After careful weighing of adl these circumstances, we can consider the treatment. This is effective only because the most important and for thc present the only really valuable therapeutic aid, namely, the stimulus excited by the child in sucking, brings about the desired result. To accomplish this most effectively, if there is not a second child at our disposal, we put the infant to both breasts each time, arid perhaps let it nurse more often. If we do not obtain results after a trial of two or three weeks, we resort to inixed feeding, the "allaitenient mixte" of the French authors. This can be carried out in two ways (Budin). By the first plan, we ascertain the difference between the daily amount of breast-milk taken and the amount which should be taken. Then we may use bottle feedings of cow's milk, sterilized and properly diluted alternating with the breast, the amount given at a feeding being so adjusted that the total number of feedings will make up the deficiency. By the second plan we may- add to each breast-feeding the amount of nutriment which is lacking in the form of cow's milk. The first method has the drawback, that the childre» are not put to the breast often enough, and also that they soon prefer the easily sucked bottle, and either refuge the breast entirely, or else do not suck with the force neces sary to increase the secretion. For these reasons the second method is to be preferred, and by its use it not infrequently happens, that in the course of a few weeks the secretion of the maternal breast has been so muct increased, that the additional feeding can be steadily reduced in amount, and finally entirely abandoned.
There are numerous measures which have been recommended to increase the secretion of the mammary glands. Their very multiplicity gives rise to a doubt as to their value, a doubt which is confirmed by practical observation. I will only remark very briefly that neither from somatose, from Heyden's "nahrstoff," nor from laktagol have I seen any result, and I have employed faradization of the breasts without etTect. As to the treatment proposed by Bouchacourt (cited by Malian) consisting in the administration of sheep's placenta, for which a theo retical basis at least cannot be denied, I have had no personal experience. The giving of large amounts of milk to the mother is often resisted and is of no value. The various preparations of galega ofheinalis (Madan) and numerous other measures should, as Ilarfan says, be used only to meet the eagerness for therapeutic accomplishment on the part of the physician, and to attain results on the part of the mother by suggestion. In so far RS they are of a harmless nature they can be employed now and then. If the measures mentioned above do not in a relatively short time accomplish the desired result, one is compelled in order to meet the danger of loss of the power of swallowing, and fall of body- temperature, to put the child to a freely flowing breast, since under such conditions artificial feeding has few chances of success.
As to a hired wet-nurse with primary- hypogalaktie, such a nurse should not bc accepted. If a temporary diminution of the milk supply comes on as a result of change of diet, the appearance of menstruation, or similar causes, one simply waits quietly for the supply to increase again. If the diminution persists, another nurse is secured.
If we have to do with secondary hypogalaktie, our procedure is also variable, according to whether we arc dealing with the nursing mother or a hired nurse. In the former case, we first try mixed feeding. If this does not produce the desired result, or if the child is still young, under the fourth or fifth month, we will engage a 'wet-nurse; if it is olcier, one can wean it. Secondary hypogalaktie of a persistent nature in a wet-nurse with a young child calls for a change of nurse; in an older child, beyond the first six months, it calls for weaning.
C. From Unsuitability of a Special belonging to this category are relatively infrequent, although we have no right to deny their existence, since they have been frequently established iezerny-Keller). Obviously, it is an essential characteristic of this condition, that it should involve a child born at full term and thor oughly healthy, who is nourished at the breast of mother or wet-nurse in accordance with all the fundamental principles which we have desig nated as rational and who is neither overfed nor insufficiently nour ished. Under such conditions one sees at times that no regular thriving growth appears, in spite of the most careful observance of all the rules of nutrition, the administration of food being properly controlled by weighing, and the nurse being in perfect health. Instead, the children show restlessness, and dyspeptic bowel movements, of which the num ber is usually increased. The stools are of a varying appearance, usually green and slimy, more rarely pale yellow and harder, with a glistening oily appearance. The weight shows numerous fluctuations, with a pronounced tendency toward loss. Then, after we have reached a cer tain conviction that the feedings are neither too frequent nor too abun dant, we proceed with the investigation of the nurse's milk, whieh usually reveals nothing abnormal either in the shape and develop ment of the breasts and nipples, or in the macroscopic appearance of the secretion. This investigation does not always lead to a positive result, although we have at our disposal a number of reports, in which such a result was obtained, and treatment adapted to correspond with this result was effective. This failure to reach a definite result depends partly upon the fact that the technique of human milk examination is still largely incomplete, especially in respect to any proceeding which can be carried out in practice without great loss of time. Moreover the amounts of the various nutritive elements present fluc tuations of a rather wide extent, so that the analyzing of particular parts of a feeding is of no reliable value.