NEONATOLOGY ON THE WEB

The Nursling

Lecture 7

Gentlemen,

In our last lecture we studied various conditions in which it is still a vexed question whether breast-feeding should be encouraged or not. There are others, however, in which we have no option -- such as those in which congenital malformation prevents an infant from exercising the suction necessary to extract milk from the mother's breast. Here we are compelled to have recourse to artificial feeding.

For example, on March 17, 1893, an infant was born in the Clinique with a hare lip and cleft palate. As it was absolutely impossible for him to be suckled, he was fed from the first on undiluted sterilised milk with excellent results. When three days old he weighed 2825 grams, and when seventeen weeks, 6925 grams. He had thus increased by 4100 grams, or, on an average, 39 grams daily. His curve was quite superior to the normal (Fig. 76). He progressed in such a fashion that at the seventh month, when the malformation was surgically treated, he weighed 11 kilos. After a slight halt, consequent on the operation, he began once more to increase, and to-day is one of the finest children I know.

Recently, I saw another case of the same kind. As the infant was incapable of sucking, it was fed first with asses' and later with cows' milk, undiluted and sterilised (Fig. 102).

Strange to say, there are infants who will not take the breast. This abstention is sometimes only temporary, but occasionally it is permanent. You have just seen in the wards a case of a full-term, well-developed infant whom, at the beginning, we could get to accept nourishment only by means of gavage; he afterwards consented to be fed from a spoon, and some days later to be suckled by his mother. As we had meanwhile given another infant to her to nurse, her mammary secretion was fully established, and she was able herself to rear her child.

On November 6, 1893, I assisted at the delivery of a strangely wayward infant. He was perfectly developed in every particular, except that the roof of his mouth was slightly more arched than usual. He sucked a little at first, but soon altogether refused the breast. Several wet-nurses were tried without success. On November 14 the infant weighed 3030 grams. On November 15, as he would take only 248 grams from the breast, he was given asses' milk in addition. The details of his feeding were as follows:--

Date	Breast Milk	Asses' Milk	Total
November 15	248 grams	300 grams	548 grams
" 16	270	380	650
" 17	318	220	538
" 18	195	490	685
" 19	0	700	700

A second wet-nurse was obtained; as her own child became ill she had to leave, and a third was immediately chosen:--

Date	Breast Milk	Asses' Milk	Total
" 20	385 grams	270 grams	655 grams
" 21	160	505	665
" 22	120	575	695

On the 23rd, in spite of all persuasion, the infant would not suck. Breast-feeding having thus, perforce, to be suspended, asses' milk was given, diluted with lime-water. This mode of feeding was continued till December 2, during which time I still had hopes of ultimately persuading the infant to take the breast. I was then obliged to reconcile myself to rearing him artificially, and from December 3 he took nothing but undiluted sterilised cows' milk. The digestive tract behaved admirably; all our difficulties disappeared, and the curve rose to surpass the normal. On April 5 the infant reached 7550 grams; as it had gained 4085 grams in 123 days its average increase was 33.5 grams per day.

Other infants quite capable of being suckled are yet unable to tolerate human milk. I published a curious example of this in 1893. A child born on February 21, 1893, with a weight of 4800 grams, did not weigh more than 4575 grams on March 2, in spite of having an excellent wet-nurse. Whenever he was suckled he became deadly pale, and between the breast-feeds he seemed to be threatened with syncope. As I was therefore obliged to feed him artificially, I prescribed asses' milk on March 5, and the wet-nurse was dispensed with; on March 9 he weighed 4820 grams. A second wet-nurse with an abundant supply of milk was procured, but, several days after, his stools became badly digested, the pallor on being suckled reappeared, and the semi-syncopal attacks again occurred. On March 16 convulsive movements were observed, and on March 19 he absolutely refused to take the breast. He was again fed exclusively on asses' milk, and this wet-nurse, like her predecessor handsomely compensated, was also allowed to go. Asses' milk succeeded very well to begin with; on April 5, at the seventh week, the infant weighed 5500 grams. But then the former symptoms reappeared; the digestion became imperfect, and the pallor and sync opal attacks recurred. Fearing that there might be some cerebral origin for these attacks, on April 8 I had a consultation with the distinguished neurologist, Dr. Simon, who expressed the opinion that the symptoms arose from purely alimentary causes. On April 10 the infant resolutely refused asses' milk. As this state of affairs persisted on the following day, I was forced to place him on cows' milk. It was sterilised, and given sometimes undiluted, sometimes with one-fourth of its bulk of water added. It was found that he always began to cry about an hour and a half after taking the diluted milk, whereas, after the pure milk he waited two hours without protest. Pure milk was then given exclusively. He throve thenceforth, and his curve became superior to the normal. When aged fifteen months he had twelve teeth and weighed 11,500 grams.

Sometimes it is not the infant but the mother who is the source of difficulty. Some women have practically no mammary secretion. They are extremely rare, but I shall have occasion, later, to report to you in detail the history of a woman, named Liv____, who had three children whom we were compelled to rear artificially as she never had any milk; her breasts were absolutely flat and her nipples umbilicated. Other women have very little milk, and are thus unable to provide sufficient for their infant's wants.

In these cases some other milk must be employed either to replace or supplement the mother's supply. Rich women employ wet-nurses, poor women use animal milk.

The different milks uses are those of the ass, the goat, and the cow. Asses' milk closely approaches human milk in composition, but it is generally poor in butter. It is easily digested by the newly born, who thrive upon it; but large quantities need to be taken, and it soon becomes an inadequate diet for the growing infant (Fig. 102). Asses' are milked twice daily, in the morning and evening; the milk ought to be collected in vessels which have been thoroughly cleaned, and washed in boiling water; heated in a steriliser to about 37° C., and then given pure, without the addition of either water or sugar. Unfortunately it is very dear, keeps badly during summer, and is liable to alteration on boiling. Hence it is but little employed.

Goats' milk is much used in some countries, and is of great value, but it is rarely obtainable in large towns.

It is upon cows' milk, therefore, that we mainly rely for infant feeding. Normally, each litre of cows' milk contains 870 parts of water and 130 parts of solids. The latter comprise--

Butter	40
Milk sugar	50
Casein, salts, and extractives	40

The milk should be obtained from well-nourished, healthy cows; it should be the product of a complete milking, and it should neither be skimmed or watered.

The cows must be healthy; tuberculosis, inflammation of the udder, aphthous fever and other diseases render their milk a source of great danger to the consumer. They must be well nourished; malt and certain other food-stuffs given in excess make the milk most harmful to infants. The milk must be the product of a complete milking, for the first of the milk is generally too poor, and the last too rich, in fat. Lastly, it must be neither creamed nor diluted.

Unfortunately, in large towns, especially in Paris, these requirements are but rarely observed. In 1897, on the initiative of M. Paul Strauss, a commission was appointed for the study of milk as food. The municipal laboratory took, at random, samples of the milk offered for sale in each of the twenty districts of Paris. These specimens were analysed, and here I have depicted graphically the quantity of butter found in each (Fig. 78). The first column, that coloured red, corresponds to a normal milk with 40 grams of butter per litre. All the other columns are smaller; only 6 contained more than 30 grams of butter per litre; 14 had less than 30; and in certain samples we found as little as 19, 17, and even 15 grams. The uncoloured part of each column represents the deficiency in butter, 40 grams per litre being taken as the average. All the milks had been skimmed; the best of them was still without 10 per cent. of the fat; but in some the skimming had removed 41, 43, 45, 47, 49, and even 59 per cent. of the normal amount of butter. In some instances not only was part of the cream wanting, but the milk had also been watered.

I had previously made a similar examination in one of the poor quarters of the city, from which infants were arriving at the Consultation, obviously underfed, although their mothers asserted they were giving them milk in quantities which should have been amply sufficient. Samples of milk were obtained from the various dairies patronised by these women. Here is a graphic reproduction of the results of analyses of so-called milks taken from forty-five different sources (Fig. 79).

Numbers 1 and 2 cost twopence per litre; 3 to 36 inclusive, twopence-halfpenny; and 37 to 45, threepence.

Samples	Butter contained per litre in grams
1	37
4	32
3	31
6	30
4	29
2	28
3	27
4	26
2	25
2	24
5	23
2	22
3	19
2	17
1	16
1	15

Only once, No. 38, did the milk contain 37 grams of butter; this specimen was sold for threepence per litre by a dairyman who had just begun business. Seven times it reached 31 or 32 grams, and the remaining thirty-seven samples gave 30 grams, or considerably less.

Think of the deplorable consequences of the use of such milk for infants and invalids. How can an infant thrive on milks which contain only 19, 17, 16, or 15 grams of butter? He requires to drink a certain bulk of pure milk to obtain the necessary amount of fat. But with liquids such as these he will have to ingest two or three times that volume, which is not only a great inconvenience, but also a menace to the infant's health. Further, mothers, believing they have bought pure milk, consider it their duty to dilute these lacteal fluids with water.

The hospital milk is happily of good quality. The dairymen supply it, on contract, to the public authorities, who supervise it rigorously; it is analysed daily, and, till, 1898, had to contain 27 grams of butter per litre, but since that year the standard has been raised to 38 grams.

Pasteur and his pupils have demonstrated the dangers of milk as a carrier of infection. Bacteria develop in it with extreme facility. Some of these bacteria, as we have already seen, originate in cows affected with contagious diseases; others come from extraneous sources, such as the air, the milking fingers, or the water used to cleanse the milk vessels or to dilute the milk. Introduced into the digestive tube, these organisms multiply, and may give rise to serious disturbances. Diarrhoeas, including infantile cholera, the death-scourge of infants during summer, are caused by microbes.

The milk must, therefore, be maintained unaltered between the time of milking and that of use, and it must, in addition, be rendered inoffensive by making it sterile through the destruction of any germs it may contain.

To achieve these ends many plans have been devised.

The chemical methods of preservation should be discarded. To add bicarbonate of soda, formalin, and such substances to milk is equivalent to fraud, and is, moreover, a danger to the public health.

Preservation can be greatly aided by cold; this is, however, not only relatively a costly process, but it also leaves the microbes intact. The following is the method of refrigeration at present employed:--

A hollow metal cylinder is filled with water, which, by being reduced to freezing-point, is converted into ice. The cylinder with its contents is then inserted into a can of milk, which is accurately closed by the lid-like formation of the upper part of the cylinder. As the milk surrounding the ice-containing cylinder is thus maintained at a low temperature for many hours, it can be conveyed long distances in excellent preservation.

Cold does not destroy either pathogenic or non-pathogenic organisms. Heat is the bactericidal agent generally used for milk, and it is applied chiefly by the methods of pasteurisation and sterilisation.

In pasteurisation the liquid is heated once to about 60° C., and then rapidly cooled. This method enables the milk to be sent long distances; it retards the multiplication is germs, but it does not kill them: as milk thus treated is not sterile, neither is it harmless.

Sterilisation of milk may be achieved in various ways: the milk may be boiled; heated in closed vessels to 100° C. for forty-five minutes; raised to 110° C. for a sufficient length of time; or subjected to discontinuous heating.

It should be boiled as soon as possible after milking, and kept in, and sold from, the vessel in which it has been boiled.

It is customary to boil the milk in an open vessel; before being covered it must first be allowed to cool, otherwise the steam would condense on the cold lid in droplets, which, in running back, would carry into the milk organisms and impurities. If the milk be covered whilst hot, the lid must first be thoroughly cleansed in boiling water.

Boiling kills nearly all germs. Some, however, escape, and under favourable conditions of temperature can multiply and bring about changes in the milk. Milk, therefore, must not be placed in overheated rooms, and, especially during summer, ought to be used soon after it has been boiled.

The milk may be heated in closed vessels in a steriliser at 100° C. Soxhlet recommended that milk destined for infants should be distributed in small bottles, each containing the supply necessary for one feed only, and in quantities determined by the number of the infant's daily meals. He used bottles the mouths of which were planed so as to ensure the accurate adaptation of the stopper he devised (Figs. 80 and 81). They were maintained upright in a metal basket, and placed in a vessel containing cold water. The water having been raised to boiling-point, and kept at that temperature for three-quarters of an hour, the basket of bottles was withdrawn. A relative vacuum developed within each bottle on cooling, so that, the stopper having become more and more firmly applied, the bottle was hermetically sealed.

When a meal has to be given, one of these bottles is warmed, the stopper detached, and an indiarubber teat put on. No germs have been able to reach the milk, and it passes to the infant's stomach as pure as that which flows from a mother's breast.

Soxhlet's apparatus is ingenious; the apportioning of the milk into quantities for single feeds and the automatic closure of the bottles constitute a great advance. But it is not without its drawbacks. The indiarubber disk of the stopper soon stretches, and by rubbing against the metallic capsule becomes slippery, so that it does not remain in position when the bottles are left to cool, and is easily displaced by any slight jar during transportation. Nor does the disk continue to adhere tightly if there is any crack or unevenness in the planed margin of the neck of the bottle. In my experience the operation fails in one or two out of every ten or twelve bottles thus sterilised.

Hence several analogous inventions have since been devised to overcome these defects.

Gentile's has all the advantages without the disadvantages of Soxhlet's. It consists of a plated metal steriliser with a stand for the bottles; graduated bottles; and automatic stoppers.

The steriliser is made in various sizes and, according to its dimensions, is provided with a stand to contain five, ten, or twenty-five bottles.

The bottles are graduated in 25 grams; they contain varying amounts -- 50, 100, 150, or 200 grams, according to the infant's age. There is a large planed margin round the mouth of each bottle.

The automatic stopper is a small red indiarubber disk, on the under surface of which is a central appendage (Fig. 82).

The quantity of milk necessary for a single meal is poured into each bottle and a stopper applied. All the bottles thus prepared are placed in the metal support, which is then put into the steriliser, the cold water in which ought to reach the level of the milk in the bottles (Fig. 83). After the lid has been put on, the whole apparatus is heated over a gas burner; the temperature of the water is raised to boiling-point, where it is maintained for forty-five minutes. This having been done, and the lid raised, the bottle-stand is taken out and allowed to cool. As the temperature falls the stoppers adhere firmly. As the condensation of the water vapour, which during boiling replaced the air within the bottles, gives rise to a relative vacuum, the stopper is thus fixed by the atmospheric pressure on its upper surface, and can be seen to become depressed in the centre as the cooling progresses.

Examination enables one easily to ascertain if this vacuum exists and, hence, if sterilisation has been effected; 1st, the disc of the stopper should adhere tightly to the mouth of the bottle; 2nd, on its upper surface there should be a central depression; 3rd, the water-hammer phenomenon should be present. To elicit this the bottle is held in the left hand; it is then turned upside down, while the bottom is sharply struck with the ulnar border of the right hand; the liquid, displaced by the blow, hurls itself en masse against the sides of the bottle, producing a peculiar and characteristic sound.

Before the infant is fed the milk is heated by placing the bottle in warm water. One of the edges of the stopper is then raised, and air rushes in with a hissing noise. The contents should be tasted, so as to make sure that the milk is of normal flavour, and neither too hot nor too cold. A teat or a galactophore (Fig. 86) is applied directly to the neck of the bottle, and then the infant is fed.

The bottle mouths in Soxhlet's and Gentile's apparatus have planed margins. Not only is their cost thus increased, but if the slightest irregularity exists on this smoothed edge, the indiarubber disc will not adhere on cooling.

I have tried to do away with these special bottles, for, although they may be obtained more or less easily in large towns, they can only be got with difficulty in country districts. I desired also to cheapen the process of sterilisation, for at first the necessary appliances were somewhat costly. I made indiarubber hoods like the metallic capsules which are used on many mineral water bottles. The summit of the hood is hollowed, and at the bottom of the depression the indiarubber is specially strengthened. The free margin of the pat which encircles the neck of the bottle is thickened in the form of a ring (Fig. 84). Any small bottle will serve, such as is used by druggists, for example. It should be two-thirds or three-quarters filled with milk, covered with the indiarubber hood, and then placed in the steriliser (Fig. 85).

Under the influence of heat the milk gives off water vapour, which raises the depressed portion of the hood. To prevent its being entirely lifted off, two small holes are made near the top of the part which encircles the neck. A vacuum is produced inside the bottle on cooling, and the part of the hood over its mouth is bulged inwards so that the bottle is hermetically sealed by atmospheric pressure (Fig. 84 B and C).

These hoods have the advantage of being applicable to any small bottle whatsoever, but they have certain small inconveniences; when the bottles are taken out of the steriliser it is often necessary to readjust the hoods so as to ensure the complete closure of the bottles, and, further, the vacuum is not quite perfect, for the air slowly filters in. However, the sterilisation amply suffices for twenty-four hours; during the height of summer I have seen milk thus prepared remain unaltered for weeks. Bottles sealed in this fashion can be transported with absolute safety.

Before feeding the infant the milk should be warmed, the hood removed, and a teat or a galactophore applied (Fig. 86). The whole apparatus is simple and cheap. The bottles may be had graduated, so that the milk may be dispensed in the quantities necessary for each feed.

I first devised these hoods in June 1892, but I carefully refrained from making them known, for I thought that it was not conducive to the spread of the practice of milk sterilisation to multiply the number of apparatus. Their existence was known only to four persons, and I continued to recommend the inventions of Soxhlet and of Gentile. Imagine my surprise one day, about a year later, when I saw a prospectus lauding their merits and advertising their sale. As my confidants were no less astonished than I, an explanation was demanded from the indiarubber manufacturer, who was the only other person cognisant of them. I threatened to prosecute him. "I confess I am to blame," said he, "but let me explain how it happened. One of my children, bottle-fed, was stricken with diarrhoea and like to die. I had made these hoods for you and knew their purpose. I took several of them, and sterilised the milk given to my little one. His symptoms abated, and he gradually recovered. As I knew the prohibitive cost of the milk-sterilising apparatus on the market, I resolved to make and sell these hoods at the lowest possible price, so as to bring them within reach of the poor, and thus add my feeble efforts to the protection of infant life. I do not seek for gain, I wish only to further this work of humanity. I beg of you to let me continue. You will find the poor have no cause to regret it." I dared not refuse. It was thus my invention was popularised almost in spite of myself.

Nowadays systems without number, each more simple, more ingenious than the other, are manufactured on every side; nearly all are valuable. Competition has brought about the cheapness I so greatly desired to attain, and the only remaining difficulty is the embarrassment of making a choice.

In default of special stoppers there is yet another way of making use of ordinary small bottles. They are thoroughly washed and left to drip. The requisite quantity of milk is poured in, and they are closed by plugs of cotton wool or pieces of linen fastened over their mouths. Then they are placed in a special metal support, and, as before, introduced into a steriliser.

If it be considered needful to dilute the milk, this should be done before sterilisation.

Any milk remaining in a bottle after a feed ought not to be again offered to the infant, for it is no longer sterile. The organisms of the mouth, entering the bottle through the teat, rapidly multiply, and produce alterations in the milk.

Every bottle emptied ought at once to be thoroughly washed. Soap or carbonate of soda added to the water facilitates the removal of fatty particles. After being washed the bottles should be carefully rinsed. This cleansing is of great importance, for dregs of milk become soured and contaminate any fresh supply put into the bottle.

The sterilised milk in these small bottles should be used within twenty-four hours.

If one or more bottles have not been opened, and it is desired to use them on the following day, they must be resterilised.

These different procedures give not an absolute but a relative sterilisation. When milk has to be preserved for more than twenty-four hours it must be freed from all living organisms. This is done either by discontinuous heating below 100° C., or by one prolonged exposure to 110° C. Discontinuous heating is costly, and hence but little used. Sterilisation at 110° C. is widely practiced. Milk thus treated is sold in half-litre and in one-litre bottles. It is also dispensed in smaller bottles, each containing the equivalent of one feed -- 40, 50, 60, 75, 100 grams, &c. These bottles are corked, and each cork should bear a stamp with the date of sterilisation, so that the consumer may know when it was prepared.

Before such milk is used it ought to be rigorously examined to make sure -- (1) that it is of normal appearance, neither curdled nor dark in color; (2) that on opening the bottle the contents are sweet-smelling and do not liberate any gas; and (3) that the liquid has the usual taste of milk.

Cream that has risen to the surface should be put in suspension by shaking after the milk is warmed. The milk should be poured directly into a scrupulously clean feeding bottle. If it has to be diluted, boiled water should be used. If the small one-feed bottles are employed, it is necessary only to remove the cork and fix a teat on the neck.

Weber, Michel, and others have shown that sterilisation has no deleterious influence on the nutritive value of the milk. I need hardly say that the milk which is sterilised must be of good quality, and contain the requisite amount of nutritive matter. I once received a gracious gift of a hundred bottles of sterilised milk for the use of the women and children in the hospital. The milk did not come from the neighbourhood of Paris. On analysing it I found that it contained only 7 to 9 grams of butter per litre instead of 40.

Having discussed the preparation, distribution, and properties of sterilised milk, we can now pass, gentlemen, to the study of mixed and artificial feeding.

When the maternal milk is supplemented by animal milk the feeding is said to be mixed. The infants of the hospital wet-nurses, as I told you, are reared in this way. After several weeks of breast-feeding, if they are thriving they begin to get sterilised milk in progressively increasing quantities -- 100, 200, 300 grams per day, and so on. The infant receives less and less of its mother's milk, which is diverted more and more to the exclusive use of the weaklings. I have also told you of mothers who wished to nurse but yet had not, at first, enough milk, and how we supplemented their efforts either by asses' milk (Fig. 40) or by cows' milk (Fig. 50). Mixed feeding in these cases enabled us not only to await and encourage the maternal supply but also ultimately to ensure that the infant would be fed exclusively at the mother's breast. Therefore, do not hastily conclude that a woman will prove an inadequate nurse. A little patience on your part will save many a mother from the humiliation of employing a wet-nurse, and many a child from the danger of artificial feeding.

Let me cite to you several cases.

A woman named R____, confined at the Charité on December 31, 1892, gave birth to a child weighing 2775 grams. She had not much milk at first. When she left the hospital on January 11, 1893, the baby had attained a weight of 2940 grams. Two days later it was brought to me weighing 2990 grams, and, as it was being fed exclusively at the breast, I thought the mother was going to prove a very satisfactory nurse. On February 17, however, the infant was only 3500 grams. From birth its average daily gain had been only 15.5 grams, which was considerably below the normal (Fig. 87). I prescribed then three bottles per day, each of which contained 50 grams of sterilised milk. A marked improvement immediately followed. Early in May the mother's supply became sufficient and the sterilised milk was suppressed. This child weighed 6570 grams on July 14.

The next is rather a curious case. For some time the mother had no milk at all, and yet she ultimately became a fairly good nurse. This woman, S____i, was prematurely delivered at the Charité of an infant, weighing 2075 grams, which was immediately put in an incubator. When the child was a few days old, an accidental burn on the left arm gave rise to a reflex diarrhoea, which lasted three days. The infant was too weak to suck; it was fed with sterilised milk from a spoon. On January 26, although the child weighed only 1950 grams, the mother insisted on going home. Next day it was found to have lost 50 grams. The mother was carefully instructed how to express the little milk she had from her breast, directly into the child's mouth. In addition, eight bottles, each of 50 grams of sterilised milk, were given daily. On February 3 the burn was nearly healed, and the infant weighed 2150 grams. As it was now beginning to suck, the quantity of sterilised milk was gradually reduced. Artificial feeding was then succeeded by mixed feeding, which, in turn, gave way on March 3 to breast-feeding. The infant's curve (Fig. 88) became superior to that of the average full-term child. Sterilised milk and mixed feeding enabled this mother to complete her maternal function.

But how is one to determine when it is necessary to supplement breast-feeding by sterilised milk; and, after being convinced as to its need, what quantities must be give? The guide is the balance. If the infant's weight is stationary or only slightly increases during a period of, for example, a week, a search should be made for any pathological condition that may account for this tardy growth. If none is discovered, and if the colour and consistency of the motions show that the assimilation is not at fault, then you will find, on weighing the infant before and after each feed, that it obtains but a small amount from the breasts, as the milk secretion is probably deficient. The child is being underfed, and the mother's supply must be reinforced by the addition of sterilised milk.

Never forget the observation I made to you in one of the earlier lectures: "It is better at first to give too little than too much. An underfed child does not increase in weight; it may even diminish; but it is free from digestive troubles, which are mainly the results of excess. The amount can be gradually and safely increased till that necessary for the satisfactory progress of the child is reached."

I can best demonstrate my usual mode of procedure by giving you a few examples.

A woman named Guill____, delivered on June 16, 1896, left the hospital on June 26, when her infant weighed 3940 grams.

On July 11 it was only 4070 grams. Its average daily increase had been 8.5 grams (Fig. 89). After July 13, as the mother's milk was becoming less abundant, sterilised milk was added to the infant's diet in quantities of 320 and, later, of 400 grams per day. On July 18 the infant weighed 4310 grams. In one week it had increased by 240 grams, or at the daily rate of 34.2 grams. On July 28 he was found to have gained only 60 grams in the ten days. The mother's milk, I thought, was probably still diminishing. As weighing the child before and after each breast-feed proved this to be the fact, the sterilised milk was increased to 480 grams per day. On August 22 he was found to weigh 5120 grams. He had, since his diet was increased, gained on an average 31 grams per day. As on August 29 he was only 5160 grams, his daily allowance of sterilised milk was raised to 560 grams. On October 10 he weighed 6310 grams, and had thus gained 1150 grams in forty-two days. On October 17 his rate of growth was found to have again diminished. In the week which had elapsed since the last weighing his average increase had been only 9.4 grams per day. As the mother's supply was steadily dwindling, the supplement was then raised to 640 grams per day, and a fortnight later his weight had increased by 310 grams. And so the history continues. The mother secreted less and less milk, and thus, from time to time, as the child paused in its growth, the sterilised milk had to be increased until the feeding became exclusively artificial.

A woman, by name Mor____, delivered on June 21, 1896, left hospital on July 1, with her infant weighing 3900 grams. On July 4, on being brought by her to the Consultation for Nurslings, he was found to weigh only 3720 grams; he had lost 180 grams. As I was still hopeful that the mother might yet furnish enough milk, I resolved to delay interference. On July 18 the infant was 3800 grams (Fig. 90). The amount of his daily increase was altogether insufficient, as it had been only 5.7 grams. I then gave 150 grams of sterilised milk per day. The infant rapidly gained. On August 8 he was 4580 grams. During these three weeks he had increased on an average by 37 grams per day. In the first week the average daily gain was 45.7 grams, in the second 37.5, and in the third 28.5. It looked as if the mother's supply was diminishing rapidly. On August 15 the infant weighed 4560 grams. As there had been a loss of 20 grams in seven days, his daily ration of sterilised milk was raised to 200 grams. This had the desired effect, for on September 19 the child had attained 5450 grams. On that day an accident befell the mother, and her milk completely disappeared. The infant was given 400 grams of sterilised milk per day. The amount was rather small for one of his weight, but by underfeeding slightly I hoped to stimulate his zeal for sucking, so that the mother's milk might be lured back. On September 26 he was found to have increased by only 50 grams in seven days. As his growth was suffering from his meagre diet, I raised his daily allowance to 640 grams. He gained rapidly. On October 17 he weighed 6230 grams. During these twenty-one days his daily increase was 34 grams.

In these two cases the mothers were but mediocre nurses, and their milk, in spite of all our endeavours, gradually disappeared. In others I have happily met with more success. By improving the mother's general health her milk supply is often rendered more and more abundant, until she becomes capable of amply providing for her infant's nourishment. Then cows' milk may be dispensed with, and the infant reared exclusively at the breast. Here again the balance guides the withdrawal of the sterilised milk. The following is a typical history of a successful case.

A woman named Pouc____ was delivered on November 14, 1897. On December 18 the infant came under my care; he weighed 4070 grams. The mother having had mastitis, gave only one breast. I advised her to suckle with both, and prescribed 250 grams of sterilised milk for the child. On December 24 he weighed 4400 grams. His increase, averaging 55 grams daily, amounted to 330 grams in six days (Fig. 91). As the quantity of sterilised milk was obviously more than sufficient, it was reduced to 200 grams. On December 31 the infant weighed 4650 grams. As he had gained 250 grams in one week, his growth was still considerable. The average daily increase of 36 grams being in excess of the normal, the sterilised milk was still further diminished to 140 grams per day.

On January 8 he weighed 4880 grams. During these eight days, he had increased on an average by 29 grams per day, so I resolved totally to suppress the sterilised milk, hoping that the mother would yield sufficient for the infant's needs. On January 15 he had gained only 70 grams in the seven days. As this increase was quite inadequate, I gave him sterilised milk once more, 100 grams per day. In the fourteen days ending January 29 he rose to 5390 grams. He had increased by 440 grams, so his daily average had been 31 grams. I then gave only 50 grams of sterilised milk, but at the end of seven days, finding he had scarcely increased, I again allowed him 100 grams per day. In the next fortnight, his weight having increased by 360 grams, I made a second attempt to do away with the sterilised milk. The mother responded admirably to the increased demand, and continued the feeding unaided for a considerable period.

By means of the balance every variation in the infant's weight can be followed. It is thus easy to determine the quantity of sterilised milk required in mixed feeding to provide an adequate diet. This amount does not remain fixed. It alters with the infant's needs. Sometimes you may have to increase the sterilised milk till the feeding becomes wholly artificial; sometimes, under happier auspices, you can gradually diminish it till the child becomes exclusively breast-fed.

	Fig. 76. Infant having a hare-lip and cleft palate. Artificial feeding.
	Fig. 77. Infant who could not support human milk. Artificial feeding.
	Fig. 78. Result of analysis of the milk-supply of Paris on June 1, 1898. Columns showing the quantities of butter contained in samples of milk from the various districts.
	Fig. 79. Quantities of butter contained in forty-five samples of milk collected from a poor quarter of Paris (Rothschild).
	Fig. 80. On the left: upper part of a wide-mouthed bottle, with indiarubber disc in place. In the middle: metallic capsule for keeping the disc in position. On the right: disc after sterilisation, showing the effect of atmospheric pressure.
	Fig. 81. Section of a milk steriliser, showing bottles with discs and capsules in position, resting on a metal support.
	Fig. 82. Indiarubber stopper. On the right: stopper in position on bottle after sterilisation. The central depression shows that a vacuum exists in the bottle.
	Fig. 83. Gentile's apparatus.
	Fig. 84. A, indiarubber hood. B, appearance after sterilisation. C, section of hood and bottle.
	Fig. 85. Budin's apparatus for sterilisation.
	Fig. 86. The galactophore for artificial feeding. A, tubes for the passage of air and milk. B, indiarubber stopper by which the instrument is fixed in the neck of a bottle. C, bottle containing milk, showing the galactophore furnished with a teat.
	Fig. 87. Maternal feeding at first insufficient. Mixed feeding temporarily practised. When the mammary secretion became more abundant, the child was exclusively breast-fed.
	Fig. 88. Curve of a weakling who was first placed upon artificial feeding, then upon mixed feeding, and then upon breast-feeding exclusively. The mother, who had no milk at the beginning, ultimately proved an excellent nurse.
	Fig. 89. Curve showing how the quantity of cows' milk has to be increased in mixed feeding.
	Fig. 90. Curve showing how mixed feeding may lead to artificial feeding.
	Fig. 91. Mother had not enough milk. Child placed upon mixed feeding. The mammary secretion became more abundant till the child was exclusively breast-fed.