The practice of obstetrics has many features that are very gratifying to the nurse and physician.

Instead of a surgical operation, which has come unexpectedly and undesired; a disaster in which some part of the body is removed or altered by means of a procedure associated with extreme pain, mental tribulation and large expense, a much-wished for addition is brought to the family, with pain, to be sure, but a pain that is soon forgotten in the general joy. This is the normal condition that causes the nurse and the doctor to rejoice that such a delightful specialty has been chosen.

Then comes a case in which the labor may be complicated by some dreadful anomaly, or the puerperium burdened or disordered by some unwelcome invasion that tortures the souls of the family and may cost the life of the mother, or child, or both.

At such a time the nurse and the doctor feel the full weight of their responsibility, and after a series of anxious days and sleepless nights, they wonder why they did not choose gardening or a clerical position for their life work.

The disorders of the puerperium are many and various, but naturally the breasts and the pelvic organs are most frequently affected.

The breasts of the human female are not reservoirs of milk like the cow’s, but a pair of highly sensitive organs that functionate and produce only as the demand is made. It follows that when the milk comes in, the breasts become engorged and all the neighboring structures are involved in the new process. However, it is not milk that is overfilling the breasts, but serum, lymph and venous blood, which congest the tissues surrounding the glands and produce a hard painful mass.

The breasts become heavy, hot, and painful; supernumerary glands in the axillÆ enlarge, but there is no fever. There is but little more reason for a fever when the mammary gland begins to functionate than when the lungs fill for the first time except in the case of nervous patients who bear discomfort badly.

If fever appears simultaneously with the milk, the cause must be sought in some atrium of infection, possibly in the breasts, but usually elsewhere. There is no such thing as “milk fever.” The enlarged glands, the tense mottled skin on which blue veins run visibly here and there, the nipple, flattened and drawn into the swelling, so that the child can not grasp it with the mouth, all produce a sense of disorder that ought to be associated with fever—but is not. This is the “caked breast” of the laity, and if let alone, the hyperÆmia subsides and the function remains. The temperature in possibly two cases out of five may rise to 100° F. for twenty-four hours, but it promptly subsides. These temperatures generally occur in neurotic women.

If the breasts are irritated by binders, breast pumps, or massage,—like the blacksmith’s arm, with exercise—the trouble, if not increased, is at least much slower in disappearing.

It is reported that the young virgins of some African tribes nurse the babies in the family, the breasts being stimulated to produce milk largely by massage.

If the condition of the breasts becomes too painful, the liquids by mouth are reduced to the last degree, saline cathartics are given until frequent watery stools result, one or more ice bags are applied to each breast and codeine sulphate may be given at night. The child nurses every four hours only. Williams was the first to show that no tight binder is necessary, but only a supporting bandage. The tight binder is a cruel and useless barbarism that has been abandoned by progressive physicians. No massage is allowed; no pumps; no irritation whatever, and in twenty-four hours the trouble has disappeared. Hot dressings to the breast are equally archaic. They should never be applied to any breast unless it is desired to hasten suppuration.

If the child dies, or for any reason can not nurse (inverted nipple, cleft palate, harelip) and it becomes necessary to dry up the milk, the treatment for “caked breast” is continued. After twenty-four hours the breasts are comfortable and rarely give trouble again.

Cracks, Fissures and Abrasions of the Nipple.—The care of the nipples should be inaugurated about six weeks before labor, as elsewhere described:

The nipple must be inspected and its possibilities determined, early in pregnancy, if possible, for many varieties of badly shaped and ill-developed nipples exist which may make nursing difficult or impossible.

Imperfect nipples especially are predisposed to fissure and crack, and will require extreme care on the part of the nurse. She should inspect them before and after each nursing and sedulously use cleanliness and asepsis in her management. In normal and tranquil as well as in neurotic women, the nipple may become so sore as absolutely to preclude nursing, and this entails much additional work on the nurse and mother, as well as considerable peril for the child. The condition usually begins as a fissure or crack, and is accompanied by much pain. It is serious, furthermore, in another aspect since all breaks in the surface of the nipple are avenues of infection that may result in mastitis. The child may produce fissures or abrasions by rubbing the nipple with his mouth, by pulling too hard, or by the habit of holding it in his mouth and macerating it with his gums when he has finished nursing.

The child must not be left at the breast after he has nursed, but the nipple should be gently removed from the child’s mouth by passing one finger in beside the nipple. Fissures and abrasions usually occur within ten days if at all. Abrasions or erosions are due to the wearing away of the epithelial covering of the nipple in patches more or less extensive.

Thin-skinned blonde women suffer more than those with dark, dense oily skins.

A fissure is a distinct separation of tissue that goes deeply into the underlying substance.

A crack is a long abrasion which may deepen into a fissure.

Both fissure and crack may affect the top, the side of the apex, or the base of the nipple. They may be either longitudinal or circular. The entire nipple must be kept under observation and the instant a raw surface is detected, treatment must begin.

Compound tincture of benzoin, liberally applied, is a favorite and successful remedy. Our routine is to apply a paste made of equal parts of castor oil and subnitrate of bismuth. This is put on after the child nurses, and must be removed carefully before the next nursing. Sometimes the child’s stools become black and constipated and the trouble may be traced to imperfect removal of the bismuth preparation.

Whatever medication is used, the nipple must be protected from injurious friction by the clothing. This is best done by the hat-shaped lead nipple shield, which is placed over the nipple and held in place by a light binder. The shield should be boiled before use.

To protect the nipple during nursing, a glass shield may be used for a day or so, but not long enough for the babe to get accustomed to it, else he will form a habit hard to break. This shield must be taken apart after use, washed and kept in saturated solution of boric acid until the next nursing.

If all these measures fail, the fissure must be touched with a nitrate of silver stick once, or have a 2 per cent solution of nitrate of silver applied night and morning. It may be necessary to take the child from the breast for a day or so, in which case he nurses the other breast and the side with the bad nipple is pumped.

The care of the nipple is highly important since the apprehension and the actual pain of each nursing may prevent sleep, destroy the appetite, and diminish the milk. If begun early, most fissures will heal in twenty-four to forty-eight hours.

Mastitis.—From three to five per cent of lying-in women have mastitis in the European clinics, but the records in America show a much smaller number.

The disease occurs most frequently in blondes and in primiparas. It is most apt to appear during the first two weeks, when the congestion accompanying the new mammary function produces a stasis that favors the growth of germs, which may enter through the abrasion or fissures of the nipple produced by zealous activity of the child’s gums. But it may also occur when the child’s first teeth come and the nipple is again exposed to injury. At times it is impossible to find a plausible excuse for its occurrence.

Mastitis is usually described in three forms: The (a) parenchymatous or glandular type, which affects the substance of the gland or the enveloping connective tissue; in (b) subcutaneous mastitis the connective tissue beneath the skin is attacked; and in (c) the sub-glandular variety, the infection finds a lodging between the gland and the chest wall.

Mastitis is always due to the presence of microorganisms which in many cases gain access to the gland through fissures or abrasions by means of the lymphatics. In other instances the germs may be in the blood and a local stasis may encourage the infection. Still again, they seem to enter through the normal nipple openings.

Symptoms.—The parenchymatous inflammation begins with a chill, and the temperature promptly rises to 102° to 105° F. The pulse is high. The patient complains of headache and thirst. Examination reveals hard, tender nodules in some part of the gland. The skin may or may not be reddened.

If the trouble has begun in the connective tissue, the skin will be diffusely reddened, the nodule ill-defined, the temperature will rise gradually and the chill may be absent.

Treatment.—The breast is put at rest. No tight binder is applied, no breast pump, no massage. No heat is allowable.

Ice bags surround the gland night and day. The liquids by mouth are restricted and saline cathartics given. Codeine may be administered for pain. Usually the symptoms subside without suppuration in from one to two days.

Should the inflammation persist for more than two or three days, in most cases the tissue will break down and form a mammary abscess. When it is evident that suppuration has begun, heat may be applied to the gland and the process accelerated. The abscess may be superficial or deep and will be diagnosed by a bogginess in a circumscribed area or by fluctuation. The abscess must be opened as soon as possible.

The nurse sterilizes a bistoury and a pair of long artery forceps. Lysol solution and cotton sponges are made and sterile gauze for packing. The hands are surgically prepared and rubber gloves worn. If an anÆsthetic is required, gas may be used, or chloroform. The incision is made radially from the nipple so as to minimize the injury to the milk ducts. A gauze drain may be required for a few days.

In the after-care, the nurse must be scrupulously clean and not convey contagion from the breast to the woman’s genitals, to the child’s eyes, navel or vagina, nor to her own person.

Excess of milk is rare, but may be observed for a short time after the glands fill. It seldom requires treatment, but saline cathartics, restriction of fluids, and putting the child on a four-hour schedule will reduce it. Pads may be worn if it runs away freely.

Scarcity of milk is only too common. There may be enough at first and the quantity gradually diminish, or it may be deficient from the very beginning.

The faulty secretion may be due to the age of the mother, to disease (anÆmia), to bad nutrition, or to overwork. It may follow a premature child. Compression of the breasts by corsets or tight dresses may prevent development. The amount of gland tissue is very important. Many women have large, fat breasts, but a small glandular development. Mental conditions, such as fright, worry, and anxiety, will diminish the flow of milk or stop it altogether.

Symptoms.—The child is fretful, goes to sleep after nursing but soon wakes up, or may nurse awhile, and then finding it useless, will cry and refuse the nipple. He loses weight and when weighed before and after feeding, the scales scarcely vary. No secretion or very little can be squeezed from the breasts. The child may be given a bottle after which he goes to sleep.

Treatment.—When the gland tissue is defective, no treatment can succeed.

The appetite must be improved by bitter tonics and the mind relieved of its anxieties, if possible. Change of scenery may help. The fluids must be increased, milk, cocoa, chocolate and gruel must be pushed, and such vegetables added as corn and beets. Oyster stews, clams, lobsters, and crabs will help. The diet must be full and nutritious with especial stress on those foods that raise the blood pressure. Malt drinks or champagne may avail in some cases. Exercise in moderation is desirable.

Artificial stimulation of the breast sometimes succeeds. Massage will irritate the glands, increase the congestion, and promote functional activity; or a Bier vacuum apparatus may be put over the gland several times a day and the air pumped out. The breast should be kept distended for fifteen to twenty minutes. There is difficulty in this country in getting glass bells of sufficient size.

Galactorrhoea is the name applied to an abundant secretion of milk poor in quality toward the end of a long lactation or after the child is weaned. The symptoms are an almost constant flow of milk with resultant anÆmia.

Treatment.—Elix. of iron, quinine and strychnine with compression of the gland. A dry diet and the avoidance of all irritation of the breasts will aid.

To “dry up the milk,” follow the treatment for “caked breast.”

Quality of the milk may be such that the child will not take it or, if taken, it fails to nourish. In some cases this is due to overlong, or to irregular, periods between feedings; for when the nursing interval is too short, the milk becomes too rich, when too long, it becomes thinner and less nutritious.

Fright, anxiety or anger may change the character of the milk so that colic, vomiting, and diarrhoea and indigestion are produced in the child. A wet nurse becomes homesick and the milk dries up. It may become extremely indigestible, as shown in cases where a wet nurse quarrels with her husband and her foster child develops green stools. If the mother’s milk does not agree, the child may be put on feedings for twenty-four or forty-eight hours, while the milk, pumped from the breast, is sent to a laboratory for analysis. If a return to the breast is unsatisfactory, artificial feedings or a wet nurse must be supplied.

Removal of the child from the breast may be required for a variety of reasons. Thus, the mother’s addiction to alcohol or opium is good ground for taking away the child. Arsenic, bromides and iodides of potassium, saline cathartics, salicylates, alcohol, opium and belladonna must be given to the mother with great caution during lactation, for they pass over into the milk.

Acute diseases, such as erysipelas, pneumonia, diphtheria, typhoid, malaria, pronounced puerperal sepsis or persistently high fever from any cause, usually dries up the milk; while cardiac lesions, unless well compensated, chronic anÆmia and tuberculosis, obviously demand the removal of the child for the sake of both. Sometimes a new conception, especially when the milk becomes poor in the last half of gestation, compels the mother to wean her babe.

A syphilitic woman may nurse her own child, provided her condition is good and the child also is syphilitic.

Theoretically, the return of menstruation in no way affects the nursing child, unless the blood is lost to the point of anÆmia. Yet cases do occur in which the child has indigestion, colic and bad stools, as well as loses weight, when the mother is menstruating.

The quality of the milk is sometimes altered, but only for a day or so, and the child should continue at the breast unless some definite indication for removal arises.

Weaning ordinarily is completed by the ninth month, but the child should never be carried beyond the twelfth month on account of changes in the character of the milk.

When a child is weaned, the substitution of an artificial food may be made gradually,—a bottle a day, two bottles a day, etc., until, in a couple of weeks, the breasts are at rest.

The excessive prolongation of lactation is shown upon the mother by impairment of the health. The patient is pale, weak, anÆmic, fretful, and thin. Headaches, dizziness, loss of appetite, and constant fatigue will be complained of.

The treatment is to remove the child at once and put the mother on stimulating drugs and foods. A change of air and scenery, if possible, will be highly beneficial.

The wet nurse is always a tribulation, which must be endured until the child can be put on artificial food. She should have a Wassermann test before entering upon her duties. Syphilis, tuberculosis, and gonorrhoea must be guarded against. She must be kept like the family cow, in a placid frame of mind, fed on nutritious food that is not too rich, and exercised enough to keep the blood circulating.

Light housework and duties that take her out of doors part of the time are advisable. Her moral character can only be assured through those who have known her. If she brings her own child with her, she will need watching to provide for an equable distribution of the milk. The first few days is never a criterion of a wet nurse’s effectiveness. Change of food and surroundings may interfere with her usefulness.

Gas may complicate the puerperium after CÆsarean section, and even after normal labor. A rectal tube of soft rubber may be passed as high as possible into the bowel and left for some time, or enemas of S. S., turpentine, asafoetida, or milk and molasses may be given. By mouth calomel or mag. cit. is valuable.

Headache in the puerperium should be watched carefully, and the cause discovered. Pain in the head may be a habit with the patient, or it may be a symptom of some complication either present or developing, such as toxÆmia, eclampsia, or acute yellow atrophy of the liver. In general, it is due to milder conditions like exhaustion, too many visitors, excitement, nerves, or insomnia.

After-pains.—Sometimes patients are greatly annoyed by after-pains. The pain may be due to a clot retained in the uterus or possibly a stimulation of the uterus when the child goes to breast. Gentle massage of uterus, or ergot, quinine, or codeine may be required to bring about the expulsion of the clot or to control the pain. A reasonable degree of after-pain is of favorable significance. (See p. 154.)