This rogime can also be carried out with breast-milk, which should always be tried to be tnaintained in the mother or otherwise procured, by evacuating the breast either by hand or pump. Any experienced physician knows that this procedure will endanger the oontinuance of lactation, but he also knows the means how to avoid that contingency.
Of course, there can be no question of a "substitute" for breast milk, neither here nor elsewhere. If there shoukl be absolutely no means of procuring breast-milk, the choice would be full or two-thirds pre rennetized cow's milk, mixed with 13 per cent. milk sugar; or butter-milk made after the Dutch method.
Latterly, fat-poor diet has been especially recommended. The theoretical investigations in this connection have not been able to influ ence the author, for TOL,ler's interesting findings, to which reference has already been made, also admit of different interpretations. But the favorable results of empirical procedure, obtained by well-known inves tigators (Czerny, Freund, Ibrahim, Finkelstein), may indeed justify attempts with fat-poor mixtures and et-en artificial fat reduction of breast-milk. Suela a "correction of nature" will not be considered pretentious or objected to in view of the peculiar requirements of the case.
Nutritive enemata of human milk appear worthy of commendation. Fuhrrnann administers GO Gms. eight to nine times daily per rectum, and more recently I have had partial success with retention enemata of human milk to which further reference will be made later.
(b) Phpical Treatment.—A causal therapeutic measure consists in irrigation of the stomach in so far as, with intelligent procedure, it will tend to relax the musculature of the stomach walls for a certain time.* The author has demonstrated by the process of gastro-diaphany that this purpose is really effected in the living child, although only in the portion situated before the pyloric part, but it would be idle to assume that the pyloric part should not participate in the relaxation, particularly as food ingested after irrigation is usually retained. It is admitted that the pyloric tumor may remain palpable after irrigation, but this by no means excludes the possibility that the relaxation has created a lumen of sufficient width and, besides, the tumor may be pal pated for a considerable time after a spontaneous "cure" has taken place.
Gastric irrigation has accredited itself very well with the majority of authors. No doubt it signifies a rather severe interference and may lead to conditions of relapse: there is also, espeeially in the hands of the le.ss experienced, the danger of aspirating gastric eontents in greater quantities than would be lost by vomiting. Is is presumably for these reasons that Heubner, who in 1SO't considered gastric las-age useful "under certain circumstances," has discarded the same. I practise it in grave cases about twice daily with Eseherich's bottle apparatus and cold water t12-lti° C.) using great care and precaution and avoiding
great pressure.
A further favorable effect is exerted by prolonged warm baths below the gastric region and hot compresses upon the gastric region, after feeding. The so-ealled Japanese pocket warmem wrapped in several layers: of flannel, are preferable for the latter purpose to the heavy and expensive t herrnophores.
It appears from recent experience that the retention enemata, recommended by Finkelstein, do excellent service. The irrigating vessel, which is provided with a stopcock, is filled with physiologic salt or carbonate solution, the temperature of which should be maintained.
It is connected with a thin rectal tube, through which 200 c.c. are daily introduced twice hourly, one drop falling every two seconds. These enemata counteract desiccation (or may also have a different effect?) and render hypoderinoelysis superfluous. Devices constructed on the principle of incubators, or similarly, are likewise to be commended.
(c) Medicinal Treatment plays an inferior role. If there is hyper acidity, a 5 per cent. mixture of magnesia carbonate and lime water is administered after feeding. Among the drugs which have a relaxing effect upon the intestinal tract, opium in to 1 drop doses of the tinc ture, and atropine in decimilligrams, may be considered. In foreign countries, citrates are greatly praised, a 2 per cent. aqueous solution of citrate of soda being given in spoonful closes before feeding.
The most important factor in the treatment of this affection con sists in good nursing. There is hardly another affection which makes such high demands upon the art of skilful nursing, and it is for this reason that treatment in an institution will be preferable in many cases.
2. Surgical Treatment.—The following methods have so far been principally suggested: (a) Gastroenterostomy: Ibrahin) has compiled (1907) reports on f orty nine eases, twenty-nine of which resulted fatally. This means a mortality of 59.2 per cent. of the eases that have been published.
(b) Pylorus dilatation or divulsion after Loreta: There are reports on forty-four cases with twenty--nine fatal results, being a mortality of 54.5 per cent. of the published eases.
(c) Pyloroplastic: There are reports on twenty-one cases with twelve fatal results, or a mortality of 57.1 per cent. of the published cases.
These methods are also employed in a modified form, or cleverly combined, but up to the present there are no figures available to admit of a calculation of the mortality. From a statistical point of view the resulta of the methods described under a, b, and c are equally bad. In any case, however, the fact remains that up to the present time sixty one infants have survived the operation for weeks and months, and that the observations made during and after operation have increased the knowledge of the pathology of this affection in various directions.