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milk obtainable in shops was adulterated and skimmed to such an extent that the amount of fat, i.e. cream, was often reduced to about half of its normal amount. In addition, the milk was sometimes diluted with water. There is no doubt that such a liquid must be wholly unsuitable as a substitute for mother's milk. The question arose as to what could be done in order to provide cow's milk in a suitable form for its proper utilisation by infants.

It was realised, in the first place, that the milk must be unadulterated. In order to ensure this, the source of the supply must be under constant inspection by responsible persons, and the milk must be shown by analysis to be of a proper composition. This, of course, is all quite practicable; but the great mass of the milk supply in large towns must of necessity come from a distance, and some time elapses before it is delivered retail. In the meantime the microbes are multiplying. In exceptional circumstances it is possible to obtain raw milk in excellent condition, but the supply and demand must not be far apart. The greatest possible care and all aseptic precautions must be used at the farm, the milk bottled directly, kept always at a low temperature, and delivered cool within a few hours. If these conditions are fulfilled, raw milk may be relied upon, but even then it must not be kept more than a few hours before use. The additional care required for the carrying out of these measures necessitates an increase in the price, and it thus becomes out of the reach of the poorer classes. All microbes can be destroyed by heat, and, seeing the impossibility at that time of obtaining any pure raw milk, Professor Budin decided to supply milk that had been heated to a temperature sufficient to destroy all the microbes. A preliminary trial of preserved milk proved that it was unreliable, and he therefore decided to make arrangements for the supplying of pure sterilised cow's milk to the babies where such food was considered desirable. The milk was procured from a reliable source, not far from Paris, was delivered with all possible speed and precaution at the hospital, and at once put into bottles of suitable size. These were covered with a special form of indiarubber cap and were placed in vessels containing water. The whole was then raised to boiling point and kept at that temperature for forty-five minutes. The bottles of milk were then taken out and allowed to cool. The milk was found to be sterile, remaining fresh and sweet for a considerable time if the bottles remained unopened. A sample of the raw milk was analysed each day by an expert to control the supply.

The result exceeded the most sanguine expectations. The babies put on weight splendidly; and although much has been said and written in regard to other methods of dealing with milk, Professor Budin found that this mode of preparation gave the most generally satisfactory results. Up to his death, which occurred only a few months ago, he never ceased to use it, whilst, however, always very forcibly emphasising that it was only a substitute for mother's milk, at any rate during the first six to nine months of life.

Some idea of the striking results obtained by him at the 'Consultations des nourrissons' in 1898 may be gained from the accompanying diagram, where it is seen that the mortality among artificially fed children in Paris rose, as he himself expressed it, like a veritable

Weeks in the year 1 2 34 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52

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No. of deaths

Mortality among
artificially-fed children

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Mortality among

breast-fed children

Mortality at the
Consultations des Nourrissons

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tour d'Eiffel', during the summer months. The mortality for breastfed babies was much lower, while that of the babies at the

Consultations des nourrissons' remained throughout at zero. Not a single baby died. This was merely a typical year, the yearly mortality from any preventable cause since the foundation, being nil.

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The extraordinary success of this first attempt led to the formation of similar Consultations at other maternity hospitals. Professor Budin himself was the direct instigator of no less than three, and at the present time several, though unfortunately not all, of the maternity hospitals in Paris have roused themselves to follow the example of this great benefactor. Rather over four-fifths of all births take place each year under some one or other of the different auspices of the 'Assistance Publique’; if, therefore, all the branches of this body adopted these measures, there would be a very small percentage of babies without supervision. The movement spread gradually and has now taken deep root all over France ; it is continuing to grow, being in nearly all cases productive of the most far-reaching beneficial results. In addition to the hospitals, Consultations' were started in connexion with dispensaries, the first being inaugurated by M. Variot in connexion with his dispensary in Belleville in 1893. They are now to be found in connexion with a great number of dispensaries in Paris, and also in other parts of France.

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(6) Gouttes de lait

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In 1894 a slightly different movement was started, quite independently, under the title of 'Goutte de lait,' at Fécamp, by Dr. Dufour. The object was to 'combat the excessive mortality among artificially fed children of the town, especially among the poorer classes.' Briefly, the objects of this institution were twofold :

(1) To provide proper medical supervision for the infant, and

(2) To provide suitable milk in cases where mother's milk was not available.

There is no sharp line of demarcation between a ' Goutte de lait' and a 'Consultation des nourrissons'; the essential points of difference are that the original ' Consultations were in direct connexion with the maternity hospitals, whereas the 'Gouttes de lait' were in connexion with the dispensaries, or were started by private enterprise (bienfaisance privée). The 'Goutte de lait' also provides milk for children somewhat older than those attending the hospital Consultations. Both emphasise, and as far as possible insist upon, breastfeeding, and both are presided over by thoroughly competent medical

All the milk that is required for the child attending the hospital * Consultation ’ is given free; that at the 'Gouttes de lait ’ is sold at a low price, except in a few deserving cases, if the mothers are wholly unable to pay. With few exceptions the hospital only receives its own babies; the consultations' in connexion with the 'Gouttes de lait' are open to all. The idea of the 'Gouttes de lait? was taken

up almost at once, not only in and near Paris, but in other parts of France.

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In Paris there are 'Gouttes de lait ’in every arrondissement, which are all conducted on the same fundamental principles. There is great scope for slight variations in the administration, and different doctors have tried new departures, especially in relation to the treatment of the milk provided. Some Gouttes de lait' have their own apparatus for sterilising, of which there are several varieties. It may take the form of a bain-marie, or it may be an autoclave, where the milk is superheated.

Again, some prefer the milk to be Pasteurised—that is, raised to a temperature below boiling, but sufficient to destroy most of the microbes. They consider that this procedure is most likely to retain the vital properties of milk. There is, however, no proof that the milk thus treated is any more nutritious than the sterilised milk. Pasteurisation is open to several objections, one being that the milk must not be kept for more than a few hours, and another, that it does not destroy the tubercle bacillus, if that organism is present. The statistics so far available do not show that there is any advantage in Pasteurisation, and sterilisation is certainly safer.

Many doctors are of opinion that pure undiluted cow's milk is an unsuitable food for babies. They prefer it humanised--that is, water and sugar are added in such proportions as to bring about an approximation to the composition of human milk. The humanising may be carried out in the 'Goutte de lait' or at the farm, or sterilised whole milk may be given to the mother, with directions as to how she should prepare it.

All the depots have the same object in view, namely, the preservation of infant life by the instruction of the mothers, the encouragement of breast-feeding, and the provision of a good form of milk for those who cannot be breast-fed or who are being weaned. The difference between the cost of the milk and the sum charged is borne by the

Goutte de lait' or dispensary. All ‘Gouttes de lait' are under medical supervision.

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V. RESULTS

Some of the results obtained at the Consultations des nourrissons' have been shown in the diagram. Looking back on some fifteen years, Professor Budin was able to say that the mortality from preventable causes at the Consultations' presided over by him was nil. This is the general experience.

In Table III. the rates and causes of infantile mortality in Paris from 1893 to 1905 are given. Prematurity is registered separately in Paris, and does not come under the heading of debility, as in England.

TABLE III.

Deaths per 1000 Births among Children from 0 to 1 Year of Age.

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It is seen at once that the figures under the heading of diarrhoea are by far the most striking; nothing else approaches it in the amount of its decrease. Evidently diarrhoea is a preventable disease, and its striking prevention in Paris is undoubtedly due to the measures that have been adopted.

A few figures relating to other towns will be instructive. The infant mortality at Saint Pol-sur-mer from 1897 to 1902 was 288 per 1000. In 1903, after the foundation of a Consultation des nourrissons,' the mortality was 209, and in 1904, in spite of a very hot summer, it had fallen to 151.

In the department of Pas de Calais statistics from eleven towns with Consultations and eleven without show that the infantile mortality has dropped in every one of the towns having Consultations, and dropped very considerably, viz. from 283 in 1898 to 181 in 1904; again in another town from 281 to 174 in the same years, and so on. The towns without · Consultations' show a uniform increase in infant mortality ; for the same years it was 83 and 235 respectively in one town and 172 and 272 in another. These are fair samples of what has occurred over the whole of France.

The number of mothers who feed their children naturally has greatly increased under the influence of the Consultations' at the hospitals and dispensaries. At the dispensary in the Rue Oudinot, directed by M. Bresset, the number of nursing mothers rose during the five years 1899-1903 from 61 to 81.4 per cent. ; and it would be possible to quote a large number of similar figures, but it is quite unnecessary. It will be obvious to all who are interested in the matter what splendid results have been obtained.

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VI.-DEDUCTIONS AND SUGGESTIONS What is the meaning of the whole matter? We have seen that France was faced with the questions, How shall we prevent depopulation? What are the causes of depopulation ? The reply is given by statistics. These show decreasing marriage-rate, decreasing birth

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