rule, and the same holds good for mothers who have borne children in rapid sequence. The milk of neurotic or emotional mothers is far from normal, and is not apt to be influenced very favorably by judicious management.

The diet and exercise of the nursing mother are of great importance in the production of good milk. Liberal feeding and no exercise will frequently give an overrich milk with 6 per cent of fat; hard work together with poor food is responsible for a very poor milk with less than 1 per cent of fat. Irregularity in nursing makes good milk bad, and frequent nursing is found to give a concentrated milk and produce colic in the child; too prolonged intervals in nursing are apt to decrease the total solids and produce a milk easily digested but not nutritious. A very concentrated milk may be nutritious, but is difficult to digest.

Acute and chronic illness often occasion bad breast milk, particularly such diseases and conditions as tertiary syphilis, nephritis, typhoid, and sepsis. The milk from a suppurating breast is not proper food for an infant, and it has been alleged that pus taken with the breast milk is occasionally responsible for multiple furunculosis in infants. During the catamenial period the breast milk changes in composition, inasmuch as the fat percentage is low; but, as this period of depression lasts but a few days and former conditions are again established, the appearance of the menses is not a direct contraindication for the breast. Finally, it is well to remember that all secretory and excretory organs of the body are in close touch with the general circulation, and powerful drugs are apt to exert their effects upon an infant through the medium of a nursing mother. The following analysis, taken from Rotch, expresses in percentage the various changes in the composition of breast milk:

CONTRAINDICATIONS FOR BREAST MILK.-Tuberculosis, cancer, syphilis, epilepsy, any form of sepsis, cachexia from chronic or subacute disease, very acute illness, convulsive attacks-all of these conditions are prime. indications for weaning. In a case of sore nipple without suppuration of the gland the milk may be pumped from the breast and fed from a breast bottle.

In case of pregnancy or gradual diminution of the milk supply of the mother, it will not be necessary to wean suddenly. If possible, wait for the approach of cold weather before taking the child from the breast, gradually substitute other food, and have no regard for dentition. When the breast supply gives out gradually, it is a very good plan to give half breast and half bottle food. The selection of the latter will depend upon. circumstances. All things being equal, diluted top milk, sterilized in warm weather, should be selected (see cow's milk for infant feeding).

How to Influence the Composition of Mother's Milk

If a child at the breast shows symptoms of dyspepsia and no gain in weight, study the conditions affecting the composition of the mother's milk as discussed in the foregoing remarks, and if possible determine the amounts of fat and proteids in the milk. If the milk is overrich, the mother is to be placed upon a plain diet; and the inactive, phlegmatic, lazy mother should be made to engage in active exercise (e. g., walking). If the milk is poor in the beginning of nursing, appropriate efforts should be made to increase the percentage of fat by allowing the mother a liberal diet of albuminoids (eggs, meat), and curtailing exercises. Liquids (beer, porter) increase the flow of milk, but do not enhance its richness. Fat does not increase fat. (See article on Diet.)

In making an analysis of milk for practical purposes we have to inquire into the percentage of fat and casein therein contained. The microscopical and specific gravity tests are uncertain and furnish no very definite data. The Babcock and other centrifuge tests for fat are adaptable for laboratory use and purposes. Many physicians are fortunate enough to be able to rely upon the services of a friendly apothecary for ordinary analysis.

To approximately determine the percentage of fat present in the milk under investigation, a small calibre test tube graduated from 1 to 100 is filled to the 100 mark with milk pumped from the breast, an indefinite quantity of ether is added thereto, and the contents are thoroughly shaken. After the lapse of half a day, on standing, the liquid separates into two layers, ether and fat, and milk minus fat; then, for example, if the point of demarcation between the two layers is at 97, we have 3 per cent of fat represented in the specimen examined. We now decant the ether and fat solution and precipitate the casein contained in the skim milk by the addition of acetic acid or rennet; the curd formed is then collected on a filter (the weight of the filter being known), and the salts, etc., are washed out with water; filter and curd are dried in an oven and weighed together. Deduct the weight of the filter from the total weight and the weight of the curd remains; thus, e. g., if in a test tube graduated in grammes the weight of the curd was found to be 2.0 gm., the percentage of proteid is two, approximately. An inexpensive Swiss milk tester in the shape of a flat disc can now be obtained, which enables one to tell rich from poor milk at a glance. Holt has devised an inexpensive milk tester.

Summary

Overfeeding, excessive fats or proteids, may cause dyspeptic symptoms in the nursing infant. Proteids and fat in mother's milk may be increased or diminished in many cases by diet and exercise. A deterioration of the breast milk occurring early or toward the end of lactation is accompanied by insufficient gain or loss of weight in the child unless the condition of the milk can be improved or an addition made to the child's diet. The proteids are high during the colostrum period, and may provoke dyspeptic symptoms in the premature or full term infant.

The dietetic management of infants is not solely a question of accurate percentages of fat, casein, and sugar; the composition of breast milk

varies within certain limits all the time, in the healthiest individuals; it varies from day to day and varies within the day. Those who attempt to regulate the physiological processes occurring in the animal economy by methods brimful of mathematical accuracy, viewed solely from the standpoint of chemistry, are as much at fault as those who make no attempt to study and understand the subject. The chemical behavior of food stuffs in the laboratory is entirely different from the chemical behavior in the animal economy. Conclusions drawn from such comparisons as practically applicable to the necessities and workings of the human economy are frequently grossly erroneous. In our attempts to aid and imitate nature, common sense will establish limitations and keep us away from gross scientific errors.

HOW TO NURSE

The new-born child may be put to the breast after the mother has had a refreshing sleep. In the mean time or in case the milk is somewhat delayed, it may receive warm and sweetened fennel tea. Should the milk be delayed beyond the second or third day, artificial feeding must be done at regular intervals. Almost all infants can be trained to nurse and sleep regularly. Mothers and nurses who fail to appreciate this fact, or lack the necessary firmness and common sense, will suffer much wear and tear during the nursing period. For the first two months ten feedings a day are the average, including two night nursings; and it should be the aim of the mother or nurse to accustom the child to abstinence and sleep for four to six hours at night. As the child grows older, the intervals between nursings increase, and one night nursing will suffice.

After the child is six to eight weeks old, it should be taken out of doors in all but stormy weather for from two to six hours each day. The sleeping room should not be heated above 65° to 68° F. Children kept indoors in overheated apartments become dyspeptic in a short time. Medication in such cases is absurd-fresh air to breathe is Nature's tonic and digestant.

Wet Nursing. If maternal feeding is out of the question, a good wet nurse is to be preferred to artificial feeding. It is the writer's experience that children artificially fed, all other factors being equal, succumb more readily to severe infectious disease than do breast fed children. At the same time it must be emphasized that in private practice infants can be raised on the bottle without much difficulty. The moral question involved in depriving an infant of a poor mother of its natural nourishment is usually not taken into serious consideration, but, inasmuch as a healthy woman with full breasts can readily nourish two infants until they are several months under way, such an arrangement might well be suggested by a well meaning physician.

In selecting a wet nurse, the physician will investigate carefully as to marked anæmia, syphilis, tuberculosis, gonorrhoea, the condition of the breasts, nipples, lymph nodes, etc.; and endeavor to secure for the nurse the proper diet and sufficient rest to insure if possible an adequate supply of good milk. A wet nurse need not be rejected if her child is four or six weeks older than the one to be nursed.

Weaning.-Deterioration in human milk is marked by a reduction in the proteids and total solids. This deterioration takes place normally during the later months of lactation, and is accompanied by a loss of weight, or a gain below the normal standard, unless supplementary feeding is established. Deterioration may be the forerunner of the cessation of lactation, or well directed treatment may improve the condition of the milk.

Weaning should be done gradually and if possible in cold weather, with no regard to the period of dentition. Any sudden change in food is apt to be followed by indigestion. Sudden weaning may be required in severe acute illness of the mother, but if this is of short duration, it is often wise to keep up the flow of milk by means of the breast pump.

In weaning, the artificial food must be of low strength at first, with a gradual increase in the strength of the milk food. The mother is made. more comfortable by a binder holding up the breasts. The management of inflamed breasts and sore nipples is discussed elsewhere.

Mixed feeding is a combination of breast and bottle feeding, and in many cases is superior to artificial feeding alone.

1. The breast milk may be good, but lacking in quantity. 2. It may flow well, but be poor in fat. As regards point 1, we can make the intervals between the nursings longer and feed by bottle once, twice, or three times. As regards point 2, we can endeavor to increase the richness of the breast by a special diet for the mother and feed by the bottle several times a day, and thus continue lactation for a long time. Mixed feeding is often necessary in retarded convalescence after parturition.

No Drugs for Nursing Infants.-The medicinal mismanagement of dyspepsia, or indigestion, in nursing infants is one of the greatest wrongs that a medical adviser can inflict upon the innocent and helpless. Indigestion in nursing infants is managed by diet, abstinence, fresh air, and rectal enemata, and not by drugs. The following case from the writer's experience will serve as an illustration for these remarks:

A breast fed infant seven days old had a dyspeptic diarrhoea three days after birth. Instead of cutting off the breast milk for a short time and feeding on farinaceous water, in order to give the gastroenteric tract a chance to readjust itself, the infant was at once drugged according to the prevailing fashion, and calomel, lactopeptine, bismuth, and salol were given in rotation. As there was no improvement, resorcin was ordered in quarter grain doses every four hours, and after the sixth dose of this drug the child became cyanotic, pulseless, clammy, and cold, and the urine which had been voided before collapse set in was smoky in color. Resorcin poisoning was at once suspected, and the subsequent management was as follows: The child was given a hot bath, 110° F., every two hours and kept warm by hot water packs, the bowels were flushed with a warm saline solution every three hours, and warm sweetened tea was given by a spoon frequently. The child recovered completely in the course of a few days and again took the breast at regular intervals and remained well.

FACTS ABOUT MILK

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FACTS ABOUT MILK

As cow's milk is the basis of artificial infant feeding, its properties and the various methods of its handling and its modification should be thoroughly understood by the practitioner. For that reason some extra space in this volume is devoted to the important subject of milk and milk diluents.

Guaranteed, or certified, milk is pure, clean milk for the nursery as furnished by dairymen under the following safeguards: (1) The veterinary care of the herd and its protection against tuberculosis, sepsis of the udder, and other infectious diseases of the cow herself. (2) The medical care of the attendants in regard to their health, the hygiene of their homes, and the practical quarantine of the farm. The careful sterilization of the milkers' clothing and the cleanliness of their hands and arms during the process of milking. (3) The care of the cows, the absence of manure in the barns, the practical exclusion of fecal matters from the milk, and precautions against the entrance of dust. (4) The extraordinary precautions placed around the milk in the milk house and in the processes of transportation and delivery.

Standard of Cleanliness

It has seemed wise to establish a standard of cleanliness, or a bacterial standard, to which dealers must conform. The standard prescribed by the commission of the Medical Society of the County of New York, and of the medical commission of the Walker Gordon Milk Laboratory, and of similar commissions in other cities is that the acidity must not be higher than 3 per cent, that the milk must not contain more than 30,000 germs, or bacteria, of any kind per cubic centimetre, and that the butter (fat) must reach 3.5 per cent.

Out of twenty samples examined on a winter day, November 19th, the smallest number of germs found was 90,000, and the highest 2,280,000, while on June 29th, with the thermometer at 90°, out of twenty samples examined, the smallest number found was 240,000, and the highest 516,000,000 per cubic centimetre. The prevalence of bacteria, to a great extent, arises from the dirt of the milk. "There are seven conditions on which the amount of bacteria depends-the cleanliness of the barn, condition of the cow, condition of the milker, condition of the utensils, the cooling process, the transportation, and the cleaning of the milk bottles before. they are returned."

Aeration is not a success to-day as used by the ordinary farmer. In good hands it might work all right, but in many cases, as at present used, it results in an increase of germs. The three things which are absolutely necessary to secure milk comparatively free from germs are strict cleanliness, rapid and sufficient cooling, and thorough icing of the milk until it reaches the consumers. In the transportation of milk ordinary freight cars should not be used, and the ends of the cars should be kept closed, thus preventing the heated air from passing through the car and breeding the germs. The railroads could be asked to cooperate and furnish refrigerating cars in which the milk could be kept constantly on ice, and after being unloaded it