In a similar way local processes in the mouth of an inflannna tory nature can be injurious, since on the one hand they render the act of swallowing difficult and painful, and on the other hand they give rise to an extension of the process to the mucous membrane of the lower alimentary canal. I mention particularly in this connection catarrhal and aphthous stomatitis, both of which processes require especial atten tion in early life and must be carefully treated, to avoid these results, Tongue-tie is frequently blamed as an obstacle to sucking, and the cutting of the shortened frenum is still performed by many phy sicians. It has no influence on sucking, inasmuch as we know from investigations on the physiology of the sucking movements, that the muscles of the floor of the mouth, the lips, the cheeks, and the soft palate play the dominant part, while the tongue remains quiet and serves as a conduit for the passage of the milk, a function which cannot be interfered with by a short frenum. The desire that the frenum be cut should be energetically combated, because such a measure can be followed by bad results.
On the other hand, sublingual tumors of notable size and rapid growth can form a real obstacle to the acts of sucking and swallowing, and therefore such conditions must be relieved by operation.
Also facial paralyses, which not infrequently develop as EL result of difficult labor, especially when forceps have been used, are an obstruction to sucking worthy of attention and compel us to carry out the nutrition of such children in the early weeks by artificial meas ures. Fortunately this paralysis is usually transitory, and by energetic treatment with electricity we can soon bring about the appearance of normal sucking power.
Narrowing of the nasal cavity is caused or favored by a peculiar anatomic arrangement of the arch of the palate, which is of high and narrow structure. With the occurrence of catarrhal swelling of the mucous membrane such a narrowing can lead to complete obstruction of the passage, and often constitute an obstacle to nutrition which is severe and highly descry ing of attention. The child during nursing is unable to breathe on account of the nasal obstruction, and constantly lets go of the nipple. Filially, tired by the exhausting effort, he re fuses the breast altogether, and consequently takes an entirely insuffi cient amount of food. Sueh a condition requires local treatment, such as cleansing with a lukewarm boric acid solution, cauterization of the mucous membrane with a I per cent. or 5 per cent. silver nitrate solu tion, or perhaps even the introduetion of drainage tubes while nursing. In syphilitic infants applications are made of tampons with blue ointment or yellow precipitate ointment. Besides these measures, the breast can be administered indirectly by means of a sucking appa ratus, such as those proposed by Bouchut, Aurard, and others. They are of such construction that the nurse by sucking through a tube aspirates the milk from the breast into a glass vessel pressed about the nipple, while the child drinks from the vessel through a second tube. These implements are hard to keep clean, and in spite of all precau tions such as cotton plugs the aspirated milk is very easily contami nated by the saliva of the nurse. This leads to disturbances of diges tion in the child which soon counterbalance the advantages of more abundant food. It therefore appears preferable in such cases to express the nurse's milk and give it from the bottle or with the spoon. The natural method of sucking should be restored as quickly as possible by energetic treatment of the nose.
E. From Bacterial Contamination of the forms, which as we shall see have been long recognized, and play an exceedingly important part in artificially fed infants, are found relatively infre quently in exclusively breast-fed infants. Positive diagnosis is based
upon the fact that the child gets nothing but human milk to drink and upon the demonstration of the exciters of the infection in the food, and in the stools. Human milk is not easily subjected to bacterial contamination, on account of its method of production by the mother and of abstraction by the child. It is very possible that (luring the prog ress of certain general infections, such as puerperal processes, severe pneumonia, and similar affeetions, their exciting agents are excreted through the mammary glands, although usually such diseases so affect the general condition of the mother that she quickly loses the power of nursing her infant. On the other ha»d, local processes in the breast, especially infections of the glandular substance resulting from fissures of the nipple and leading to abscess-formation can contaminate the milk, and it is a question whether infectious diseases of nutrition cannot arise in this way.
Damourette, who has done thorough work on this subject, is in clined to assign to this fact of milk contamination an importance which in my opinion is rather excessive. He cites in his monograph a large number of instances, in which digestive disturbances varying from a mild to the most severe and even fatal character appeared after the taking of such "pus-milk." But a closer analysis of his cases shows that they did not conform to the postulates mentioned at the outset as requisite, in that neither the condition of exclusive breast-feeding, nor of avoidance of overfeeding, nor finally of the demonstration of the exciting organisms in the breast-milk and movements, were fulfilled. Epstein frequently had the opportunity of observing infants w-ho for days and weeks were swallowing pus from suppurative processes in their mouths, particularly abscesses of the salivary glands. He was never able to establish the fact of any influence from this cause upon nutrition, although such cases are not signifieant in this class of dis eases because the infectious ntaterial came from the child's own body, and therefore there can be a eertain auto-immunization against it. On the other hand, Moro has described a streptococcus enteritis ob .served by hint in a number of infants exclusively nourished at the breast of a thoroughly healthy nurse, in a rational way. These cases fulfil all requirements and are a proof that diseases of nutrition can occur in this way. Through a number of researches which have been col lected in the above-mentioned brochure of Damourette, we have learned that the fact of the sterility of normal human milk is only true with certain limitations, since the portion that first flows out of the mammary gland show-s a variable bacterial content. These organisms are mainly the staphylococcus aureus and albus, less often the strep tococcus, the bacillus coli eommunis and others. They probably gain entrance from the surrounding skin by w-ay of the collecting ducts of the nipple. In view of the fact that they have no pathogenicity toward animals, and produce no lesions in the mammary tissue, no significance has been attributed to them, and it has been assumed that the protect ing power of the digestive tissue of the infant is sufficient to render them harmless. Moro, pursuing these investigations still further has shown that if cultures are made from sufficient quantities of milk, pus organisms, particularly the staphylococcus pyogenes albus, can always be demonstrated in the portions of the milk pressed ottt of the emptied breast after careful cleansing of the nipple. Less often he found the aureus and the bacillus acidophilus; occasionally also mycelium and sarcince.