that in a broad sense she is not ill, in so far as no pathological
condition exists. But she is in a transitional state and may become
acutely or chronically ill if not carefully watched and nursed. In
general her mental, physical and nervous forces must be conserved and
increased, and this requires thoughtful and devoted attention from the
nurse. She must be scrupulously clean in her care of the nipples and
perineum, and in order to be able promptly to inform the doctor of any
departure from the normal in the patient’s condition, the nurse’s
watchfulness should embrace regular observations upon the following:
1. The patient’s general condition; the amount and character of her
sleep; her appetite; her nervous and mental condition.
2. The temperature, pulse and respiration.
3. The height and consistency of the fundus.
4. The quantity, color and odor of the lochia.
5. The persistence and severity of the after-pains.
6. The condition of the perineum.
7. The condition of the nipples and breasts.
8. The functions of the bladder and bowels.
If all goes well and there are no complications, the patient will
usually be able to assume full charge of her baby by the sixth or eighth
week, and practically return to her customary mode of living, with the
difference that she now has the care of a baby which she did not have
before. The care of that baby requires certain, definite care of
herself, as a nursing mother, which will be described in detail in the
next chapter.
To sum up the general principles of nursing the young mother during the
puerperium, we find that just as during pregnancy and labor, the nurse
must first be familiar with the normal changes that occur in order that
she may recognize the abnormal. Then, as before, the nurse’s care of the
individual patient must rest unfailingly upon a foundation of
cleanliness in order to prevent infection; watchfulness, which implies
ability to recognize normal changes and unfavorable symptoms; adjustment
to the methods of the attending physician and to all of the
circumstances surrounding the patient, and the wisest and tenderest
consideration for her patient as an individual.
CHAPTER XVI
THE NURSING MOTHER
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.
[Illustration:
FIG. 138.—Position of mother and baby for nursing in bed.
]
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.
[Illustration:
FIG. 139.—The Nursing Mother. (By permission from a pastel by Gari
Melchers.)
]
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:
─────────────────────┬──────────────────────────────────┬─────────────
│ Day │ Night
│ │
First and second days│ 6 12 6 │ 12
First three months │ 6 9 12 3 6│ 10 2 a.
│ │ m.
Third to sixth month │ 6 9 12 3 6│ 10
After the sixth month│ 6 10 2 6 │ 10
─────────────────────┴──────────────────────────────────┴─────────────
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.
PERSONAL HYGIENE OF THE NURSING MOTHER
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.
CHAPTER XVII
NUTRITION OF THE MOTHER AND HER BABY
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.
“The moving finger writes; and, having writ,
Moves on; nor all thy piety nor wit
Shall lure it back to cancel half a line,
Nor all thy tears wash out a word of it.”
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.
[Illustration:
FIG. 140.—This baby is totally blind in the left eye as a result of
ulcers, due to a long continued diet of cereals with a little
skimmed milk; in other words, a diet poor in fat-soluble A. The
right eye became involved but administration of cod-liver oil was
followed by speedy recovery and partial vision was saved. There is
little doubt but that the baby would have been totally blind had the
faulty diet been continued. (From the Newer Knowledge of Nutrition,
by E. V. McCollum.)
]
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.
[Illustration:
FIG. 141.—Rachitic baby and normal baby of the same age, showing
dwarfism and deformities caused by rickets. (By courtesy of Dr.
Leonard Findlay, Glasgow, Scotland.)
]
=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.
[Illustration:
FIG. 142.—Exterior of thorax of normal rat and rachitic rat of same
age. The latter shows dwarfism and deformities resembling pigeon
breast so frequently seen in human beings suffering from rickets.
(From The Newer Knowledge of Nutrition, by E. V. McCollum.)
]
=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.
[Illustration:
FIG. 143.—Interior of specimens in Fig. 142 showing nodules, due to
rickets, protruding into thoracic cavity and encroaching upon space
occupied by heart and lungs. This is a factor in the respiratory
diseases which frequently complicate rickets.
]
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.
CHAPTER XVIII
COMPLICATIONS OF THE PUERPERIUM
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.
[Illustration:
CHART 3.—Chart showing rise in temperature about 3rd day after
delivery in a _streptococcus infection_.
]
[Illustration:
CHART 4.—Chart showing rise in temperature about 7th day after
delivery in _gonorrheal infection_.
]
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.
PART VI
THE MATERNITY PATIENT IN THE COMMUNITY
CHAPTER XIX. ORGANIZED PRENATAL WORK. Mortality in Childbearing. Aims
of Prenatal Care. Difficulties: Educational, Economic, Social,
Professional. Prenatal Work in Other Countries. Progress of Prenatal
Work in this Country. The Women’s Municipal League of Boston.
Maternity Centre Association of New York. Routine and Methods.
Results. The Situation in the Country as a Whole. Prenatal Care in
Rural Communities. Forms and Routines used by Maternity Centre
Association, New York City.
CHAPTER XX. HOME DELIVERIES AND CARE OF THE YOUNG MOTHER BY VISITING
NURSES. Forms and Routines of the Philadelphia Visiting Nurse
Society.
CHAPTER XIX
ORGANIZED PRENATAL WORK
The foregoing discussions of prenatal care and the principal
complications of pregnancy, and the dangers to which expectant mothers,
young mothers and their babies are exposed, bring us sharply face to
face with the questions, “What can be done about it?” “What is being
done about it?” and, “Is anything more possible?”
We have considered the problem, and the remedy, at very close range;
that is, from the standpoint of the individual patient. We are now
concerned to know whether or not the remedy, in the shape of care and
supervision during pregnancy, may be extended in proportion to the
enormous multiplication of the problem, when instead of one patient we
must think of millions. In other words, is country-wide prenatal care,
with all that it implies, practicable? And if so, by what means or
method?
Let us review the problem for a moment, and acknowledge the pathos and
tragedy of it.
Child-bearing is so dangerous, under present conditions in this country,
that it stands second only to tuberculosis as a cause of death among
women between the ages of 15 and 44. The discharge of woman’s supreme
function is apparently very hazardous.
Dr. Dublin summarizes as follows the rate at which mothers die
throughout the country at large:
1. “More than seven women die from disorders of pregnancy or
childbirth out of each 1,000 confinements. This is equivalent to
one maternal death out of every 140 confinements. (About 20,000
in 1920.)
2. “Forty-five babies out of every 1,000 births, or one out of every
22, are born dead. (About 112,000 annually.)
3. “Forty babies out of every 1,000 born alive, die before they are
one month old. (About 100,000 annually.)
“Such are the dangers to mother and infant at the present time.”
And then, as though in answer to our question, “What can be done about
it?” he states that, “among women who receive prenatal and maternal care
under skilled direction:
1. Only _two_ women instead of _seven_ die out of every 1,000
confinements.
2. Only _twelve_ babies, instead of 45, are still-born in every 1,000
births.
3. Only _ten_ babies, instead of 40 per 1,000 born alive, die before
they are one month old.”
Obviously, then, only a few—too few—American women are receiving the
minimum of care that makes child-bearing a reasonably safe adventure.
Perhaps it will be well for the nurse to pause just here for a fresh
reminder that the end really to be desired through prenatal care is not
so much the mere prevention of death among mothers and infants, as the
promotion of health, as well; our charges must be not only saved but
saved to mental and physical health, vigor and well-being, capable of
being useful, productive citizens. Happily, both life and health are
conserved by the same measures, and effort toward either end helps to
accomplish both.
Although the inhabitants of a prosperous country like the United States
should be a hardy people, the results of medical examinations by the
draft boards, during the war, gave us a rude awakening to the fact that
they are not.
An appallingly large number of young men who were passing in every day
life as normal were found to be physically unfit for military service.
And we know that a large part of this unfitness resulted from inadequate
care, of some kind, during the weeks and months that comprise the
beginning of life.
It can scarcely be doubted that the most critical period in the life
history of the individual is the first ten months—the nine months of
intra-uterine life and the first month after birth. Good care, then,
during this critical period is indispensable in the building of a
healthy race. The difficulty in the way of giving this care, at present,
seems to be fourfold: educational, economic, social and professional,
and may be summed up somewhat as follows:
1. From the educational standpoint, almost universal ignorance of the
need of skilled obstetrical care.
2. From the economic standpoint, financial inability of the average
woman to afford such care.
3. From the social, or administrative, standpoint, a fairly general
failure on the part of public authorities to recognize the
situation as one of grave national importance.
4. From the professional standpoint, inadequacy of available
obstetrical service, both medical and nursing.
In many of the large cities women have access to excellent obstetrical
and prenatal care; both those who can pay for it and also the poor woman
who cannot, though very many in both groups still fail to take advantage
of the opportunities that are open to them.
But the city women of moderate means, and those in small towns and rural
communities are in general unprovided for. And it is their babies who
grow up and later constitute the backbone, weak or strong, of the
nation.
Certain foreign countries which have evinced more concern for the
welfare of mothers and babies than has the United States have
demonstrated that widespread prenatal care is entirely possible and
practicable, and they regard it also as an imperative measure toward
promoting the national welfare.
The actual origin of this prenatal care is somewhat difficult to locate.
There are the consultations for pregnant women instituted in Paris
several years ago by Dr. Budin. But Dr. Ballantyne, of Edinburgh, is
generally regarded as the father of the prenatal work because of his
work on abnormalities of pregnancy and his insistence upon the
importance of what might be accomplished through intelligent care and
supervision of all women, not alone abnormal cases, throughout
pregnancy.
In England for nearly twenty years the supervision and instruction of
expectant mothers has been an integral part of the work of midwives who
are trained, registered and controlled by government authority. Of late
the work among mothers and babies has been so extended that during the
war, always a destructive period for babies, the infant death rate was
reduced to the lowest figure in the country’s history. This was
accomplished partly through a maternity benefit which helped the mother
to pay for obstetrical care, and partly through indirect government aid,
in the form of: compulsory notification of births; a great increase in
the number of “health visitors” and welfare centres, and government
grants to local authorities which defrayed half the expense of giving
prenatal, natal and postnatal care and of instructing mothers in the
care of themselves and their babies. Especial effort has been made to
help the mothers in rural sections; more small hospitals being
maintained, more physicians being provided and assistance given in
caring for older children, during the mother’s absence, if she was
obliged to go to a hospital at the time of delivery.
New Zealand also has made marked progress in its work of saving the
lives and promoting the health of its mothers and babies, having at
present the lowest infant death rate in the world. This has been brought
about largely through the efforts of the “Society for the Health of
Mothers and Children,” an organization employing visiting nurses, called
Plunkett Nurses, in honor of the family by that name which has greatly
aided the work.
The outstanding features of this work are educational and preventive;
the mothers being instructed from early in pregnancy about the care of
themselves and the preparation for, and subsequent care of their babies.
Prenatal clinics are maintained and the facilities for hospital care are
being steadily increased and improved.
One is impressed by the spirit animating this organization, as expressed
in a statement of its “functions,” one of which is as follows: “To
uphold the sacredness of the body and the duty of health, to inculcate a
lofty view of the responsibilities of maternity and the duty of every
mother to fit herself for the perfect fulfillment of the natural calls
of motherhood, both before and after childbirth, and especially to
advocate and promote the breast feeding of infants.” Work based upon
such idealism could not but be effective.
The New Zealand undertaking is regarded as patriotic, rather than
philanthropic, and mothers who are visited and cared for are accordingly
encouraged to pay for this service, if financially able to do so. The
Government supervises and warmly supports the work of this Society and
also aids by enforcing the most perfect system of birth registration in
the world, without which the results of the work could not be accurately
gauged.
England and New Zealand, as countries, have pointed the way toward
accomplishing a nation-wide reduction of maternal and infant mortality
and morbidity by making provision for widely organized prenatal care.
They recognize the problem as one of public concern. They get at the
heart of it: ignorance on one hand and poor or inadequate care on the
other. They apply a practical solution, comprising a system of
preventive, instructive prenatal care, together with improved and
increased facilities for medical and nursing care at the time of
delivery and afterward.
This country has been strangely laggard in making widespread, organized
effort along these lines, to safeguard its mothers and babies, through
prenatal care. But sporadic, volunteer effort has been made in certain
cities, and has been crowned with brilliant success.
The first of these attempts in this country was made in Boston, in 1909,
with a maternity nurse working under the auspices of the Women’s
Municipal League. The work, which was established by Mrs. William Lowell
Putnam, was designed to show what could be accomplished by intensive
work in a small group of city mothers, and suggest the feasibility of
its extension to larger numbers.
“The routine, which has been evolved through a five-year experiment by
the Prenatal Committee of the Women’s Municipal League,” says Mrs.
Putnam, “has reduced the infant deaths, among those cared for by a third
to one-half, as compared with cases not receiving this care.
Still-births have been cut in half. Premature births have been reduced
to seven-tenths of one per cent. These results were obtained by
supervision during pregnancy only, and at a cost of less than $3.00 per
patient; an expense which the patients were always encouraged to meet if
possible.
“The success of this venture proved to be so satisfactory that the
Boston workers have gone still further toward supplying the needs of
mothers and babies by adding to the prenatal care, care at the time of
birth and afterwards until the mother is again on her feet. Through the
courtesy of one of the largest Boston hospitals, a clinic is held weekly
in its Out-Patient Department. The hospital is in no way responsible for
the clinic, simply lending the room in which the clinics are held. The
medical care at the clinic and in the patients’ homes is given by
obstetricians from the staff of the Boston Lying-in Hospital. Medical
examinations are made during pregnancy at the clinic, and a nurse visits
and instructs the patient during the period of expectancy, always under
the direction of a physician. The delivery is performed in the home by a
physician connected with the clinic, at which the nurse also is in
attendance. She visits the mother and baby twice daily for three days
subsequent to the delivery, gradually making her visits less frequent
thereafter. The doctor pays from two to four postnatal visits, as may be
needed. For this prenatal, natal and postnatal, medical and nursing
care, $40.00 is the entire amount charged, and the work is
self-supporting with the nurse’s time filled. Prenatal care, alone, is
given if desired by a physician and with visits at the clinic included;
the charge for this service is $10.00.”
I refer to the work in Boston, particularly, as its inauguration by Mrs.
Putnam marked the beginning of this branch of public-health work in this
country, though to-day the same kind of service is available to
expectant mothers in many of the large, and some of the smaller cities.
Visiting nurse associations, the country over are giving postnatal and
infant care (in some instances, excellent prenatal care, too), often
providing for or assisting with the deliveries, and effecting an
enormous saving of life and health by so doing. But the number of
patients who are cared for by each organization is relatively so small
that even the aggregate of the work done reaches a pathetically small
proportion of the mothers and babies in the country as a whole who need
care.
The first comprehensive effort, in the United States, to meet the need
of all expectant mothers in an entire community, was inaugurated in New
York City, in 1918, by the Maternity Centre Association, the chief
function of the organization being to coordinate the work of agencies
already in existence.
This Association was formed as a result of the work of the Maternity
Protective Committee of the Women’s City Club and the Maternity Service
Association of Physicians and Hospital Superintendents.
The form of organization, purpose and methods of work of this
association may be studied with profit, for having been started on a
small scale as an experiment, it now constitutes a demonstration of how,
through co-ordinated effort, prenatal and obstetrical care may be
extended almost indefinitely to expectant mothers in urban districts,
and at a low cost.
The purpose and scope of the work are described by Miss Anne Stevens,
its former Director, who tells us “that it is the aim of the Association
to cover completely the need for maternity care, prenatal, delivery and
postnatal, in a given community, by providing for every woman in that
community, medical supervision and nursing care from the beginning of
her pregnancy until her baby is one month old. This is being attempted,
not by establishing another medical and nursing agency, but by
establishing a centre through which the maternity work of every
hospital, private physician, midwife and nursing agency in the community
may be co-ordinated and developed to its fullest extent; a centre at
which there will be a complete record of every pregnancy in that
district; a centre from which the whole community may be educated to
realize the need of and to demand adequate medical supervision and
nursing care for every woman and her baby before and after birth.”
It is not, then, an experiment in prenatal clinics, many of which have
been conducted, both in New York and elsewhere; but it is an experiment
in its attempt to provide adequate care for every pregnant woman in the
community from the beginning of her pregnancy until her baby is a month
old.
Standards for adequate prenatal care, upon which to base the work, were
formulated by the Maternity Service Association of Physicians. The
nurses worked with these standards as a guide and gradually developed
detailed routines, as a result of frequent conferences over the
difficulties and problems arising in the course of their daily work
among the patients.
These various adaptations were, of course, approved and authorized by
the Medical Board of the Association. Because these routines meet the
doctor’s requirements so satisfactorily, and have been evolved out of
the experience of many nurses, concentrating their best efforts upon
this work, they are copied on pages 423 to 436 with the belief that they
will be suggestive, and perhaps save time and effort for those who may
wish to inaugurate similar work.
Every effort is made by the Association to reach all of the expectant
mothers in the ten zones into which, for the purposes of the work, the
Borough of Manhattan was divided by the preliminary committee[14] called
by Dr. Haven Emerson, who at that time was Commissioner of Health for
New York City. This Committee was called for the purpose of surveying
the obstetrical facilities of Manhattan, and offering suggestions as to
how they might be utilized in an effort to decrease the persistently
high infant mortality.
Patients are reported for care by hospitals, dispensaries, clinics,
relief agencies, church clubs, settlements and the like and are
discovered in various ways by the nurses on their rounds.
The nurse’s first visit to a patient is little more than a friendly one.
In fact, she may have to make several such calls before she is able to
so far win the patient’s confidence and friendship that she will consent
to place herself under supervision. For in addition to obtaining her
verbal consent, the establishment of this sympathetic relationship is
found to be necessary before the nurse can feel sure that the patient
will freely tell of her symptoms and follow the advice given.
Before making plans, or talking to the patient about prenatal care, the
nurse ascertains what arrangements, if any, the patient herself has made
for care at the expected confinement. She finds that the expectant
mothers fall into four groups:
1. Those who have registered with a hospital.
2. Those who have arranged to be cared for by a physician.
3. Those who have arranged to be cared for by a midwife.
4. Those who have made no arrangements of any kind.
The nurse’s relation to a patient registered with a hospital for
delivery depends upon the scope of the work of that particular
institution. Some hospitals will register patients early in pregnancy,
and assume the entire medical and nursing care and supervision from that
time until after the baby is born. The Maternity Centre nurse,
obviously, has no responsibility for these patients. But she does give
nursing care and instruction to patients registered with hospitals which
have not facilities for prenatal clinics or visiting nurses to send into
the patients’ homes. The hospital resident, in these cases, assumes
responsibility for medical supervision of the patients and receives a
report from the Maternity Centre upon each nursing visit; and the nurse
in turn urges the patient to return to the hospital, periodically, to
see the doctor, in accordance with instructions received from the
hospital.
This form of co-operation has proved to be so satisfactory that many
hospitals now do not wait for the Maternity Centre nurses to discover
patients registered with them, but each day notify the nurses of newly
registered patients and ask that they be given the routine nursing care
and supervision by a Maternity Centre nurse.
When a nurse finds, upon her first visit to a patient, that she has
engaged a physician to attend her at the time of confinement, she gives
no advice, but sends to the doctor a form letter, prepared by the
Medical Board, offering to nurse that patient according to the routine
of the Maternity Centre Association if he wishes, and to report to him
upon each nursing visit. A very small percentage of physicians refuse
this offer of assistance, the majority accepting it with eagerness.
Patients who have engaged their own physician for delivery, naturally,
are not asked to go to the Maternity Centre clinics for medical
examination or advice, but are invited to go for the nurse’s
instructions, and to attend the group conferences that will be described
later.
If the patient belongs to the third group, having engaged a midwife, the
nurse goes in person to see the midwife, as letters are usually of
little avail. She asks the midwife to bring her patient to the clinic,
explaining that, though midwives are taught to conduct deliveries, they
are not taught to make the examinations that are now known to be so
important to the future welfare of mothers and babies, but that such
examinations can be made at the clinic by the doctor. If the initial
examination discloses any abnormality, this fact is explained to the
midwife and also that the rules governing her practice forbid her caring
for such a patient. The nurse, midwife and patient then plan for
adequate care at the time of delivery. In this way the nurses win and
retain the confidence and good will of the midwives; and since these
women exert a powerful influence over their patients and their families,
their co-operation is of considerable value in persuading the patients
to accept more skilled care than midwives can offer.
If, on the other hand, the initial examination does not disclose any
abnormality, the midwife is simply asked to allow the nurse to visit the
patient at regular intervals, in a supervisory way, and to have the
patient report to the clinic doctor for his periodic observations and
advice. The intelligent midwives, who speak English, are usually
co-operative, but the others are sometimes suspicious and persuade their
patients to refuse the nurse’s supervision.
For the patients in the fourth group, those who have made no arrangement
for care at the time of delivery, the nurse is even more responsible.
The plans for these patients include three fundamental requirements: a
complete physical examination; the correction of physical defects, so
far as is possible, and a study of the environment and social status of
the patient; this in order to adapt the care during pregnancy and at the
time of delivery to each individual’s condition and circumstances.
From time to time the nurse explains to the patient, as much as she can,
about pregnancy and the changes that accompany it and the reasons for
the advice that is given, in order to secure her intelligent
co-operation. Experience has taught that it is not enough to advise the
patient to do thus-and-so because the doctor thinks best. But if she
understands that examination of her urine, for example, may disclose
conditions that can be cured, but which if neglected may cause
headaches, or convulsions, she is much more likely to provide a specimen
for examination than if she is asked for one without explanation.
The care of each patient is a tactful adjustment of the prescribed
routine to the condition, habits and temperament of that patient. It is
carried on through a combination of visits which the nurse makes to the
patient’s home and visits which the patient makes to the nurse at the
Maternity Centre in her district. The advantages of this combination of
visits are, that the nurse first knows the patient in her own home, and
can help to plan for the desired care with the conditions of this home
in mind, and perhaps evolve from the patient’s simple belongings the
equipment needed for her care; also that at the Centre it is possible to
assemble the patients and give them a certain amount of informal group
instruction. There is at each Centre a doll model of a baby; a model of
a baby’s bed (Fig. 144), showing that a box or a basket may be used with
entire satisfaction; a model of the mother’s bed, prepared for delivery
at home and protected with newspaper pads; a complete layette (Fig. 145)
to show the mothers how simple such an outfit can and should be;
patterns for making each garment and some one to help the women to make
them; a breast tray (Fig. 146) and a baby’s toilet tray (Fig. 147), so
complete and yet so simple that no woman with a few chipped or cracked
cups to spare need be dismayed.
[Illustration:
FIG. 144.—Separate bed for the baby improvised from a market basket.
(By courtesy of the Maternity Centre Association.)
]
In the course of this group instruction the women are taught how to
prepare for, and later care for their babies. One week, the nurse
demonstrates to the group how to handle the baby, dressing and
undressing or bathing it; or explains the reason for making each article
in the model layette, or the purpose and use of each article on the
toilet tray, and shows them how to make boric acid solution and swabs.
In short, each detail in the care of the baby is gone over. Every
alternate week the mothers demonstrate to the nurse. They dress and
undress the doll model; explain and demonstrate how to make boric acid
solution; how to prepare sterile water and give it to the baby. Many of
the mothers attend the classes for several weeks in succession, and
frequently a mother returns with her three-week-old baby to make sure
that she has not forgotten any of the details of infant care which the
nurse tried to teach her before the baby came.
[Illustration:
FIG. 145.—Layette recommended to patients by Maternity Centre
Association:
A. Flannel binder.
B. Knitted band with straps.
C. Shirt.
D. Petticoat.
E. Dress or nightgown.
F. Diaper.
G. Pad for basket-bed.
H. Flannel square.
]
[Illustration:
FIG. 146.—_Breast tray_ improvised from articles to be found in any
home, contains: Jar of cotton pledgets; bottle of liquid petrolatum;
soap on saucer, covered with cup for water to bathe nipples. (By
courtesy of the Maternity Centre Association.)
]
A patient is not asked to go to the Centre for any reason if she seems
very reluctant to go; or if her going is inadvisable for physical
reasons or if it would entail great hardship, because of young children
who would have to be taken with her, or left at home alone. But when
they can go, it simplifies the work and enables each nurse to supervise
a larger number of patients than if she did all of the traveling and
visiting.
[Illustration:
FIG. 147.—_Baby’s toilet tray_ equipped with jelly glasses, bottles,
celluloid hair receiver for cotton, and a soap dish, containing:
1. Safety pins sticking in cake of soap.
2. Jar for sterile nipples.
3. Jar of sterile water.
4. Jar of boracic acid solution.
5. Nursing bottle.
6. Sterile water to drink.
7. Nursing bottle for water.
8. Small tooth pick swabs.
9. Liquid petrolatum.
10. Gauze mouth swabs.
11. Absorbent cotton.
12. Soap.
(By courtesy of the Maternity Centre Association.)
]
Each patient is seen by a doctor or a nurse every two weeks until the
seventh month of pregnancy, and once a week after the seventh month. At
each visit the nurse follows as much of the prescribed routine as is
possible; this routine consists of testing for albumen in the urine;
taking the systolic blood pressure; listening to the fetal heart;
questioning the patient and looking for the objective symptoms of
complications. During these visits to the homes the nurses are able also
to help their patients assemble entirely satisfactory outfits for the
care of their nipples, consisting perhaps of jelly glasses, cheese jars,
or handleless cups. And they help to find a place on the shelf where
this little equipment may be kept undisturbed and always ready for use.
When it comes to the measuring of urine, they explain that the regular
size tomato can holds just a quart, and is therefore quite as
satisfactory for that purpose as a costly graduated glass measure.
No patient is dismissed for failure to follow advice; the nurse
continues her visits, unless the patient positively refuses to admit
her, and she continues to advise, adjusting and modifying the ideal
routine and persuading the patient to do as much as she can, or will.
If abnormalities develop during pregnancy, the nurse arranges for
immediate medical care, either at the patient’s home or in a hospital.
If the clinic doctor feels that the patient should have hospital care,
but she will not or cannot go to a hospital, she is persuaded to engage
a doctor, and a nurse from the Centre helps, as a visiting nurse, to
take care of the patient in her own home.
The next responsibility of the nurse is to advise the patient in
arranging for care at the time of delivery, this advice being based upon
the patient’s physical condition, the circumstances of her home life and
the available facilities for care. Although hospital care may be the
ideal for all patients, from an obstetrical standpoint, the mother
cannot always be removed from her home with safety to the family circle.
Her physical and social conditions therefore are considered together; if
there is no complicating home problem, it is usual to advise hospital
care for primiparæ and for all patients who have, or develop
abnormalities, or have a history of previous difficult labors,
complications or abnormalities.
Patients who, the doctors think, give promise of having complicated
labors and who prefer to remain at home are advised to engage a doctor,
and to arrange with the Henry Street Settlement for nursing care at the
time of delivery and during the puerperium, as the Maternity Centre
nurses do not perform this service.
At one time, however, the Centre provided assistance to patients
delivered at home, in the shape of a working housekeeper to discharge
the mother’s household duties while she remained in bed the necessary
length of time after the baby was born, or in some cases, while she took
much needed rest during the latter part of pregnancy. For this purpose
the nurses had a list of women who were good housekeepers and clean
workers and whose own children were partly grown. These women were glad
of an opportunity to do part time work and earn a little extra money.
They were paid thirty cents an hour, twenty-five cents for lunch and
whatever their carfare amounted to, the patient paying whatever she
could afford toward the fund, provided by the Women’s City Club, from
which these working housekeepers were paid. This service, which in no
wise replaced the nurse’s care, has been temporarily discontinued
because of lack of funds, but proved to be so valuable that it will be
resumed as soon as possible.
Supervisory postnatal visits are paid to patients, not under the care of
the visiting nurse service, who have been under Maternity Centre
Association care during pregnancy, as well as to those who have not had
this care but are referred to the Centre, by hospitals, upon their
discharge. The nurse first visits to satisfy herself that the mother is
able to care for her baby and to give any instructions that seem to be
necessary. She then visits the patient, or the patient visits the nurse,
when she is able, until the baby is a month old, when she is urged to
register the baby at a baby health station.
The importance and value of birth-registration is explained to the
mother and the nurse endeavors to have a copy of a birth certificate in
the mother’s hands before the case is dismissed.
The importance of post-partum examinations, not later than six weeks
after delivery, is also impressed upon the patient. Patients who are not
to be examined by the doctors who delivered them are given a post-partum
examination by a doctor at the Maternity Centre, to make sure that they
are dismissed in good condition, or are referred to the proper agency
for further care, this being the first step in prenatal care for the
next baby.
Is all of this elaborate organization and detailed care worth while?
A recent statement issued by the Maternity Centre Association replies
convincingly that it is. It says that during 1920 among women in the
Borough of Manhattan not under Maternity Centre supervision:
1. One mother died for every 205 babies born. (One out of 14 for the
rest of the country.)
2. One out of every 26 babies born, died under one month of age.
3. One out of every 21 babies was born dead.
Whereas, among women in Manhattan who were supervised by the
Association, during the same period:
1. One mother died for every 500 babies born.
2. One out of every 51 babies born, died under one month of age.
3. One out of every 42 babies was born dead.
The Association does not usurp nor supplant, but endeavors to give
impulse to public and private agencies alike in affording the best
possible supervision and care for expectant and parturient mothers and
their babies.
Thus has the stupendous problem in New York been attacked with courage
and with gratifying results. Much might be accomplished in smaller and
less complex communities with proportionately less difficulty.
But all of the foregoing relates to city dwellers. What about the
expectant mothers in isolated and rural communities?
I wish we did not have to say.
Prenatal care is practically unknown among them and there is scarcely
any provision for obstetrical care, either. The nearest physician may
live miles away and even though one were near, country women and their
husbands do not always feel that the expense of employing a doctor, for
mere childbirth, is justifiable.
In certain Northern and Western communities, that were considered fairly
representative of those sections, conditions have been studied at some
length by agents of the Federal Children’s Bureau. They found that about
half of the mothers in those communities had no medical attention
whatever in childbirth. Untrained women, friends or neighbors,
frequently someone’s grandmother, were in attendance. Or husbands or
workmen were pressed into service. A few women were entirely alone in
their hour of trial. Scarcely a mother among them received prenatal care
and instruction worthy of the name.
In the Southern states, the proportion of women delivered by physicians
seems to be even smaller than in the North and West, and in some of the
mountain regions the conditions are distressing. From one such locality
we learn that when a woman goes into labor the first passing teamster is
hailed, or perhaps a member of the family hurries down the road for the
nearest tanner or blacksmith, or any one else, who in total ignorance
will fearlessly rush in to meet the great emergency. The results of this
practice—dismembered infants and badly injured or dead mothers,—are too
sickening to describe, but may be imagined by any nurse who has seen
good obstetrical work and appreciates its value.
From another mountain region in the South comes the contrast in accounts
of the work done by Miss Lydia Holman, founder of the Holman
Association, as evidence of what skill and desire may accomplish.
Something more than twenty years ago this nurse started volunteer
visiting nursing among the mountain people, with no precedent to follow
and no Board to direct or advise. But there were sick people all about,
people needing care, and Miss Holman was not only trained but eager to
nurse them, and after all these qualifications are the chief requisites.