Today we’ll be diving into the breastfeeding recommendations in The Diseases of Children, by Dr Tuley, published in 1913. On the topic of infant feeding he makes clear his strong opinions in favor of maternal breastfeeding:
“I cannot refrain from saying a word against the unnatural mother who refuses to nurse her infant from purely selfish reasons, that she may have more time for society or pleasure. No physician should be a party to this or encourage it in any way, unless it can be plainly shown by most careful examination that the milk is unsuited and beyond remedial measures. The very fact that artificially fed infants show so much greater rate of mortality than the breast-fed infant, is sufficient reason for advocating breast feeding.”
Yet, then as now, breastfeeding is not always straightforward and is sometimes impossible due to issues with supply, anatomy, as well as maternal or infant health. Dr Tuley gives his suggestions on how to help women continue breastfeeding or resume breastfeeding if they’ve had to stop, as well as when it is time to consider the alternatives.
“No substitute has ever been found for normal mother’s milk for the nourishment of the infant. mother’s milk contains the food elements, fat, sugar, proteid, mineral water and salts, in the proportions best suited for its digestive capacity and nutrition.”
While they recognized the positive health benefits of breast milk for babies, they weren’t entirely sure what it was composed of, not even agreeing on whether it was acidic or alkaline, some arguing that it was amphoteric.
However, they were beginning to understand its macronutrient components,
“The usually accepted analysis of mother’s milk shows, fat 3.5%, sugar 6%, proteids 1.5%.”
He notes that there is a wide variation in the “proteid” and fat content of the milk based on the time of day, though the sugar content remains the same.
And they understood colostrum to be beneficial but not exactly why,
“The infant should be put to the breast as soon as the mother has had a rest from her labor, as the colostrum, present in the breast before labor, is essential for its purgative effect on the child.”
Newborns usually lose weight in the first few days after birth while the mother’s milk is established (more so today because mother and baby are often over-hydrated after being hooked to a constant saline drip through labor). Regardless, then as now, the weight loss is worrisome for parents and medical providers alike and Dr Tuley recommends supplemental feeding.
“Before the milk comes, in order to prevent a too rapid loss of weight, there should be given at regular intervals a 2% solution of sugar of milk, or even plain sterile water.”
In addition to the concerns over neonatal weight loss, after the birth but before the mother’s milk comes in newborns may experience a starvation temperature:
“The accompanying charts indicate the condition which is frequently seen during the first few days after birth, the second or third, as a rule, in which there is a rise in temperature, which subsides after the administration of an artificial feeding, or which will disappear as soon as the milk appears in the mother’s breast. It is a phenomenon too infrequently noticed, as the temperature of but few new-born babies is taken.”
While I was aware of the normal drop in weight in the few days between birth and milk coming in, I hadn’t heard of a starvation temperature before. I wonder if it is beneficial for a newborn to have a bit of a fever after birth as protection from infection. Paediatricians/nurses out there, please chime in if you know more about this! Dr Tuley recommends that if the fever isn’t accompanied by other symptoms that the baby should be given artificial feeding if the mother isn’t producing milk.
“Primipara should be instructed in the proper method of putting the child to the breast and holding it while nursing. During the puerperium, the mother lying partly on her side, the baby is put to the breast so it can readily grasp the nipple, which has been previously prepared, and one finger depresses the gland so that it will not press upon the nose and interfere with its breathing. The baby can either be supported upon the arm or lie flat upon the bed, the mother’s arm being raised.”
He goes on to warn about the importance of keeping the breast tissue away from the baby’s nose with an anecdote about a newborn who suffocated while breastfeeding. Please remember this is 106-year-old medical advice- an anecdote at that- we have no way to verify the claim. A baby can bury its nose in the breast while nursing and be just fine. They will unlatch and jerk their head back if their breathing becomes obstructed, rest assured they cannot continue nursing if they cannot breathe.
In the section on newborn care, he states,
“As a routine the mouth should be washed with boracic acid solution before and after each nursing, before nursing to protect the mother’s nipple, and after, to remove any particles of milk remaining in the folds of mucous membrane. The development of thrush or sprue is an evidence of carelessness and neglect.”
To wash the newborn’s mouth out, he recommends creating a swab using gauze soaked in the boracic acid solution and wrapped around the little finger, then gently and carefully swabbing the newborn’s mouth, being careful not to rub too hard because any abrasion could become infected. In addition, the mother’s nipple must be cleaned in the same manner, before and after each nursing.
Dr Tuley recommends a gradual introduction to breastfeeding after the birth to preserve the nipple,
“If nursed every two hours during the first three days the tugging and pulling on a flabby, empty breast results in an erosion or fissured nipple.”
Newborn Feeding Schedule:
- Day 1: every six hours
- Day 2: every four hours
- Day 3: every three hours
- Day 4 (or as soon as the milk comes in): every two hours
“After the milk comes, the nursing should be by schedule, every two hours during the day and every three hours at night: From 6 a.m. to 10 p.m. every two hours, and one or two nursings at night. Under no conditions should a baby be allowed to sleep with its mother; the danger of over-laying is great, as is the danger of the child nursing most of the night. This always results seriously to the child’s digestion.”
“The child should nurse from one breast at each nursing, alternately, and should be satisfied in from 10 to 15 minutes. If it must be nursed from both breasts each time, and is unsatisfied when the nursing is finished, the quantity is inadequate for its needs. By regularity being established early both the baby is trained to good habits, and the breasts to secrete at regular intervals.”
Dr Tuley believes that giving water to breastfed babies between nursings should be a rule, and strangely, that babies can tell time and read his book to know they only get 15 minutes for meals. Note: today, water is not recommended for babies under 6-months-old because it can screw up their electrolyte balance which is very dangerous for tiny babies.
Mother’s diet and activity
While Dr Tuley recommends that the nursing mother should stick to a light and easily digested diet for the first few days after giving birth, he has no particular limitations on her regular diet:
“A nursing mother should lead a perfectly normal, healthy life. Her diet should be generous and varied. There are practically no articles of diet which, if they agree with the mother, will cause the milk to disagree with the child.”
For a sample menu from Dr Tuley’s book check out my post on his Postpartum Menu.
As this is a textbook for medical students or a reference for practising doctors, it goes into a lot of scientific testing of breast milk to determine what might be going wrong with the breast milk itself when feeding problems arise. He discusses “supervision of breastfeeding” and what it could accomplish to ensure the continuation of breastfeeding. Effectively, this is a time when physicians took the role of a medically trained lactation consultant.
- The increase of a too-small supply.
- Changing the character of the milk
- decreasing the proteids
- increasing the fat
- decreasing the fat
- To make serviceable nipples out of flat and depressed ones.
- To supply an artificial or adjuvant food in case of a good but too small supply from the breast.
- To continue nursing should there be suppurating mastitis, and retain the integrity of the glad after a subsidence of the inflammation.
“A fissured or eroded nipple should not be nursed from directly, but protected by a nipple shield.”
And after each nursing session, the nipple should
“be painted with a solution of nitrate of silver, 20 grains to the ounce of water, care being taken to limit the application directly to the affected part.”
If you’ve had a baby with an umbilical granuloma, you may have seen your doctor use a silver nitrate stick (which looks like a big matchstick) to cauterize the stump.
Flat or inverted nipples
“There may be amply supply of good milk, but the absence of a serviceable nipple may prevent the child’s obtaining it.”
Dr Tuley recommends that doctors examine their patient’s nipples early in pregnancy so that they can give instructions for the massage and training of flat or inverted nipples to correct them.
“By massaging and training a very serviceable nipple can be made from an unpromising one if the treatment is begun early enough. The wearing of tight corsets or clothing should be advised against during pregnancy, but especially in the presence of flat or depressed nipples.”
Low supply of breast milk is evidenced by the baby not gaining weight or even losing weight, or if the baby is
“crying within a few minutes after leaving the breast and sucking vigorously on its fists after nursing.”
Dr Tuley recommends that the mother add more galactagogues to her diet,
“free drinking of milk, cocoa or chocolate, and the cereal gruels.”
The gruels can be of oatmeal, barley, or cornmeal and need to be cooked for several hours before serving with enough milk that they can be drunk or eaten with a spoon like a soup. He highly recommends the drinking of cow’s milk,
“No article of diet so stimulates the function of the gland as cow’s milk, and in connection with the cereals excellent results are seen.”
Unfortunately for the beer lovers out there, he strongly advises against it,
“as they encourage the secretion of a milk with a deficiency in its life-giving properties and an increase in the watery element.”
It was recognized that certain medications could be passed through breast milk,
“opium, belladonna, cascara, mercury, iodides, bromides and salicylates.”
Though he doesn’t think that it’s a reason to stop breastfeeding, to stop taking the drugs, or an efficient means of deploying these medications to the infant.
“The elimination of drugs in the milk is not sufficiently certain or exact to employ this method of medication in infants, nor enough to remove the child from the breast for, if any of these drugs were indicated in the mother.”
So, you can go ahead and chase the dragon and still breastfeed.
Colic has been reported since antiquity, in the west it has always been assumed to be associated with tummy troubles (there’s no evidence that true colic has anything to do with digestion).
In 1913, the new theory was that too much protein (or fancy proteids) in the breastmilk was the cause and maternal exercise was the treatment:
“A too high percentage of protieds is evidenced by colic, crying, with a doubling up of the legs, tense abdomen, green stools containing mucus and curds. This often occurs during the puerperium, but as soon as the mother gets up and is able to take the proper exercise, the increased proportion of proteids is generally decreased.”
In addition to getting exercise, Dr Tuley recommends that the foremilk be pumped and dumped and the baby fed only on the “middlemilk and strippings”. But this doesn’t make sense given the excess proteid theory, as the middlemilk and strippings, as he calls it, would have the greater percentage of protein.
And he recommends an old classic treatment for colic: barely water.
“Taking the child from the breast before it has finished nursing and giving it a small quantity of barely water, previously dextrinized, from a bottle, will often relieve the colic, lessen the diarrhea and make the curds smaller.”
Reasons to stop or supplement
“While, as a general rule, it may be stated the ideal food is a healthy breast milk, this is not always the case, for not infrequently a mother has an abundant supply but secretes a milk which is unsuited to the needs of her own baby.”
In his opinion, there are “but few contraindications to maternal nursing”. These include a severely inverted nipple, mothers with tuberculosis,
“malignant disease; diphtheria; rheumatism or chorea; acute contagious diseases and pneumonia; erysipelas; albuminuria; typhoid fever, as the typhoid bacillus is excreted in the breast milk; the acute exanthemata; pregnancy occurring during lactation; epilepsy or nephritis, or if the mother has suffered from puerperal hemorrhage, nephritis, eclampsia or infection.”
Throughout the section on infant feeding, Dr Tuley makes clear that it’s not all or nothing deal, and he recommends combined feeding when possible.
“If it is apparent that a child is not gaining rapidly while nursed exclusively, by giving one or two artificial feedings a day, of modified cow’s milk, very good results can frequently be obtained.”
For babies who are getting supplementary formula in addition to breast milk, the recommendation is for the night feedings, if any, to be breast milk for convenience sake (remember this is before microwaves, electric or gas stoves, electric kettles, and electric lights and refrigeration was an extreme luxury). But there’s one caveat:
“The only objection to this is the possibility of the mother falling asleep and allowing the child to lie with the nipple in its mouth for several hours at a time.”
Hiring a Wet Nurse
“In premature infants with no maternal milk supply, or where sudden weaning from any cause becomes imperative, a wet nurse should be obtained.”
Considerations for employment of a Wet Nurse:
- Her age
- The age and weight of her infant
- Her general health, development, and general surroundings
- Tuberculosis and syphilis positively excluded
- Breast milk examined
He recommends that the diet of the wet nurse must not be changed because, “lack of exercise may change the character of her milk entirely.” And to be honest, I have no idea what he meant by that. Would her diet influence her exercise? Let me know what you think.
While manual breast pumps and hand expression of breast milk were done at the time, it wasn’t exactly practical for regular feeding and it’s not as though they had a means to keep breast milk fresh. So when bottle feeding is discussed it is with formula (or water) in mind. Dr Tuley recommended that a breastfed baby be introduced to the bottle when a few weeks old, just one bottle feeding a day to accustom it to the bottle,
“to enable the mother to have a few extra hours of recreation, occasionally, if the demand arises.”
Big of him.
I’ll be getting into more of his recommendations for bottle feeding, including his favorite brands and how to properly clean, store, and prepare bottles in a future post.
What do you think about Dr Tuley’s breastfeeding recommendations? Do you have any family stories about feeding babies from this time period?
I was surprised by his rules for breastfeeding, insofar as making breastfeeding more difficult than it needs to be. Many of his suggestions are now known to make people less likely to keep up breastfeeding. For example, having to clean the nipple and the baby’s mouth before and after each feeding, his criticism that oral thrust is a sign of neglect, and the warnings about babies suffocating on breast tissue while nursing.
But there are some things that are still heard from medical professionals today, for example, his opposition to co-sleeping while nursing. Today creating a bed that is safe for a nursing baby is fairly straight forward but beds in Dr Tuley’s era would have been difficult or impossible to modify for newborn safety. Reading between the line: clearly, co-sleeping to facilitate breastfeeding was something that was done in his time or he wouldn’t have repeatedly warned against it.
I am curious about the idea that nursing too much at night negatively affects the baby’s digestion. It’s something I have seen in infant care manuals throughout history, in the Tudor era and in the early modern, but it doesn’t seem to be an issue outside of the western world at least where cosleeping for breastfeeding is commonplace. Yet, for older children and adults we know that eating too much too close to bedtime isn’t great for digestion or blood sugar, for example, reflux is more likely if you eat before bed. Do you cosleep for easy nightfeedings? Have you noticed poor sleep quality in your baby from digestion issues?
This was still an era in western history in which babies are expected to be at home and based on Dr Tuley’s writings, if the mother is a “good” mother she will be at home to breastfeed it every two hours, save those occasional few extra hours of recreation for which her baby will need to take a bottle because the baby is not expected to be involved in any kind recreation. And if baby is out of the home for an airing in the carriage with their mother, breastfeeding would require necessary preparation for a feeding (borax nipples) if they are following the rules.
I have no doubt in my mind that Dr Tuley was a generally good person who was passionate about saving babies from preventable deaths due to inappropriate or unsafe feeding. The infant mortality rates was a very serious public health issue at the time: in 1912 nearly 40,000 infants in the U.S. under two years of age died from diarrhoea and enteritis (and that’s a minimum as not all infant deaths made it into the records) caused by unclean or adulterated cow milk. For Dr Tuley, the thought of a mother who could breastfeed but chose not to was tantamount to the negligent homicide of their baby.
Yet, however strongly he advocated for maternal breastfeeding, he was also working to make the alternatives safer through the education of medical professionals on the handling of milk in the home and infant nutrition. In addition, he was a founding member of the Certified Milk Commission, which helped improve conditions of dairy products from cow nutrition to the milkman’s delivery and lobbied for regulations, such as pasteurization.
I am curious to know what he would think about his work making it safe for more “unnatural” mothers to choose not to breastfeed. Was his ire focused on infant mortality alone or was there animosity against mothers who had priorities beyond breastfeeding? Today, formula feeding is as safe and nutritious as breastfeeding, provided the product is used as directed and when water is required, that the water is safe for infants to consume– and we have folks like Dr Tuley to thank for that.
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