NEONATOLOGY ON THE WEB

The Nursling

Lecture 9

Gentlemen,

In our last lecture we began the study of artificial feeding, and I laid stress upon the great value of cows' milk, undiluted and sterilised, as a food for infants.

How can we determine the amount to give in any particular case? The capacity of the stomach is too difficult to estimate, and varies too much, to serve as a guide. Neither is the age of use as a standard, for sometimes an infant weighs 2600 grams at birth and sometimes 5000 grams, and this want of uniformity is present at all ages. The weight of the infant would probably furnish a better indication, yet the assimilative power varies in infants of the same weight according to the state of the digestive tube and the composition of the milk. These are factors which further complicate the problem.

The general tendency is towards overfeeding, and I would impress upon you my former remark: "Infants who are underfed are free from digestive troubles. They do not gain weight, but, by gradually increasing the quantity, it is easy to attain in safety an adequate diet for any given case, and then the child will grow rapidly." This is the ruling principle in my work. Each new case is a fresh subject for investigation. For the first few days I always prefer to err by giving too little than by giving too much. Having gradually reached the requisite amount for the nursling in question, I do not increase it unless I am thoroughly convinced of the necessity.

A few examples will enable you better to grasp the details of my method.

A woman named Liv____ was confined on April 19, 1897, of her third child. She had never been able to suckle. The chest was quite flat, the mammary glands were undeveloped, and the nipples were represented only by depressions. She came to the Consultation on May 1. Her infant weighed 3050 grams, and I prescribed 400 grams of sterilised milk per day, divided into eight feeds. On May 8 he had lost 80 grams. I examined him carefully: as he seemed in perfect health, the only possible explanation of the decrease in weight was that he was being underfed. I raised his ration to 450 grams. In one week he had gained 390 grams, and he continued to thrive, so this quantity of milk was obviously sufficient and remained unaltered. From July 17 to 24 he had a slight attack of diarrhoea, which was quickly cured by small doses of calomel. In the ten days ending July 27 he lost 90 grams, and was very irritable after each meal. Thinking he was getting too little, I increased his allowance to 675 grams, and in the following week he gained 250 grams. Similarly, on August 21, he had gained only 60 grams in seven days. I raised the daily amount of milk to 750 grams, and during the next week he increased at the average rate of 51 grams per day. On October 30, 900 grams were given, and on January 29 a little farinaceous food was added to the milk at one of the feeds, so as to make what we call a "soup." On February 26 the milk was increased to 1000 grams. The weight of this infant described practically the normal curve (Fig. 105). My first estimate of its needs, 400 grams of milk, was too small, but when I arrived at the amount sufficient, 450 grams, the child increased in weight by 390 grams in one week. From time to time, when I found he was not progressing to my satisfaction, although his digestive tube seemed to be acting normally, I slowly augmented his daily allowance, and on each occasion the curve rose steeply.

A baby boy, J___ M___, was born on February 1, 1898, with a weight of 3150 grams. At first he was suckled by a wet-nurse, whose milk, however, not being sufficient, was supplemented by asses' milk. On my return to town after three weeks' absence I found that the wet-nurse, having lost her milk, had weaned the child. Greatly against my inclination I continued to feed him artificially. On my prescribing cows' milk, undiluted and sterilised, in carefully graduated quantities, he enjoyed complete immunity from all digestive troubles, and his curve rose superior to the normal (Fig. 106). The wet-nurse, although no longer able to suckle, was retained; she was very intelligent, but her zeal for the child's welfare often put a great strain on her obedience. One could hardly conceive the difficulty I had in preventing her from overfeeding the infant. She was haunted with the idea that he was not getting enough; she was openly displeased at his rate of growth, and pestered me to give him more milk. But as I traced his curve from week to week and found it uniformly above the average, I resisted her importunity to the best of my ability, and gave way only when I thought an increase in his allowance was absolutely necessary.

The milk given to this infant was of excellent quality, as it contained on several analyses 40 to 41 grams of butter. It is remarkable how small an amount the infant required.

He was given 400 grams when he weighed 4070 grams.

He was given 480 grams when he weighed 4800 grams.

He was given 540 grams when he weighed 5400 grams.

He was given 570 grams when he weighed 5800 grams.

In fact the amount he absorbed corresponded to about one-tenth of his total weight.

A woman named Leq____ was confined at the Maternité on December 15, 1893, of a son who, when he left the hospital ten days later, weighed 3050 grams. The mother, unable to rear him herself, through having to work for her living, entrusted him to a woman in the country. We did not see him again till July 8, on which date the mother, having gone to visit him and finding him ill with diarrhoea and in a wretched condition, brought him to us. He had been as one of the family, the wet-nurse had protested, and in all their food, meat, vegetables, &c., he had shared. In the 195 days since his departure he had gained only 2600 grams (Fig. 107).

I prescribed eight bottles of 75 grams, i.e. 600 grams of sterilised milk per day, and on July 15, having gained on an average 31.4 grams per day during the week, he weighed 5870 grams. On August 19, the mother left town, and I carefully instructed her to give him the same amount of milk till her return. The infant weighed 6820 grams, and in the previous forty-two days had gained on an average 28 grams per day.

She came back on September 23. During the interval her child had suffered almost continuously from diarrhoea, and having gained on an average only 13.8 grams per day, he now weighed 7300 grams. On September 28 he was given eight bottles of 75 grams, i.e. 600 grams of sterilised milk per day. On September 30 the digestive troubles had quite disappeared, but the weight was only 7030 grams. His daily allowance was inadequate: 600 grams of milk for an infant weighing 7030 grams was not enough. I increased it to 675 grams per day, and in a fortnight he had gained 470 grams. He progressed steadily till the week ending November 18, in which I found he had lost 70 grams. He was perfectly healthy: he weighed 8120 grams, and absorbed 675 grams of milk per day. As this was evidently insufficient, I gave eight bottles of 100 grams, and he began again to increase in weight. On December 9 his ration was raised to 900 grams, and on December 23 he was given one "soup." Shortly afterwards he caught a bad cold; he lost his appetite, and his weight diminished. He did not take all his milk, so I reduced it to 800 grams per day. Once cured, he rapidly gained the weight he had lost. On February 10 I found, at his weekly weighing, that he had lost 70 grams. He then weighed 9230 grams, and was getting only 800 grams of milk per day and one "soup." He was given 900 grams, and his curve rose steadily till it attained the average height to which hitherto it had been inferior.

Here is another interesting case. A woman named Bon____ was delivered at the Maternité on November 13, 1897, of an infant weighing 3000 grams. In due course she left the hospital, and put her child out to nurse. She returned on January 8, 1898, bringing the infant, a letter, and a certificate. The letter was written on paper with a gorgeous floral design round the margins; it was dated December 30, and conveyed the congratulations of the wet-nurse to the proud mother on the splendid progress her infant was making. She also wished the mother a happy New Year, and gently recalled the fact that January 1 was the time for handsels.

A few days later a certificate arrived from the local doctor to say that the child was so ill as to not be able to support cows' milk, and that breast-feeding was indispensable. The poor woman immediately sought her child, and found it in a state of collapse, suffering from diarrhoea. Its diet had been boiled bread and milk, and since birth it had gained only 370 grams (Fig. 108). I recommended a breast wet-nurse, but as nothing would induce the mother again to part with her little one, I consented to try sterilised milk, and prescribed 400 grams per day. On January 15 the digestive troubles had greatly diminished, the new diet was being admirably supported, and the weight had increased by 200 grams in seven days. On this small amount of milk the infant continued to thrive until March 19, when I had to give 450 grams. The weight was then 5000 grams. A submaxillary abscess appeared on March 5, and had to be incised. This slowed the child's growth for a time, but after it healed the weight-curve steadily rose.

The following observation shows how easy it is to give excess to infants. A woman named Lech____ was delivered of twins on May 8, 1898. When they left the hospital ten days later, the one, Albert, weighed 3410 and the other, Louis, 3250 grams (Fig. 109). The mother not having sufficient milk to satisfy both, I gave them each two 50-gram bottles of sterilised milk per day. On this amount they continued to thrive till July 11, when it became necessary to increase it first to 150 and then to 200 grams each per day, for the mother was gradually yielding less and less.

On October 3 they returned from a two months' stay in the country. I had given the mother a steriliser, so that she might suitably prepare their milk during their absence from the Consultation. I now found that she had weaned them completely, and was giving each a daily allowance of 1000 grams of undiluted sterilised milk. They were in perfect health, and weighed precisely the same, 7860 grams.

The large amount they absorbed made me somewhat anxious regarding them. According to my experience, it was certainly excessive; I therefore reduced it to 800 grams per day for each. This quantity was quite large enough; their growth continued uninterruptedly, and their curves rose steadily (Fig. 109). On December 5, when they weighed 9220 and 9140 grams respectively, their daily supply was increased to 900 grams. You saw them the other day, two big, strong boys, each well worthy of the name he bears, Lechêne [French: the oak]. This case also demonstrates the easy transition from mixed feeding to weaning.

When infants are suffering from digestive troubles, it is necessary first to cure them before proceeding to determine how much milk they require for their daily needs.

On July 27, 1897, a mother brought her dying infant to me. He had been born on May 11, and since birth had gained only 20 grams. He was suffering from diarrhoea and vomiting, and was being fed only on chicken broth. I prescribed 450 grams of sterilised milk per day; the infant supported it splendidly, rallied, and soon began to gain weight, although the diarrhoea persisted more or less till the beginning of October. On July 31 he weighed 3300 grams, and on August 7, 3350. He was given nine bottles of 25 grams of sterilised milk, which was a daily allowance of only 225 grams. His weight fell to 2950 grams, but the diarrhoea and vomiting now began to subside, and soon he reached 3500 grams. He continued to thrive until October 2, when his daily milk supply was raised to 450 grams, which on November 20 was further increased to 600 grams. In spite of influenza, a cold, chicken-pox, and whooping-cough, each of which left its impress on his curve (Fig. 110), little "Chicken Broth," as he was called in the wards, weighed 11,100 grams when he was two years old. His daily ration then consisted of 1125 grams of sterilised milk and three "soups" per day.

An infant was brought in March 1899, weighing 5420 grams. Born on July 30, 1898, he had since gained 2420 grams, which was a daily average of only 11 grams. He was absorbing 1 1/2 litres of milk, diluted with 1 litre of water, i.e. 2500 grams per day. The mother was certain that he was yet underfed, for he cried, "as if still hungry," after every meal. 2500 grams for an infant weighing 5420 grams is equivalent to a daily allowance of 28 litres for the average adult of 60 kilograms. In spite of this enormous quantity the infant was practically a skeleton; his face was seared with wrinkles, his ribs were beaded, and the huge size of his abdomen formed a striking contrast to his emaciated condition. He was very constipated, and incessantly passing urine.

How was he to be dieted? As his stomach was dilated it was out of the question to start with the average amount required by an infant of his weight. I prescribed, amidst vehement protests from the mother, nine bottles of 125 grams, i.e. 1125 grams of undiluted sterilised milk per day, and on March 17 he weighed 5700 grams. During these eight days his average daily increase had risen from 11 to 40 grams. I then essayed to reduce his allowance to 900 grams, but on March 24 I found he had lost 60 grams since the previous weighing. As 900 grams was evidently not enough, once more I reverted to 1125, and the curve resumed its upward course. On April 21 I again tried 900 grams, and again failed, for he lost 80 grams in seven days. I substituted 1080 grams, and on this allowance he reached 6530 grams on may 12. Again I ventured 900 grams, this time with success, as you can see from his curve (Fig. 111). He continued steadily to increase, and on May 26 reached 6950 grams. Dieted thus, he had gained an average 33 grams per day for forty-six days. He was now taking only 900 grams of milk, instead of 1500 grams of milk and 1000 of water, and the wizened, ancient-looking little creature was transformed into a plump, contented, and thriving infant.

Artificial feeding gives excellent results, but only so long as it is attentively supervised. This fact was strikingly exemplified in the history of the infant Leq___ (Fig. 107), and I wish further to emphasize it by briefly narrating two other cases which demonstrate the importance of carefully regulating the quantities of milk which the child receives.

The infant D___, born on March 23, left the hospital on April 1, weighing 3965 grams (Fig. 112). Breast-fed, he grew steadily, and on July 7 reached 6980 grams. The mother, having taken him to the country, weaned him, and fed him with 1000 grams of cows' milk and two "soups" per day. When he returned to the Consultation on November 10, he weighed 7420 grams. In 126 days he had gained 440 grams, which was an average of only 3.5 grams per day. His curve during this period described almost a horizontal line. I regulated the quantity of milk he daily received, and on December 8 he weighed 8405 grams. In four weeks he had gained 985 grams, and had thus increased at the rate of 35 grams per day. His diet was carefully adjusted from time to time, and his curve, except for some small oscillations due to bronchitis and teething, steadily rose. At twelve months he weighed 9480 grams, and had eight teeth.

An infant named S_____ was brought to our Consultation on April 14, 1893, weighing 3040 grams (Fig. 113). Ten bottles, each containing 50 grams, were given to him, and his curve made a regular ascent. On July 21 he weighed 5330 grams, and on October 13, 6840. The mother then ceased to come for a time, and when next we saw the child, on May 4, 1894, he weighed 8430 grams; in 203 days he had increased by only 1590 grams. His curve had entirely changed its direction; it had steadily sunk below the normal, to which formerly it had been proceeding in parallel.

Boissard records a case which strikingly illustrates the difference between the results of well-regulated and haphazard artificial feeding. An infant H____, born at the Hôpital Tenon, weighed when he left on March 19, 1899, 3150 grams. He had then been twenty-nine days in the wards, and had gained 620 grams. The infant was artificially fed, for the mother had no milk. He was given carefully regulated quantities of undiluted sterilised milk, and on April 8 he attained 3700 grams, which was an average increase of 31 grams per day for twenty days (Fig. 114). The mother became ill, and was admitted with her child into another hospital. The infant was still fed on sterilised milk, but his weight diminished considerably, and on May 1 he weighed only 3080 grams. In spite of her great weakness the mother, afraid for the life of her child, insisted on leaving the hospital, and carried her little one in all haste to M. Boissard, who found the infant much emaciated, and suffering from an acute infectious diarrhoea. Sterilised milk in small and accurately graduated amounts was given till the digestive tube recovered its normal healthy state. The infant began once more to increase, and on May 23 weighed 3680 grams, his curve, as you see (Fig. 114), then assuming the normal aspect.

Notwithstanding its success, artificial feeding by means of sterilised milk is vastly inferior to breast-feeding. I cannot insist too much upon this. The mother's milk, or that of a good wet-nurse, should always be given where possible, for it is the easiest to digest and entails least risk to the nursling. I have already referred to the case of the twins Leu____, who were born at the Maternité on December 10, 1893. The mother not having enough milk for both, we had recourse to mixed feeding, and I gave her a sterilising apparatus, as she lived far from the Consultation. The infants throve, and their curves steadily rose superior to the normal. On Saturday, July 1, the mother was obliged to entrust them to a neighbour for the day while she went to Paris to transact some business. On her return next morning she found them both suffering from diarrhoea and their weights fallen, the one by 600 the other by 370 grams (Fig. 96). Under their mother's loving care they quickly recovered, but their history strikingly illustrates the ease and rapidity with which digestive troubles arise when artificial feeding is improperly directed. If the sterilisation is not perfect, if the bottle is left for some time uncorked, if the milk is of bad quality -- in fact, if there is any want of care in conducting the feeding -- accidents may happen which, especially in summer, assume an extreme gravity. The smallest error or the slightest negligence allows organisms to penetrate the milk, which, once contaminated, becomes a menace to the infant's safety. When, on the other hand, a nursling takes the breast, it may not always obtain a perfect milk, but it gets, at least, a sterile food, and enjoys immunity from acute infectious diarrhoeas.

If mixed or artificial feeding be a necessity, there are three cardinal laws which govern the use of animal milk. 1st. Give milk of good quality. 2nd. Give milk in correct quantities, neither too much nor too little; and 3rd. Sterilise all milk. The small graduated bottles, which each contain only enough for one feed, are of the greatest service, for they prevent excess not only the daily allowance but also in the individual meals.

I shall conclude by placing some of my results before you, but I wish first to direct your attention for a moment to several points, reference to which I must not neglect.

With regard to the reappearance of the menses in a nursing woman, I shall not reiterate what I have already said. You have seen that some menstruating women are good nurses while others are not. At the menstrual periods nurslings may have digestive troubles, and this applies not only to frail and sensitive weaklings (Fig. 65) but equally to children born at term. You may recollect the instructive curve of the infant Calm____, upon which the mother's periods imprinted themselves as a series of notches indicative of the temporary loss of weight (Fig. 67).

Has the evolution of the teeth any real influence on the infant's general health? Hippocrates made the first study of this question, and it does not seem to be settled yet. It is a subject well worthy of minute investigation. Many infants cut their teeth without any signs of a general disturbance. Some present symptoms recurring at the piercing of each tooth, for which on careful examination no cause can be detected other than the dental evolution. The child seems out of sorts; he is restless, fretful, and sleepless; he may have diarrhoea, colic, and other troubles, all of which disappear the moment the tooth emerges through the gum. To-day I wish to restrict my examples to a few, significant of the accompanying loss of weight.

The curve of the infant Guil____, who was born on July 6, 1896, was at first inferior to the normal (Fig. 115); but, when the mother's inadequate supply was supplemented by sterilised milk, the child increased in weight with a most gratifying regularity. Teeth were cut during the 26th, 47th, 48th, and 56th weeks, and coincidentally with each, as you see, the infant lost weight.

The infant Van der St____ was born at the Maternité on December 6, 1896. At first he was fed exclusively at the breast, but, the supply proving insufficient, mixed feeding had soon to be adopted (Fig. 116). His curve is somewhat mediocre, for the mother's milk gradually dwindled till, early in July, the infant was completely weaned. However, on July 3, when he was six and a half months old, two teeth appeared; others came through on July 31, August 7, August 14 (2), December 4, and December 21, and the curve shows that at these periods the weight either remained stationary or diminished. The same phenomenon is observed on the curves of the infants Liver____ (Fig. 105) and Go____ (Fig. 68).

After a period which varies within wide limits, the mother's milk ceases to be sufficient for the infant's needs. Either it quality deteriorates or its amount diminishes. It is then necessary to substitute cows' milk or other foods, and this constitutes weaning.

Weaning is not always an easy matter. Some infants persistently refuse every other form of nourishment but the breast. Most of you remember the woman Dubois. She was an excellent nurse, and for a long time her little son throve to my entire satisfaction. But the mother gradually lost her milk, and, in spite of all we could do, the child absolutely refused to take anything but the breast. He soon ceased to grow, and, little by little, dwindled away till he was but a shadow of his former splendid self. I tried him with sterilised cows' milk, sweetened and unsweetened, "soups" made with milk, and other forms of nourishment too numerous to mention, but all without avail. Such infants soon waste considerably, and your ingenuity will often be severely taxed in trying to steer them through this difficult period of weaning.

Similar cases are not rare among infants suckled by their mothers, but they are much more common among those entrusted to wet-nurses. To a wet-nurse weaning may mark the termination of her engagement; it is, therefore, not to her financial interest to facilitate the process. Not infrequently she pleads her inability to get the infant to take anything but the produce of her breasts, but her efforts require very little discouragement. She would soon devise some means of supplementing her inadequate supply if it were a question of her own child, but when it concerns only the nursling she is hired to suckle, her finer feelings become submerged in her business instincts.

On the other hand, weaning is an easy matter when an infant, besides the breast, has been accustomed to take one or two bottles of sterilised milk daily. All that is necessary is gradually to increase the number of bottles per day, and the child will be rapidly and safely weaned. Many mothers train their infants in this way from the beginning -- some because they have not quite enough milk, others because they do not wish their night's rest interrupted; yet again others have duties which take them away, and sterilised milk replaces breast-feeding during their absence. These mothers can wean their children very readily, as you will have occasion forcibly to realise if you leave them to their own discretion.

Infants are not fed exclusively on cows' milk after they are weaned: they are also given light "soups," prepared from milk and farinaceous substances, such as arrowroot, tapioca, racahout, rice, potatoes, wheat, oats, barley, &c. At first, the "soups" contain only a small amount of feculent matter, which is very thoroughly cooked. Some practitioners do not employ them till after the first year, but I have often given them earlier. I have frequently heard doubts expressed as to the utility of these "soups," but I think it is easy to prove that they are often of the greatest nutritive value. They are made with a portion of the infant's daily allowance of milk, and on adding one "soup" to the dietary of a stationary infant, without in any way altering his quantity of milk, I have frequently seen his weight begin steadily to increase.

A woman named Mer____ was sent to me by the Superintendent of the Hôpital Cochin. She had weaned her newly-born infant, because she had to work for a living, and he asked me to grant her the daily milk required by the child. The feeding was therefore exclusively artificial. If you examine the curve (Fig. 117), you will see that on June 10 the infant was receiving 900 grams of milk and one "soup." On June 24 a second was given, and this sufficed, without any augmentation of the daily milk allowance, till November 18. Yet, in this interval, the child having increased from 7100 to 9500 grams, had gained 2400 grams.

Another woman, called Fi____, was delivered on June 19, 1896, and when she returned from a convalescent home on July 25, she no longer had any milk. She was not one of my patients, but the Director of the Maternité, moved to compassion by the poor woman's extreme solicitude for her child, asked me to direct its feeding, and to supply it with the necessary milk. At first I gave 400, then 600, and on January 23, 1897, 1000 grams of sterilised milk per day. On March 6 the first "soup" was ordered, and on April 24 another was added, yet till June 26 the quantity of milk remained unaltered. The infant had continued steadily to increase, owing to the influence of a few teaspoonfuls of flour made into "soups" with the milk (Fig. 118).

As a rule I do not allow broths, gravies, nor any other foods. I prescribe only milk or "pap" made with milk during the first two years. When they have completed twenty-four months they are discharged from the Consultation, but the greater number are brought back from time to time by their proud and grateful mothers for my inspection.

I have now outlined my methods of infant feeding. How have they been justified by results? This you may judge for yourselves, gentlemen, any day you care to visit our Consultation.

It has been said that infants reared on mixed, and especially on artificial feeding, are fat and flabby, and have very little resisting power to disease. They are alleged to be prone to all sorts of evils -- abdominal enlargement, a special form of dyspepsia arising from the use of undiluted milk, rickets, eczema, scurvy-rickets, &c.

The tumid abdomen is almost unknown among my nurslings. I have met with it in only one case. The child in that instance was receiving 2 1/2 litres of diluted milk per day, and on reducing his allowance to 900 grams, his abdomen regained its normal volume.

I am absolutely unacquainted with the so-called "undiluted milk dyspepsia." We always inquire as to the colour of the infant's stools, and the mother almost invariably replies that it is yellow. White stools of the consistency of putty, the pathognomonic sign of the new dyspepsia, indicate merely that the infant is is being overfed. We never see them, for we do not overfeed; it is rarely that we need to prescribe more than 1000 to 1200 grams of milk even for infants in their second year.

As for rickets, not a single case has occurred in any of my Consultations since I first began in 1892. One was sent to me from the dispensary of one of my colleagues. You may remember I described it to you; the poor little unfortunate was getting 2500 grams of fluid per day.

A distinguished doctor came from Budapesth not long ago in order to see my Consultation. He had been accustomed to believe all sorts of accusations against undiluted sterilised milk as an infant's food. To convert him from error and remove his doubts I had all of the children stripped, and then invited him to examine them. This he did with the greatest care, but to his profound surprise did not find a single child which presented even a trace of rickets.

Neither will you see eczema among our little patients. Since 1892 I have observed only two cases, both of which were suckled by mothers indulging to excess in food and drink. I have given you my opinions on this subject in an earlier lecture (Fig. 64). Our infants on mixed and artificial feeding are never affected with eczema, for they are not overfed, they are free from digestive troubles, and they are kept clean.

Tuberculosis we practically never see, for we distribute nothing but sterilised milk.

As for the so-called "infantile scurvy" which is alleged to follow the use of sterilised milk, I have heard a very great deal about it during the last few years, but I am still looking for my first case. What constitutes these "antiscorbutic properties" of fresh milk? I do not understand how sterilisation causes them to disappear.

Infants fed on animal milk are also alleged to be without strength and resistance, although heavy and fat. This has not been my experience. Mothers, from time to time, bring back my former little patients to see me, and I have always found that in general health and physique they would compare favourably with any children of their age.

In our next lecture, the last on the subject of infant feeding, I shall discuss in detail the organisation of Consultations for Nurslings and their results.

	Fig. 105. Quantities of pure milk taken by an infant on artificial feeding.
	Fig. 106. Showing the quantities of undiluted milk taken by an infant on artificial feeding.
	Fig. 107. Artificial feeding. Curve of the infant Leq___, showing the daily quantities of milk he took.
	Fig. 108. Infant badly fed by a wet-nurse. Curve showing the results of regulated feeding by undiluted, sterilised cows' milk. Daily quantities of milk indicated in blue.
	Fig. 109. Mixed feeding of twins. At first a small quantity of cows' milk sufficed, but the mother went to the country, and in spite of my advice greatly increased the amount. On her return I diminished it. Quantities of cows' milk taken per day are indicated by the blue columns.
	Fig. 110. Infant admitted in a dying state, suffering from diarrhoea and vomiting. Artificial feeding -- recovery. Curve shows the effect of various contagious diseases on the infant's weight. Quantities of milk per day in red.
	Fig. 111. Curve of a rachitic admitted to the consultation. His daily allowance was 2500 grams of fluid. I first gave him 1125 grams of undiluted milk, which I ultimately succeeded in reducing to 900 grams.
	Fig. 112. Curve of an infant who, while attending the Consultation, was breast-fed. Mother went to the country and weaned him. His weight during this period was practically stationary. When the artificial feeding was properly directed his curve rose. The interrupted red line represents the curve during his absence from the Consultation.
	Fig. 113. Artificial feeding. Curve of infant S____. Ceased to attend the Consultation on the twenty-seventh week; returned on the fifty-sixth. Observe the change in direction of the curve during this period.
	Fig. 114. Artificial feeding carefully supervised, the infant grew normally; badly directed, the infant had diarrhoea and lost weight; feeding again properly regulated, diarrhoea ceased and the infant rapidly increased (Boissard).
	Fig. 115. Feeding first mixed, then artificial. Curve shows the effect of teething on the weight. D, Evolution of a tooth.
	Fig. 116. Feeding first mixed, then artificial. Showing the effect of the dental evolution on the infant's weight. D, Evolution of a tooth.
	Fig. 117. Artificial feeding. Daily allowance of milk from the thirty-fourth to the fifty-seventh week was 900 grams. In this interval the weight rose from 7100 to 9000 grams, and the diet had been augmented by two "soups" only.
	Fig. 118. Feeding first mixed, then artificial. Curve showing the effect on the weight of the addition of "soups" to the infant's diet.