In France premature births range from 15 to 30 per cent. of all births, according to place and local conditions. Besides this about 5 per cent. more are so feeble at birth as to survive just a few days. According to the law of Malthus, "when the increase of population is not arrested by any obstacle it doubles every twenty-five years in a geometrical proportion," this gives an annual increase of 4 per cent.
Supposing the premature births and those born at full term so feeble as to live but a few days to be only 15 per cent., which is a very conservative estimate, and apply the law of Malthus to the United States, with a population of 70,000,000. This would give us annual births of 2,800,000; 15 per cent. of this gives 420,000 premature and feeble born in these United States annually, the most of which are quietly laid away with but little if any effort being made for their rescue. It is only in the home of the childless or where offspring are greatly desired that any considerable efforts are made to save them.
It is maintained by some that it is inconsistent with the best physical development of the men and women of our nation to rear these little creatures, it being assumed that they will have impaired physical vigor and transmit this to their offspring. I believe this assumption is entirely groundless, and unless these infants inherit syphilis, tuberculosis or other constitutional disease their expectation of life after the second or third year is as good as those born at full term. Lyman Beecher was a seven-months child, so small and feeble that the nurse expressed regret at seeing him breathe and show signs of life. Yet Lyman Beecher lived to a good old age and gave to the world two children whose names will be immortal. It is evident that anything that can be done to lessen the death rate in this army of little mortals is in direct accord with the highest aims and purposes of our profession.
There are two causes that operate to produce the heavy mortality in these cases:
1. The rapid radiation of heat which, unless counteracted, speedily reduces their temperature to two or three degrees below normal.
2. Their lack of ability to digest and assimilate nourishment to keep up vital functions.
Weight at birth is an indication in regard to the viability of the child.
From a tabulated record of 182 premature births at Nice, France, we find that all under 2 1/4 pounds died on the day of birth; all over 5 1/2 pounds lived. This table showed conclusively that every additional ounce increases their expectations of life.
The indications for their care are to maintain a uniform, equable temperature at or near normal, and to administer suitable nourishment at regular intervals and in proper amounts.
In some of our large metropolitan cities there are wards connected with maternity hospitals where there are incubators heated by steam, the temperature is regulated by a thermostat, the receiving air is filtered as it enters, and the amount is regulated by a fan in the chimney. The baby in its little hammock, on a bed of down, can be watched through the glass case. A thermometer at its head registers any variation of temperature. Every two hours the infants are taken out to an adjoining ward where healthy wet-nurses are in attendance. The infants are fed, washed if soiled, and returned to the incubators.
But as only a small percentage of these unfortunates can have the benefit of such treatment, it is necessary to adopt methods applicable to the masses, and the method will vary with the season of the year and the environment of our little patient. If it comes to the home of the well-to-do, where the parents live in warm, comfortable houses, well heated, and are able to provide competent, intelligent nurses, variations of external temperature and inclemency of the weather are not serious difficulties to overcome. But in the homes of the poorer classes of society, the improvident, the impecunious, and the intemperate, inclemency of the weather is a prolific cause of mortality. Artificial heat can be obtained by hot water bags, hot bricks, etc., by direct radiation from stoves, furnaces, or steam radiators, or from these methods combined.
I have taken two children's bath-tubs of metal, one several sizes smaller than the other, padded the smaller with cotton batting and flannel, placed the child in this, and set it in the larger with 2 inches of water between them; under the whole I placed one or two kerosene lamps and maintained an equable heat of the desired temperature in the coldest of weather. In every case it is indispensably necessary to have a thermometer at the child's head to register variations of temperature.
Sudden changes and draughts of cold air are to be carefully avoided, especially when feeding and dressing. If the house is cold and open, I generally curtain off the warmest corner for the baby and its nurse. The food should be mother's milk, or that of a healthy wet-nurse. Almost always these infants are too feeble to nurse, and have to be fed, in which case mother's milk is drawn and fed to them. Some cases refuse or are unable to swallow, and resort must be had to the introduction of a soft catheter into the stomach, through which the milk can be poured.
In cases where mother's milk or that of a healthy wet-nurse cannot be obtained, modified cow's milk may be used. Those who have access to the milk laboratories of our large cities, can prescribe the required amount of the different elements, and know that their prescription will be filled accurately and scientifically.
But to us, who do not possess these advantages, a few general facts will enable us to prescribe with approximate accuracy. Different breeds of cows, and the same cows at different seasons of the year, and under different sanitary regulations, will vary considerably in the amount of fat, proteids and carbohydrates which their milk will contain. The same is also true of mother's milk. An analysis of woman's milk and cow's milk will show that the fats are about the same in each; that the sugar is two and seven-tenths per cent. greater in woman's, and identical in chemical and physiological properties; and that cow's milk contains four per cent. of proteids to one and one-half per cent. of woman's milk. Hence to modify cow's milk and make it approximate mother's milk, we must maintain the fat at its normal percentage, increase the sugar and decrease the proteids. This can be done by taking cream with the required percentage of fat, reducing with sterilized water and adding milk sugar. We are very apt to think of cream, as entirely different from milk, but it differs only in a higher percentage of butter fat, and slightly less of proteids and sugar.
Cream obtained by the centrifugal method contains sixteen per cent. of butter fat, can be obtained from new milk without standing, and is very stable in its constituents; it would, therefore, be well to use it as a unit of measure. But when we cannot have access to cream made by this process, we can get approximate results by the gravity method. Set a four per cent. milk on ice, or in cold water for six hours, skim the top layer, and you will get a twelve per cent. cream; let this same milk stand twelve hours, and it will yield a sixteen per cent. cream. The reduction and combination of these with whole milk, sterilized water, and milk sugar, will give almost any desired percentage of fat, proteids and carbohydrates.
To overcome the acidity of cow's milk and render the curd flocculent and more easily digested, one part of lime water may be added to every sixteen parts of the mixture.
December 7, 1896, I delivered Mrs. H. of twins at the seventh month of gestation. The sum of their weights was four pounds, one being an ounce or two heavier than the other. The parents' living rooms were over a butcher's shop, and were quite cold. The babies were washed about the face, wiped, oiled with warm olive oil, wrapped in cotton batting and flannel, placed in a sewing basket on a stand near a hard coal stove, and curtained off from the rest of the room, through which cold draughts were constantly passing. A thermometer was placed between them, and the temperature maintained at 99° to 100° Fahrenheit. They were fed with milk drawn from their mother every two hours. Once a day the cotton was removed, and fresh oil and cotton applied.
The first four days they moaned continuously and were fed with difficulty. After two weeks they were able to nurse, but were kept oiled and wrapped in cotton for two months, at which time they weight about six pounds each. At the present time they are as active and vigorous as the average children of their age.
The object in using warm olive oil is to keep the skin soft and moist, and prevent the dermatitis that so frequently attacks premature and feeble infants; it also does away with the necessity of frequent bathing of the child, and thereby exposing it to the danger of becoming chilled. I would use the warm olive oil only during the coldest part of the season, and wrapping in cotton batting is preserable [sic] to putting on cloths in all these cases.
I am indebted to Dr. Rotch's tables and to Westcott's article in the January, 1898 number of the Archives of Pediatrics for some of the facts contained in this paper.