Such insufficiently nourished infants are usually not very rest less, nor clo they pass the time between feedings in crying, but they sleep a great deal on account of their lower vitality-, and must be waked up to nurse. They also feel cool, and in this respect, as Budin point edly remarks, remind one of premature babies. The same author has also made the important observation, that with a longer duration of this condition an inability to swallow comes on, so that nutrition even by means of a spoon is not successful, and must be effected by tube feeding (gavage).
If the under nutrition is of a slight grade, with constant though slight gain in weight, ale stools showing a milk residue, and the passage of urine occurring several times a clay, then we can simply wait with out hesitation, since experience teaches that such conditions improve with time, because the sucking stimulus constantly exercised byt the child causes finally a more abundant secretion of the breast-glands of the mother. Such a result is still more quickly brought about, when a strong and vigorously- sucking child is put to the breast of a mother with insufficient milk, a procedure which does very well in hospitals, but in private practice can usually- not be carried out. One can seek a similar measure of help by trying several times a (lay partially to empty the breast by manual expression or by the use of a breast-pump, but these manipulations have but little value.
The causes of this primary "hypogalaktie" are not wholly clear, though indeed in very rare cases it may be traced to an under develop ment of the breast-glands resulting from a possible hereditary or racial influence. Besides this primary "hypogalaktie ", which in its mildest form presents itself as a belated appearance and slow establishment of lacta tion, there is a secondary- form, which can conte on at various times in the course of a lactation hitherto favorable. It is often in a certain sense a physiologic process, in that glands which have for a long time functioned properly, simply cease to secrete, which gives a natural appearance to the failure of lactation. This finds its clinical expres sion in the child, in a stand-still in weight, and beginning constipa tion; and in the mother by the breasts becoming emptier and cooler. To be differently interpreted are those cases in which a failure of secre tion occurs after a relatively short duration of activity, without any excessive demands (as perhaps too frequent nursing), having been made upon the breast. Such a condition is shown by weighing the
infant before and after nursing, and thus finding the amount of milk (trunk insufficient. It is often temporarily observed during menstrua tion, when we must simply wait to see whether or not it persists. It eah become persistent through the supervention of pregnancy. In wet nurses, the long journey to the place of their engagement and the changed conditions of life in their new sphere of activity frequently bring about a similar temporary diminution in their milk; but this usually lasts but a short time. On the other hand, nursing mothers of the upper classes who are often of inferior physical strength, fre quently show at first a sufficient or abundant supply of milk, and later a relatively early diminution and premature disappearance. Neverthe less, the influences of diet, and of psychical affections, whether sudden or lasting in their action, have been much exaggerated. The former, if it, does not directly affect the health of the nurse and produce disturb ances of the appetite and digestion, is without any importance. Psy chical factors might affect the quality of the milk (although this also is not extensively proven), but they are without effect on the quantity.
The next question is, What mode of treatment should be adopted when the breast-milk is undoubtedly insufficient? Onc.e more it must be emphasized that in the first place the existence of this condition must be indubitably established. Other processes leading to caclaexia must be excluded, such as tuberculosis, syphilis, chronic diseases of nutri tion which usually' cause diarrhma and not constipation, malformation of the anus, rectum, or other parts of the intestine interfering with the expulsion of the feces, and affections of the nose or mouth causing difficulty in sucking. It is further to be noted that the thorough under standing of this particular condition requires a rather long observation of mother and child, at least Iff to 14 clays, and that it, must not be forgotten that early deficiency, especially in primiparre, frequently improves spontaneously, and consequently a retarded lactation should not make the physician impatient.