The early failure of breast feeding; a clinical study of its causes and their prevention.

In the last fifty years, which have seen so much achieved in the protection of infant life, little has been added to our understanding of the unreliability of lactation; yet the key to this riddle would remove what is still the greatest risk surrounding the first weeks of life. In the attempt, which will be described here, to find part of the solution, lactation's common tendency to fail will be treated as a defect of the mammary gland and not, as is more usual, as arising primarily from faults in the conduct of breast feeding. This approach in no sense overlooks the importance of correct management but is adopted with the object of trying to define with greater clearness certain factors governing the maintenance of milk secretion. To separate physiological factors from the details of practical management may seem artificial, and it is not intended that the distinction should be rigidly binding. If the instruction given to women is to be helpful and, above all, if the teaching given to pupil midwives is to be of service to their patients, they should rest upon a sound physiological basis and find their confirmation in practice. It is doubtful if even the hardiest supporter of present-day teaching could advance this claim for its results. As a broad generalization it may be said that women's experience of breast feeding is of two main kinds. In one there is from the outset no break in the continuity of a free and plentiful yield of milk. In the other the yield, though it may be plentiful enough at the start, declines or ceases completely within a few weeks: it may be even within a few days. This difference over-rides all others based on circumstances or social standing, and transcends in importance all the range of variation in human temperament and character which is so apt to occupy discussions on the prevalence of artificial feeding. There can be no doubt many women resume domestic work too early after delivery and need a longer convalescence; are over-burdened with family cares; are unskilled in infant management. Some are incapable of the discipline necessary to succeed in breast feeding and a few are frankly unwilling. Let it be granted also that failures arise from the lack of interest shown by doctors, from mistakes made by maternity nurses and health visitors; and, as is frequently emphasized, from the rigidity and bustle of hospital routine. To all these causes, at one time or another, I have attached a major importance. But after a closer study of the ways in which lactation starts it seems necessary to place above and apart from them all the breast's productive power and the ease with which milk flows into the baby's mouth. If these two conditions are present in full measure women will, as a rule, be found in the group who succeed; and they will succeed without skilled assistance and quite often with a cheerful disregard of the rules framed so carefully for their guidance. In the presence of factors which lower production or interfere with the free passage of milk from breast to baby, women commonly find the task more than they can accomplish. Although I believe this rough classification is substantially correct, I would repeat it is put forward mainly to focus attention on the functional properties of the breast.