NEONATOLOGY ON THE WEB

The Nursling

Lecture 10

Gentlemen,

In 1892 I was authorised to organise at the Charité the first Consultation for Nurslings.

I wish to devote to-day's lecture to the consideration of these consultations and their results, so that you may realise what is being done to better the condition of infants during the difficulties and dangers of their early days.

Every week mothers who have been delivered in this Clinique bring their infants to the hospital to be examined and weighed. In a special register all information regarding the children, such as weight, teething, illness, &c., is recorded, and from these data the infants' curves are plotted.

I do my utmost to encourage breast-feeding, and where a mother's supply is not quite adequate for her infant's needs, I still utilise all the milk she is capable of furnishing, sometimes with the happy result of abundance developing out of insufficiency.

In cases where breast-feeding alone is manifestly impracticable, I prescribe a variable quantity of sterilised milk, which the mother obtains here every morning. Sometimes a mother has no milk at all, and then we are obliged to feed her infant exclusively on sterilised milk.

Each mother receives a pasteboard card, on which is written the infant's number in the register, data of birth, weekly weight, mode of feeding, and daily allowance of milk (see Appendix).

When necessary an infant is brought more than once a week.

Many mothers, though ignorant and poor, are eager to fulfil their obligations to their children, and, instead of abandoning them to their devices, is it not our duty to supervise, direct, and help them to the best of our ability? As one of my pupils has aptly said, "These Consultations are really schools for mothers, for in them not only do we tend the child, but we also instruct the mother, giving her directions for present and future guidance."

You must not infer that my task is always easy. Obedience is scarcely the distinguishing feature of women of the poorer classes. They are beset by the clamorous counsels of their well-meaning but ignorant neighbours, and many a time have they rendered my labour fruitless by supplementing the daily allowance I was giving to their infants, according to the standard laid down by the infallible busybody who lived next door. Now, I limit my Consultations to those who leave my wards. They are already accustomed to be governed by my advice, and are educated to the value of weighing their children from daily observation of the process in hospital. If a nursling is ill, its mother keeps me informed of its progress until the moment of its return to the Consultation.

Of the Consultations for Nurslings which I created at the Charité and at the Maternité, the former is now directed by Dr. Maygrier, and the latter by Dr. Porak. That which I installed here, at the Clinique Tarnier, in 1898, comprised on June 2, 1899, 79 infants.

48 were breast-fed	48
14, at first breast-fed, were then on mixed feeding, for their mothers had an insufficient supply of milk
4 had been on mixed feeding from the first
9, who had been breast-fed or on mixed feeding, were weaned, for we keep infants till the age of two years
This makes a total of 27 infants for whom had been utilised all the milk their mothers were capable of producing	27
4 had been on artificial feeding from the first	4
Total	79

Very rarely does it happen that infants are reared from the beginning on artificial feeding, but these last four on their discharge from hospital had been entrusted to wet-nurses, by whom they were grossly neglected. Their mothers, finding them in a sorry state, had brought them back to us. As these women no longer had any milk, we had no option but to rear their infants on sterilised milk.

At the beginning of June 1899, as is shown on Fig. 119 --

60 per cent. of the infants attending my Consultation here were breast-fed.

34 per cent. were taking all the milk their mothers could yield.

6 per cent. were artificially fed.

Breast-feeding is our special aim. Those who feed their infants exclusively at the breast are required to attend only once a fortnight, if all is going well, while the others must present themselves regularly every week.

When I first began, mothers who were suckling, seeing how well their infants throve, ceased after a time to attend the Consultation. Only those whose infants, being on mixed or artificial feeding, were receiving sterilised milk, continued to patronise me for any length of time. But, nowadays, mothers are beginning to appreciate the benefits of medical supervision, and many who give their children nothing but the breast now attend with unfailing regularity.

The cows' milk which we distribute is contained in small sterile bottles. As in each there is enough for only one meal, overfeeding is avoided. The contents of any bottle, once uncorked, must be used immediately or discarded.

Each litre of milk we receive costs the public authorities 20 to 25 centimes. The expense of sterilisation and of distribution raises its price almost to 35. Our daily output being from 18 to 20 litres, we spend annually about 2500 francs [about one hundred pounds sterling]. With this comparatively small sum I conduct a Consultation numbering 79 infants.

What results have been obtained? What has been the general health of the infants? How has their mortality been affected?

As regards general health, I have told you in last lecture that our nurslings enjoyed complete immunity from rickets, infantile scurvy, and the dyspepsia alleged to arise from the use of pure milk. Since 1892 I have had two cases of eczema in nurslings; both were exclusively breast-fed, and the eczema disappeared when the mothers were properly dieted.

As regards mortality, in conjunction with Dr. Chavane, who has always taken an active interest in this work, I have published several series of results. Before discussing my figures let us first see, for the sake of comparison, what is the general mortality among nurslings.

The infantile mortality used to be terrible. At Reims the death-rate among infants under one year was 56.31 per cent. in 1886, and in a single district of Lille it reached the appalling figure of 89 per cent. in 1880. Since the introduction of the "Roussel Law" a great diminution has happily taken place, but the death-rate among nurslings is still considerable. Lédé made a minute and precise investigation of the infantile mortality in Paris for 1885, and found that it was 27.52 per cent. Out of 13,830 infants born, only 10,161 survived, nearly 3700 died.

Bertillon found the death-rate for the four years 1886 to 1890 to be 21 per cent. among infants dwelling in Paris, excluding those under the care of wet-nurses.

In the rich central parts of the capital the number of deaths is less than in the poor peripheral districts, so that, if the infantile mortality was represented on a plan of Paris by shades which darkened as the number of deaths increased, the city would be encircled by the deepest mourning.

Infants sent from Paris to wet-nurses in the provinces must be considered in two categories -- those who are bottle fed and those who are breast-fed.

The nearer the province is to Paris, as a rule, the lower is the mortality, for the nurses are under stricter supervision around the capital than in other parts of the country. Yet in the adjacent department of Seine-et-Oise the death-rate for the first category is 28.21 per cent., while in the more remote province of Pas-de-Calais it is almost 40 per cent.

Among those breast-fed, or considered as such, the mortality is 14.54 in Seine-et-Oise, and 28.57 per cent. in Pas-de-Calais. But these figures are not quite reliable, for many self-styled breast wet-nurses, having no milk, practise artificial feeding, so the mortality in the second category is increased at the expense of that in the first.

In Paris there were 59,112 births and 7089 deaths under one year, in 1898, which makes a mortality of 12 per cent. among infants who, not having left the capital, were nearly all under their parents' care.

From January 1, 1896, to November 14, 1897, the total mortality among infants sent to the provinces was 47 per cent.; out of 32,544 infants 15,295 succumbed.

From 1892, when I instituted my first Consultation, till June 1899, counting only those infants who have been under my care for at least one month, or at most two years, I have had altogether 435 nurslings.

238 were exclusively breast-fed, and 197 were on mixed or artificial feeding.

Out of these 435, 32 have died, which makes a general mortality of 7.3 per cent. The following were the causes of death:--

Broncho-pneumonia (5 following measles, and 1 whooping cough)	10
Pulmonary tuberculosis	1
Meningitis	7
Suppurating glands in the neck	1
Subacute peritonitis	1
Diphtheria	1
Congenital syphilis	3
Small-pox (one of the haemorrhagic type)	2
Infantile cholera	1
Convulsions without further specification from the practitioner in attendance: disease lasted only a few hours: diagnosis uncertain	5
Total	32

The case of infantile cholera was that of an infant S___, No. 881. He had several attacks of diarrhoea, and I discovered that the mother, while she went to work, left him in a day nursery where he was getting impure milk. In spite of my warning she placed him there again on April 24, 1897. Diarrhoea began that night, and next day the child was dead.

This had almost the value of an experiment, for it is the only case of fatal diarrhoea I have had in my Consultations since I started in 1892.

In the general infantile mortality there is a death-rate of special interest to us, viz. that arising from gastro-enteritis. This diseases rages especially during the height of summer, and affects mainly bottle-fed babies, for, under the influence of the elevated temperature, organisms develop rapidly and abundantly in cows' milk, till it becomes little more than a toxic fluid.

In this curve (Fig. 120), due to Malmejac, representing the mortality from diarrhoea in the Seine Department during the year 1896, July is seen to be the most fatal month.

During July 1898 diarrhoea caused 53 per cent. of all the deaths among nurslings. Ten per cent. were fed at the breast, and 43 per cent. from the bottle (see Appendix). During the intense heat which prevailed in the summer of 1898, I contrasted the condition of affairs in Paris with that at our Consultation. On Fig. 121 I have represented the weekly mortality from diarrhoea, during 1898, among infants under one year; below is found the death-rate among breast-fed infants; above, that among bottle-fed. The superposition of the two curves would give the total mortality from diarrhoea which, in order to simplify the figure, has not been indicated.

The mortality from August 7 to September 3 was frightful; in four weeks 833 infants perished from diarrhoea. From August 14 to August 27, 550 of these deaths occurred, of which 493 were among bottle-fed infants. On the curve this sudden increase in the death-rate recalls the appearance of the Eiffel Tower.

What was happening here, at the Clinique Tarnier, during this time? Dr. Chavanne made a careful abstract of all the nurslings who followed the Consultation during June, July, August, and September 1898.

There were 53 infants then regularly attending. Of these 19 were breast-fed and 34 bottle-fed. Digestive troubles arose in 12; in 9 the attacks were slight, in 3 they were serious. The morbidity from alimentary causes was consequently 22 per cent.

As there were no deaths our mortality was zero.

Below the towering columns, which indicate the mortality from diarrhoea among infants in Paris during these four months, is a horizontal line, corresponding to zero, which represents the death-rate at our Consultation. (For the year 1899 see Appendix).

Since I instituted the first Consultation for Nurslings in 1892 many others have been organised. That which Dr. Variot inaugurated at his dispensary in 1893 has given excellent results, and rendered inestimable service to the poor of Belleville. My former pupil, Dr. Henri de Rothschild, in March 1896 founded a Consultation at his dispensary; the same experiment has been made by Dr. Dubrisay, and also, at the Hôpital Tenon, by Dr. Boissard, who was my assistant at the Maternité.

On the initiative of M. Paul Strauss the General Council of the Seine have organised Consultations at their dispensaries in Paris and the neighbourhood.

Under the direction of my colleague, Dr. Napias, three others were opened in March 1899, and I am convinced that his tireless energy and boundless enthusiasm will tend greatly to further the movement.

Organisations for helping nursing mothers would materially add to their utility by including Consultations in the scope of their work. Each week a doctor could weigh and examine the infants, advise the mothers, and distribute, when necessary, bottles of sterilised milk of good quality. In this simple manner the great dangers of impure milk, overfeeding, and premature weaning would be avoided. A great stimulus, also, would be given to breast-feeding, for mothers, in receipt of monetary aid, might receive the full grant only if their breast sufficed to nourish the infant, and, if sterilised milk was necessary, the cost might be deducted from the mother's subsidy. This would prove a substantial encouragement for suckling, and would ensure that at least part of the money expended would go to benefit the child.

Some dispensaries give milk which they sterilise in small bottles; while others distribute the sterilised milk of commerce. Dr. Variot strongly recommends this. At his Consultation the majority of infants are already weaned before they come under his care. To sterilise milk in small bottles at his dispensary would be, he thinks, a complicated and costly operation, and he considers it simpler and cheaper to distribute it in large bottles. He guards against overfeeding by giving to each mother a small, graduated vessel, on which is indicated the maximum quantity of milk to be taken at any given age.

Variot and Marfan fear that milk sterilised in small bottles at hospitals and dispensaries contains toxins injurious to infants. They insist upon the importance of sterilising milk as soon as it is drawn, and laud the commercial product, which, they believe, is heated to 110° C. at once on its collection, as it should be, but, unfortunately, as it rarely is.

At the beginning I had the same fears, but the milk I use at the hospital is pasteurised to preserve it during transit, and is sterilised upon arrival. I have never seen any manifestations of these alleged toxins, and it is probably that, if ever formed, they are, like most other toxins, destroyed by the subsequent sterilisation at 100° C.

I continue, therefore, to use milk which I sterilise in the hospital. It does not cost more than that commercially sterilised, and I am certain of its age. The industrial product is not stamped with the date of preparation, and is sometimes a very ancient fluid. Each of our small bottles is immediately used; none are exposed to the danger of contamination from repeated withdrawals of small amounts; and as each contains enough for only one meal, there is never any risk of overfeeding.

All through the provinces Consultations are being organised.

In 1893, the Municipality of Dieppe unanimously voted the sum of 2000 francs for the creation of a Consultation for Nurslings.

In July 1894 Dr. Berlioz obtained a grant from the local authorities, for the distribution of sterilised milk during summer, to the infants of the poor at Grenoble. The excellent results he had obtained I communicated to the Academie de Medecine in 1897. [1]

The pioneer in the provinces was Dr. Dufour of Fécamp. In July 1894, without any knowledge of my work in Paris, he instituted a Consultation for Nurslings under the happy and picturesque title of "Goutte de Lait."

"The sphere of the 'Goutte de Lait,'" writes M. Dufour, "is to give to mothers all possible advice and encouragement in the suckling of their children.

"As often as the maternal supply is inadequate and demands an artificial supplement we provide the requisite amount of milk, and the infant is reared on mixed feeding.

"When it is proved to be a physical or social impossibility for a mother to suckle, the Consultation takes the responsibility of preparing the milk destined for the infant, so as to ensure its quality and purity.

"All infants in the town of Fécamp are admitted to the benefits of the Consultation. They are separated into three categories: 1. A gratuitous section. 2. A partial-paying section. 3. A paying section. The first comprises infants of the poorer classes; the second, those of the artisan class; and the third, those of the middle and upper classes. All, however, receive the same milk, prepared and distributed in the same manner."

Dr. Dufour does not give undiluted cows' milk to infants. He believes in modifying it so as to approximate the composition to that of human milk. He dilutes it with one-third of its bulk of water, and to each litre of this mixture adds 15 to 20 grams of fresh cream, 35 grams of lactose, and 1 gram of sodium chloride.

The milk thus modified is measured into small bottles, each of which contains the equivalent of one meal, and, after being sterilised at 102° C. for three-quarters of an hour, it is ready for distribution. Great care is taken to avoid overfeeding. He thus expresses himself with regard to his results:--

"Further, from the rigour with which they are dieted these infants derive an increased resistance to disease. I can verify Dr. Budin's assertions on this point from my own experience. My little clients, whether breast or bottle-fed, never being gorged with food, have neither eczema nor tumid abdomens; these are things unknown at the dispensary of the 'Goutte de Lait.'

"Although employing 'humanised' milk I never have a single case of rickets, and yet I rarely give quantities greater than 1200 grams per day.

"As the milk is heated for three-quarters of an hour to between 100° and 102° C., all possibility of tuberculosis is excluded.

"Our milk, freshly drawn, 'humanised,' and sterilised at the dispensary, is consumed within twenty-four hours, and although I have now been conducting this work for five years I have yet to see my first case of infantile scurvy."

Dufour's statistics are extremely interesting, for he has been able to compare the figures obtained at his dispensary with those from the town of Fécamp. The following table is a synopsis of his results.

Years	The "Goutte de Lait"		Town of Fécamp
	Number of Infants	Mortality from Diarrhoea (per cent.)	Number of Births	Mortality from Diarrhoea (per cent.)
1894-1895	33	0	400	6.80
1895-1896	73	6.80	429	18.18
1896-1897	68	3.97	420	9.51
1897-1898	125	2.26	455	12.00
1898-1899	156	1.28	434	9.67

The mortality from gastro-enteritis has been steadily diminishing at the Consultation since 1895. The year 1894-95 can scarcely be taken into account, for the Consultation was not begun till July, and, as very few of the 33 infants were members during the deadly summer months, the death-rate of zero has but little significance.

The difference between the mortality from diarrhoea in the town and in the Consultation is made more evident by the accompanying tracing (Fig. 112).

The increasing popularity of the Consultation is also noteworthy. The attendance rose from 33 in 1894 to 156 in 1898. Out of 434 born in Fécamp from July 1, 1898 to July 1, 1899, 156, that is more than one-third, became members of the Consultation, and of these a certain number belonged to the paying section.

In order to emphasise the results he obtained during the fatal summer of 1898, Dufour collected statistics from the principle towns of Seine Inferieure. He noted the number of deaths under one year from diarrhoea during the month of August, and contrasting this with the number of births, showed the loss sustained by society:--

Town	Mortality from Diarrhoea
Rouen	76.6 per cent.
Bolbec	66.0 per cent.
Havre	51.2 per cent.
Fécamp	16.0 per cent.

At the "Goutte de Lait," although the mortality from diarrhoea was calculated not for infants from zero to one year, but from zero to two years, and not for the month of August alone, but for the three months, July, August, and September, it was yet only 2.8 per cent (Fig. 123). The eloquence of results such as these, gentlemen, raises Dr. Dufour's work above criticism.

Many towns in France and other countries now have Consultations for Nurslings; their number is rapidly increasing, and the movement is taking a comprehensive grasp of the leading civilised communities.

In many Consultations, unfortunately, artificial feeding is the rule. In some dispensaries in Paris it is almost exclusively practised, for mothers bring their infants only after they have weaned them. Personally, I am much more favourably situated. The authorities limit my Consultation to infants born in the Clinique. Every woman I deliver must suckle while in hospital. On a chart at the head of her bed she notes with interest the curve, which represents from day to day the progress of her infant's weight. When she leaves the Clinique she is usually both willing and able to nurse. We do our utmost to encourage her to perservere, and we find, from year to year, that maternal feeding is steadily increasing among our patients. To utilise all the milk a mother can furnish, to advise her in rearing her child, to help her with sterilised milk when her mammary secretion does not suffice for her infant's needs, are our aims in instituting Consultations for Nurslings, and a little patience and perserverance will realise their fulfilment.

The use of sterilised milk and the careful supervision of infant feeding has greatly enhanced the value of crèches.

Dr. Drapier, who conducts a large crèche at Réthel, consulted me regarding the feeding of his little charges. In his published results he writes:--

"In 1893 the death-rate from infantile cholera was 13 per cent. I was then using ordinary milk.

"In 1894 I adopted the recommendations of Dr. Budin, and it at once fell to 5 per cent.

"In 1895 it was further reduced to 3 per cent."

If an abstract of the returns for June, July, August, and September of the fatal year 1898 be made for the four crèches in Paris in which sterilised milk is used, under proper supervision, the following table is obtained:--

Crèche	Under the Care of	Total of Infants	Simple Enteritis	Choleraic Diarrhoea	Deaths
Furtado Heine	Dr. Laborde	140	32	1	0
Rue Gauthey	Dr. Gauchas	24	4	0	0
Sainte Philomène	Dr. Belluze	74	2	0	0
Fènelon, Charles	Dr. Bouquet	44	0	2	0
Total		282	38	3	0

For the 282 infants observed in these four crèches, the total morbidity was 14.5 per cent., and that from choleric diarrhoea was 1 per cent.

The mortality was zero.

Compare this with the appalling death-rate in Paris during the same period (Fig. 121).

In a lecture which I was asked to give to the Artisan Congress on April 22, 1892, I said:

"During the last few years I have been privileged to assist in what has been little short of a revolution. Formerly a deadly affection, puerperal fever, terrorised our maternities. To-day, thanks to the progress which has followed the footsteps of Pasteur, women are delivered in safety. In properly conducted maternity hospitals death has now no place, and the results obtained are better in these institutions than at the bedsides of the rich.

"Let us hope that we are on the verge of a similar revolution in the interests of the infant. Recent work, again the outcome of Pasteur's labour, has shown that by means of sterilisation of milk, a process which each can carry out in his own home, a considerable reduction in the appalling infantile mortality is not only possible but practicable. By its use every one, poor and rich, can safeguard their little ones, and taste the sweet joys of family life without the heartrending sorrows. Your country has need of all her children, and humanity demands that we should spare no effort on their behalf."

Gentlemen, Consultations for Nurslings and "Gouttes de Lait" are the instruments from which I look to see the realisation of these hopes of mine. By giving counsel to mothers in the rearing of their children, and by the use of sterilised milk under proper supervision, this revolution may be accomplished. If you are convinced of the value of the principles I advocate -- and you can hardly be otherwise in the presence of the curves I have shown you, and of the weekly demonstrations you have had of the results obtained at the Consultation here -- you will not, I think, remain indifferent. When you see nurslings dying around you, and feel powerless to save them -- who knows? perhaps among them may be those very near and dear to you -- you will then be roused to action, you will become disciples of the principles I preach, and you will protect your little charges from the terrible scourge of diarrhoea.

Then, why wait? Be guided by one who has already been chastened by this sad experience. Begin with your first cases. Counsel and encourage breast-feeding with all your strength, carefully supervise and direct mixed and artificial feedings, and use sterilised milk.

Whether your lot be placed in town or village, organise Consultations for Nurslings.

Strive always to fulfil your function as medical men, that glorious function which consists in consecrating your intelligence and your strength to saving the lives of your fellow-beings.

Footnotes

[1] Bulletin de l'Academie de Medecine, Paris, 1897.

	Fig. 119. Consultation for Nurslings at Clinique Tarnier. A, Number of infants of the Consultation in 1899 who were reared on breast, mixed, and artificial feeding respectively. B, Percentage proportion of infants on these modes of feeding.
	Fig. 120. Monthly mortality from diarrhoea among infants breast-fed and bottle-fed during the year 1896 (Malméjac).
	Fig. 121. Death rate from diarrhoea among infants under one year of age in Paris during the year 1898. Black = breast-fed; red = bottle-fed. The horizontal line at zero shows that the mortality was nil at the Consultation in 1898.
	Fig. 122. Mortality from enteritis in the town of Fècamp and at the "Goutte de Lait" (Dufour). The blue columns indicate the mortality in Fècamp, the red the mortality at the "Goutte de Lait."
	Fig. 123. Mortality from enteritis among infants under one year of age in the principal towns of Normandy and at the "Goutte de Lait" during August 1898 (Dufour).