of infants living less than one day,
8
Infants living more than one day but less than three days
7
Infants living between three and ten days
3
Infants living more than ten days
10
This shows that mortality is greatest during the first four or five days. If infants live as long as one week their chances are very good.
Budin finds that exposure immediately after birth with a reduction of the body temperature has a marked influence on the mortality. Infants whose rectal temperature has fallen below 93° have little prospect. On the other hand, overheating the premature infant so that its rectal temperature reaches 103° is also harmful.
It was the rule that premature infants brought a great distance on a train or in the ambulance invariably succumbed. It is, therefore, preferable to try and rear a baby at home, however poor its surroundings, than to ship it to a distant city for incubator treatment. No infant lived that came farther than five miles in the city. None lived which came from places outside of St. Louis.
In summer the gastroenteric infections are most to be dreaded. It was a curious fact that the death-rate of the nursery graduates was higher than that of the incubator babies during the epidemic which has been previously mentioned. This is accounted for by the fact that the former receive substitute feeding and were less isolated than the babies in the incubator. A catastrophe like this epidemic endangers all institutions and is the most powerful argument against baby asylums of any kind.