NEONATOLOGY ON THE WEB

The Nursling

Lecture 2

Gentlemen,

In our last lecture I spoke to you of weaklings, i.e. infants born before term. I showed you how important it was to pay great attention to their temperature; I pointed out how rapidly they became chilled; and I also impressed upon you that cold could injuriously effect the better-developed and more resistant full-term child.

Yesterday, we had a striking example of this. A mother, delivered here several weeks ago, wished, in spite of the cold, to bring her infant to the Consultation. She was extremely anxious to have our advice, as after ten pregnancies this was her only living child. She came from the outskirts of Paris. On arrival, the infant had a sort of cold stroke; it was dyspnoeic, cyanosed, and had a rectal temperature of 35° C. It was rubbed, put in a hot bath, and gradually it revived. It was cared for in the hospital till it had thoroughly recovered, and every precaution was taken to obviate chilling on the homeward journey.

If such serious symptoms can arise in a full-term child of several weeks, from an exposure to cold, it is easy to realise how frequent and fatal is the chilling of premature infants.

The temperature of weaklings must, therefore, be maintained at normal. Thanks to the use of incubators, hot baths, and other means, this may be done; but it is not the only essential. A living being must generate heat. The infant must produce its own animal heat, and we must provide it with fuel by giving it food.

You know what takes place. Food is introduced into the alimentary canal, and there modified by the various digestive juices.

The products pass into the blood and lymphatic vessels of the intestine, and thence are carried to the right side of the heart by the inferior and superior venae cavae.

The blood containing the assimilated food-stuffs is sent to the lungs, where it obtains oxygen from the air, and then it returns to the left side of the heart to be propelled throughout the body.

In the midst of the tissues the food-stuffs are brought into intimate relation with the oxygen, and combustion takes place, with the production of heat. To generate animal heat two things are thus necessary: (1) oxygen; (2) substances which can be oxidised, or burnt up in the economy. This entails not only a pulmonary apparatus capable of functioning, but also a digestive tube capable of rendering nutritive materials assimilable.

How are these different functions performed in infants born long before term?

There is no doubt that in those who come into the world after only six or seven months of intra-uterine life, the various organs are not fully developed. Respiration at the beginning is purely bronchial, and as it is only little by little that air penetrates into the pulmonary alveoli, the blood is at first imperfectly oxygenated. In the digestive apparatus, the salivary and gastric glands, the liver, pancreas, and intestinal villi are also, probably, incompletely developed. At present, the actual structure of these various organs is still under investigation, and is a very interesting field for anatomical research.

How do the substances elaborated by these embryonic glands act on the food which the weakling ingests? Here, again, is considerable scope for research. What I have said, however, suffices to show you, that an infant born before term is not very fit to carry on the work of digestion and assimilation essential to the generation of its animal heat.

To say that the newly born is only a digestive tube is certainly to exaggerate. Nevertheless, the importance of the alimentary tract must not be underestimated, for, if digestion and assimilation are not properly performed, the gravest of symptoms, even death itself, may result.

Let us, then, see how infants born prematurely, congenitally feeble, ought to be fed.

Almost from the time I undertook the direction of the department for weaklings at the Maternité, I was greatly impressed not only by the facility with which they became fatally chilled, but also by a curious clinical phenomenon of which, till then, I had had little experience. I observed that a few days after their admission infants frequently had attacks of cyanosis. They suddenly became blue, as if part of the milk they had taken had passed into their air passages, and was choking them. If assistance was not immediately rendered, they died. If, however, energetic measures were promptly taken, they usually revived, although many succumbed to subsequent attacks.

In searching for the possible cause of these cyanotic attacks, I noticed that, as a rule, infants, in whom they occurred, were underfed.

In order to find the amount of food taken by weaklings, they were weighed before and after each meal, and the difference between the two weights showed how much milk had been swallowed. This was marked on a card, and it was only necessary, at the end of the twenty-four hours, to add up these differences to ascertain what quantity had been taken throughout the day. Obviously, there may occasionally be some difficulty in giving a fixed quantity at each meal, but it can be done to within a few grams.

It was thus easy for me to prove that, in general, infants attacked by cyanosis were insufficiently nourished. Here, for example, is the history of a weakling brought to the Maternité, in 1895, and registered as No. 194. It was born in Paris on May 30, and carried to us the same day. On admission, it had a rectal temperature of 34.9° C., and weighed 1930 grams.

On the sixth day it vomited a little; on the eighth, June 7, it had cyanotic attacks, which recurred on the following days. The infant took very little nourishment, and it was impossible to increase the quantity, for it continued to reject most of the milk given. On the sixteenth day the vomiting ceased, and with it the cyanotic attacks (Fig. 8). During the succeeding days the quantity of milk was increased, but on the twenty-first day the cyanotic attacks again appeared. Under the circumstances, the amount absorbed was, perforce, insufficient, and as is seen, on Fig. 8, the quantity of milk ingested was less than that which is indicated by the dotted line, representing the amount which ought normally to have been taken.

The vomiting ceased at last on the thirty-sixth day. On the thirty-seventh, there was still some cyanosis, but from this date we were able to greatly augment the supply of milk, until we even surpassed the average amount. The infant had no further attacks. It began to grow regularly, and on August 9 left hospital in good health, weighing 2600 grams.

Among my other cases of this affection, there is one with an equally interesting history, for, as it was brought to me in summer, it is impossible to attribute its cyanotic attacks to cold. Born on June 24, 1895, it was admitted on July 3, and registered as No. 231. It had, on entry, a rectal temperature of 36.7° C., and weighed 2290 grams. This infant was nourished by its mother. On arrival at the Maternité it had an attack of cyanosis, and others occurred on the following days. It was vomiting, but its stools were yellow. It was receiving insufficient nourishment, as is seen on the curve of the quantities it took (Fig. 9). It soon ceased to vomit, and from July 10, seven days after admission, we were able to increase the doses of milk. The cyanotic attacks disappeared, with the exception of two slight relapses on the tenth day. The infant took more and more each time it was put to the breast. On July 28 it left the hospital, with a weight of 2650 grams, and the mother continued to suckle it.

On August 3 it was brought back, again suffering from attacks of cyanosis. It was not taking the quantity of milk we had laid down as its normal; instead of 560 to 600 grams it was ingesting only from 410 to 490 grams. More was given, and the cyanotic attacks ceased. The infant left, again in good health, on August 13, weighing 3030 grams.

I am convinced by such cases that cyanotic attacks may arise from underfeeding; and if this origin be proved in any particular instance, then, sufficient food should be given, and, provided vomiting does not interfere with assimilation, the attacks will cease.

What ought to be your treatment in cases of cyanosis in weaklings?

The first thing to do is to put them in a glass incubator. I insist on the use of this kind. It is pleasing to the eye; the little inmate is never hidden from the mother's anxious sight; but above all, it facilitates the thorough and unremitting supervision by day and night which these cases demand, for where one attack of cyanosis has occurred the chances are that there will be a second.

When an attack takes place the weakling must be lifted out of its incubator, and everything tried to bring about the re-establishment of the respiration. It should be undressed, and friction applied to the limbs and trunk. Too great force must not be used for fear of injuring the delicate abdominal organs, especially the liver. Rhythmic pressure should be made on the thoracic walls, and if the mouth contains any mucous, it should be cleared out. Sometimes it is of service to hold the infant up by the legs, head downwards, so as to determine an afflux of blood to the brain, and I have had recourse with success to insufflation in a few cases. When breathing recommences the infant is plunged into a hot or a stimulating bath. After it has fully recovered, it is put back into the incubator. Oxygen, supplied through a funnel, the large opening of which is placed beside the infant's face, may then be used with advantage.

Afterwards, it is necessary to supervise the feeding with a view to increasing the amount absorbed. If the child does not wish to take the breast, or is not strong enough to suck, it must be fed from a spoon, and if it cannot swallow, gavage [feeding by stomach tube] must be employed.

Sometimes vomiting is present, which forms a very embarrassing complication. We must then give only a small quantity of milk at a time, and compensate by feeding every hour and a half or every hour. Food thus given in small bulk is retained and digested more easily.

I have sometimes given potassium bromide. It is of value when gavage is necessary, as it decreases the sensibility of the pharynx. A solution is made, which ought to be used within twenty-four hours, containing 20 centigrams of bromide, the amount which can be administered to an infant weighing about two kilograms.

These are the various measures which I have found useful in the treatment of weaklings attacked with cyanosis. Sometimes in spite of all, they die very quickly, but often they are happily saved. The struggle may be long and anxious; in one of the cases I have just cited, four weeks elapsed before success was assured. So never despair.

I have shown you, gentlemen, that infants attacked with cyanosis need more food. When I first proposed to increase their ration, I ran counter to the opinion of my predecessors in the wards, who held that if more was given than these infants wished to take, digestive disturbances would arise and probably cause death. "But," I reasoned, "these infants have cyanosis, and one thing is certain, they will die if they are not adequately fed. Is this fatal diarrhoea inevitable? I think not, and, at any rate, it is far better to try to do something than to abandon them to their fate for fear of the visionary risks of treatment."

Perhaps you remember the refrain of an old song:

... "puis qui'il nous faut mourrir
Suivons, au moins, le chemin du plaisir."

In this case, the path of pleasure, for adults, is drinking. May it not be the same for infants? I increased their absorption of milk with, as you have seen, the happiest of results.

You must not think I was giving these infants an excessive diet, I raised their ration only to sufficiency. I wish you to be quite clear on this point, for nothing is further from my thoughts than the advocacy of overfeeding, the scourge of infancy. In the wards, you will often see infants put to the breast at every moment of the day and night. They rapidly swallow large quantities of milk, and at the end of each twenty-four hours the weighings show that they have taken far too much. We are forced to keep them apart from their mothers. We allow them to suck only at stated intervals, and for a few minutes at a time. Under this dieting any digestive troubles disappear, diarrhoea ceases, and the infant's weight increases normally. Only this morning, you saw a woman weeping in the wards because her infant, overfed, and, in consequence, indisposed, had to be separated from her. Weaklings are more readily affected by excessive diet than full-term infants. Let me give you a typical case.

An infant, No. 157, born on March 11, 1895, was brought to the Maternité on March 26, with a weight of 2120 grams. This weakling, who has a fine curve (Fig. 10), was a source of great concern to me for some time; its stools were liquid, almost quite green, and only partially digested. It increased in weight, but its digestion remained far from good. At the bottom of the figure, you will see the total amount of milk it took each day. This greatly surpassed that which it should normally have absorbed, according to its weight, and which you see indicated by the dotted line. Little by little, however, I reduced the amount to what it should have been, and the stools gradually improved.

These overfed infants suffer from indigestion and diarrhoea, and they very quickly lose weight. It is only by careful dieting that their digestive tube can be restored to a healthy state.

You see in what a predicament you may be! If too little be given, there is the danger of inanition, cyanotic fits, and death; if too much, there is the dread of digestive troubles, which may also prove fatal. The two extremes, overfeeding and underfeeding, must be avoided, so the average quantity of milk for an infant has to be ascertained.

With a view to establishing this average the post-mortem capacity of infants' stomachs, at various periods of intra-uterine life, has been estimated, but this method does not seem to me to be reliable; the walls of the stomach are not inextensible, and after death the organ may be found dilated even when empty.

I have proceeded on a different plan. Every day the quantity of milk taken at each meal by weaklings at the breast was observed: for infants, who for various reasons were not suckled, what was introduced by gavage or otherwise was noted. A simple addition enabled the total quantity taken in twenty-four hours to be thus ascertained.

I accumulated a large number of such observations relating to infants of known weight, taking the quantity of milk sufficient for their normal development. They presented neither cyanosis nor diarrhoea. Their weight increased regularly and adequately, and their daily temperature was normal.

My method, then, was based purely on clinical observation reinforced by the balance and thermometer.

In the days immediately following their birth weaklings do not take much milk, but the amount increases day by day. From the ninth or tenth day, however, it augments relatively at a much slower rate, so it is necessary to distinguish between --

A. Infants during their first ten days.

B. Infants after their tenth day.

A. During the initial ten days of a weakling's life, when all goes well, the weight at first diminishes, then remains stationary, and finally increases.

The quantity of milk ingested becomes progressively greater: quite inconsiderable at the beginning, it augments more and more as the days go on. Since it varies with the infant's weight, I have divided them into three categories:--

1. Infants weighing between 1350 and 1800 grams.

2. Infants weighing between 1800 and 2200 grams.

3. Infants weighing between 2200 and 2500 grams.

Of those in the first category I have 11 observations.

Of those in the second category I have 31 observations.

Of those in the third category I have 25 observations.

In the following table the average quantities taken each day are reproduced:--

	1. Infants weighing less than 1800 grams	Infants weighing from 1800 to 2200 grams	Infants weighing from 2200 to 2500 grams
	11 infants	31 infants	25 infants
2nd day	115 grams	128 grams	180 grams
3rd day	160	175	236
4th day	210	226	295
5th day	225	308	335
6th day	250	324	370
7th day	280	335	375
8th day	285	350	385
9th day	310	380	415
10th day	320	410	425

In each category, the quantity of milk absorbed by the infant is seen to augment from the second to the tenth day. It is greater for infants in the second category than in the first, and in the third than in the second.

This is quickly seen on looking at the three tracings at the foot of Fig. 11, where the quantities of milk are indicated.

On the same figure, I have placed above each of the tracings of the quantity of milk the weight curve of an infant belonging to the corresponding category.

To represent infants weighing between 1350 and 1800 grams, I have taken the curve of a weakling, No. 662, born at the Clinique Tarnier on May 15, 1898, with a weight of 1690 grams. It was carefully guarded from cold, and it left hospital on June 14, weighing 2050 grams.

For the second category, between 1800 and 2200 grams, the curve is that of an infant born at the Clinique Tarnier, on November 22, 1898; it then weight 2030 grams. By the tenth day it had attained 2130 grams, by the twelfth 2190, and by the twenty-third, when the mother wished to leave, 2475 grams.

In the third category is found the curve of an infant born on October 31, 1898, weighing 2270 grams; it was kept warm, and it had a very fine curve (see also Fig. 17).

If these three curves be compared, it will be seen that that of the infant in the first category, after its initial fall, has but tardily begun to rise, and has made a slow ascent. The curve of the infant in the second category has commenced to mount sooner, and has risen more rapidly. That of the infant in the third category has risen still earlier, and has progressed still more rapidly.

When infants are smaller than those in our first category, their weight is seen to fall lower; their curve remains longer stationary, and mounts even more slowly. This was well shown by an infant born on April 21, 1898, with a weight of 1270 grams (Fig. 6, p. 16). On May 1, it weighed 1070 grams, a loss of 200 grams in ten days. On May 31 its weight was 1550 grams, an increase of only 480 grams in thirty days. On December 22, 1898, it weighed 4800 grams.

The conclusion that follows from these observations is that little milk should be given to a weakling during the first days of its life, but that the quantity should be increased progressively and according to the weight of the infant, in the proportions indicated on the table of the category to which it belongs.

It is possible thus to avoid, on the one hand, the fatal consequences of inanition and cyanosis, and, on the other, digestive disturbances and diarrhoea, caused respectively by insufficient and excessive feeding.

When infants are very tiny, they absorb only small quantities at each meal. In rare cases, it may be of service to make them drink every hour and half, so that at the end of twenty-four hours they will have ingested the amount adequate to their needs.

When infants are feeble, they sometimes refuse to suck. Milk is then made to trickle into their mouths, directly from the nipple, by exerting pressure upon it, or they are fed from a small spoon, till they become strong enough to take the breast; but, if they allow the milk to dribble out of their mouths, if they do not swallow, or if they reject what is given to them, gavage, feeding by the stomach tube, must be considered.

In March 1884, Tarnier began to practice gavage methodically, but, in 1851, Marchant of Charenton advocated and described the procedure, and his example was followed by Legroux in 1860, Rizzoli in 1861, Fabri in 1865, and Belluzi in 1870.

The instrument which Tarnier employed was a miniature of that used by Faucher and Debove for washing out the stomach in adults. In 1866 I devised a small instrument for the purpose. It has a glass capsule graduated to 15 cubic centimetres, which enables one exactly to measure the quantity of milk introduced into the stomach (Fig. 12). With this apparatus nothing is easier than to gavage an infant. Tarnier thus describes the manipulation: "The tube, having been moistened, is introduced as far as the base of the tongue. After the infant, by instinctive movements, has caused it to enter the oesophagus, it is gently pushed on, till, having traversed a course, including the mouth, of about 15 centimetres, it reaches the stomach. When the tube has been compressed between the fingers, the nutritive fluid is poured into the capsule, and then, on the pressure being released, the liquid, by virtue of its weight, penetrates to the stomach. The instrument is then withdrawn, but if this is not done by a rapid movement, the nutritive food will follow, and be rejected."

We have seen the quantity of milk which must be given to a weakling during the first ten days; but, how much should it take subsequently. When it does not receive enough, its curve, instead of continuing to rise, forms a plateau. If, after assuring ourselves that the digestive tube is quite healthy, and that no pathological condition is present, we augment the quantity of milk, the infant's weight at once increases, and its curve ascends.

Here is, for example, an infant, No. 88, born on February 12, 1895, and admitted on February 17. It then weighed 2390 grams. At first, owing to the passage of the residue of meconium, it lost weight. Then it began to gain, but after a time, it was found to have become stationary; in four days it had increased by only 20 grams. It was taking a quantity of milk below the proper average for its age: this average is represented by the dotted line on Fig. 13. It was made to take 70, 100, and 120 grams more, and it began at once to put on weight. I should add that it was suckled the whole time by the same wet-nurse.

If, then, an infant does not increase, and you find the functions of the digestive tube being properly performed, but the quantity of milk insufficient, give it more, and its curve will at once begin to mount regularly.

There is a remark to which I attach very great importance, and which I must not omit. If an infant does not take quite enough, it remains stationary. It has no digestive disturbances; its stools are rare, perhaps, but they are perfectly yellow. If more be given, assimilation is rapid, and the weight quickly increases. This observation applies not solely to weaklings, but also to full-term infants, and even to children who weigh five or six kilograms, or more. It is therefore far better at first to give infants too little than too much. If they take too great a quantity, they will assuredly have diarrhoea, and time will be taken up in restoring their alimentary canal to a healthy state.

B. By the observation of many infants, I have been able to fix approximately the quantity of milk, necessary after the tenth day, for those who weigh about 2000 grams, between 1800 and 2500 or 2600, for example. Judging from a great number of facts, which are graphically recorded in the curves I am about to show you, I think that we can find a means of estimating this quantity quickly and with sufficient accuracy.

Let us take, for example, an infant of 2000 grams. Suppress the last nothing, 200 is left. Multiply this figure by two, 200 X 2 = 400; that is to say, about 400 grams of human milk ought to be given to an infant of two kilos. I say about, for, as a rule, more is needed. Give, then, 400 grams, with a small quantity -- 20, 30, or 40 grams -- in addition, always provided that the alimentary tract is healthy, and you will find that such infants under your care will steadily increase.

Let us take as another example an infant of 2500 grams. Suppress the last nothing, you have 250. Multiply this number by two, 250 X 2 = 500.

You ought to give this infant 500 grams of milk plus a small amount, which will vary according to certain conditions, such as the quality of the milk and the assimilative powers of the digestive tube.

It is by the accumulation of many observations that I have arrived at these figures. I must tell you at once, they are true only for infants weighing about 2000 or 2500 grams. They are no longer applicable above 2800 grams, as infants over this weight take a quantity relatively smaller. If, for example, an infant weighed 4000 grams, I would not say it ought to receive 800 grams of milk. This would be altogether too much. These figures, therefore, apply only to healthy weaklings, weighing between 2000 and 2500 grams, and larger infants require proportionally less.

The weakling thus requires an amount slightly more than one-fifth of its body weight. Consequently, if its weight be divided by five, the result will be the quantity of milk it should absorb. An infant of 2000 grams would take a little more than 2000 / 5, i.e. a little more than 400 grams.

Here are several cases in support of these figures.

The first is that of an infant (admission number 116) born on February 14, 1895, and brought to the Maternité on March 2. It was given what we have indicated as the average quantity of milk. This amount is represented in Fig. 14 by the dotted line. The exact quantity absorbed each day is shown by the blue columns. The infant increased regularly: its stools were yellow and of normal consistence. Sixteen days after its admission it was taking a little more than this amount. It continued to assimilate well and to augment steadily. In ten days it gained nearly 400 grams, an average of 40 grams per day.

Another infant, born on July 8, 1895, was admitted on July 9, and registered as No. 246. It weighed 1440 grams. After the usual initial fall, it began to increase. Its curve (Fig. 15) indicates its progress from week to week and not from day to day. The quantity of milk taken from the tenth day closely follows the dotted line, which represents what we have laid down as the normal. The infant left hospital in excellent health on September 16, weighing 2990 grams.

Obviously these figures constitute only an average, and have but a relative value. It is necessary to take into account the state of the alimentary tract, the weakling's powers of assimilation, and also the quality and composition of the milk.

There are some infants who take larger quantities and thrive. So long as their digestive tube functions well, one can afford to wait. For example, an infant was born in Avenue Carnot, on January 1, 1898, weighing 2180 grams. At the beginning it lost weight, then it began to gain. On examining its curve (Fig. 16) you will see that from the tenth day it took much more than the average, till it reached an excess of 100 grams. Its alimentary tract was acting perfectly, so I did not interfere. It increased 700 grams in seventeen days, an average of 40 grams per day.

This weakling was in charge of a wet-nurse, who also suckled her own infant. She made the nursling feed first, so he took the milk less rich in butter, and hence was able to digest a great deal of it without disagreeable consequences.

Other infants, on the contrary, take less than our normal and still augment regularly. This is because the milk ingested contains excess of fat, and thus is more nourishing in smaller volume.

The infant D_____, born prematurely on October 31, 1898, weighed only 2270 grams (Fig. 17). After the initial descent it had a rapid rise. It was fed by a wet-nurse, who also suckled her own child, an infant three months old. You see on the tracing that for a certain time Baby D_____ took a quantity of milk barely equal, or even inferior, to the average we have laid down. On the eleventh day, for example, when it weighed 2440 grams, it absorbed only 400 grams; but the wet-nurse was suckling her own little one first, so that the nursling was taking the last of the milk, which was very rich in butter; an analysis showed it contained 51.55 grams of butter per litre, instead of 35, nearly half as much again as normal milk. From the point of view of butter, therefore, it was the same as if the infant had taken 600 grams and not 400. All was not being assimilated. The motions were copious, and contained 35 per cent. of fat instead of 20; they were badly digested and sometimes also liquid. Thus, although taking less than the average, this infant was increasing greatly, for he was receiving a very rich milk.

The quantities have therefore only a relative value. If the milk be poor in butter, the infant may absorb a larger quantity without danger; if, on the contrary, it be rich in fat, the infant ought to take less, otherwise the excess appears in the stools, and troubles arise from the alimentary tract.

To put it briefly, you will give to an infant a quantity of milk, determined in accordance with its weight, but varying more or less in proportion to the richness of the milk in fat.

Here is an observation which emphasizes the importance of the quality of the milk. An infant, No. 237, born on January 21, 1895, was received on February 16, 1895, weighing 1820 grams. At the beginning he had a very good wet-nurse, whom we shall call A, who was giving him only a little milk, between 400 and 500 grams per day; with her the infant's curve rose regularly. This wet-nurse had to leave. She was replaced by another, B, from whom the infant drank greater quantities; he was now absorbing 500-600 grams, 100 grams more than he had taken from A, and yet he was stationary. His curve formed a plateau during the whole of this period. A third wet-nurse, C, was given to him; at first she gave the same quantity of milk as B, but the infant increased considerably one more (Fig. 18). Later, having a greater weight, he required more.

Here, then, was a healthy infant whose digestive tube was functioning well. He had three wet-nurses in succession; his digestive tube remained unaltered. With the first, who had an excellent milk, he increased considerably; with the second, although he took more, he remained stationary; whilst with the third, although at the beginning he absorbed the same quantity as he did from the second, he had again a very fine curve. You see, therefore, the great importance of the quality of the milk.

Lastly, there is another matter to which I wish to refer. Infants are sometimes brought suffering from diarrhoea. These are little ones, already born some time, who have been badly fed. Some have taken too much, and others have absorbed cow's milk of bad quality, or injurious food preparations. They are often dangerously ill, and our first care is to put their alimentary canal in order.

On July 18, 1896, an infant, No. 193, was brought to us. It had been born on June 19. Its rectal temperature was 35° C., and its weight 2290 grams. It had diarrhoea and vomiting; its stools were copious and green, and its buttocks erythematous. As may be seen on Fig. 19, the infant was put on a reduced diet; albumen water and milk were given, and some intestinal antiseptics were prescribed. The diarrhoea with green stools persisted several days; then the motions, still liquid, became more yellow. The infant continued to lose weight until August 5, and the quantity of milk taken was almost uniformly below normal. The motions became of good consistence. Assimilation was being properly performed once more; and the infant, thus cured, began to increase in weight. The quantities of milk ingested soon rose to the average, and even surpassed a little the line corresponding to one-fifth of its body weight.

Here is another example: An infant, No. 215, born on July 13, 1897, was brought to the Maternité on August 28, weighing 2890 grams. It was not a weakling in the proper sense of the term; it was not affected with congenital debility, but it was enfeebled from an attack of enteritis. The stools were green, and for some days the temperature oscillated between 39° and 40° C. It was cared for, put on an appropriate diet, and at the end of eighteen days the stools became normal, and the infant began to increase in a regular and rapid manner. You see once more (Fig. 20) that the quantity of milk taken was below the average, for some days.

In these cases, therefore, it is essential, first and foremost, to cure the infants by suitable means, of which dieting is of prime importance. When the digestive tube has been completely restored to its normal condition, when the fever has disappeared, when the motions have become yellow and of the proper consistence, the infant begins to assimilate. It then increases in weight, and takes without inconvenience the quantities of milk which we have indicated as the average.

You see, gentlemen, the importance of the digestive tube in the premature infant. Excess and insufficiency in their feeding may give rise to fatal consequences. The quantity they absorb must be regulated. It varies with the age and weight. Immediately after birth the weakling takes very little, but the amount increases regularly till the tenth day. After that the basis for calculation is the weight. On an average a quantity slightly surpassing a fifth of the body weight will be adequate, but this figure is not absolute. It varies with the quality of the milk and the assimilative power of the weakling. If the alimentary canal be in an unhealthy condition, the first thing to do is to cure it, otherwise the infant cannot assimilate, and dies of inanition. You ought to warn the family that it is going to lose weight, but that when its motions become yellow it will increase again, and its curve will rise regularly.

These points being thoroughly settled, how ought we to direct the feeding of a congenitally feeble infant? How one can best avoid errors and have most chance of success, we shall study in our next lecture.

	Figure 8. Cyanotic attacks in a weakling due to under-feeding. The blue columns, which represent the daily amount taken by the infant, do not attain the interrupted line, which indicates the minimum amount required by an infant of this weight. The attacks ceased when then infant was adequately fed.
	Figure 9. Attacks of cyanosis disappear immediately a weakling receives sufficient nourishment. The blue columns indicate the quantities of milk taken per day. The interrupted line shows the minimum required.
	Figure 10. Weakling taking excess of milk and increasing in weight at an abnormal rate. Digestive problems arise, and disappear only when the daily allowance approaches the normal. The interrupted line indicates the normal, the blue columns the actual amount taken each day.
	Figure 11. The blue columns indicate the quantities of milk which ought to be taken each day during the first ten days of life by (1) Infants weighing less than 1800 grams; (2) Infants weighing between 1800 and 2200 grams; (3) Infants weighing between 2200 and 2500 grams.
	Figure 12. Graduated apparatus for gavage.
	Figure 13. Infant taking insufficient milk. It scarcely grows, and remains stationary from the nineteenth to the twenty-third day. The curve becomes normal on increasing the amount of milk. The blue columns represent the quantities of milk taken each day; the interrupted line the average amount required by the infant.
	Figure 14. A weakling ought to take, in general, a quantity of milk equal, or a little superior to, one-fifth of its body-weight. This average amount is represented by the interrupted black line. The quantity actually taken per day is indicated by the blue columns. Curve taken from day to day.
	Figure 15. A weakling ought to take, in general, a quantity of milk equal, or a little superior to, one-fifth of its body-weight. This amount is represented by the interrupted black line. The blue columns represent the average quantity of milk taken daily during each week. Curve taken from week to week.
	Figure 16. Weakling who took the first of the milk flowing from the breast, a milk, consequently, poor in butter. He absorbed a quantity which greatly exceeded one-fifth of his body-weight. Blue columns = daily allowance of milk. Interrupted line = one-fifth of body weight.
	Figure 17. Weakling who, suckled by his wet-nurse after she had given the breast to her own infant, took a milk very rich in butter, and absorbed a quantity inferior to one-fifth of his body weight. Blue columns represent the daily allowance of milk. The interrupted black line corresponds to one-fifth of the body-weight.
	Figure 18. Weakling suckled successively by three wet-nurses, A, B, and C, the quality of whose milk differed. From the first, A, he took less, from the second, B, and from the third, C, more than the amount corresponding to one-fifth of his body weight. With A his weight rapidly increased, with B it remained stationary, and with C it again increased. The blue columns indicate the quantities of milk taken per day. The black line corresponds to one-fifth of the infant's body weight.
	Figure 19. Weakling brought with diarrhoea. Treated by dieting. His weight began to increase as soon as the stools became yellow. He was then allowed to take the normal quantity, which corresponds to a little more than one-fifth of the body-weight.
	Figure 20. Enteritis. As soon as the stools became yellow the infant's weight began to increase.