Sudden weaning is not advisable unless, while the breast is being presented, there is an absolute refusal to take artificial food from either a bottle or a spoon. This is most apt to occur when food has been given too frequently, and when the breast has been used as a means to quiet crying. The plan is also to be recommended when the mother's health becomes so affected as to render any further suckling a positive peril to the child's life; attacks of erysipelas or of small-pox are instances in point.

The physician is often forced to decide upon the advisability of premature weaning. His decision must be made cautiously and after thorough investigation of two propositions, namely: a, the effect of further lactation upon the health of the mother, and b, the requirements of the child.

a. Lactation being a physiological process is not a drain upon the systemic strength so long as the functions of nutrition are actively performed, but under other circumstances it very frequently becomes so. A mother must make no attempt to nurse if she has tuberculosis, advanced cardiac or active kidney disease, hysteria, epilepsy, marked anaemia, cancer, goiter, oris septic or convulsed after child-birth. Premature weaning is necessary when the mother is attacked by a contagious disease or by any acute disease threatening dangerous temporary prostration, such as typhoid fever. Ordinarily, however, the general condition that leads to withdrawal of the breast is one of simple loss of strength and flesh on the part of the mother. Undoubtedly these indications often warrant the procedure, but every one who has seen much of children's practice must have met with many cases in which the advice to wean has been given carelessly and unnecessarily, and in which the child might have had its natural food had proper attention been given to the health of the mother.

If a woman be worn out by household cares; if she wear herself out by a round of dinners, balls or shopping, or if she expose herself to injurious atmospheric conditions and eat improper food, she grows weak and thin whether she be nursing or not; and a woman heedless of her health will probably care little whether she suckles her child or gives it up to a wet-nurse or to the bottle.

In addition to making nursing the important duty of her life for the time being, a mother must be as free from household cares as possible. Mental and physical fatigue must be avoided, sufficient exercise must be taken to maintain a healthy appetite and digestion, abundant time devoted to rest and sleep, and regular evacuations of the bowels secured. As to diet, the nursing mother requires a plentiful supply of fluids and of plain and easily digestible food, with a judicious portion of meat, vegetables, and fruit. She should eat three regular meals daily, with a cup of milk, cocoa or gruel at early bed-time, and in some cases between meals. She may be allowed eggs, plainly cooked; cereals and nearly all soups and vegetables; sweet fruits, and meat, usually once and never more than twice a day; but must avoid acid fruits, salads, pastry and rich desserts; tea and coffee, except in extreme moderation, and wine or beer absolutely.

Should the secretion of milk be scanty, it may often be increased by the free use of animal broths, chocolate, gruel, or milk, and sometimes the employment of a good malt extract may be necessary. Such tonics as ferrated elixir of cinchona, bitter wine of iron, and the preparation known as "beef, wine and iron," are useful when there is anaemia, or when the general failure of strength cannot be overcome by food and attention to hygienic rules.

The ordinary local conditions indicating the necessity of premature weaning, on the mother's account, are fissures of the nipple, and mammary abscess.

Fissure being usually a unilateral condition, it is only necessary to retire the affected side from duty and nourish the child alternately from the unaffected gland and from the bottle until healing takes place, the disabled breast being pumped or massaged in the meantime to keep up secretory activity. Should both sides be affected, weaning may be imperative, on account of the extreme pain produced by sucking, although, even under these circumstances, an effort must be made to maintain the flow of milk by regular pumping. Sometimes women are able to struggle through the attack by taking advantage of the relief and protection afforded by a nipple-shield.

Fissures of the nipple may be preceded by various diseases of the delicate skin of the part. They result, also, from want of cleanliness or from keeping the nipple too moist, and when constant sucking is allowed or when there is a continual flow of milk. They may be prevented by proper attention to the nipple before confinement. During the latter months of pregnancy the clothing covering the breast must be loose, and the wearing of a wire tea-strainer over the nipple to prevent pressure has been recommended by one authority. Each day, for three months before labor, the nipples should be washed thoroughly with hot water in the evening and anointed with cocoa-butter in the morning. At the same time, should the nipples be small or retracted, the woman must be taught to use her thumb and finger to draw them out. This process is not only an advantage in giving proper size and shape, but brings the skin into good condition without hardening it. The application of alcoholic and astringent lotions is not to be recommended. They tend to harden the tissue, which should be soft and pliable rather than tanned, and render the nipples liable to crack.

When a fissure exists, it is best first to see whether or not nursing can be continued by means of a nipple-shield. Should the child refuse this, a good plan is to fill the shield with warm milk and invert it over the nipple. The infant then draws the fluid at once and without difficulty, and will often continue sucking until the breast milk follows. After nursing and removing the shield, the nipple must be dried thoroughly with absorbent cotton, and the following lotion applied with a camel's-hair brush:

Take of-

Boracic acid.............

Mucilage of acacia......

20 grains. 1 fiuidounce. Mix.

Mammary abscess requires careful surgical attention.

b. On the part of the infant, there are several indications for anticipating the time of withdrawing the mother's breast, but this is always a serious matter and must never be advised without most careful consideration.

The occurrence of pregnancy during lactation necessitates immediate weaning, but this is by no means the case with the re-establishment of menstruation. Usually the function of the breasts stops on the return of the monthly flow, and sometimes, while secretion continues, the milk is so altered in quality as to be unfit for food; but, at others, though the quantity may be diminished, the quality is unchanged and the infant keeps well and gains steadily between the periods. Under these conditions the baby should be kept at the breast, though it may be advisable, during the first day or two of menstruation, to feed partially or entirely from a bottle. Premature weaning is also necessary if the mother contracts a dangerous contagious disease, as small-pox, scarlet fever, or erysipelas; if the mammary glands become inflamed; if the breast does not afford sufficient nourishment and artificial food be refused; and, finally, if dentition be markedly delayed and the premonitory symptoms of rickets appear. As to the amount of nourishment, it must be remembered that the breast milk may be of good quality, but so diminished in quantity that it is insufficient; or, while abundant in quantity, so poor in quality that it does not meet the demands of nutrition. Even without a minute examination of the milk, it is possible to form a good idea of which condition is present from the behavior of the infant in the act of sucking. If the milk be good in quality but deficient in quantity, the baby, when put to the breast, seizes the nipple as if famished and draws upon it vigorously for a time, and then drops it with a scream of rage. On the contrary, should there be an abundant supply of poor milk, the nipple is grasped languidly, the child lies a long time at the breast and falls asleep there. Consideration of the final indication 11 opens the question of the propriety of regulating weaning by the progress of dentition. This is certainly a good guide, but not in the way implied in the old precept, that the child must not be taken from the breast until evolution of the stomach and eye teeth. Insufficient food is one of the chief causes of rickets, and rickets more than any other disease delays dentition; consequently, should the teeth not pierce the gum in time, the inference is for other food rather than a continuance of the faulty maternal supply. In this connection one must remember what has already been stated in regard to "mixed feeding," and if the breast secretes only enough milk of good quality to serve for two or three daily feedings, even so little must be carefully conserved during the earlier months of life and the deficiency made up by a properly modified cow's milk mixture administered from a bottle. When the mother's milk so disagrees as to warrant withdrawal of the breast, the baby does not thrive, ceases to gain weight or loses steadily, and presents the evidences of disordered digestion. It may vomit or eructate, though the symptoms being, as a rule, intestinal rather than gastric, there are, usually, discomfort, constant crying, poor and restless sleep, distention of the abdomen, colic, frequent expulsion of flatus from the bowel, sometimes constipation but usually diarrhoea, with loose green evacuations containing mucus and passed with much gas.

Habitual vomiting does not necessarily indicate weaning. In such cases an effort must be made to overcome the trouble before resorting to extreme measures. If vomiting occurs soon after nursing, it may simply mean that the infant has taken too much food, therefore, shorten the time of lying at the breast, give one breast only, and interrupt the sucking by short periods of rest, thus preventing too rapid feeding. Vomiting taking place sometime after nursing and repeated, is often due to the milk being too rich in fat, and may be overcome by increasing the intervals between nursings, or by giving, from a feeding bottle, immediately before each meal one or two tablespoonfuls of pure boiled water, lime-water and water, or barley-water. When there is constant colic the milk is too rich in proteids, and the mother should take more exercise in the fresh air, eat less meat, avoid worry and control her emotions. The element of constipation associated with colic can be but little influenced through the mother's milk.

Where all expedients fail and one is reasonably sure that the only proper course is to anticipate the time of weaning, the next point to consider is whether the infant shall be brought up by hand or by a wet-nurse.