The puerperium^[8] is ordinarily regarded as comprising the five or six weeks immediately following delivery. During this period the mother’s body undergoes various changes which restore it very nearly to its pre-pregnant state, leaving the patient in a normal, healthy condition. The most important of these changes are involution of the uterus, loss of weight and improvement in tone of the abdominal and perineal muscles. The alterations which produce this restoration are normal physiological processes, but mismanagement or lack of care while they are taking place may result in serious complications; these may be immediate or remote, such as hemorrhage and infection or chronic invalidism.

Recognition of these dangers, and the possibility of preventing them, is responsible for the present custom of obstetricians to watch over their patients during the puerperium. This is in sharp contrast to the old practice of the doctor’s visiting the puerperal woman only when there was a complication so apparent that he was summoned.

The precautions and the care which the doctor takes of his patient after delivery involve intelligent and watchful nursing. In order to give this the nurse must understand something of the normal physiology of the puerperium, just as she did in pregnancy and labor. Otherwise she may not be able to distinguish evidences of normal changes from symptoms of complications.

Involution. Considerable attention is centred in the remarkable atrophic changes that take place in the uterus during the puerperium, for it is upon their being normal that the patient’s recovery and future well-being so largely depend. Immediately after delivery the uterus weighs about two pounds; is from seven to eight inches high; about five inches across and four inches thick. The top of the fundus may be felt above the umbilicus, and the inner surface, where the placenta was attached, is raw and bleeding. At the end of six or eight weeks the uterus has descended into the pelvic cavity and resumed approximately its original position and size, and its former weight of two ounces; a new lining has developed from the few glands which have not been cast off in the discharges.

This rapid diminution in the size of the uterus is termed involution and is accomplished by means of a process of self-digestion or autolysis. The protein material in the uterine walls is broken down into simpler components which are absorbed and eventually cast off largely through the urine. This change and absorption of uterine tissues is similar to the resolution that takes place in a consolidated lung in pneumonia.

Since satisfactory involution is necessary to the patient’s future health, its progress should be watched with deep concern and interest, and all possible effort made to promote it; firm consistency of the uterus and a steady descent into the pelvis and normal lochia being the chief evidences of satisfactory involution. There is evidently a close relation between the functions of the breasts and of the uterus during the puerperium, and as a rule involution accordingly progresses more normally in women who nurse their babies than in those who do not.

The so-called “after-pains” are also affected by nursing, being more severe as a rule when the baby is at the breast than at other times. These pains are caused by the alternate contractions and relaxations of the uterine muscles and are more common in multiparÆ, than in primiparÆ, because the muscles of the former have somewhat less tone than the latter and therefore tend to relax, and then contract, whereas the better muscle tone of the primipara tends to keep the uterus steadily contracted.

These after pains usually subside after the first twenty-four hours, though they may persist for three or four days. They may amount to little more than discomfort, but not infrequently are so severe as to require the administration of sedatives. Persistent after pains may be due to retained clots.

The cervix, vagina and perineum which have become stretched and swollen during labor, gradually regain their tone during the puerperium, and the stretched uterine ligaments become shorter as they recover their tone, finally regaining their former state. Until the ligaments and the pelvic floor and abdominal wall are restored to normal tonicity the uterus is not adequately supported and therefore may be easily displaced.

The lochia consists of the uterine and vaginal secretions and the blood and uterine lining which are cast off during the puerperium. During the first three or four days this discharge is bright red, consisting almost entirely of blood, and is termed the lochia rubra. As the color gradually fades and becomes brownish it is called the lochia serosa. After about the tenth day, if involution is normal, the discharge is whitish or yellowish and is designated as the lochia alba. The total amount of the lochial discharge has been variously estimated at from one to three pints, being more profuse in multiparÆ than primiparÆ, and in women who do not nurse their babies. Under normal conditions the discharge is profuse at first, gradually diminishing until it entirely disappears by the end of the puerperium. There may be small amounts of blood retained during the first day or two and expelled later as clots, without any serious significance, and there may be a pinkish discharge after the patient gets up for the first time, but if the lochia is persistently blood-tinged it may be taken as an indication that the uterus is not involuting as it should.

The normal characteristic odor is flat and stale. A foul odor, no odor at all or a marked decrease in the amount of the discharge is suggestive of infection.

Loss of Weight. One of the striking changes during the puerperium is the loss in weight, due largely to three factors: the elimination of fluids from the edematous tissues; the decrease in the size of the uterus and the escape of vaginal and uterine secretions, termed the lochia. The smaller amount of food taken during the first few days post-partum also may be a factor.

This loss in weight is extremely variable, fat women naturally losing more than thin women and those who nurse their babies losing more than those who do not.

Dr. Edgar estimates that the loss through the lochia amounts to something over three pounds, and the loss through fluids from the tissues, from nine to ten pounds. According to Dr. Slemons, the loss in fluids equals about 1/10th of the patient’s weight at the beginning of the puerperium, while all agree that the uterus decreases about two pounds in weight. All told, then, the patient may normally lose from twelve to fifteen pounds during the puerperium. This loss may be somewhat controlled, however, by a suitable diet, and under most conditions the patient should return to not less than her pre-pregnant weight by the end of the sixth or eighth week.

Menstruation. Although in the ideal course of events, the mother does not menstruate while nursing her baby, that is, for eight to ten months, Dr. Slemons estimates that about one-third of all nursing mothers begin to menstruate about two months after delivery, while according to Dr. Edgar one-half of those who do not nurse their babies begin to menstruate in six weeks after delivery.

Menstruation is more likely to return early in primiparÆ than in multiparÆ. Patients sometimes wonder whether this early discharge is menstrual or lochial, and though they can not tell, a physician can easily decide by examination, and it is important that he be given the opportunity to do so. A nursing mother may menstruate once and then not again for several months or a year; or she may menstruate regularly and nurse her baby satisfactorily at the same time, though menstruation is usually regarded as unfavorable to lactation.

Lactation. During the first two or three days after the baby is born, the breasts secrete a small amount of yellowish fluid called colostrum, which differs from milk chiefly in that it contains less fat and more salts and serum-albumen than milk and in the fact that it coagulates upon boiling. About the third day after delivery, the meagre amount of colostrum is replaced by milk and as it increases rapidly in amount, the breasts usually become tense and swollen at this juncture, and sometimes very painful; but this turgidity usually subsides after a day or two.

The function of the breasts, that of secreting milk, is definitely stimulated by the baby’s suckling and will not continue for more than a few days without this stimulation, a fact to be remembered if it is desirable for any reason to dry up the breasts.

The ideal condition is for the breasts to secrete a quantity and quality of milk which will adequately nourish the baby for eight or ten months. The reverse of this condition is sometimes found in very young or in elderly women, or in very fat or frail, undernourished women.

Ovulation is usually suspended during lactation, but a mother may become pregnant a few weeks after delivery even while nursing her baby, though the quality of her milk is likely to be unfavorably affected by the pregnancy. But, as has been explained, the return of menstruation does not necessarily exert as unfavorable an influence upon lactation as was formerly believed.

Abdominal Wall. The abdominal wall is usually overstretched during pregnancy, and immediately after labor when the tension is removed, the skin lies in folds and the entire wall is soft and flabby. The normal and desirable course is for the muscles gradually to regain their tone; for the excess of fat to be absorbed and the walls to approach their original state in the course of a few weeks. The striÆ usually remain, and the muscles sometimes fail to regain their tone, as for example when pregnancies follow each other in rapid succession or when there has been excessive distension. In such cases there is likely to be the pendulous abdomen so often seen in multiparÆ, and a diastasis, or separation of the rectus muscles.

Digestive Tract. During the first day or two after delivery the mother may have very little appetite but she is usually very thirsty. She will almost inevitably be constipated, because of the loss of intra-abdominal pressure; the sluggishness of the intestines acquired during pregnancy; her recumbent position, lack of exercise and the fact that she is taking relatively less food than usual and that her bowels were freely evacuated at the onset of labor.

Temperature. The temperature often rises to about 99° F. immediately after labor but it should drop to normal in a few hours and practically remain so. For various causes, some of which are unexplained, the temperature will not infrequently be slightly above normal at times during the first few days of the puerperium, without the patient’s seeming to suffer any ill effects. But the fairly general agreement among obstetricians seems to be that a temperature of 100.4° F. is the upper limit of normality and that infection is to be suspected if it reaches that point and remains there for twenty-four hours.

Pulse. The normal pulse rate is usually slower during the puerperium, being about 60 or 70 beats to the minute, and is referred to as puerperal bradycardia. It is thought that this is due to the absolute rest in bed and the decreased strain upon the heart after the birth of the baby.

Skin. There is usually profuse perspiration during the first few days, while the elimination of fluids is most active, but it gradually subsides and becomes normal by the end of a week. The perspiration sometimes has a strong odor and there is not infrequently an appreciable amount of desquamation.

Urine. Many patients find it difficult, even impossible, to void urine during the first several hours after delivery because of the removal of intra-abdominal pressure; the recumbent position and the swelling and bruised state of the tissues about the urethra. The bladder is likely to be less sensitive than usual and the patient will be able to retain an abnormally large amount of urine for several hours without discomfort, or desire to void.

The output of urine during the first few days is greater than normal, and there is also a considerable increase in the amount of nitrogen excreted, beginning two or three days after delivery. This is evidently derived from the broken down proteins in the uterine wall, and the excess gradually subsides as involution progresses, and disappears by the time the uterus descends into the pelvis.

When one considers the severe ordeal that the young mother has just passed through, her recovery and return to a normal state are surprisingly rapid, when she is given good care.

Not infrequently the nurse remains with her patient after the end of the puerperium, and therefore she may have the care of the mother and baby for several weeks, or even months. The most valuable single service which she can perform in this capacity is to help in making it possible for the mother to nurse her baby at the breast. For both the nurse and the mother must realize that the breast-fed baby is much more likely to live through the difficult first year, and is markedly less susceptible to disease and infection than is the bottle-fed baby.

The first step is to convince the young mother of what it means to her baby and her obligation to try to nurse him, since, excepting under very rare and unusual conditions, she can nurse him if she wants to enough to make the necessary effort and sacrifice.

The important contra-indications for attempting breast-feeding are retracted nipples, tuberculosis, eclampsia, severe heart or kidney disease and certain acute infectious diseases such as typhoid fever.

It seldom happens that the mother who has had average prenatal care, followed by good care during and after delivery, is unable to nurse her baby if she orders her life in the way that is known to be necessary to promote and maintain lactation. The first essential is her real desire to nurse her baby; next, her appreciation of the continuous care of herself that is necessary and third, her whole-hearted willingness to take this care for her baby’s sake.

It is safe to say that if the doctor and the nurse and the patient all want the baby to nurse at the breast, and all do everything in their power to make this possible, they will almost invariably succeed. This assertion can scarcely be made too positively, and the nurse should never lose sight of the fact that if the baby is not breast-fed he is being defrauded, and in the vast majority of cases, because of insufficient effort on the part of the doctor, nurse or patient, or all three.

A favorable frame of mind and state of good nutrition in the mother are the two indispensable factors in establishing breast-feeding and in maintaining the secretion of an adequate supply of breast-milk. These conditions, in turn, are both affected by her general mode of living, as long as the baby nurses.

Women with happy, cheerful dispositions usually nurse their babies satisfactorily, while those who worry and fret are likely to have an insufficient supply of milk, or milk of a poor quality. And in addition to this sustained influence, the temporary effect of a fit of temper; of fright; grief; anxiety or any marked emotional disturbance is frequently injurious to the quality of milk that previously has been satisfactory. Actual poisons are created by such emotions and may affect the baby so unfavorably as to make it advisable to give him artificial food, for the time being, and empty the breasts by stripping or pumping, before he resumes breast feeding.

A mother’s lack of faith in her ability to nurse is so detrimental in its effect that she must be assured over and over, that she can nurse her baby if she will persevere. If the nursing does not go well at first she must not give up, but must continue to put the baby to the breasts regularly, as this is the best means of stimulating them to activity. His feeding should be supplemented with modified cow’s milk, if the breast milk is inadequate, either in amount or quality.

Method of Nursing. The baby should be put to the breast for the first time between eight and twelve hours after he is born. This gives the tired mother an opportunity to rest and sleep, and the baby, too, is benefited by being kept warm and quiet during this interval. His need for food is not great as yet, nor is there much if any nourishment available for him.

In preparing to nurse her baby, the mother should turn slightly to one side, and hold the baby in the curve of her arm so that he may easily grasp the nipple on that side. She should hold her breast from the baby’s face with her free hand by placing the thumb above and fingers below the nipple, thus leaving his nose uncovered, to permit his breathing freely. (Fig. 138.) The mother and baby should lie in such positions that both will be comfortable and relaxed, and the baby will be able to take into his mouth, not only the nipple but the areola as well, so as to compress the base of the nipple with his jaws as he extracts the milk by suction.

The nurse may have to resort to a number of expedients in persuading the baby to begin to nurse, for he does not always take the breast eagerly at first. He must be kept awake and sometimes suckling will be encouraged by patting or stroking his cheek. Or if his head is drawn away from the breast, a little, he will sometimes take a firmer hold and begin to nurse. Moistening the nipple by expressing a few drops of colostrum or with sweetened water may stimulate the baby’s appetite and thus prompt him to nurse.

The young mother must be prepared to find very discouraging the early attempts to induce the baby to nurse, but if the nurse will help her to persevere in making regular attempts she will almost certainly succeed.

During the first two or three days the baby obtains only colostrum, while nursing, but the regular suckling is extremely important, not alone for the sake of getting him into the habit of nursing but for the sake of stimulating the breasts to secrete milk.

Moreover, the irritation of the nipples so definitely promotes involution of the uterus that this process goes on more rapidly in women who nurse their babies than in those who do not. If the nipples are not sufficiently prominent for the baby to grasp them, a shield will have to be used while they are being brought out. But the shield should be discarded as soon as possible for it is the baby’s suckling that produces the physiological effects. If a shield is used, it should be washed and boiled after each use and kept, between nursings, in a sterile jar or a solution of boracic acid.

The length of the nursing periods and the intervals between them have to be adjusted to the needs and condition of each baby; his weight, vigor, the rapidity with which he nurses, the character of his stools and his general condition, all of which will be considered in connection with the care of the baby. The intervals between nursings are measured from the beginning of one feeding to the beginning of the next, and are fairly uniform for babies of the same age and weight. The length of the nursing period itself is usually from ten to twenty minutes.

The average baby nurses about every six hours during the first two days, or four times in twenty-four hours. According to one schedule he will nurse every three hours during the day for about three months, beginning with the third day, and at 10 p.m. and 2 a.m., or seven times in twenty four hours. From the third to the sixth month he nurses every three hours during the day and at ten o’clock at night, or six times in twenty-four hours, and from that time until he is weaned he should nurse at four hour intervals during the day and at ten o’clock at night, or five times daily, as follows:

It is becoming more and more common to omit night feedings after 10 p.m., even during the first three months, with the average baby who is in good condition. When this practice is adopted the baby not only seems to do as well as he normally should, but to benefit by the long digestive rest during the night. Certainly the mother profits by the unbroken sleep which this makes possible.

As a rule the baby should nurse from one side, only, at each nursing, emptying the breasts alternately, but if there is not enough milk in one breast for a complete feeding both breasts may be used at one nursing. Neither the mother nor the baby should be permitted to sleep while he is at the breast, but he should pause every four or five minutes to keep from feeding too rapidly.

After the mother sits up, she may occupy a low, comfortable chair while nursing the baby. She should lean slightly forward and raise the knee upon which the baby rests by placing her foot on a stool, supporting his head in the curve of her arm, and holding her breast from his face, just as she did while in bed. (Fig. 139.) She should nurse him in a quiet room where she will not be disturbed nor interrupted and where the baby and her breasts will be protected from drafts or from being chilled. Many women prefer always to lie down when nursing the baby.

Before the nurse leaves her patient she should teach her how to care for her nipples, including the preparation of boric solution; the importance of washing her hands before bathing her nipples, and of keeping the breasts covered with clean gauze between nursings.

The personal hygiene of the nursing mother should be virtually a continuation of that which is advisable during the latter part of the puerperium; a normal, tranquil kind of life which is unfailingly regular in its daily routine.

But this is not quite as easy as it sounds, for during the puerperium the young mother is still something of a patient and is regarded as such, while during the months that follow she is simply a nursing mother, who must live sanely and moderately for her baby’s sake, and at the same time take her place among people who are not under compulsion to place any special restrictions upon their daily lives. It is much easier to take precautions and follow directions for a few days or weeks, while the situation is novel, than it is to persist month after month without help or encouragement. The young mother’s family often fails to appreciate the difficulty of her problem and for this reason she is sometimes unable to care for herself, as she should, with the result that she cannot nurse her baby successfully.

As long as the nurse remains with her patient, therefore, she must try to impress upon both the patient and the members of her household that the most important single factor in the care of the new baby is the sustained and regular care which the nursing mother should take of herself. For it must be remembered constantly that it is not alone breast feeding, but satisfactory breast feeding that nourishes and builds and protects the baby. Unsatisfactory breast milk may be positively injurious, and irregularity and thoughtlessness in the mother’s mode of living will usually produce milk of this character.

Therefore, for ten or twelve months after the baby is born, the mother should discharge her responsibility and obligation to him by regulating her own life to meet his needs.

Diet. Throughout the entire nursing period the mother’s diet must be such that it will nourish her and also aid in producing milk which will meet the baby’s needs. His needs are that the daily demands of his growing body shall be supplied and that he shall be given those materials which will build a sound body, with resistance against disease and infection.

So important is this matter of nutrition, and the principles upon which it rests, that it is discussed at considerable length in the succeeding chapter. At this point, however, it may be stated briefly that the most valuable article in the nursing mother’s dietary is milk, and that to this should be added eggs and the vegetables which are designated as “leafy,” and fresh fruits, particularly oranges. These foods are rich in the materials which are essential to the baby’s nutrition, good health, and resistance.

She should have a generous, simple, nourishing mixed diet, then, consisting largely of milk, eggs, and leafy vegetables. She must steadily guard against indigestion for if her digestion is deranged the baby is almost sure to suffer. Rich and highly seasoned foods must be avoided, as well as alcohol, strong tea and coffee or any articles of food or drink that might upset her.

It becomes apparent that although the expectant mother does not have to “eat for two,” the nursing mother does, in certain respects. She should augment the nourishment provided by her three regular meals, by taking a glass of milk, cocoa or some beverage made of milk, during the morning, afternoon and before retiring.

The morning and afternoon lunches had better be taken about an hour and a half after breakfast and luncheon, respectively, in order not to impair the appetite for the meals which follow.

It is very important that the nursing mother shall take her meals with clock-like regularity and enjoy them, but at the same time she must guard against overeating, for fear of deranging her digestion. She must drink water freely, partly for the sake of promoting intestinal activity.

Bowels. The nursing mother’s bowels must move freely and regularly every day, but she should not take cathartics nor even enemata without a doctor’s order.

She will usually be able to establish the habit of a daily movement by taking exercise, eating bulky fruit and vegetables, drinking an abundance of water and regularly attempting to empty her bowels, every day, preferably immediately after breakfast.

Rest and Exercise. The nursing mother will not thrive, nor will the baby, unless she has adequate rest and sleep and takes at least a moderate amount of daily exercise in the open air. She should have eight hours sleep, out of the twenty-four, in a room with open windows, and as fatigue has an injurious effect upon the character of the milk, the average mother should lie down for a while every afternoon.

Her exercise will have to be adjusted to her tastes, customary habits, circumstances and physical endurance, for it must always be stopped before she is tired. Walking is often the best form of exercise that the nursing mother can take, though she may engage in any mild sports that she enjoys. Violent exercise is inadvisable because of the exhaustion that may follow.

Recreation. Part of the value of exercise lies in the pleasure and diversion which it gives, for a happy, contented frame of mind is practically indispensable to the production of good milk. In addition to some regular and enjoyable exercise, therefore, the mother needs a certain amount of recreation and change of thought and environment. If her life is monotonous and colorless, the average woman is likely to become irritable and depressed; to lose her poise and perspective; to worry and fret, and then, no matter what she eats nor how much she sleeps, her digestion will suffer, her milk will be affected and the baby will pay. This, of course, goes back to the question of her mental state and the condition of her nerves as being determining factors in the young mother’s ability to nurse her baby successfully.

For the sake of giving her an opportunity to go out, mingle with her friends or enjoy some music or a play, it is often a very good plan to replace one breast feeding, some time in the course of each day, with a bottle feeding. The freedom which this long interval between two nursings gives the mother for diversion and amusement, will usually affect her general condition so favorably that the quality of her milk is better than it otherwise would be, and the baby is benefited as a result. This single supplementary feeding cannot be regarded lightly, however, for it must be prepared with the same cleanliness and accuracy as an artificial diet.

Weaning. One advantage in giving the baby a supplementary bottle, once a day, is that it paves the way for weaning, when the time comes to make this change. Under ordinary conditions, the mother begins to wean her baby about the eighth or tenth month. Having started by replacing one breast feeding, daily, with a bottle feeding, she should gradually increase the number of daily artificial feedings until all of the breast feedings are discontinued by the time the baby is eleven or twelve months old. There are exceptions to this general rule, of course, and under any conditions the weaning should always be directed by a doctor, for the baby will suffer unless it is skillfully done.

If the mother’s milk is satisfactory and the baby is doing well, it is often considered wiser not to discontinue the breast feeding entirely, during the hot summer months, even though the weaning falls due at this time.

It was formerly deemed advisable to wean the baby for any one of several reasons, but at present the only indications for this step which are generally accepted by the medical profession, are: pulmonary tuberculosis, acute infectious diseases in the mother, and pregnancy. Menstruation, which is normally suspended during lactation, was long regarded as incompatible with satisfactory nursing, but it is now known that if the mother is taking proper care of herself and is in generally good condition, the effect of menstruation upon the milk is usually for the duration of the periods only. It may be necessary to supplement the breast feeding with suitably modified cow’s milk during menstruation, but the baby should be put to the breast regularly, just the same, for if the stimulation of the baby’s suckling is discontinued, the temporary reduction in the amount of milk secreted will probably be permanent.

The state of pregnancy, however, is different, for though some women nurse the baby satisfactorily for some months after becoming pregnant, it is not considered advisable to subject a woman to the combined strain of pregnancy and nursing. Moreover, the mother’s milk is usually impoverished during pregnancy and the nursing baby suffers in consequence.

Drying up the Breasts used to be a great bugbear. Lotions, ointments and binders were employed and often a breast pump as well. Various drugs were given by mouth and the patient was more or less rigidly dieted. It is true that some of these measures are still employed and are followed by a disappearance of the milk. But at the same time, the breasts dry up quite as satisfactorily when none of these things is done, provided the baby does not nurse. It is not known what starts the secretion of milk in the mother’s breasts but certain it is that absence of the baby’s suckling prevents it.

If the drying up of the breasts is left to the nurse, as it so frequently is, her wisest course will be to do nothing beyond applying a supporting bandage if the breasts are heavy enough to be uncomfortable. She may rely absolutely upon the fact that the baby’s suckling is the most important stimulation in promoting the activity of the breasts and if this stimulation is not given, or is removed, the secretion of milk will invariably subside in the course of a few days. It is true, that the breasts may be engorged and very uncomfortable for a day or two, and in addition to a supporting bandage the doctor may order sedatives, but the discomfort subsides as the secretion disappears. This is true whether the reason for drying up the breasts is that the baby is still born or has died, or a live baby’s nursing is discontinued.

Naturally, the nurse will not press her patient to drink an extra amount of milk if it is not desirable to promote the activity of the breasts, but, unless otherwise ordered, there is no necessity for placing any other restrictions upon her patient’s diet.

In thinking over the period of lactation, as a whole, it is apparent that the most valuable service which the nurse can offer to the nursing mother, is assistance in planning and living a simple, normal, tranquil life; helping her to eat, sleep, bathe, and exercise and to nurse her baby with unfailing regularity—all for the sake of providing her baby with adequate nourishment. This must be the chief end and aim of her existence.

Normal breast-milk is the ideal baby food and there is no entirely satisfactory substitute. It greatly increases the baby’s chances of living through the first year, and protects him from many diseases.

Quite evidently, breast-feeding is every baby’s right and the nurse can and should help him to secure it.

The importance of providing the expectant and nursing mother with suitable food has been stressed so insistently in the preceding pages, that it is advisable to explain to the nurse the reason for these recommendations, in regard to certain groups of foods, and thus make clear why a young mother may eat a large amount of food and have an adequate amount of breast milk, and yet fail to nourish her baby satisfactorily.

The following material is available in these pages through the interest and generosity of Dr. E. V. McCollum and Miss Nina Simmonds, Professor and Assistant Professor of Chemical Hygiene, School of Hygiene and Public Health, Johns Hopkins University. This information is the result of many years of research and experimentation on many thousands of laboratory animals and of observations upon human beings as well. Dr. McCollum and Miss Simmonds offer the fruits of their labors to obstetrical nurses, in the belief that they are in a peculiarly favorable position to aid in improving the nutritional state of the coming generation.

In order that such a discussion may not seem irrelevant to obstetrical nursing, the nurse must remind herself anew, that the object of obstetrics to-day is not only to carry a woman safely through childbirth, but to give her such care from the beginning of pregnancy that she and the baby shall emerge from this experience, not merely alive, but well and vigorous and with every prospect of continuing to be so.

It is the acknowledged obligation of those engaged in obstetrical work to strive toward improving the health of the race at its source—the health of the mothers and babies. Malnourished mothers and malnourished babies do not develop a hardy race.

It is probably safe to say that the two most influential factors in creating and maintaining a satisfactory state of health are suitable nutrition and prevention of infection; and although we shall concern ourselves solely with nutrition in this chapter, it should be stated in passing that a state of good nutrition goes far toward protecting the individual from infection.

It will help in clarifying the subject to explain in the beginning that a state of good nutrition is not necessarily evidenced by one’s being tall nor by being fat. But it is evidenced by normal size and development; sound teeth and bones; hair and skin of normal color and texture; blood of the normal composition; stable nerves; vigor both mental and physical; normally functioning organs and resistance to disease, and above all that indescribable condition which is summed up as a state of general well-being.

That this degree of nutritional stability is not as prevalent in this country as might be desired is disclosed by reports upon findings of the examining boards for army service, over a period of three years and physical examinations of various groups of school children throughout the country. It was found in the first case, that about sixteen per cent. of the apparently normal young men who were inspected for military service, were undernourished in some degree, and according to Dr. Thomas W. Wood, Professor of Physical Education, Columbia University, “Five million children in the United States are suffering from malnutrition.” This army of undernourished children, which represents about one-third of the children of the country, is on the broad highway to ill health, invalidism of various kinds and degrees, instability and inefficiency. They are certainly not developing into the clear-eyed, alert, buoyant individuals that go to make up good citizenry.

The tragic aspect of this state of undernourishment is that though a great deal can be done to nourish and build up the malnourished child or adult, a certain amount of damage that results from inadequate nourishment during the early, formative weeks and months cannot be entirely repaired later on in life.

As the baby grows and develops, certain substances are needed at the various stages of its progress, and if these are not supplied at these stages, there will always be some degree of inadequacy in the adult make up. It is much like the futility, when building a house, of using bricks without straw for the foundation instead of firm, durable rock, and then trying to make it substantial and secure later on by using good materials when constructing the upper stories.

The solid foundation and substantial beams and girders for men and women are put in during infancy and early childhood in the shape of good material that forms good nerves, muscles, bones, teeth and general physical stability. It is practically impossible to make up to the older child or adult for damage caused by failure to supply sufficient nourishment to the growing, developing, infant body.

We see all about us the results of this form of neglect of babies, in the bow-legged, knock-kneed, undersized, misshapen, chicken-breasted adults and in those who are nervous and below par in endurance; are susceptible to colds and other infections and may be summed up as being “not strong.”

The reasons for much of the undernourishment among people in this country to-day are to be found in certain widespread misconceptions of long standing as to what constitutes a state of good nutrition or malnutrition and the value and purposes of different foodstuffs. For malnutrition does not necessarily describe a simple condition due to an insufficient amount of food, but to any one of several complex conditions due to a lack in the food of one or more essential substances.

One may eat a large amount of food and even have a well-padded body and yet be seriously in need of certain food factors—in other words, be incompletely nourished in some particular.

That was possibly the first misconception—the belief that one simply needed enough food, and accordingly was well nourished if three large meals were eaten daily, irrespective of the composition of those meals. A step forward was taken when housewives and people generally accepted the fact that quantity alone was not enough to consider in providing food, but that the dietary should consist of balanced amounts of the five food materials: fats, carbohydrates, proteins, minerals and water, in order to build and maintain the body in a state of health.

But this, too, was found to be an error, in so far as it was only a part of the truth, for it was next ascertained that even provision for a suitable balance of the five food groups was not enough to nourish us, but that we must consider the heat and energy producing properties of these component parts, as measured by the caloric unit, and each must daily take in the requisite number of calories if we would keep our engines going.

It is now known that even this is not enough, for we may eat food in ample quantities, consisting of the properly balanced fats, proteids, carbohydrates, minerals and water, and it may daily yield the required number of calories, and still we may suffer from seriously faulty nutrition.

Hess and Unger state in this connection, that, “in framing dietaries for children and adults, our minds are still focused on insuring a sufficient supply of calories in the food, and we have not yet reacted in practice to the newer knowledge that ample carbohydrates, fats and proteins may constitute a dangerously deficient diet.”^[10]

We find an explanation for this fact in the comparatively recent recognition of three substances, as yet not clearly understood, which are contained in a certain few articles of food, each one of which is essential to growth and normal health and well-being, though not necessarily concerned in the production of heat or energy. Various terms have been applied to these mysterious, but necessary substances, such as vitamines, accessory food substances as applied to all, or fat-soluble A, water-soluble B and water-soluble C to designate them separately.

A surprisingly small amount of each of these substances is sufficient to meet the needs of an individual, but no one of these, even in this small amount, can be safely dispensed with, for if the diet is deficient, or lacking in one or more of them some form of nutritional disturbance will result. It may be severe enough to be diagnosed as a disease, or it may be only enough to keep the individual below a normal state of health.

When the disturbance is profound enough to produce a definite, recognizable condition, it is designated as a deficiency disease, of which there are three: scurvy, beri-beri and xerophthalmia. With these are sometimes included rickets and pellagra. The exact cause of the two latter disorders is not definitely known but both are associated with faulty nutrition. Poor hygienic conditions may enter into the causation of rickets, and infection may be a factor in the occurrence of pellagra, but neither disease appears among those who are suitably fed while both diseases may be produced by faulty diet and both may be cured with suitable food.

But probably of graver importance to the public welfare than the well defined nutritional disturbances, themselves, is the fact that between a state of good health and the level upon which a disease is recognizable is a long scale, along which are ranged an uncounted army of under-par, half-sick people. These are the ones who are tired, nervous, susceptible to infections, with feeble recuperative powers, and in general are more or less ineffective in the business of life.

It is this borderline state, or as Dr. Goldberger terms it, “the twilight zone,” which cannot quite be called disease but is not health, that is serious to the masses, for diagnosed disease is given treatment, but nervousness, lack of energy and endurance, weakness and inefficiency are not treated; they are merely tolerated, as a rule. The sufferers fail to reach their highest possible development and they fail to be of highest value to society.

This is the condition which can be so largely prevented by giving the baby a good nutritional foundation; this must be started during its prenatal life, carried through the nursing period and then continued throughout the rest of his life. Since the nurse is very likely to be entrusted with the arrangement of the patient’s dietary, being told merely to give a liquid, soft or light diet and possibly to avoid certain articles, it will mean much to the coming generation if nurses at large are able so to compose the various diets for the expectant and nursing mother, that they will provide not only the requisite fats, proteids, carbohydrates, minerals and water and yield the necessary calories, but also contain all three protective substances: fat-soluble A, water-soluble B and water-soluble C. It can be demonstrated that when these food factors are not present in the mother’s diet, they will not appear in her milk, and accordingly will not be supplied to her baby.

This is the crux of the whole matter. If the mother’s diet is faulty, her milk will be faulty in the same respect and the baby will start life with tissues which contain an inadequate amount of the substances that are necessary to make them sound and promote health.

That is what we have in mind when we say that the mother’s milk must be satisfactory not alone in quantity but in quality as well.

In order to make quite clear how damaging are the results of diets which are deficient or lacking in these protective substances, we shall take up, briefly, the deficiency diseases in turn.

Scurvy (scorbutus) is caused by a lack or deficiency of the substance called water-soluble C, the most unstable of all the protective substances, being easily impaired or destroyed by heating, drying or aging. This anti-scorbutic substance is present in fresh milk, potatoes, oranges, lemons, onions, and such fresh vegetables as lettuce, raw cabbage and celery and in apples, pears, peaches, bananas and cantaloupe. Tomatoes are rich in the anti-scorbutic substance and, moreover, this form is but slightly injured by heating or aging, for which reason canned tomatoes are frequently used both to prevent and to cure scurvy.

Scurvy is a disease which develops slowly. The patient loses weight, is anemic, pale, weak and short of breath. The gums become swollen, bleed easily and frequently ulcerate; the teeth loosen and often drop out. Necrotic areas in the bones may result. Hemorrhages into the mucous membranes and the skin are characteristic. Large black and blue spots develop in the skin, after trivial injury, or even spontaneously. The ankles become edematous and in severe cases a hard, board-like condition of the skin and subcutaneous tissues develops. There is sometimes severe headache and in the later stages there may be convulsions and delirium.

Although scurvy has been known to exist for centuries, well developed cases are not often seen among adults to-day, because experience has taught the importance of including some fresh food in the dietary, and present transportation facilities make this a fairly simple matter for most people. The disease was doubtless limited almost entirely to soldiers and pioneers until after the discovery of America. This event marked the beginning of long sailing voyages, with diets of dried and otherwise preserved foods, and scurvy began to take a heavy toll of life among the mariners. It became known as “the calamity of sailors” because of its frequency on shipboard. A notable instance in the history of the disease was the voyage of Jacques Cartier, in 1536, when he lost twenty-six of his party from scurvy, and only saved the remainder by the use of an infusion of pine needles. The efficacy of fresh fruits and vegetables in the prevention and cure of scurvy was discovered by common experience; when it became customary to administer lime- or lemon-juice to all sailors, scurvy practically disappeared from the service.

Although we seldom see actual cases of the disease among adults to-day, it is believed that there are large numbers of border-line cases among people who subsist largely on meats, canned and dried vegetables and canned fruits, the meat-bread-and-potato type of diet, for several months at a time, as during the winter season.

“Every individual requires a certain amount of anti-scorbutic substance in his dietary, or to put this statement in a broader way, every nation has need for a per capita quota of foodstuffs containing this necessary food factor, if scurvy is to be avoided.”^[11]

Infantile scurvy is seen among babies who are fed solely on milk that has been heated, boiled, pasteurized or canned, since the anti-scorbutic substance in milk is practically destroyed by heating or aging. The disease is characterized by malnutrition, pain, typical changes in the structure of the bones and hemorrhage in various parts of the body, most frequently in the gums and beneath the periosteum. The disease develops slowly, the first symptoms appearing between the seventh and tenth months. Tenderness or pain in the legs is perhaps the most common symptom and may be detected first by the baby’s crying when its diaper is changed or its stockings are put on. And a baby that previously has been cheerful, playful and active will prefer to lie quietly and will cry whenever it is touched. He grows pale, listless and weak and fails to gain in weight or length. The large joints are likely to be swollen and tender; the swollen gums may bleed; the urine may be diminished in amount and contain blood and there also may be edema. But it is quite possible for a baby to be in serious need of an anti-scorbutic and still not present well defined symptoms of scurvy, or it may suffer from the latent or subacute type of the disease. In the latter case there may be stationary weight; fretfulness; a muddy complexion; rapid pulse and respirations; edema over the tibiÆ with perhaps tenderness of the bones and tiny hemorrhagic areas over the body.

Scurvy may be both prevented and cured by giving orange juice, potato water, or tomato juice to a baby whose diet consists of milk that has been heated and is therefore lacking in water-soluble C. Many doctors believe that an anti-scorbutic should be started as early as the end of the first month, with babies fed on pasteurized milk, for the disease develops so slowly that severe damage may be done if the administration of this material is delayed until symptoms appear.

Scurvy, itself, does not often cause death among babies, but its occurrence is serious since it renders the infants very susceptible to infection, particularly nasal diphtheria and “grip.” Recovery from even severe attacks is amazingly rapid, sometimes being complete in a week or ten days as a sole result of giving orange juice.

It is sometimes recommended that modified milk, for infant feeding, be made up with potato water, instead of barley water, since the latter has no anti-scorbutic properties, while potatoes are somewhat protective even after being cooked.

Spinach water is sometimes given, but there is doubt in some minds about its anti-scorbutic value, which seems to be more damaged by heat than that of potatoes and tomatoes.

Canned tomatoes are valuable because of being inexpensive and preserving their anti-scorbutic properties, even after heating. It is the opinion of many pediatricians that babies tolerate canned tomatoes very well, and in some cases may be given as much as four, six, or even eight ounces daily, without causing trouble.

Infusion of orange peel also is used in the prevention and treatment of scurvy and has the advantage of being inexpensive since the orange itself may be used for other purposes.

But orange juice and lemon juice are generally accepted as being the most valuable of all anti-scorbutics. Orange juice may be started early, and to be of value as a preventive, must be started early or scurvy will have started to develop. The common practice is to give a dram, daily, at three months, increase it to an ounce by the sixth month and two ounces when the baby is a year old. It should be diluted with water and given in two doses, midway between two morning and afternoon feedings.

To sum up: Scurvy in infants or adults is the result of a diet which is deficient or lacking in the anti-scorbutic substance, called water-soluble C, and may be prevented or cured by adding to the faulty diet those articles of food which contain this substance, namely, fresh milk, oranges, leafy, green vegetables, cabbage, onions, potatoes or tomatoes. Although scurvy is seldom seen in breast-fed babies it is believed that an infant nursing at the breast of a woman whose diet is poor or lacking in the anti-scorbutic substance may suffer a certain degree of starvation for this food factor.

Recent work at the University of Minnesota has shown that milk from cows on dry feeds is very much lower in anti-scorbutic properties than milk from cows on green pasture. This provides a strong argument for giving orange juice to all artificially fed babies, for one cannot always know how the cows, from which the milk is obtained, are fed.

Beri-beri is a deficiency disease, chiefly characterized by paralysis and caused by a diet which is lacking or poor in water-soluble B. The foods which entirely lack this substance are polished rice, starch, sugar, glucose, and the fats and oils from both animal and vegetable sources, while those which are poor in it are the products of degerminated cereal grains, such as tapioca, hominy, cornmeal, macaroni, spaghetti and the muscle cuts of meat, such as steak, roast, chops, ham and fish and fowl muscle. Foods which are rich in water-soluble B are beans, peas, the root vegetables as beets, carrots, white and sweet potatoes, leafy vegetables, fruits, milks, eggs and the glandular organs such as liver, kidneys and sweet breads.

The early symptoms of beri-beri are fatigue and depression; numbness and stiffness in the legs; more or less edema of the ankles and face, followed by tenderness of the calf muscles, and tingling or burning sensations in the feet, legs and arms. There are two types of the disease, the dry and the wet. In the dry type, wasting anesthesia and paralysis are the chief symptoms, while the most marked evidences of the wet type are the edema, which may be excessive, affecting the entire body. The death rate from beri-beri is usually high.

We are accustomed to thinking of this disease as occurring chiefly among the Orientals, for it was long confined to Southern China, Japan, the Dutch East Indies and the Malay Peninsula. But it may occur among any people whose diet is poor in those foods containing the particular substance which protects against it. It is common in Newfoundland and Labrador and certain parts of South America and among people who eat little aside from staple, non-perishable, cereal products, wheat bread made from bolted flour, fish and salt meats. An evidence of this near at home was an outbreak of typical beri-beri, in the jail at Elizabeth, N. J., in 1914, caused by the faulty diet of the inmates.

The disease may be prevented or cured only by including in the diet such food as milk, eggs, fresh fruit and vegetables.

Xerophthalmia is a deficiency disease characterized by eye lesions and due to a lack of, or deficiency in the diet of the protective substance which has been designated as fat-soluble A. This substance is absent in polished rice, and present in but small amounts in barley and other cereals; in muscle cuts of meat; in peas, beans and other vegetables excepting those described as “leafy.” It is contained in cod-liver oil, butter, cream, egg yolk, liver, kidneys and the leafy vegetables.

In the early stages of the disease the eyes are inflamed and the lids badly swollen. If the diet is wholly lacking in fat-soluble A, the disease progresses rapidly, the eye balls frequently rupture and the lens and vitreous humor are expelled, with total and permanent blindness as the tragic result. On the other hand, the malady clears up in a very spectacular manner if, in the early stages, the patient is fed those foods which contain the mysterious, but indispensable fat-soluble A.

Well developed xerophthalmia is not common in this country but one sees inflamed eyes and corneal ulcers in young children which clear up with little local treatment after a mother has been persuaded to give the patient more fresh milk, butter and green vegetables.

Mori reports upon about 1500 cases occurring in Japan, in 1905, among children between the ages of two and five years. He states that the disease does not occur among the fisher folk but among people whose diet is largely composed of rice, barley, cereals, beans and “other vegetables,” but he does not state what the other vegetables are. Prompt relief of the eye symptoms was observed when cod-liver oil, chicken livers and eel fat were administered.

Bloch describes cases of xerophthalmia among infants under one year of age, in the vicinity of Copenhagen, during the years of 1912 and 1916. (Fig. 140.) The babies were also suffering from malnutrition and the skin was dry, shrivelled and scaly. Their diet consisted largely of separator skimmed milk, which was, therefore, practically fat-free, oatmeal gruel and barley soup. The milk was pasteurized and then cooked in the home before being fed to the babies. Such a diet was so faulty that the infants in question may well have been border-line cases of scurvy and beri-beri, as well as developed cases of xerophthalmia. It is also evident that the children were unquestionably suffering from rickets.

It is believed that the condition known as night-blindness is related to, or a mild or early form of xerophthalmia. It occurs in Newfoundland and Labrador, among men in lumber camps and elsewhere, whose diet consists chiefly of wheat flour, beans, meat, fish, molasses, raisins and coffee. Such a diet is made up of those parts of the plant or animal which have good keeping qualities, but these qualities do not compensate for the poverty of the protective substance.

Dr. Anna Strong, who has had experience as a medical missionary in India, observes that night-blindness is common in the vicinity of Calcutta, and it is said to occur frequently in Russia during the Lenten fasts. The popular treatment for this condition consists of poulticing the eyes with fresh goat’s liver and giving the liver as a food as well; while in Japan the efficacy of eating liver to cure night-blindness has been recognized from early times.

Pellagra is a disease of obscure origin, associated with faulty nutrition, which involves the nervous and digestive systems and the skin. Usually one of the first symptoms is soreness and inflammation of the mouth, then a remarkable, symmetrical eruption appears on parts of the body, which, with weakness, nervousness and indigestion form the most characteristic picture of the disease.

There are some indications that infection may be the immediate cause, but the strong evidence is that a faulty diet is the chief predisposing cause of the disease. Certain it is that pellagra is both prevented and cured by a diet containing liberal amounts of milk, eggs and leafy vegetables. On the other hand, those who live during the winter months on a diet chiefly derived from bolted white flour, degerminated cornmeal, polished rice, starch, sugar, molasses and fat pork, furnish the victims of this dreaded disease in the spring.

Pellagra was discovered in Northern Spain, by Cassal, in 1735, but for many years it had been of common occurrence in parts of Italy, and during the last century has been prevalent in parts of France, the Balkans, especially Roumania, and for a lesser time, in Egypt. In America the disease was not recognized with certainty until 1908, but from that year its incidence apparently increased, until by 1917 there were 170,000 cases of pellagra recorded in the United States, principally located in the Southern States.

In 1914, Dr. Joseph Goldberger, of the United States Public Health Service, began an investigation of the factors concerned in causing pellagra. After he had studied its prevalence in various orphanages in the South, and had relieved the situation by improving the diet with milk, fresh vegetables and meat, he was anxious to know whether the disease could be produced by a faulty dietary, of the type common among pellagrins. He planned an experiment to this end, which would restrict men to a diet similar to that which had been supplied in the institutions where pellagra had been endemic, and where it had been relieved by the improvements in the food supply which have been mentioned. This type of diet was also very characteristic of that used in the homes of the cotton mill workers throughout the South, where pellagra was so common. The Governor of Mississippi offered pardon to any of the healthy white men in the state prison who would submit themselves as subjects for the experiment, and eleven actually underwent the test.

The men were put upon a diet consisting of articles made from white, wheat flour, degerminated cornmeal (maize), polished rice, starch, sugar, molasses, pork fat, sweet potatoes, coffee and very small quantities of collards and turnip greens—so small as to furnish inadequate protection against a certain degree of undernourishment. At the end of five and a half months six of the eleven men developed the skin lesions characteristic of incipient pellagra.

As a result of his investigations, Dr. Goldberger points out the important fact that when milk, eggs, meat, fresh fruit and vegetables are included in the diet, pellagra does not develop, also that the disease may be cured by giving these articles of food to the afflicted person.

Rickets. The actual cause of rickets is not definitely known, but the disease apparently results from wrong proportions between calcium and phosphorus, and to unfavorable amounts of these two substances in the food. Accordingly, it may be said to be due to a faulty diet—one which is rich in carbohydrates and poor in fats and possibly some substance as yet unrecognized—and it may be both prevented and cured by what is now regarded as suitable feeding.

The chief characteristics of the disease are arrested growth and softening of the bones, with dwarfism and deformities as a result. (Fig. 141.) It is essentially a disease of infancy, occurring as a rule, between the fourth and eighteenth months but some of its unfavorable effects, such as bone deformities and poor resistance to disease, may persist throughout life.

Although babies rarely die of rickets alone, it is one of the most serious of all health problems and obstacles to normal development and stability, since it predisposes to such diseases as bronchitis, pneumonia, tuberculosis, measles, and whooping cough and in general greatly enfeebles the powers of resistance and recuperation.

It is common among babies who are fed solely or continuously on heated milk, either boiled or canned, and on proprietary foods and sweetened condensed milk. There has been some speculation about the possible relation between rickets and fat-soluble A, but no definite conclusions have yet been reached. It is known, however, that rickets may develop among nursing babies whose mothers are on faulty diets, and that the disease may be prevented and cured by the administration of cod-liver oil, which is rich in fat-soluble A. Sunshine, also, seems to have a pronounced effect in preventing and in curing the disease.

Symptoms. The common symptoms of rickets which appear early are irritability; restlessness particularly at night; a tendency toward convulsions from very slight cause; digestive disturbances and profuse perspiration about the head. The baby may be fat, but is likely to be flabby and to have a characteristically white, “pasty” color. The fontanelles are large and late in closing; the abdomen is large and the chest narrow; dentition is usually delayed and the teeth may be soft and decay early. But the most conspicuous effect of rickets is upon the entire bony skeleton, due to the inadequacy of the lime deposit. The bones are soft, easily bent and broken and often misshapen. Their growth is likely to be retarded and the ends of the long bones may be enlarged, giving the familiar swollen wrists and ankles, while the nodules which form at the junction of the ribs and sternum, produce the beaded appearance so commonly called a “rickety rosary.” The bones in the arms and legs may become curved as the baby lies or sits in its crib, making him either bow-legged or knock-kneed. The deformity is increased by walking because the soft bones are easily bent by the weight of the body. The spinal column may be curved or too weak to permit the baby to sit straight or stand alone. The entire chest wall is often deformed (Figs. 142, 143) producing the familiar “chicken breast,” as well as a serious decrease in the size of the thoracic cavity, and through loss of rigidity of the bony wall, the respiratory movements may be seriously impaired. The forehead is prominent and the whole head looks square and larger than normal, while the pelvic deformities in girl babies often give rise to very serious obstetrical complications later in life, as has been previously explained.

Although lack of fresh air and sunshine seem to be factors in producing rickets, it has been observed that the disease does not develop in poor surroundings if the diet is suitable or if cod-liver oil is given to babies fed artificially, or on unsatisfactory breast milk; but that it may occur in the presence of satisfactory hygienic conditions if the diet is faulty in certain respects. For children under a year old, the desirable food is good breast milk, or, lacking that, fresh, certified cows’ milk, with fruit juices, scraped beef, eggs and strained vegetable purÉes, started as early and increased as rapidly as the baby can digest them.

Treatment. Cod-liver oil and sunshine, together with proper food, are the essentials in treating rickets. When cod-liver oil is given to a baby whose diet is faulty, it exerts a marked tendency toward enabling the bones to develop satisfactorily even when the mineral content of the food is unfavorable. The use of sunshine, either by moving the baby from a dark to a light house, or by exposing his body to the direct rays of the sun is found to be of pronounced therapeutic value. These factors, in addition to general good care constitute the treatment, but it is a long slow process, taking from three to fifteen months, and it is doubtful if the damage which the disease works can ever be entirely repaired.

Rickets is more common during the cold months of the year, winter and spring, than during the milder summer and autumn seasons. A possible explanation for this lies in the higher value of the cows’ food during the warm months when green things form the diets of animals. Since it is now recognized that milk is not a constant product, but that its properties vary with the food of the animals that produce it, cows’ milk would be favorably influenced by their being put to pasture.

Similar evidence of such an influence is seen in the fact that although rickets is not seen among breast-fed babies whose mothers are on satisfactory diets, it may and does occur in breast-fed babies who are nourished by mothers who are, themselves, on dietaries which are poor in milk and fresh fruit and vegetables.

Drs. Hess and Unger made a study of the occurrence of rickets among colored babies in a section of New York City and the value of cod-liver oil as a preventive of this disease. In commenting upon their findings, they state, “This tendency is so marked that it may be safely stated that over ninety per cent. of the colored babies have rickets, and that even a majority of those that are breast-fed show some signs of this disorder.” They ascertained that the average diet of the mothers of these rickety babies was largely made up of carbohydrates and proteins, being poor in fats, although the diets yielded a daily quota of calories which represented almost the requisite amount for their individual weights. But they took little fresh milk or fresh fruit or vegetables, using canned and dried products freely.

It is important to note here that it is a diet of heated milk, rich in carbohydrates but poor in fats, that produces rickets in a bottle-fed baby—almost the same type of diet which in a nursing mother results in rickets in a breast-fed baby.

In an endeavor to prevent rickets among these incompletely nourished babies, Drs. Hess and Unger carried on a definitely organized experiment. “Our plan,” they report, “was to give infants under six-months one-half teaspoonful of oil three times daily and older infants twice this amount. It was found that almost all babies can take cod-liver oil, although it may disagree temporarily and may have to be discontinued for short intervals when there is digestive disturbance. Infants of from two to three months tolerate the oil in half-teaspoonful doses, and younger ones may be given still smaller amounts.” In commenting upon the tabulated results of this interesting study they say: “It is seen that we were able to prevent the development of rickets in more than four-fifths of the infants who received the oil for six months, and in more than half of those who were given it for four months. This result must be considered satisfactory when we note that, of the sixteen infants who did not receive the oil, fifteen showed signs of rickets, though all of them lived under the same conditions and many in the very same families. No other treatment was given, nor was a change of diet or mode of life attempted which could account for the difference in the results between the two groups of cases.” The poor quality of the breast milk of these inadequately nourished mothers is suggested by the further statement: “Table two shows that the cod-liver oil proved to be a more potent factor than breast feeding in warding off rickets, and that almost all the colored babies developed rickets even though nursed.”

It may seem like a far cry from scurvy among sailors, on shipboard, xerophthalmia among lumbermen in Labrador, and beri-beri among the Orientals to the nursing mother and her baby in our care.

But when we gather all of these apparently unrelated threads together and consider them in their possible relation to this same nursing mother and her baby, right here at hand, the following facts stand out as being of insistent importance to their well-being:

1.

There are five recognized diseases resulting from faulty nutrition, which may be both prevented and cured by a diet which contains the protective substances which are now regarded as essential to normal growth, development and well-being.

2.

These essential substances are not necessarily provided in adequate amounts by a diet that is satisfactory in bulk or in its balance of fats, carbohydrates, proteins, salts and water or that yields the requisite number of calories. The familiar diet of meat, potatoes, peas, beans, bread, pie and coffee is so far from providing complete nourishment that those who are limited to it are in a state of partial starvation.

3.

The diseases resulting from a lack or deficiency of the protective substances, fat-soluble A, water-soluble B and water-soluble C, respectively, are xerophthalmia, beri-beri and scurvy. With these are often included pellagra and rickets, the causes of which are not definitely known but result from diets that are poor in certain respects. The serious aspect of the deficiency diseases, however, does not lie entirely in those conditions which are well enough developed to be recognizable, thus prompting treatment; but also in the wide prevalence of malnutrition, of some form, which is not severe enough to be diagnosed as disease, and which is caused by a sustained diet that is poor in one or more essential food factors. This condition is serious because it produces a legion of individuals who are spoken of as being “not strong.” They are tired, nervous, susceptible to infections, have poor recuperative powers and in general fall short of a normal state of health and efficiency.

4.

Although the breast tissues are capable of converting into milk certain substances which they extract from the blood, and may, for example, convert poor proteins into proteins of higher value, they cannot create the protective substances which we have been considering. They can merely excrete these substances if they are contained in the mother’s diet. The absence, or shortage of these food essentials in the mother’s diet, and therefore in her milk, may result in rickets or other malnourished conditions in the baby, or in a degree of faulty nutrition which is not marked enough to be diagnosed, but enough to keep him frail. Enough to give him the poor start that is so likely to put him, ultimately, in the class of those adults who are more or less unfit, though not actually ill.

We must see to it, therefore, that our selection of food for the expectant and nursing mother provides those substances which are necessary to promote growth and development and preserve health, if we are to live up to our claim that the aim of obstetrical nursing is to aid in building a strong, vigorous and buoyant race.

The nurse may find herself feeling a bit dismayed at the prospect of trying to remember at all times which foods contain fat-soluble A, for example, and which are poor in water-soluble C, but she can remember in general, that milk and leafy vegetables are the great protective foods and that any diet which is poor in these is incapable of nourishing satisfactorily; and by calling to mind the deficiency diseases, previously described, she will be impressed anew by the seriousness of faulty nutrition.

By milk we mean, in addition to fresh milk, cream, butter, butter-milk, cream-soups and sauces, custards, ice-cream and all dishes and beverages made of milk.

By leafy vegetables we mean lettuce, romaine, endive, cress, celery, cabbage, spinach, onions, string beans, asparagus, cauliflower, Brussels sprouts, artichokes, beet greens, dandelions, turnip tops and the like.

Other foods which are rich in protective substances are fresh fruit, egg-yolks and glandular organs.

Nearly all of the common foods are deficient in some respect, but as the shortcomings of the various groups are different, we can arrange entirely satisfactory diets by combining foods which supplement each other’s deficiencies. This explains to us why the meat-potato-peas-beans-bread-and-pie type of meals fails to supply adequate nourishment. These foods belong in the same general group and are deficient in about the same kind of food factors, thus tending to duplicate, rather than supplement each other.

If such a fare is enriched by the addition of the protective foods, milk and leafy vegetables, we have a well rounded diet in which the deficiencies of one group of foods are supplied by the properties of the other groups. In fact, it is only by such a supplementing combination that an entirely satisfactory diet can be secured.

Dr. McCollum points out that the mother on a faulty diet cannot nurse her baby to his advantage. “The mammary gland,” he says, “picks up from the blood both of the chemically unidentified food essentials, fat-soluble A and water-soluble B, and passes these into the milk, but it is unable to produce either of these substances anew. When one or the other of these is absent from the mother’s diet it is not found in the milk. We have shown the possibility of producing milk, poor or lacking in each of these substances and therefore not capable of inducing growth.”^[12]

Dr. W. E. Musgrave gives dramatic accounts of the effect upon nursing babies of faulty nutrition among mothers in the Philippines, as follows: “Infant mortality in Manila,” he writes, “is greater than it is in any other city from which we have records. The underdeveloped and undernourished condition of the great masses of the Filipino people is due to a number of causes, the principal one being insufficient quantity and injudicious variety of foodstuffs employed. The cause of the enormous influence of the faulty nutrition of the mothers upon infant mortality directly and indirectly is one of the most important subjects within the scope of any investigation of this character. The mortality in breast-fed children is higher than it is among children artificially fed. This condition so far as we know is peculiar to the Philippines. The logical, and we believe, the correct explanation of this is the deficiency in quality and quantity of the mother’s milk. There are not in history more pathetic examples of unavailing self-sacrifice than are daily seen in our large clinics of poor, half-starved, undernourished mothers attempting to supply from their breasts food enough for one or more children, when their own metabolisms are in a starved condition. When asked the direct question as to the supply of foodstuffs these mothers almost invariably state that they have plenty to eat and the pathetic part of the story is that they believe that they are stating facts. These abnormal premises are the result of a peculiar unexplainable psychology that is of very wide application in this country that the administration of food is more to satisfy hunger than to produce flesh and blood, and that the cheapest way in which hunger may be satisfied produces a satisfactory form of existence.”

It is generally agreed that the two big problems of babyhood are proper nutrition and the prevention of infection, but nutrition is perhaps the greater problem, since any form or degree of malnutrition lessens the baby’s powers to resist and to recover from infection. Whether breast-fed or bottle-fed, therefore, it is imperative that the baby be nourished in the complete sense of being given all of the food materials which are essential to normal growth, development and protection against disease.

If the baby is artificially fed on milk that has been heated, his diet needs to be augmented by such protectives as cod-liver oil and orange juice, since the protective properties of milk are impaired by heating. If he is breast-fed, the mother will be able to supply to her baby the requisite nourishment and protective substances only if she, herself, is adequately nourished and in good condition.

That is the point of this entire discussion: The nursing mother must be on a satisfactory diet or she cannot satisfactorily nurse her baby. And by satisfactorily nursing her baby we mean, to give him from the beginning, through her milk, the materials necessary to build well and firmly that temple, in the shape of his body, which he will occupy throughout life; a structure so securely built, from the foundation up through each stage, that it will be able to withstand the attacks of disease and weather the inevitable storm and stress of life.

BIBLIOGRAPHY

McCollum. The Newer Knowledge of Nutrition, 2nd edition. New York, 1918.

McCollum and Simmonds. The American Home Diet, Detroit, 1919.

McCollum. Newer Aspects of Nutrition, Proceedings of the Institute of Medicine of Chicago, 1920, iii, 13.

Musgrave, W. E. The Philippine Jour. of Science, Series B, vol. 8, 1913, 459.

Goldberger, J. Jour. Amer. Med. Assoc., 1916, lxvi, 471.

Hess, A. F. and Unger, L. J. Prophylactic Therapy for Rickets in a Negro Community.

The most important of the complications of the puerperium are subinvolution and malpositions of the uterus; breast abscesses; hemorrhage and infection.

The importance of these to the nurse lies in their preventability, by means of the clean and efficient care which she helps to give during pregnancy, labor and the early weeks after the baby is born.

The nurse’s part in prevention and treatment of subinvolution, malpositions of the uterus and breast abscesses is so bound up in the daily care of the young mother that it was described in the preceding chapter.

Hemorrhage. Under ordinary conditions, a patient may lose as much as 500 cubic centimetres of blood during or immediately after labor, without serious results, but a loss of 600 cubic centimetres or more is regarded as a hemorrhage and as requiring speedy attention.

According to Dr. Williams, severe hemorrhage occurs only once in every few hundred labors, and with proper treatment, should not result fatally in more than one out of every 2000 or 2500 cases.

The severe hemorrhage due to a partially separated placenta occurs during the third stage of labor and was discussed in that connection. As the danger of hemorrhage, after labor is completed, is greatest during that critical hour immediately following, it is practically routine the country over to watch the patient closely during this period, both for the sake of preventing bleeding and detecting its early evidence, should hemorrhage occur, thus making prompt treatment possible.

The causes of post-partum hemorrhage are: Deep cervical tears, retained portions of the placenta, and atony of the uterus.

The treatment of hemorrhage due to tears of the generative tract is suturing the torn edges.

Since the retention of even a small piece of placental tissue will prevent the uterus from contracting firmly, the treatment of hemorrhage from this cause is immediate removal of the retained fragment. It is to obviate this occurrence that the placenta is carefully inspected after its expulsion. If it is not intact, the obstetrician may introduce his finger and remove the retained portion, thus making it possible for the uterus to contract properly and close off the open blood vessels.

Atony, or impaired tone of the uterine muscles, may result in hemorrhage because of failure of the muscle fibres to constrict the vessels. Quite evidently, the first step toward controlling hemorrhage from this cause is to stimulate the muscles to contract; this is done by means of massage and the administration of pituitrin and ergot. Elevation of the foot of the bed and application of ice-bag to the abdomen are also employed.

In severe cases, the doctor may give an intra-uterine douche of hot, sterile salt solution and if this fails he may pack the uterus tightly with sterile gauze. The douche and pack represent operative maneuvers and, therefore, are never to be undertaken by the nurse. Her assistance is important, however, as strictest asepsis is imperative and she will have to prepare the patient and the necessary articles with the greatest care.

Should bleeding become profuse during the doctor’s absence the nurse must stay with the patient and massage the fundus and have some one else elevate the foot of the bed on the seat of a straight chair or upon firm blocks and summon the doctor. In anticipation of such an emergency the nurse must always have an understanding with the doctor about the administration of pituitrin and ergot. If there has been no understanding, and the doctor is delayed or the bleeding becomes alarmingly profuse, the nurse will usually be upheld if she gives 1 cubic centimetre of pituitrin, hypodermically and a dram of ergot by mouth.

It is, of course, definitely understood that nurses do not give medicines without orders, but a single dose of pituitrin and ergot upon the occurrence of a profuse hemorrhage can scarcely do harm and may actually save the patient’s life. Such a situation is an emergency fortunately a rare one, and the nurse will have to be quick-witted and use the best judgment she is capable of.

The patient is usually more or less shocked by the time the bleeding has been controlled and needs the rest, quiet and stimulation that are ordinarily employed in such cases. She should be well wrapped in blankets and surrounded with hot water bottles placed outside the blankets, watched constantly and moved frequently; salt solution or strong coffee are sometimes given by enema, or saline infusions or intra-venous injections may be given. The patient must be kept warm and quiet and pressed to drink large amounts of fluids.

But above all the nurse must remember that severe hemorrhage from a relaxed uterus can almost always be prevented if the fundus is kept hard, by massage when necessary, during the first hour or so after delivery.

Puerperal infection is usually regarded as a condition which results from the entrance of infective bacteria into the female generative tract during labor or the puerperium, to distinguish it from other infections which may occur coincidently with the puerperal state, but not necessarily be related to it.

Puerperal infection is one of the most destructive and most dreaded of the complications which may overtake the obstetrical patient, and has evidently been so considered since the days of Hippocrates. Until recent years this veritable scourge was so utterly baffling that it was regarded as more or less of a dispensation of a Divine Providence and therefore to be accepted with the same philosophical resignation as earthquakes and cyclones.

In dramatic contrast to this unresisting attitude is the present knowledge concerning the cause and prevention of this disease, and the general belief that it is a wound infection and therefore practically preventive; that it is to be ascribed to the carelessness of mankind rather than to the indifference of Providence.

This change is due very largely to the devoted work of three men who were deeply stirred by the tragic frequency with which young women laid down their lives in so-called “child bed fever.” These men were Ignaz Semmelweiss, Oliver Wendell Holmes, better known to Americans as poet and humorist, and Louis Pasteur, each contributing his own special observations to the sum of knowledge which was to mean so much to mothers of the future. Also the theories of Lister concerning antisepsis and the inauguration of the use of sterile rubber gloves by Dr. Halsted, of Johns Hopkins Hospital, has had the same life-saving effect upon obstetrical patients as upon all surgical patients.

In 1843, Oliver Wendell Holmes read a paper before the Boston Society for Medical Improvement, entitled “The Contagiousness of Puerperal Fever.” In this paper he presented striking evidence that in many instances, something was conveyed by doctor or nurse, from an ill person to a maternity patient with puerperal fever as a result. He was attacked and ridiculed for his theories and some of the leading obstetricians declared that it was an insult to their intelligence to expect them to believe that creatures too small to be seen by the naked eye could work such havoc.

In 1847 Ignaz Semmelweiss, of the Vienna Lying-in Hospital, decided as a result of some of his investigations that puerperal infection was a wound infection, and that the infecting organisms were introduced into the birth canal on the examining finger of the doctor or nurse, after contact with an infected patient or cadaver. Accordingly he required that all vaginal examinations be preceded by washing the hands in chloride of lime, after which precautions the mortality from infection dropped from 10 per cent. to less than 1 per cent. In 1867 Semmelweiss offered his theories and conclusions in a masterly work on this subject, the title of which may be translated as “The Etiology, Conception and Prophylaxis of Child-Bed Fever,” but the actual cause of the disease was still unknown.

But about 1879 Pasteur demonstrated what is now known as the streptococcus, in certain patients suffering from puerperal fever.

“Pasteur,” wrote M. Roux, “does not hesitate to declare that that microscopic organism (a microbe in the shape of a chain or chaplet) is the most frequent cause of infection in recently delivered women. One day, in a discussion on puerperal fever at the Academy, one of his most weighty colleagues was eloquently enlarging upon the causes of epidemics in lying-in hospitals; Pasteur interrupted him from his place. ‘None of those things cause the epidemic; it is the nursing and medical staff who carry the microbe from an infected woman to a healthy one.’ And as the orator replied that he feared that microbe would never be found, Pasteur went to the blackboard and drew a diagram of the chain-like organism, saying: ‘There, that is what it is like!’ His conviction was so deep that he could not help expressing it forcibly. It would be impossible now to picture the state of surprise and stupefaction into which he would send the students and doctors in hospitals, when, with an assurance and simplicity almost disconcerting in a man who was entering a lying-in ward for the first time, he criticised the appliances, and declared that the linen should be put into a sterilizing stove.”^[13]

Slowly, but very slowly, the teachings of these earnest men were adopted by the medical profession, with the result that in well-conducted, modern hospitals the precautions which have been described in preceding chapters are rigidly observed. And to-day, one woman in about 1,000 in such hospitals dies of puerperal infection, instead of one in ten, as in the early days. In the year 1864, 23 per cent. of the patients at the MaternitÉ, in Paris, died of puerperal infection.

But unhappily, the decline in the occurrence of puerperal infection, in this country is largely confined to the hospitals, for in the homes throughout the land the disease is almost as common as it was in the days of our fathers, or even grandfathers. Of approximately 20,000 deaths from childbirth in this country during 1920, about one-half, or possibly 10,000 were from puerperal infection.

To the nurse there is considerable significance in Pasteur’s characterization of the infected young mother as an “invaded patient,” for the nurse’s preparation for labor and her care of the patient during the puerperium should be enormously influential in preventing this “invasion.” In this connection she may well ponder Miss Nightingale’s assertion that “The fear of dirt is the beginning of good nursing.” Certainly the obstetrical patient cannot be well cared for unless the nurse has this fear in her heart.

Puerperal infection, then, in the light of present information, is regarded as a wound infection caused by the streptococcus, gonococcus, colon bacillus, gas bacillus or any other pus producing organism. Of these, the streptococcus infection is the most frequently seen and is also the most serious, about 10 per cent. of such infections resulting fatally; while the gonorrheal infection, though seldom ending in death, usually causes sterility.

Infection during the puerperium occurs most often in the uterus, and, if mild, may amount to nothing more than endometritis, or inflammation of the uterine lining. In more serious cases, the inflammation may spread to the tubes and ovaries; may cause abscesses in the broad ligament and general peritonitis. A streptococcus infection may spread through the lymphatics and cause general septicemia.

Infection of the raw and bleeding placental site may occur at any time during labor or the ten days following, though the danger of infection decreases steadily after the first day postpartum.

Symptoms. The symptoms vary greatly according to the infecting organism and according to the site and extent of the inflammation. In mild types of infection, the patient may be entirely normal for the first three or four days and then complain of chilliness or even have a chill; her temperature will be slightly above normal, finally reaching about 101° F., where it hovers for ten days or two weeks, after which it drops again to normal and the patient recovers.

The severe type, which is so dreaded, is the one in which the patient is normal until the third or fourth day when she complains of tenderness, chilliness, weariness, and of being generally wretched. She may complain of chilliness but more often has a chill.

The pulse is usually rapid and the temperature goes up somewhat abruptly. (Chart 3.) The condition of the lochia depends upon the infecting organism. In streptococcal infection the lochia is often greatly decreased in amount and almost odorless, while in colon bacillus infections the lochia is profuse and foul-smelling. The attack may be very acute and result fatally in a few days, or it may gradually subside and the patient recover.

In gonorrheal infections the temperature does not go up until later, from the sixth or to the tenth day, as a rule. (Chart 4.) The patient is not usually very ill and generally recovers. But the gonococcus is very likely to produce an inflammation of the tubes and to close up the fimbriated opening. Thus it is impossible for ova thereafter to enter the tube and gain access to the uterus and accordingly the patient cannot again become pregnant. Unlike other infections, gonorrhea is not conveyed to the patient during or soon after labor on instruments or examining fingers, but is already present in the vulvo-vaginal glands and from them may travel to the uterine cavity and to the tubes.

Treatment and Nursing Care. Preventive. There is so little that can be done toward curing a patient suffering from puerperal infection that the greatest effort should be made to prevent the disease. The nurse’s part in preventing this complication is an important one and consists of making such preparation for labor that it may be conducted with absolute cleanliness; maintaining the same asepsis during delivery as she would throughout a major surgical operation and protecting the perineum from infection after delivery.

Curative. The curative treatment for puerperal infection resolves itself largely into good nursing care. The patient should be kept warm and quiet and as comfortable as possible; elimination is promoted, her strength is saved and her general resistance increased in every way possible. The head of the bed is frequently elevated, to promote drainage; the windows are kept open to provide plenty of fresh air; the diet is light and nourishing and the patient is encouraged to drink an abundance of water. Ice caps to the head and abdomen are frequently used to make the patient more comfortable; also cold sponge baths when the temperature is high.

A patient suffering from puerperal infection should be conscientiously isolated. If the nurse who cares for her is forced to come in contact with other patients, she should wear gloves and a gown while attending the infected woman and thoroughly scrub and soak her hands after each attention.

It was formerly the practice to curette the patient suffering from puerperal infection, and give intra-uterine douches, but it is now pretty generally believed that neither of these procedures does any appreciable good, but on the other hand may do harm. The objection to curettage is on the ground that by this means the protective wall which Nature has developed to prevent the further invasion of bacteria into the uterine tissues, is removed and a new bleeding area is provided for further and easy development of the inflammation.

Antiseptic douches seem to be useless, for if they are strong enough to be germicidal they are likely to injure the tissues and also do harm by being absorbed into the system; while weaker solutions will not destroy the organisms but are likely to carry more infective material up into the uterus. In cases of putrid endometritis, however, if the doctor cleans out the uterus with his finger, a douche of sterile salt solution is often given for the purpose of removing any putrefactive material which may have been left behind.

Phlegmasia alba dolens or “milk leg.” In some cases of puerperal infection, thrombi are formed in the veins of the pelvis, from which particles may be broken off and carried to various parts of the body and cause phlebitis or even abscesses. If thrombi lodge in the large vessels of the thigh, the interference of the venous circulation results in swelling and tenderness of the leg which is often referred to as “milk leg.” This condition is rather rare and does not usually appear until the second or third week after delivery.

The swelling ordinarily starts at the foot and gradually extends up to the thigh. The patient complains of pain in the calf of her leg and she may have an elevated temperature, rapid pulse and the general wretchedness associated with an infection.

The main feature of the treatment is rest in bed; the patient should be kept there for at least a week after her temperature becomes normal; her leg should be elevated, wrapped in cotton batting and the bedclothes held from it by means of a bed cradle or some sort of a light frame. The nurse should never rub the affected leg, and the patient should also be cautioned against this for fear of dislodging a particle of the thrombus and causing an embolism elsewhere, possibly in the lungs. For the same reason, the patient must be warned not to make sudden or violent movements for some time after she is allowed to be up and about, but to walk and move rather slowly. The swelling and discomfort may subside in a few weeks or they may persist for months.

Puerperal Mania. A word about extreme mental unbalance during the puerperium is worth while at this point because the nurse will frequently hear of this distressing condition, and will almost inevitably come in contact with it at some time. It was formerly believed that there were certain mental disorders which were peculiar to pregnancy and the puerperium, but this belief has given way before the present knowledge of psychiatry.

The puerperal patient is sometimes delirious and violent for longer or shorter periods of time, but apparently these conditions are due to toxemia or fever, or a mental unbalance has resulted from her reaction to the idea of motherhood, just as it would have resulted from an equal strain of some other character.

In other words, the young mother may suffer mental derangement from the same causes that would produce this state in any other person, but not from causes or conditions which are peculiar to the puerperium.

If the excitement or delirium are due to a toxemia, they are relieved by treating the cause, while from the nurse’s standpoint the care would be the same as for any delirious patient. The patient should not be left alone and she should be protected against doing herself any injury.

A mental disturbance which is due to the patient’s inability to adjust herself to the state of motherhood, and all that that implies to her, is a different matter, and is discussed in the chapter on mental hygiene.

“Sympathy with, interest in the poor so as to help them, can only be got by long and close intercourse in their own houses—not patronizing—not ‘talking down’ to them—not ‘prying about’—sympathy which will grow in insight and love with every visit.”—Florence Nightingale.