If the patient desires the highest degree of protection an experienced nurse is indispensable, for she will make systematic observations which would consume too much of the doctor's time for his personal attention, yet without which he would not be sufficiently conversant with his patient's condition to guide her properly. The temperature, the rate of the pulse, and of the respiration should be recorded at regular intervals during the day and night. An elevation of temperature at the conclusion of labor need give no uneasiness, for experience has shown that it generally subsides within a few hours. Moreover, slight elevations in the course of the following week are so frequent that obstetricians have agreed to regard as a normal temperature for this period 100.4 degrees instead of the usual normal of 98.4 degrees. The pulse-rate most frequently does not depart from what is characteristic for the individual, though about one-fifth of puerperal women have a slowing of the pulse, a phenomenon of favorable significance. Any difficulty in breathing that may have existed in the latter part of pregnancy disappears when the abdominal distention is relieved, and the respiratory rate becomes normal. So long as the body is getting rid of the tissue-substance essential to pregnancy, but now without any purpose, more than the usual amount of waste material is present in the expired air.

The Elimination of Waste Material.—As we might expect from the loss in body weight, the excretory organs are particularly active during the lying-in period. In quantity the loss of water exceeds all the other waste-products together; and pronounced activity of the kidneys or of the sweat glands may become a source of annoyance. Since it is undesirable to interfere with these functions, whatever inconvenience either may cause will be borne with less complaint if the patient understands that a large loss of water at this time indicates a healthful condition of the body.

Shortly after delivery there may be difficulty in emptying the bladder; and, under such circumstances, the doctor or nurse used to catheterize the patient immediately; this habit once begun, it was often necessary to repeat the operation day after day, or, for that matter, several times a day. But as physicians came to know more of the relations of bacteria to inflammation of the bladder, they grew more cautious, and preferred to wait a long time before resorting to the catheter. The reward of this patience was to find that, with remarkably few exceptions, puerperal women ultimately void of their own accord. Accordingly catheterization after child-birth is now postponed, and is never performed until a number of devices to get the patient to void spontaneously have been tried without success. Often urination follows putting a hot-water bottle over the bladder; or pouring warm water over the vulva; or placing the patient upon a bed-pan from which steam is rising. When these and other devices well known to every nurse are not effective, catheterization becomes necessary. With the elaborate precautions taken to avoid infection of the bladder, catheterization is now performed with very slight risk.

Constipation, for various reasons, becomes a regular feature of the lying-in period. The confinement in bed, restricted diet, relaxation of the abdominal wall, and sensitiveness about the region of the rectum, all have a tendency to prevent spontaneous movements of the bowels. As one of these influences after another is removed the bowels begin to act naturally. Childbirth may cause chronic constipation, but this sequel would occur much less often if a little care were taken to prevent it.

The routine use of enemas deserves to be condemned. I see no objection to an occasional enema if purgative medicine has been taken without effect, but constant use of them, more than likely, will result in the enema habit. Similarly, long-continued administration of strong purgatives tends to make them a permanent necessity. While in bed if medicine is taken every other day the bowels will have opportunity on the intervening days to move spontaneously, though we do not really expect them to move naturally until six or eight weeks after the delivery, when the patient is able to take as much exercise as she likes. Toward the end of the second week, however, mild laxatives generally prove effective, and it is important to select one the dose of which may be gradually decreased. Senna prunes, which were described in Chapter V, fill the purpose very well. Six or eight of them may be needed at first, but the number may be gradually reduced, until finally none are necessary.

Cleanliness.—In view of the excessive elimination of waste products from the body, the maintenance of cleanliness during the lying-in period may require the use of a large amount of linen. Occasionally patients perspire so freely that the night clothes have to be changed several times in twenty-four hours, and the bed linen only a little less frequently. But at any cost it is imperative not to hinder but rather to promote this function and to keep the skin in a healthful condition through bathing and massage. Nurses are taught, on this account, to give a warm soap and water bed-bath in the morning and an alcohol rub at night. Patients are usually allowed to take tub-baths after the third week.

Local cleanliness, which is a matter of the very first importance, can only be attained through bathing the vulva with an antiseptic solution and the use of sterile pads. At first the pads are changed very frequently, but after the discharge becomes less profuse they are renewed at intervals of four to six hours.

The Diet.—For the first week of the lying-in period not all patients are given the same diet, and the physician always leaves specific directions regarding it. Generally the diet consists of liquids, such as milk and broths, for a couple of days; under some circumstances liquid nourishment is continued longer. As the appetite increases easily digestible but nutritious food is added, and before long the patient resumes her ordinary diet.

The modern tendency is to give solid food and to give it in substantial amounts much earlier than was once customary; restrictions, none the less, are still observed so long as the patient remains in bed. With the body at rest, its food requirements are diminished and hearty meals are unnecessary. If convalescence proceeds satisfactorily such wide latitude in the choice of food is permissible that the nurse may regulate the diet, consulting the physician whenever necessary.

The Environment.—A large, bright room that can be quickly heated and easily ventilated adds notably to the comfort of the lying-in period. The windows may be opened through the greater part of the day and at night should always be left so. To make thorough airing of the apartment more feasible and to protect the mother from annoyance when the baby cries, it is more satisfactory to have the baby occupy an adjoining room where the nurse sleeps within call. Under any circumstances some arrangement must be made so that the mother's rest at night will not be broken needlessly.

No pains should be spared to keep the patient quiet for at least ten days. Household cares and petty worries materially delay convalescence. During this period only a limited number of the immediate members of her family ought to see her, and their visits should be brief. Unfortunately, if too many relatives and friends visit her a number of questions will be repeatedly asked which are decidedly wearing on any patient.

The Time for Getting Up.—How long a woman should stay in bed after the birth of a child is a question which has given rise to prolonged discussion. The majority of obstetricians adhere to the traditional ten days; but there are advocates of a longer period and advocates of a shorter one. The generalizations of many writers upon this subject are too sweeping, for exceptions may be found to any rule. Each patient is best counselled when the advice given is based upon her own condition and particularly upon the progress made in the involution of the uterus, which does not advance with the same rapidity in all cases.

More or less in imitation of the custom among savages, Charles White, in 1776, recommended that women should not remain in bed longer than a day or two after child-birth. Very likely the inadaptability of the method to civilized women soon became apparent; at any rate his suggestion was not widely adopted, and had been completely forgotten until a few years ago, when the custom was revived in one of the German clinics. The innovation met with violent opposition in Europe, and, so far as I know, has found but scant favor in America.

Generally patients are allowed to sit up in bed toward the end of the first week, but if there are stitches, sitting up is deferred until ten days or later, when the stitches have been removed. Under the most favorable circumstances, however, sitting up in bed becomes wearisome, for the weight of the body does not fall upon the spine, as it should; and besides the extended position of the legs is fatiguing. No one should force herself to keep this posture, for at best it does no more than relieve monotony. The exercises previously suggested prepare her much more effectually for getting upon her feet.

Between the tenth and the fifteenth day patients may leave the bed and sit quietly in a chair. The condition of the uterus, the character of the lochia, and the firmness of the pelvic floor will determine the day, but usually it proves wiser to defer it until fully two weeks have lapsed. As a rule, the patient remains out of bed an hour the first day, two the second, three the third, and so on until she is up all day. She should not attempt to walk until the second or third day. At first she should take only a few steps, but gradually she may increase the number and finally walk with freedom and ease. Several reasons make it advisable for patients to remain four weeks on the floor where they have been confined; going up and down stairs is especially tiresome, and, of still greater importance, patients pass from the doctor's control as soon as they go down stairs. For fear of overtaxing the strength none of the household cares should be assumed before the fourth week, and not all of them then, for women are not capable of resuming their accustomed duties fully until the sixth week; and some are not strong enough to do so until a somewhat later date.

Since patients generally feel well during the lying-in period they are apt to object to remaining in bed two weeks. Most of them acquiesce as soon as they understand the organic changes in progress and appreciate the lasting benefits of a temporary forbearance, but a few must be made to realize that very serious penalties may be attached to undue haste. For the latter it might be better if the alarming consequences of getting up too early—discomfort, hemorrhage, and collapse—occurred more frequently than they do. As it happens, the ill-effects of such indiscretion are not usually felt immediately; when too late the lesson is learned that many of the operations upon women in the later years of life are dependent on imprudent conduct just after the first child was born.

THE FINAL EXAMINATION.—Looking to complete restoration of the woman's health, the modern management of obstetrical cases breaks decisively with tradition at three points. An utter disregard of precaution has given way to very careful preparations before and at the time of labor; definite rules for the management of the lying-in period are carried out under the supervision of the physician; and finally, prompted by the same impulse, the physician examines his obstetrical patients before discharging them. Satisfactory conditions are generally found; if they are, it is a great comfort to be assured of the fact; and if not, timely treatment of the abnormality may readily correct it; with delay, on the other hand, treatment often becomes more formidable.

The end of the fourth week of the lying-in period proves a convenient time for this examination. As yet the restorative changes in the reproductive organs have not been completed, but one may definitely say by this time whether or not they will culminate in a satisfactory manner. Besides, making the examination while the changes are in progress sometimes enables the physician to treat approaching complications before they actually develop. Thus, when the pelvic floor has not regained its strength sufficiently, the patient will be advised to forego the liberty in moving about ordinarily granted at this time. When the womb inclines to an improper position, a temporary support may be introduced to hold it where it belongs; later, upon removing the device, the womb usually retains a good position. Again, there are conditions which a douche will relieve, and still others benefited by medicinal treatment. If an abnormality is recognized which cannot at once be treated to the best advantage, arrangements will be made for such prompt treatment that the woman will not become an invalid. Instead of placing obstacles in the way, patients should rather insist upon this examination, for it is important in guarding their future health.

Now and then patients are kept under observation for a longer period, but, as a rule, they are discharged as well as examined at the end of four weeks. They may also discard the abdominal binder about this time and put on corsets, which, however, should not be tightly worn. Although thrown upon her own resources from this moment, the patient will clearly understand that she must continue to exercise sound discrimination in what she does. And here, of course, we encounter the greatest difficulty in offering practical advice, for what one may do easily will overtax another. Generally speaking, going up and down stairs more than once a day is inadvisable until another two weeks have passed. Likewise the mother who would adopt a conservative policy will not take full charge of her baby before it is six weeks old, though there can be no objection if she wishes to direct its care. The same advice applies to running the household. Over- exertion, no matter what the source, delays convalescence from child- birth to such an extent that the safe plan is always to err on the side of doing too little, rather than to run the risk of doing too much.



CHAPTER XII

THE NURSING MOTHER

The Breasts—Human Milk—The Technique of Nursing—Hygiene of the Mother: Diet; Psychic Influence; Recreation and Rest—The Supplementary Bottle—Weaning.

When the obstetrician pays his final visit the mother usually has ready a number of questions, most of which anticipate difficulties in the care of the baby. At that time, however, minute and far-reaching directions cannot always be given. Unforeseen peculiarities in the development of the child may modify such general principles for the management of infants as could be laid down in advance. With a few exceptions, therefore, mothers require during the early years of a baby's life skilled advice as to his upbringing—advice for which neither instinct nor haphazard counsel is a safe substitute. It is an excellent plan, and one which is becoming more and more popular, to have a physician supervise the care of the baby through the period of most active growth. According to this plan, the mother, even though her baby is well and developing as it should, consults the physician at regular intervals, once a month for example, and upon these occasions secures help in solving problems which are certain to present themselves. Such an arrangement shows a merited appreciation of the proverbial "ounce of prevention," and when serious difficulties do arise materially counteracts the tendency to panic which is exhibited by so many young mothers.

Among the problems which the mother must solve, that of nutrition outranks all others in importance; and unless the infant is nourished with human milk, it also exceeds them in perplexity. For, although great advances have been made in artificial feeding, science has not yet removed all the intricacies and dangers involved in the use of the bottle. On the other hand, mothers who nurse their babies rarely meet with difficulty. Human milk is perfectly adapted to the wants of the infant; and all substitutes, though carefully designed to duplicate it, are only partially successful. We have learned how to modify cow's milk so that in chemical constituents, at least, it is a very close imitation of human milk; but human milk possesses, in addition to its chemical properties, other desirable qualities which cannot be instilled into an artificial food. We must agree, therefore, that attempts to disseminate a wider knowledge of the correct principles of bottle-feeding do not have the highest aim. Our real need is a vastly greater proportion of women who nurse their children.

THE BREASTS.—For success in nursing the first essential is healthful breasts. With this the largeness or smallness of a breast has nothing to do, for size is no more an index of its capacity for producing milk than is the weight of a woman an index of her energy. The breast is not a warehouse, but a factory, with very limited storage capacity for its product. Differences of size are generally to be explained by the variable amount of fatty-tissue the breast contains. And so far as the secretion of milk is concerned the fat is entirely passive; it fills in the space between the glandular elements; and a layer of fat just beneath the skin protects the glands against external influences that otherwise might disturb their activity. Stripped of their fatty envelope the structures which actually secrete the milk and convey it to the nipple resemble a miniature cluster of grapes. Each tiny, spherical gland corresponds to one of the grapes and contains a cavity lined with cells which manufacture the milk. From this cavity the milk flows through a microscopic tube which unites with similar tubes to form a larger one; this in turn joins others of its kind; and so on, until ultimately the milk enters a relatively large duct— the figurative stem of the cluster—which conducts the milk to its destination. There are from ten to fifteen of these terminal ducts; each drains a separate group of glands, but all end in the nipple.

Shortly after conception the breasts become congested; in consequence they enlarge, become tender, and begin to show swollen veins beneath the skin. The most significant alteration, however, occurs in the cells which line the glands; these increase in size at first; and then, by a process of cell division, their number multiplies. After pregnancy has advanced six to eight weeks these cells begin to elaborate the thin, watery fluid called colostrum. Contrary to popular belief, the quantity of colostrum is not prophetic of the character of the milk; there is no ill-omen, to be sure, in a plentiful secretion, but a meager one is quite as likely to be followed by successful lactation. At present we are unable to predict by any means either the quantity or the quality of the milk which a prospective mother will produce.

Some writers contend that influences which come into play during girlhood ultimately affect the capacity of the breast for making milk; for example, irregular habits in youth and the wearing of improper styles of clothing are said to be particularly detrimental influences. Of course, a healthful mode of life at the time when a girl is approaching maturity reacts favorably upon her development in every way, and naturally enough the breasts share this benefit; but the relation between unhygienic habits at about the time of puberty and a subsequent deficiency in lactation has been exaggerated by many writers. It is impracticable, certainly, to institute special measures to prepare the breasts for their function until the need of such measures is clearly evident. Throughout pregnancy clothing about the breasts should be loosely worn. If the nipples are not already prominent they should be drawn out; and about six or eight weeks before confinement is expected they should be given the treatment described in Chapter V.

For the first day or so after the infant begins to nurse its efforts have a tendency to injure the skin which covers the nipple; and unless measures to render the nipple resistant have been previously adopted, nursing may cause the mother considerable discomfort. Moreover, it is extremely important throughout lactation to keep the skin covering the nipple free from abrasions, for if it cracks bacteria have thus an opportunity to enter the glands and set up an acute inflammation which may result in the formation of an abscess. This complication is to be avoided, not only because of the unpleasant symptoms which attend it, but also because for the time it brings the usefulness of the breast to an end. Fortunately an abscess seldom impairs the breast permanently.

At any period of lactation there may be an overproduction of milk. In this event the breasts are likely to become distended, hard, and very tender. Most frequently "caked breasts," as this condition is called, develop a few days after delivery, when the secretion of milk is just beginning, for at first the secretion is more plentiful than need be. Generally twenty-four hours later there is an adjustment between the supply of nourishment and the natural demands of the infant. Occasionally a longer interval elapses before the breast is completely emptied at each nursing.

Formerly it was customary, whenever the breasts became tense and uncomfortable, to express an excess of milk by means of massage; but this mode of treatment lost favor as soon as physicians realized that massage stimulated the glands to greater activity. Drawing the milk with a breast-pump has a somewhat similar though less potent influence, and, because pumping often affords relief when the breasts are distended, there is rarely any objection to it. In the light of modern experience, however, most physicians prefer to avoid manipulation of the breast so far as possible, and generally resort to other measures to relieve the mother's discomfort. Thus most patients are made comfortable if an appropriate bandage is used to transfer the weight of the breasts from the arm-pits and the front of the chest to the bones of the shoulder-girdle. It may be necessary also in some cases to swathe the breasts in warm cloths; in others cold applications are more acceptable; the choice between these methods will vary with the time of year, and usually may be left to the patient herself. Now and then medicine will be employed to relieve the pain, but the administration of drugs to diminish the production of milk is inadvisable. It is never very long before the amount of milk becomes adjusted to the infant's wants, and then distention disappears spontaneously. No artifice can bring about the adjustment as ideally as nature does.

During the later months of lactation the liability of the breasts to over-filling is slight, provided the infant empties them regularly and completely. Nevertheless, so long as a mother is nursing her child she must be careful to keep the breasts in a healthful condition. They require support, yet must not be compressed. And they should be covered with clothing which will adequately protect them from sudden changes of temperature. This latter precaution, perhaps, requires more emphasis than formerly, on account of the present popularity of motoring; for the chill which one experiences when driving fast may have a very unpleasant effect upon a nursing mother unless her breasts are carefully protected. Occasionally fever and neuralgic pains in the breasts are caused by motoring, or by exposure to the air-current from an electric fan playing directly upon them. But even under these circumstances an abscess need not be feared unless the nipples are sore.

Human Milk.—Between the time of birth and the beginning of lactation there is always an interval during which the breasts secrete colostrum, just as they do throughout pregnancy. Although the nutritional value of this fluid is not great, it is doubtful if colostrum serves any other essential purpose than as nourishment. Possibly it also stimulates the intestines to expel the material which has collected within, them during fetal development, yet we know the bowels will move without a purgative; and often do so long before the infant is placed at the breast. Typically, the secretion of milk begins the third day after delivery; yet in perfectly normal patients it may appear as early as the second or as late as the fifth, and occasionally lactation does not begin until the baby is more than a week old.

As to what starts the secretion of milk we have only a vague idea; but we know that when the flow is once established its continuation depends primarily upon the sucking efforts of the infant. If nursing is discontinued the secretion dwindles and the breasts dry up. On the other hand, the strong, persistent stimulus of the infant's suckling gradually brings the secretion to a high degree of efficiency. Within the first two weeks, therefore, the daily secretion increases from a few ounces to a pint or more. Subsequently the output fluctuates between one and two quarts daily, according to the demands made upon the breasts; the secretion is larger, consequently, if there are twins. Astounding yields of milk have been recorded, as in the case of a wet-nurse in a German institution who nursed a number of infants and became capable of supplying three to four quarts daily.

That newborn infants thrive better on human milk than on any other nourishment is a conviction that must come home to every one who has had even a limited experience. It keeps the babies in health, serves to make them grow, and promotes the development of all their organs as nothing else will. Because there are present in this fluid all the elements necessary for nutrition, physiologists have called it a perfect food. Quantitatively its most important ingredient is water, which constitutes about 86 per cent. of its weight. It also contains about 7 per cent. of milk-sugar, 4 per cent. of butter fat, 2 per cent. of protein, and 0.2 per cent. of mineral matter.

The milk of all animals contains a relatively small quantity of mineral matter; judged from this standpoint, the mineral matter would seem of minor importance, but it is actually as vital as any other constituent. Without it the bones would hot harden properly; and other services which it performs are absolutely essential to life. As we should expect, human milk contains all the mineral ingredients necessary for the development of the infant; indeed, with the single exception of iron, they are present in the precise amounts in which they are needed. In this omission, however, nature is guilty of no oversight, since the infant has already been provided by the time of birth with a rich supply of iron.

THE TECHNIQUE OF NURSING.—Since the mother should have opportunity to recuperate from the fatigue of labor, physicians generally recommend that an interval of at least twelve hours elapse between the birth of the infant and the time it is first put to the breast. Moreover, the best interests of the infant demand that it be kept warm and left undisturbed while becoming accustomed to its new environment. There is no immediate need of food; and if there were, nature does not fit the mother to supply it, for at this time the breasts contain merely small quantities of colostrum.

Some babies nurse vigorously at the outset, but later, discouraged because they get so little, become indifferent and restless, or even decline to take the breast. And the mother, who is handicapped by inexperience and by the awkwardness of nursing in a recumbent position, often feels desperate. Fortunately technical difficulties are confined to the first few days, and, trying as they sometimes are, no one should be discouraged or imagine that she is incapable of nursing; for practically every woman who persists will succeed.

For a week or ten days the mother will nurse in the recumbent posture. She turns to one side or the other, according as the right or left breast is used, and holds the corresponding arm to receive and support the baby, which will lie beside her. Then with the opposite hand she holds the breast, placing her thumb above and her fingers below so as to keep it from the baby's face, for only in this way can the infant breathe freely. One must also remember that the infant draws the milk into the terminal ducts chiefly with the back of its mouth, and drains the ducts by compressing the base of the nipple with its jaws; the infant therefore should take into its mouth not only the nipple, but also the areola, the area of deeply colored skin round about it. Mothers frequently disregard these directions, and the failure of their infants to nurse properly may be thus explained, for it is impossible to secure undisturbed nursing unless they are obeyed.

Generally the breasts are employed alternately, but both may be used at each nursing if one is insufficient. To fix the duration of the nursings arbitrarily is impossible; from ten to fifteen minutes generally proves satisfactory, but in each case systematic observations of the change in the baby's weight, of the character of its stools, and of its general condition must determine how long to leave it at the breast. The common error, unfortunately, is to be over-indulgent, and, as a result, infants are more frequently ill because the nursings are too long, than too short. Furthermore, the duration of the feedings can never be gauged accurately if the infant is allowed to nap while nursing.

The successful training of a baby begins with the development of regular habits of nursing. The old-fashioned custom of allowing the baby to nurse whenever it cried, tacitly—and incorrectly—assumed that it could have no other sensation than hunger. As a matter of fact an infant may have pain from overfeeding. Again, it may be thirsty, or uncomfortable from the pricking of a pin, from the monotony of one position, from a soiled napkin, or from neglect of many simple details in its care. Any of these things make a baby cry, for it has no other means by which it can express disapproval.

So long as the breasts contain colostrum the nursings should be at least three hours apart during the day; at night it is preferable not to disturb the mother at all. As soon as milk appears the interval is usually shortened to two hours during the day. In many cases, however, the three-hour interval will be retained even after the milk appears, for otherwise the infant may not become hungry and will fail to nurse as strongly as it should. The following schedule is adapted to the average infant:

Age Interval During Total Number the Day of Feedings From 1st to 4th week 2 hours 9 " 4th " 8th " 2-1/2 " 8 " 2nd " 4th month 3 " 7 " 4th " 10th " 3 " 6 " 10th " 12th " 4 " 5

After the first few days most young infants require one feeding in the middle of the night, which is usually given about 2 A.M. The day feedings then begin at 6 A.M., and are repeated at regular intervals until 9 or 10 P.M. The daily bath should be scheduled so that a feeding will be due just after the bath has been completed. If asleep when the next succeeding feeding falls due, the infant should not be waked, but at other times nothing should interfere with the regularity of the schedule. Occasionally there may be difficulty in getting the child to nurse during the day, but it must be taught to do so; otherwise it will want to nurse throughout the night.

At no time should an infant remain in the bed with its mother after it has finished nursing; at night this rule must be rigidly enforced, for mothers have been known to fall asleep and smother the baby, an accident known as over-lying. Infants can frequently be trained to go without feeding in the middle of the night even when a month old; and such training is always advisable, since it affords the mother opportunity for six or eight hours' continuous sleep.

Before and after each nursing the mothers' nipple should be cleansed with a solution of boric acid made by placing a tablespoonful of the powder in a tumbler which is then filled with water. Such cleansing protects the breasts against infection, a complication which the nursing mother must spare no pains to prevent. Now and then, in spite of conscientious efforts to harden them, the nipples become sore. If they crack, the baby's mouth must not come in direct contact with them, since nursing with a cracked nipple is a common source of a gathered breast. Fortunately when a nipple cracks we may employ a shield, obtainable at any drug-store, which enables the infant to nurse without any danger to the mother. Most babies will take the shield as well as the breast itself; nevertheless, its use should be discontinued as soon as the nipple heals, for while the shield is used the secretion of milk is not stimulated as vigorously as when the infant nurses directly from the breast. In the rare cases in which the shield cannot be used satisfactorily the infant must be taken from the breast temporarily and given a bottle. Radical as this advice may appear, the mother must consent to follow it, for, as I have pointed out, to permit an infant to nurse a cracked nipple is extremely hazardous. When treatment is begun promptly the cracks will generally heal within twenty-four hours.

HYGIENE OF THE MOTHER.—Since the mammary glands manufacture their product from the constituents of the mother's blood and their activity is controlled by her nerves, it is clear that her physical condition and her state of mind will influence the secretion of milk. Intelligent women who understand this desire to know how they should live that they may best insure an ample supply of good milk. Fortunately the first important step toward success has been taken when a mother wishes to nurse her baby; but there are also necessary wholesome food, habits conducive to health, and a mind free from worry.

It is unfortunate that current beliefs throw many restrictions about nursing-mothers which are unreasonable and unsupported by scientific investigation. There was a time when mothers did not question their ability to nurse, they assumed this duty as a matter of course. Indeed, they were compelled to do so, since refined methods of artificial feeding had not as yet been devised. Among the agricultural class, even to-day, it is exceptional for mothers to fail to nurse their children, if they are provided with the ordinary comforts of life. But women who live at the higher tension of city life are frequently unsuccessful, because they are more inclined to be nervous or because they disregard, among other things, the need of fresh air, plain food, or regular habits. It is wrong to suppose that elaborate rules of conduct are necessary for nursing mothers; the instruction they require is simple and scarcely different from that to be given anyone who desires good health. If she lead a wholesome existence a woman will not only nurse her child successfully but will gain in strength.

Diet.—In manufacturing centers, where a large proportion of the women are employed in confining work, the percentage of mothers who are able to nurse their children is exceedingly small; consequently the infant mortality is very high. Better nourishment for the mother, it has seemed, would render her more capable of successful lactation, and would decrease or even eliminate badly executed artificial feeding, and would therefore reduce the death rate among the babies. In a few foreign cities the idea has been put into practice. Free restaurants have been established for working mothers, and they have thus been enabled to perform their maternal duties much more successfully. Incidentally it has been shown that nourishment may be supplied mother and infant at a smaller cost than proper artificial food for the infant alone.

The quantity of nourishment required by nursing mothers is not so large as might be expected, and in many instances it is over-feeding rather than under-feeding that must be guarded against. Very accurate observations have been made which indicate that during the early weeks of nursing no more food is needed than at other times; in all probability this remains true throughout the whole period of lactation. Over-eating, as many of us know, is a frequent cause of indigestion. It is of the first importance, therefore, that nursing mothers should not take more food than they can assimilate, for indigestion will provoke disturbances in the milk which in turn will make the baby uncomfortable. For a similar reason mothers should have their meals at regular intervals.

As a rule the appetite is a reliable guide not only as to how much to eat, but also as to the choice of food, for without exception what is good for the mother is good also for the child. Generally the diet should be a mixed one, consisting of milk, gruels, soups, vegetables, bread, and meat. In order that monotony may not dull the appetite, no one article of food should be employed continuously. With this exception food should be selected with regard only for its wholesomeness and digestibility. All food is milk-making food; no sharp distinctions between the various kinds can be recognized. Milk, because it contains all the elements necessary for perfect nutrition, is particularly wholesome. Water also, since it forms such a large proportion of their milk, should be taken freely by nursing mothers. Generally it proves advantageous to take milk or some other nutritious drink between meals and again before retiring at night, but the danger of ruining in this way the appetite for solid food must not be overlooked.

It ought to be unnecessary to say that a nursing mother should deny herself any article of food, no matter how much she may want it, if she knows it will disagree with her; but she must remember also that the same article of food will not necessarily disagree with other mothers. Generalizations of this kind are largely responsible for the wrongful tendency to reject from the dietary many altogether harmless articles. There would be little left for a nursing mother to eat if she avoided every article of food which one person or another assures her will damage her milk.

No belief regarding what a nursing mother should eat is held more widely, I suppose, than that she should abstain from salads, tomatoes, and fruits which contain acid. This view is erroneous. The very idea upon which it is based is incorrect, since acids are neutralized as soon as they pass from the stomach to the intestines and cannot enter the milk. With certain persons some varieties of fruit invariably cause indigestion. Lactation does not correct such an individual peculiarity, and a nursing mother who knows she possesses it will act accordingly. Occasionally those who have no such idiosyncrasy worry after they have eaten something which contains an acid because they have heard it will do harm. In such cases it is the mental state of the woman which disturbs her milk and upsets the baby. With the exception of those who have such an idiosyncrasy and those inclined to worry, nursing mothers may partake of fruits and salads with impunity.

There are vegetables, of which the onion and turnip are good examples, that contain ingredients that find their way unaltered into the milk. So long as these do not disturb the mother their presence has no unfavorable influence upon the child. Similarly a number of substances appear in the milk when administered as medicine to the mother. In one way this is fortunate, for under certain circumstances it provides a very satisfactory method of treating unhealthy children without giving the medicine directly. In another respect, however, it is a disadvantage, for it sometimes interferes with giving the mother purgatives, which she may need. So far as possible, therefore, the taking of medicine should be limited during lactation, and certainly no drug should be employed without the advice of a physician.

Time and again some drug, some beverage, usually one that contains alcohol, or some special article of food has been recommended as a means of increasing an inadequate secretion of milk, but thus far all attempts in this direction have failed of general application. There are at present on the market widely advertised preparations for which astounding efficiency is claimed. None of them, however, has a definite or consistent value; and it is unfortunately true that no substance has yet been discovered that has the specific action of increasing the production of milk.

Psychic Influence.—Although the nerves of the breast which regulate the secretion of milk do their work whether the mother wills it or not, her state of mind has an influence over the process, just as it has over digestion. No one doubts that our minds influence our digestions as has been so clearly proved by the skillful experiments of Pawlow, an eminent Russian physiologist. Cheerfulness promotes perfect assimilation of the food, whereas mental depression decreases the secretion of the digestive juices or checks them altogether. In a similar way, perhaps, we shall some day have explained to us the unquestioned fact that mothers who maintain a happy disposition nurse their babies efficiently, while those who are inclined to worry often experience real or imaginary troubles with lactation.

The most striking manifestations of such psychic influences are those in which, as a result of some strong passion or deep sorrow, the secretion of milk suddenly ceases altogether. Fortunately such effects occur rarely and are never permanent. After a few hours at most the secretion is reestablished; and if there are alterations in the quality of the milk, these will correct themselves just as quickly.

More common, and therefore much more important, are cases in which, because the mother allows herself day after day to worry over one thing or another, the secretion of milk suffers permanent disturbance in quantity or in quality. Sometimes worrying lest the milk will be unsatisfactory causes it to become so. Generally, however, unnecessary anxiety for the baby is to blame. Again and again, when there is really nothing out of the way, inexperienced mothers make themselves miserable because they fear something may go wrong. Such a state of mind always invites trouble; not infrequently it is the direct cause of insufficient or unwholesome milk. The self-assurance gained through taking care of the first baby is responsible more than anything else for the greater success mothers have in nursing subsequent children.

The mother who is nursing her first baby should take success for granted, and never mistrust her ability to succeed. If the physician has been asked to visit the baby regularly, as was suggested at the beginning of this chapter, he will quickly detect the evidence of failure should failure be imminent. His opinions should be accepted and his directions followed, for by so doing the mother will most readily acquire the assurance which is so necessary to success. The habit, easily fallen into, of paying attention to promiscuous advice is unwholesome, for such advice is injudiciously given and is usually incorrect. More often than not the counsel of well-meaning friends only serves to perplex and distress the mother.

Recreation and Rest.—Next to worry no influence upon lactation is more detrimental than neglect of recreation and rest. Both are very necessary to a nursing mother, for without them she will soon begin to exaggerate minor troubles and even to worry though nothing is wrong. A mother who has the care of a baby added to other responsibilities may have extraordinary difficulty in finding time for outdoor exercise, for congenial companionship, or for diversion of any kind. Occasionally it may seem almost impossible even to get time for sleep, a necessity so fundamental to health that, as we should expect, a mother deprived of it would fail utterly in nursing her infant. Difficult as it may seem, however, the mother must find time for recreation, for if she does not there will follow disturbances, generally in the quantity, or sometimes in the quality, of her milk.

Keeping in mind that whatever benefits the mother will react favorably upon the infant, one should regulate exercise during lactation with regard to the kind and the amount of exercise to which she has been previously accustomed. Walking usually fulfils all the requirements satisfactorily, and there is ordinarily no reason why nursing mothers should not participate in sports that are unattended by violent exertion. Exhausting sports, however, must be shunned, because fatigue has the same injurious effect upon the secretion of milk as lack of exercise.

As might be expected, women who are frail are most susceptible to the strain of nursing, especially if they fail to get sufficient rest. All nursing mothers ought to have at least eight hours of sleep in the twenty-four. The night-feeding, generally advisable for the first six to eight weeks, does not break the mother's rest longer than half an hour if the baby is well trained. But if a baby that has not been properly trained turns night into day and keeps the mother awake for long intervals, the milk will quickly deteriorate. Under such circumstances someone must relieve the mother of the care of the infant during the night; she should not be disturbed even to nurse it. The night-feeding will then be supplied artificially; as will also one feeding during the day in order that the mother may have opportunity for exercise and diversion.

THE SUPPLEMENTARY BOTTLE.—At first glance it may seem that in the suggestion that the infant be given one artificial feeding each day the mother's comfort alone has been considered. As a matter of fact, however, the adoption of the plan benefits mother and infant alike. The diversion and recreation which the mother, thus relieved of her maternal duties for from four to six hours, has time to secure becomes a direct benefit to the infant. Not infrequently by pursuing this plan, mothers who would otherwise be incapable of nursing are assured successful lactation. The child, moreover, having thus become accustomed to the bottle, is much more easily denied the breast when the time for weaning comes.

Objections have been raised to giving the baby even one bottle when the mother has an ample supply of milk, but none of them are valid. Since cow's milk is acknowledged to be less easy of digestion than is human milk, it will occur to someone that there is danger of upsetting the baby by giving it a bottle. But this need not be feared; extensive experience has shown that if an infant is getting human milk of satisfactory quality at all its feedings during the twenty-four hours, save one or two, at these times it will digest properly modified cow's milk without the least inconvenience. Nor is it true that if once a day cow's milk is substituted for that of the mother, the infant will come to prefer the bottle to the breast. There is no danger, on the other hand, that the mother's milk will dry up. Very thorough investigation of these objections has failed to substantiate them in the least.

Of course, it will be necessary in preparing the supplementary feeding to take the same precautions as if the infant were on the bottle exclusively. To avoid contamination of the milk care must be exercised to have everything perfectly clean that comes in contact with it. And it will be necessary also to vary from time to time both the strength and the amount of the feeding. These alterations will be made most successfully if left to the judgment of a physician who is familiar with the development of the infant and who may be guided accordingly.

WEANING.—Occasionally, even before they are delivered, women express the conviction that they will be incapable of nursing. A few mothers who take this attitude, which it would seem is becoming more and more common, make no attempt at nursing, and others give it up after a very short trial. Premature weaning is practiced among the women of two widely different classes: those who are unwilling to deny themselves social pleasures, and those who, because they must earn a living, cannot be encumbered with maternal duties. A still larger class, however, are those mothers who wean the baby for neither of these reasons, but rather because they become discouraged and conclude that there is something wrong with their milk. In this way many infants are weaned without sufficient reason. Before giving up nursing her child a mother should submit several samples of the milk for analysis. If it is unfit for the infant, reliable evidence of the fact will often be secured in this way.

With the exception of tuberculosis, physicians recognize no condition that necessarily unfits a mother for nursing. As we have already seen, pregnancy is generally incompatible with lactation; in the event of conception the mother's milk almost always takes on qualities which render it unsatisfactory for the infant, and yet occasionally pregnancy advances several months before these changes in the milk occur. Meanwhile the infant suffers no inconvenience, and often in these cases the symptoms of threatened miscarriage give the first intimation of the mother's condition. Under all circumstances, however, nursing should cease as soon as the mother recognizes that she is pregnant, for probably no woman is strong enough to provide nourishment for her infant and for the development of the embryo simultaneously.

Menstruation, on the other hand, rarely if ever provides a good and sufficient reason for weaning. In the great majority of instances this function is re-established before lactation ends. There may be a reduction in the amount of milk during menstruation, but if the infant has been given the breast as usual, the supply increases as soon as the period ends. Qualitative disturbances which would render the milk unfit for use are practically never a consequence of menstruation.

It may happen as the infant grows older that the flow of milk will diminish; then the breast feedings will of necessity be more frequently replaced by the bottle, and the question of weaning will settle itself. But if the time of weaning is a matter of choice, it should be approximately coincident with certain notable developments in the infant's digestive functions, which occur toward the end of the first year. The fact that the infant is prepared to take other food is outwardly shown by the appearance of teeth, of which there are usually six or eight at the end of the year.

If the suggestion regarding the daily substitution of one bottle for the mother's milk has been adopted, there will be no difficulty in discontinuing breast-feeding whenever it is desirable; otherwise an infant may raise strong objection to the change. The mother, on the other hand, will not be seriously inconvenienced by the weaning, provided she leaves her breasts alone.

Until recently mothers were advised to employ a very elaborate treatment for drying up the breasts. The diet was restricted, and as far as possible liquids of every kind were forbidden; strong purgatives were administered daily; and, in addition, the breasts were covered with some ointment, swathed in cotton, and tightly compressed with a bandage. Fortunately, we now realize that none of these measures are required. When nursing is discontinued the breasts are apt to become distended and uncomfortable. They require support while the distention lasts, which is never very long, and if they become painful, medicine may be employed to give relief. But other measures, some of which occasionally do harm, are absolutely unnecessary, for, at whatever period of lactation the breasts cease to be used, they dry up spontaneously.



GLOSSARY

[Footnote: The Century Dictionary has been freely used for these definitions.]

ABNORMAL.—Irregular; deviating from the natural or standard type.

ABORTIFACIENT.—Whatever is used to produce an abortion.

ABORTION.—The expulsion of the embryo during the first four months of pregnancy.

AFTER-BIRTH.—The mass of tissue expelled from the uterus at the end of labor. It includes the placenta, the umbilical cord, and the membranes of the ovum.

ALIMENTARY CANAL.—The digestive tract. It begins with the mouth, includes the stomach and the intestines, and ends with the rectum.

AMNIOTIC FLUID.—The liquid inclosed within the amniotic membrane.

AMNIOTIC MEMBRANE.—The innermost of the two membranes which envelop the embryo; the lining membrane of the closed sac familiarly called "the bag of waters."

ANEMIA.—A deficiency of some of the constituents of the blood.

ANATOMY.—The science which deals with the structure of the body.

ANTISEPTIC.—Anything which destroys bacteria.

AREOLA.—The colored, circular area about the nipple.

ARTERY.—A vessel through which the blood flows away from the heart.

ASEPSIS.—The exclusion of disease-producing bacteria.

ASEPTIC.—Free from injurious bacteria.

ASPHYXIA.—The extreme condition caused by lack of oxygen in the blood, brought about by interrupted breathing.

ASSIMILATION.—The process by which living creatures digest and absorb nutriment so that it becomes part of the substance composing them.

ATROPHY.—To waste away.

AUTO-INTOXICATION.—Poisoning by material formed within one's body.

BACTERIA (the plural of bacterium).—Exceedingly minute, spherical, oblong, or cylindrical cells which are concerned in putrefactive processes. Some varieties cause disease.

BACTERIAL DECOMPOSITION.—Putrefaction brought about by the action of bacteria.

BIOLOGY.—The science which deals with the phenomena of life.

BIRTH-CANAL.—The passage through which the child enters the world. It is composed of the uterus and the vagina, and is surrounded by the pelvic bones.

BLADDER.—A thin, distensible sack acting as a reservoir for the urine between the time it is secreted by the kidneys and leaves the body.

BREECH.—The buttocks.

CESAREAN OPERATION.—The operation by which the child is taken out of the uterus by an incision through the abdominal wall.

CALORIE.—The unit ordinarily employed by scientists to measure heat.

CAPILLARIES.—The minute blood vessels which form a network between the terminations of the arteries and the beginnings of the veins.

CARBOHYDRATE.—Any one of a group of chemical substances of which starch and sugar are the most familiar members.

CARBONIC ACID GAS.—An animal waste product eliminated in the breath. In daylight plants absorb it energetically from the atmosphere through their leaves, and decompose it, assimilating the carbon, and returning the oxygen to the air.

CARTILAGE.—A firm, elastic tissue; gristle. From this material many of the bones develop.

CATHETERIZE.—To empty the bladder by means of a tube-like instrument which is introduced into the passage through which the urine normally leaves the bladder.

CELL.—One of the microscopical structural units which make up our bodies.

CELL-DIVISION.—The process by which a single cell becomes two cells.

CEREBRUM.—The portion of the brain which is the seat of mental activity.

CHORIONIC MEMBRANE.—The outermost of the two membranes which surround the embryo.

CHROMATIN.—A substance within the nucleus of a cell which has a special affinity for certain staining agents.

CHROMOSOMES.—One of the pieces into which the chromatin is broken during the act of cell-division.

CLINICAL.—Pertaining to the sick-bed.

COLOSTRUM.—The fluid secreted by the breasts during pregnancy and for two or three days after the birth of the child.

CONTRACTION.—The act by which the muscle fibers of the uterus become shorter and press upon its contents.

CURETTAGE.—Scraping out the lining of the uterus.

DELIVERY.—The birth of the child.

DIAGNOSIS.—The determination of either normal or abnormal states of the body.

DIAPHRAGM.—The muscular partition between the chest and the abdomen.

DIETETIC.—Pertaining to the diet.

DUCT.—A tube which conveys the secretion from a gland.

EMBRYO.—The offspring before it has assumed the distinctive form and structure of the parent.

ENEMA.—A quantity of fluid injected into the rectum.

ENGAGEMENT.—The entrance of the fetus into the birth-canal.

ETHNOLOGY.—The science which deals with the character, customs, and institutions of races of men.

EUGENICS.—The science which deals with the improvement of the human race by better breeding. (Davenport.)

EXCRETION.—Waste substance thrown off from the body.

FEBRILE.—Attended with fever.

FETUS.—The unborn child after the third month of development.

FOOD-STUFF.—Anything used for the sustenance of man.

FUNCTION.—The discharge of its duty by any organ of the body.

GASTRIC JUICE.—The digestive fluid secreted by the wall of the stomach.

GERMINAL CELLS.—The structural units from which a new individual takes origin. The cell contributed by the mother is called an egg- cell or ovum; that contributed by the father, a spermatozoon.

GESTATION.—Same as pregnancy.

GLAND.—An organ which separates certain substances from the blood, and pours out a material, usually fluid, peculiar to itself.

HYGIENE.—That department of medical knowledge which relates to the preservation of health; sanitary science.

INANITION.—The condition which results from insufficient nourishment.

INFECTION.—A disease due to bacteria.

INTESTINE.—The bowels; the long membranous tube extending from the stomach to the rectum.

INVOLUTION.—The process by which the uterus returns after child- birth to its former size and position.

LACTATION.—The secretion of milk.

LIGAMENT.—A band of tissue serving to bind one part of the body to another.

LIGATURE.—Anything that serves for tying a blood-vessel.

LOCHIA.—The discharge continuing for several weeks after the birth of a child.

LOTION.—Any liquid holding in solution medicinal substances intended for application to the skin.

LUNAR MONTH.—A month of twenty-eight days.

MAMMAL.—The highest order of animal, namely, one which suckles its young.

MAMMARY.—Relating to the breast.

MASTICATION.—The act of chewing.

MENOPAUSE.—The permanent abolishment of the menstrual process, which generally occurs between the 45th and the 50th years.

MICRO-ORGANISMS.—Bacteria and other living agents of disease which are visible only with the aid of the microscope.

MISCARRIAGE.—The termination of pregnancy prior to the seventh month.

MUCOUS MEMBRANE.—The lining of certain cavities of the body, such as the mouth, stomach, intestine, uterus, etc.

MUCUS.—The material manufactured by the glands in a mucous membrane.

MUSCLE-FIBERS.—The muscle-cells.

NARCOTICS.—Drugs which produce sleep.

NITROGEN.—One of the chemical elements.

NUCLEUS.—A clearly defined area found in every cell which seems to be its seat of government.

OBSTETRICS.—The branch of medicine which deals with the treatment and care of women during pregnancy and child-birth.

OVARY.—The organ which contains the egg-cells or ova.

OVIDUCTS.—Two tubes, each of which leads from the neighborhood of one of the ovaries; both terminate in the uterus.

OVUM.—An egg: the cell contributed by the mother to her offspring.

OXYGEN.—One of the chemical elements.

PATHOLOGY.—The branch of medicine which deals with the altered structure and activity of diseased organs.

PEPSIN.—A ferment found in the digestive juice secreted by the stomach.

PELVIC FLOOR.—The muscles, ligaments, and other tissues which form the bottom of the basin inclosed between the hips.

PELVIS.—The bony ring formed chiefly by the hip bones. Posteriorly the ring is completed by the sacrum.

PERINEUM.—The region extending backward from the outlet of the vagina to the rectum; it is the most essential part of the pelvic floor.

PHYSIOLOGY.—Scientific knowledge of the manner in which the various parts of the body perform their duties.

PIGMENT.—Any coloring matter.

PLACENTA.—The organ through which the communication between the mother and the offspring is established. One of its surfaces is attached to the wall of the uterus; at about the middle point of the other surface the umbilical cord takes its origin.

PRENATAL.—Pertaining to the period before birth.

PROTEIN.—A food-stuff which is distinguished by the fact that it contains nitrogen and is a tissue builder.

PROTOPLASM.—The living substance in the cells which compose our bodies.

PUBERTY.—Sexual maturity in human beings.

PUBIC BONES.—The part of the pelvis which forms an arch in front of the bladder.

PUERPERIUM.—The same as the lying-in period.

RETINA.—The innermost coat of the eye-ball and the one which receives visual impressions.

RICKETS.—A disease of infancy characterized by softening of the bones.

SECRETION.—The product of the activity of a gland.

SEDIMENT.—The material which settles to the bottom of any liquid.

SPERMATOZOON (plural spermatozoa).—The microscopic cell contributed by the male parent, which stimulates the ovum to begin its development.

SUPPOSITORY.—A medicinal substance made into the form of a cone to be introduced into the rectum.

TERM.—The time of expected delivery.

THERAPEUTIC.—Concerned with the treatment of disease.

THYMUS GLAND.—A structure located behind the breast bone near the root of the neck. Only traces of it are found in adult life.

TISSUE.—An aggregation of similar cells in a definite fabric, as muscle, nerve, gland, etc.

TUBES.—The oviducts.

UMBILICAL CORD.—The structure carrying the blood vessels which pass between the placenta and the child's navel.

UTERUS.—The womb: a hollow muscular organ designed to receive, protect, nourish, and expel the product of conception.

VAGINA.—The canal through which the child passes from the uterus into the world.

VEIN.—A vessel through which the blood flows back to the heart.

VERNIX.—The fatty substance deposited over the skin of the newly born infant.

VIABLE.—Capable of living.

VILLI (singular villus).—The microscopic, finger-like processes which hang from one of the surfaces of the placenta and are surrounded by the mother's blood.

VISCERA.—The internal organs which occupy the cavities of the chest and the abdomen.

VULVA.—The folds of tissue which surround the outlet of the vagina.

THE END