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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

BIBLIOGRAPHY

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

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

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

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

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

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