by Julius H. Hess, M.D.
The Problem.-When there is a positive inability on the part of the mother to nurse her offspring, either through inadequate functioning.on the part of the breast or systemic disease, we are confronted with the problem of securing human milk from another source, as notwithstanding -the numerous isolated reports on successful raising of premature infants on artificial foods, the statistics of infants fed by artificial foods, when compared with those of infants fed on human milk are so strikingly in favor of the latter that the obtaining of human milk must be considered imperative.
How Obtained. -- In our experience, even in a large city, great difficulty has been met in obtaining a regular supply of wet-nurses. On several occasions various charitable and hospital societies have attempted to establish a wet-nurses' registry as a clearing house for the several maternity and general hospitals of Chicago. These attempts have not been successful for two reasons: (1) Because of the irregularity in the demand, and (2) because of the lack of cooperation on the .part, of the various institutions caring for this class of cases.
The Nationality of the Wet-nurse.--This is of considerable significance where the supply allows of a selection. The phlegmatic temperaments as seen in women of Northern and Central Europe of Teutonic and Slavic descent, offer the ideal material, while other nationalities, such as Italians, and the Southern negroes when removed from their home environment to a Northern climate with the consequent change in diet, secrete a milk poor in quality. However, even the latter in an emergency should not be neglected.
Requirements of a Good Wet-nurse. -- 1. She should be in good health, and, especially, free from all contagious and infectious diseases, and also from local diseases of any kind, such as those involving the nose, throat, skin, etc.
2. Her mammary glands should be of such quality that she can secrete sufficient milk of good quality, and the nipples sufficiently developed to allow ,of nursing; or proper expression of the milk (Figs. 54 and 55).
3. Whenever possible her age should be not less-than eighteen and not more than thirty-five years.
4. The age of her baby, as compared with that of the baby she is to nurse, is a matter of indifference in most instances. However, the first weeks, or if possible the first two months, of lactation should be avoided, because of the presence of colostrum and the rapidly changing. quality of the breast milk, which not infrequently causes serious gastric and intestinal disturbances in very susceptible infants, as evidenced by vomiting, colic and diarrhea. Multiparity may be considered an asset, if the nurse has demonstrated her ability to care for and feed previous cases. A multipara is also less 'likely to be affected by her new surroundings, especially if this . be a private home. When the wet-nurse has more or less direct charge of the infant, one who has been nursing her own or other infants will be likely to meet the technical difficulties in the care of her charge.
Examination of the Wet-nurse.--The examination of the wet nurse should always be made in a systematic manner to insure against overlooking important things.
1. A careful history should be taken as to the number of her children, miscarriages and the presence of constitutional diseases in her family.
2. She. should be thoroughly examined, all parts of the body being exposed, and the examination should include the skin and hairy parts of the body for the presence of skin lesions and parasites, as well as for old luetic scars. The organs of the chest and abdomen should be subjected to careful examination.
3. The breasts should be examined.
4. The genitalia, including the cervix and the urethra, and in all cases a cervical (and where suspicious, a urethral) smear should be taken and examined for gonococci., As a single smear is often misleading, in cases of the slightest suspicion where a girl baby is to be nursed the examination of the cervical and urethral smears should be repeated.
5. An examination and search should be made for chronic infections, especially for syphilis. A Wassermann test should be made in every case, and reported upon before she is allowed to supply milk, as it is well known that a syphilitic mother, in a very great number of cases shows no clinical evidence of syphilis. The mouth and pharynx, neck, anus and genitalia, entire skin and lymphatic glands should also be examined for evidence of syphilitic lesions.
Tuberculosis.-The lungs, glands and osseous system should be examined, and a careful history as to susceptibility to colds and to recurring bronchitis elicited.
6. Acute Infections.-She should be questioned as to exposure to contagious disease, and she should be examined for evidence of acute infections of the nose, throat and ears.
7. Her teeth should be examined and defects and pyorrhea corrected, if necessary, at the expense of the family.
8. The urine should be examined (a) for evidence of nephritis, (b) for evidence of diabetes. It should, however, be remembered that a positive. reaction, for sugar should not be overestimated, unless the sugar is proven to be dextrose, as very commonly in our experience during the early weeks of lactation a lactosuria is present. The kind of sugar can easily be determined by the phenylhydrazine test, followed by a microscopical examination of the crystals.
9. Nervous and psychic disturbances, such as epilepsy, insanity, hysteria, should, if found, by all means exclude the subject.
10. Her child should be examined for evidence of syphilis. Possibly one of the best arguments for the non-employment of a wet-nurse during the first two months of her lactation is the possibility of a latent syphilis. Where there is the slightest doubt, a Wassermann reaction should be made on the infant. The general condition of the child gives us the best evidence both as to the quantity and to the quality of the maternal milk. Unless the source of the nurse be known, it is well to be certain that she is nursing her own baby. In case of its death or its absence, every effort should be made to obtain its condition at birth and its later development.
So far as possible she should not be subjected to annoying questioning on the part of the family, which is entirely unnecessary, if she has been properly examined by the physician. It has been our experience that such unnecessary questioning has led to nervousness, and not infrequently has caused her to decline the position, at a time when she was most needed.
Her Place in the Household.-She should be treated neither as a guest nor as a menial, but so far as possible should be graded according to her previous station in life. There is grave danger of mental depression on the part of a woman, well-born and sensitive, who, through misfortune or necessity, is forced to seek this means of employment, and also of an exaggerated estimate of self-importance on the part of a woman but little accustomed to the luxuries of life upon her entrance into the home of employment, particularly if attentions are paid to her. As has been previously stated, all instructions and demands should be made by the person best qualified in the individual case. A divided responsibility will always lead to future complications.
Her quarters should be well located; their ventilation should be supervised, and she should be held responsible for their general cleanliness. The wet-nurse's baby should always be kept in the room with her, so that she may feel the full responsibility for its health and care.
The Quantity of Milk to be Expected from a Good Wet-nurse.-The quantity and quality of milk supplied must vary greatly with the glandular development of the individual wet-nurse, the state of her health, and the factors quoted elsewhere which would affect it temporarily. The amount and variety of stimulation applied to the breasts, of which the direct nursing by a full-term infant is the most valuable (at least for the purpose of stripping the breasts), must be given. due consideration. In view of the many emergencies and influencing factors, no absolute standard for quantity and quality can be set for general rule. A wet-nurse who does not secrete sufficient milk during the first few days in her new employment should not be discharged until every effort has been made to improve her milk production. Frequently the change in environment is sufficient to reduce it temporarily.
Cost of Milk.-The wet-nurses in the Sarah Morris Hospital receive their board and room and $10 per week. Figuring the former at $8 per week, this would total a cost to the institution of $18 per week for each nurse. With an average of 30 to 40 ounces of milk per nurse daily, or 210 to 300 ounces per week, the average cost will be about 6 to 9 cents per ounce, or approximately $2 to $3 per quart.
When milk is dispensed to patients outside of the hospital, a charge of 15 cents an ounce is made for it, which is a reasonable price when all of the contending factors are taken into consideration.
Number of Nurses Needed.-Each good wet-nurse can care for the needs of about two infants, depending upon their weight and development, beside allowing the strippings for her own child.
Length of Lactation. -- No time limit is placed upon the employment of a wet-nurse as long as the quality and quantity of her milk is sustained, and she continues in good health. One of our nurses had a lactation period of eighteen months. Such long periods of lactation, however, are not to be advised.
The Wet-nurse's Baby.-The presence of the wet-nurse's baby predisposes to her peace of mind, and wherever possible, she should take,it with her. Her baby's state of health is by all means the best indication as to her ability as a nurse, and, with this, of the presence of constitutional disease in herself. It may be of immense value, if the baby is strong and healthy, to keep up the flow of of milk, in case the baby to be nursed is a weakling. It may also be used to estimate the functional capacity of a wet-nurse by nursing at regular intervals, and weighing before and after the nursing for twenty-four-hour periods. If in perfect health it may be put to the breast, after the weakling has taken such milk as it has strength to draw. If this is not practicable then the weakling should be nursed alternately with the well baby on each breast. It is also of immense value in emptying the breast after the wet-nurse has removed as much milk as it is possible by expression or by the breast-pump, if this is the means of drawing the milk for the weakling. It is a well-known fact in all institutions where wet-nurses are used, that the greater the degree to which the breasts are stimulated by suckling infants, the greater will be the reward in production. If the milk is insufficient for both babies, partial or entire meals of artificial food may be substituted for the wet-nurse's infant,
At the first sign of an acute illness on the part of the wet-nurse's baby, it should be separated entirely from the other baby, and removed from the breast; its illness should be given the same serious consideration as that of the other infant, so that the mother's anxiety may be relieved. It should receive as much of its mother's milk as can be spared. This can be expressed from the breasts and fed from a bottle.
Feeding of the Wet-nurse's Baby.-When a single infant is to be nursed the second baby is often a necessity in the promotion of the development and stimulation of her breasts. No breast can be developed to its fullest capacity with the breast-pump or hand expressions. It is a well-known fact that the breasts will respond in proportion to the demand placed upon them, and in most instances during the first few weeks of the premature's life, when its demands are met by from 4 to 16 ounces of milk, the wet-nurse can supply sufficient milk for both babies. When her supply becomes insufficient to meet the demands, her baby can be put upon partial bottle feedings of the strength as indicated by its age and development. The progress of the wet-nurse's baby has great influence on her peace of mind, which may spell success or failure in her ability to carry out her work. When the premature infant gives evidence of sufficient strength to be placed upon the breast, we have 'found the application of the wet-nurse's baby to the other breast a very valuable expedient in aiding the flow of milk into the breast which is to be nursed by the weakling. In many instances we have seen the milk flow from the second breast by this.method so freely that but very little effort was required on the part of the weakling to obtain its food.
In general, everything that has been said in the chapter on hygiene of the nursing mother applies also to the wet-nurse-of course, with the proper modifications, made necessary by peculiarities of her position.
Clothes.-Her clothes should be simple, and in every part washable. As the care of her undergarments is of even greater importance than her outer clothing, it is well that her laundry should be done with the family work, so that the family laundress who is trusted by the family may be charged with its inspection.
To simplify nursing or the drawing of milk, the author has devised two garments for wet-nurses. The material used for the outer garment is of yellow gingham, such as is used in the making of hospital uniforms-the yellow color being selected to distinguish the wet-nurse from the blue, as used by the nursing corps. The corset-waist is to be made of heavy muslin. The corset, if worn at all, should be of a very low type so as to avoid all pressure on the breasts. It is best of a cheap quality so that it can be replaced frequently for sanitary reasons. Each wet-nurse should be supplied with four uniforms and six nursing corset-waists (Figs. 56 and 57).
The Diet of the Wet-nurse.-There is danger of the creation of indolent habits through neglect of regular exercise and the lack of regular household duties, but even greater danger lies in the direction of overfeeding with unusual foods. The average wet-nurse is either obtained from an institution or a home in which the luxuries of life are limited, and she has been accustomed to a simple nutritious diet. Every attempt 'should be made to supply the nursing woman with a well-rounded diet of simple foods, with milk and cereals as the basis, and these supplemented with meats, soups, the common vegetables, limited amounts of fruits and plain desserts. Insofar as possible the aromatic vegetables, unripe and highly acid fruits, fried meats and rich pastries' are to be avoided. We believe that, on the whole, too great stress has been laid upon the danger of the diet in the mother of a full-term infant, and in most cases the average mother can partake of a very full diet. However, in the case of the woman nursing premature infants, it should become a custom to allow only such foods during the first few days after her installation as can be given with perfect impunity. When a full, free flow of milk is established other vegetables and fruits can be added, one at a time, and after each addition to the diet a try-out should be given the milk. We have on numerous occasions seen marked intestinal distention and diarrheal attacks following even seemingly slight indiscretions of the diet on the part of the wet nurse.
The diet should be sd constituted as to meet the following requirements
1. Furnish enough food of the proper kind to satisfy hunger and meet the physiological requirements of her body and produce a milk of good quality. This includes keeping the food elements in their proper proportions.
2. Prevent the presence of any obnoxious substances in the milk.
3. Prevent gastric and intestinal indigestion, constipation, or anemia in the wet-nurse.
4. Maintain the weight of the wet-nurse with little or no variation. '
It is our hospital practice to furnish each wet-nurse with two quarts of good wholesome milk daily, and at least one pint of cereal gruel, preferably farina or cornmeal. A mixture of milk and cereal gruels makes a very good combination for drinking midway between meals. The remainder of the milk may be taken with the meals, either pure or in the form of cocoa, tea or weak coffee, in whichever form it is best taken by the individual woman. The latter is of considerable importance, as in the forced diets which are required, where an abundance of milk is demanded, distasteful foods soon become obnoxious.
Meats.-Beef, lamb, chicken, fish, bacon. Eggs.-Soft cooked only.
Vegetables.-Potatoes, carrots, spinach, lettuce (no vinegar), beets, string beans, canned corn, squash, asparagus, celery.
Fruits. -- Prunes, apples, oranges, peaches, pears, apricots, raspberries, blackberries, cherries, strawberries (stewed only).
Cereals.-Rolled oats, rice, farina, cream of wheat, hominy grits, Wheatena; Pettyjohn's and all cooked 'wheat, oats, rice and corn cereals.
Fats.-Cream, butter, olive oil.
Desserts.-Soft puddings, gelatines.
Breads.-Wheat, rye, bran, corn, crackers, zwieback, coffee-cakes and plain cakes.
Liquids.-Milk, buttermilk, kazol, cocoa, weak tea and coffee, malted milks.
Soups.-Broths and soups made with beef, chicken or lamb. Vegetable soups made with milk or with meat stock and vegetables.
Avoid.-Aromatic vegetables (onions, cabbage, turnips, cauliflower) ; acid vegetables (tomatoes, pie-plant, cucumbers), acid fruits; highly spiced or seasoned foods; salads with acid dressings; raw fruits, except oranges; fried foods.
Fruit (orange, prunes or apple-sauce).
Cereal with cream and sugar.
Bacon (2 slices), or some other easily digested meat if desired.
Bread, toast or rolls.
Cocoa or milk or weak coffee.
Broth or soup.
One meat from list given (roast beef or broiled chop).
Potatoes (old) in any form except fried.
Vegetables quash, beets).
Light dessert (custard, gelatin).
Bread (white, rye or bran). Butter.
Cocoa or milk or weak tea or coffee.
One meat from list given (chicken).
One vegetable (asparagus).
Cereal with cream and sugar (rice).
Stewed fruit (peaches).
Bread and butter.
Milk or cocoa.
No candies should be allowed except as a dessert with one of the main meals.
If the nurse's appetite demands more food because of the large amount of milk secreted, or if insufficient fluids are taken with the meals to cover the fluid requirements, as previously stated, one of two midday; and one night luncheon may be given. These should consist of milk, milk and tea, malted milk or cereal decoctions, with crackers, coffee cake, etc.
Beers, malt-extracts and other rich drinks are not forced upon the nurse unless she is accustomed to them, and feels their need. It must always be remembered that an excess of fluids would naturally tend to dilute the milk unless the secreting gland be of exceptional development. Excessive feeding by giving of too frequent meals in the presence of anorexia will retard rather than increase the milk flow.
Exercise of the Wet-nurse and Her Work.-She should be impressed before her. engagement with the fact that she will be required to do a moderate amount of work and exercise regularly out of doors. The former will be of service in promoting her general health, and both the work and the exercise will serve as a nerve tonic and prevent her becoming indolent. This does not mean that she should become a drudge, but that she should at least be required to care for her own room and her own infant's clothes, and should be made to feel that in return for her laundry work she would be requested to do some light general work about the house.Her exercise in the open air should so far as possible be at regular times. The question as to the care of the napkins of both babies is open to considerable discussion; and it may be stated that whenever it becomes necessary for the nurse to express her milk by hand, she should not be subjected to the handling of soiled napkins, whenever this can be avoided.
The Nervous and Mental State of the Nurse.-The nervous and mental state of the nurse is of the utmost importance, and wherever possible an emotional, nervous, erratic woman should be excluded, because of the tendency of these influences to suppress the flow of milk. Therefore, whenever possible, a woman of more or less phlegmatic temperament is to be selected. This is especially true in the case of a woman who is to be in close contact with and is to nurse an infant with neurotic tendencies. There is also the possibility of the same influence being manifest in time of slight indisposition on the part of her own infant, and such an individual is also more likely to resent the necessity of partial or entire artificial feeding of her own child to the advantage of the premature infant, when it has reached such an age when it may make greater demands on her supply
Menstruation. -Menstruation rarely produces any serious disturbances. It is always a safe procedure to dilute the milk during the first and second day of menstruation when the nurse suffers considerable pain at these times.
Period of Lactation.-Period of lactation may or may not be a. considerable factor, depending upon the individual woman. We had in our employ a nurse who had been with the institution for sixteen and a half months, and whose infant was eighteen months old, and who supplied us with the largest quantity and the best quality of milk of the four nurses in the institution.
When possible a nurse should be selected after the first few weeks of lactation, at which time the colostrum has disappeared from the milk, and the quantity and quality of her milk has become established. After the first few weeks of lactation but little or no attention is to be paid to the age of the wet-nurse's baby as compared with that of the infant to be fed, and we have never noted any ill effects following the rule.
 The milk of this nurse was examined in the laboratories of the University of Chicago after seventeen months of lactation with the following result
Albumin 1.30 per cent
Casein 0.69 per cent
Fat 3.54 per cent
Lactose 7.025 per cent
Salts 0.1885 per cent
It must be remembered that this is an exceptional case, and but few women under the stress of ordinary life can properly nurse their infants after the ninth to twelfth month.
The Infant's Bedroom.-Under ideal circumstances, this should be separated from that of the wet-nurse. This is especially true where a trained attendant has care of the infant. It should under all circumstances also be separated from the wet-nurse when she is of a low degree of intelligence and of a type not to be trusted with the care of the infant.
Method of Drawing Milk. -- Numerous methods of obtaining milk from the breasts have been described, but only those most practicable of application will be detailed. These should be divided: (1) Into those in which the baby ;is placed directly at the breast, and (2) those methods by which the milk is drawn from the breasts and fed to the infant. Two methods, are especially applicable where the baby is fed directly on the breast, and needs assistance. because of its weakness. '`
1. The premature infant is placed at the breast, and is supported there by the nurse's right arm while nursing at the right breast, and the left hand is used to grasp the breast just above the nipple between two fingers and the milk is expressed directly into the baby's mouth. In this way the baby is taught to take the breast, and at the same time receive its food with little effort. This method can be continued until the baby has gained. sufficient strength to nurse without assistance.
2. Much the same result can be accomplished by placing the wet-nurse's baby on the opposite breast during the nursing period, whereupon the simultaneous nursing on both breasts will cause a free flow of milk into both sides.
The methods by which the milk is drawn from the breasts and fed to the infant by hand or by other means are:
1. By the breast-pump. The modification of Holz vacuum apparatus, as devised by the author. (Fig. 60), by which means the milk is drawn directly into two graduated 2-ounce flasks, which can be filled to the quantity desired, and stoppered for future use, so that the milk is free from handling, and thereby avoid contamination. This type as well as other hand pumps are less practical than drawing milk by expression. Dr. I. A. Abt, of Chicago, has recently designed an electric breast-pump which promises to be of great value.
2. By direct expression which is by all odds the method of choice and which is performed as follows:
Scrub the hands and nails with soap, warm water, and a nailbrush for at least one full minute. Wash the nipple with fresh absorbent cotton and boiled water or a freshly made boric solution. Dry the hands thoroughly on a clean towel and keep them dry. Have a sterilized graduate glass tumbler or large-mouthed bottle to receive the milk.
(a). Grasp the breast gently but firmly between the thumb placed in front and the remainder of the fingers on the under surface of the breast. The thumb in front and the first finger beneath should rest just outside of the pigmented area of the breast.
(b). With the thumb a downward pressing motion is made on the front against the fingers on the back of the breast, and the thumb in front and fingers behind are carried downward to the base of the nipple.
(c). This second act should end with a slight forward pull with gentle pressure at the back of the nipple, which causes the milk to flow out.
The combination of these three movements may be described as "back-down-out."
It is not necessary to touch the nipple.
This act can be repeated thirty, to sixty times a minute after some practice.
Both breasts may be emptied if necessary, or they may be used alternately.
The act should be carried through with such gentleness as to cause little or no inconvenience to the nurse even in the first days of lactation. Some nurses prefer to use one hand for both breasts, others become ambidextrous and prefer to change hands.
By this means, following a little practice, the nurse can express from 6 to 8 ounces of milk from two good breasts in fifteen to twenty minutes. While drawing, each 2 ounces of milk is poured directly into sterile, stoppered bottles to prevent the fingers of the nurse coming in contact with the milk by overfilling the glass.
The milk should be covered at once by a sterile cloth held in place by a rubber band and kept on ice until used.
Daily Number of Expressions.-Expression is performed six times daily at regular intervals of four hours during the day and night.
Samples of breast milk should be examined from each wet-nurse at regular intervals. Her breasts and method of expression should be inspected. It is not uncommon for wet-nurses to dilute their milk by adding cows' milk to increase the quantity when they experience a shortage.
Sick babies are not permitted to nurse from the wet-nurses' breasts; the expressed milk should be fed to the sick baby, whenever possible while it is yet warm.
If there be any question as to the reliability of the wet-nurse the milk must be drawn in the presence of a second person. Wet-nurses for prematures must not be allowed to go to a general table for their meals, but must have their meals brought to them where they may partake of their food under the eye of a nurse who understands what their diet is to be. Wet-nurses have precarious appetites, as a rule, and they are more likely than not to have a craving for something that will either diminish the amount of their milk or impart some condition that will make it disagree with the sick babies.
Wet-nurses should be kept rigidly within regular hours in the institution. They should not be permitted to go out after night because they will do indiscreet things, eat foods calculated to interfere with their efficiency as wet-nurses, drink alcoholic stimulants, and so upset themselves generally and the milk supply will be diminished. On the other hand, the wet-nurses should be made comfortable, and should be given a sufficient amount of work in the institution to keep them busy. They are disposed to resent restraint and unless their time is fully occupied, they will be sure to fret and thus diminish their milk supply.
The wet-nurse should be obliged to observe the laws of health and cleanliness; they should be obliged to bathe regularly and it should be the duty of the head nurse of the department to see that their bowels are kept in proper condition and that their genitals are clean and healthy.
Wet nurses should never be employed until the Wassermann test has been made, and until a competent physician has given them a thorough examination to determine the presence or absence of specific disease: They should never be permitted to go on duty with running ears, sore eyes, sore throat, bad teeth or any discharge from a mucous membrane, or any skin eruption.
The wet-nurse should be given a certain number of babies to feed, and as long as her milk agrees with them, and she is in perfect health, should' be kept to the same babies without any admixture of the milk of any other nurse This acts as a check on any indiscretion as it would be reflected in the baby.