from J. O. in that his are not religious in character. He imagines every now and then that some other patient, usually a quiet, inoffensive one, "has it in for him," as he expresses it. He will interpret a whisper or gesture that has no relation to him as inimical and plead to be removed to another hall; otherwise he is bright, active and seemingly sane. He, as well as J. O., is probably in a transitional stage, and later will develop egotistical delusions. Even now, the attendants tell me, he is inclined to be conceited and feels that he is superior to other patients. The next case is C. F. Nothing is known of his history; was a tramp picked up in Fayette County, and brought here. He says General Grant appointed him Commander-in-Chief of the U. S. Army and Navy. I show this case because his delusions of persecution depend on an hallucination, i. e., he says his enemies are trying to keep him out of his office, and have been try ing to poison him, and he thinks this because he imag ines he tastes the poison in his food, an hallucination of the sense of taste. So much for paranoia. tell you what he owns; he says, "The world," etc. You notice how he drawls his words, hesitates in speech, the excessive motility of facial muscles, the tremors. Now while he walks please observe the ataxic gait-how his feet are kept apart to widen the base of his support. I test his eyes and they do not respond to light or accommodation; his patellar reflex you see is abolished. The next case is A. A., aged 34, occupation merchant, no heridity during eighteen months, syphilitic and intemperate. He is also in the second stage. His delusions are not quite so extravagant and his memory much better than the preceding case, but on asking him to talk he tells you what a scholar he is, reads, speaks and writes all languages. You notice, as in our preceding case, the well-marked physical symptoms, namely: difficulty of articulation, prolonging his words, tremors, ataxia, and loss of patellar reflex. His face presents a soggy appearance, and this is often present in these cases. When he came here he said, "he would pave the streets with gold," etc., but after being here several mouths he had a reNow a few words about paresis before I show you mission and all mental symptoms disappeared, and here some interesting cases. The word paresis has several let me say, in these cases remissions are often seen for synonyms, namely: general paralysis of the insane, a few months or even years. Their friends often beparetic dementia, dementia paralytica, and in popular gin to think they have recovered, but it is a false hope. language "softening of the brain," although this is a The physical symptoms though not so pronounced misnomer, because while it is true the consistency of the brain is less firm, there is never a true necrotic soft through the remissions, usually linger to some extent, ening. Paresis is a structural disease of the brain, as is shown by the tremors, gait and speech. briefly, it is a degeneration of the cortex and a low- The next case is C. W., ex-member of legislature, grade inflammation of cortex and membranes. It is a abstractor, a wealthy and prominent man, who has been disease displaying slowly increasing mental impair-very intelligent and highly educated, aged 40, duration ment, disorders of muscular movement, disturbances of three years, no heredity, syphilitic, intemperate, and in higher reflex action, physical and mental decay. the second stage. He shows a general mental weaken The principal causes are syphilis (three out of every ing and is more emotional than the preceding cases. four cases we receive having syphilitic histories), intem. He has had delusions of grandeur, but has not now. You perance, excessive venery, indirect physical and emo. notice the physical symptoms are not marked. When tional causes, and trauma. In other forms of insanity he speaks, however, you see excessive movement of the we find ordinarily mental symptoms only, but in paresis lips. This case is slower in progress than the others, and he is much more destructive. You know the averwe have both physical and mental well marked. The principal mental symptoms are delusions of age duration of life—for this is a fatal disease—is only grandeur (although they are sometimes depressive, or three years. They are usually not committed to us unthe two may alternate), change of character, loss of til they have been paretics for some time. The average memory and impairment of volition. The emotions are duration of hospital life is only twelve or eighteen usually exalted, but they too may be depressed. The most prominent physical symptoms are inequality of pupils, difficulties in articulation, inco-ordination, muscular tremors, epileptiform and apoplectiform convulsions, and finally, paresis. The first case I show you is R. R., aged 33, occupation brakeman, duration eighteen months, syphilitic, intemperate, Keely graduate, no heredity. These cases usually do not show hereditary histories. They have in most cases well developed heads and brains. There are three stages of paresis: First or prodromatic; second or stage of expansive or depressive delusions accom panied by well marked physical symptoms; third or stage of dementia. months. The next case is L. C., merchant, aged 43, no heredity, duration two years. He is not syphilitic or intemperate, a man of good morals; so we must look elsewhere for a good cause, and here we have it. You remember I mentioned trauma as one cause; well, here is linear depression on this man's forehead, caused by a blow which preceded this attack. When I came here, less than three years ago, they had but one case of paresis and it also developed from a traumatic cause. Since then we have admitted twenty-two cases, so it seems to be de cidedly on the increase in our territory. This case of L. C., I show you to illustrate a case passing from the second into the third stage. This man This man is in the second stage. I will ask him to thought he had millions only a few weeks ago. His talk now is incoherent and he is rapidly passing into abled, there to administer to definite wants or to delib dementia. erately correct deficiencies, where formerly hardly any This case well illustrates the necessity of an early derangement would have been suspected. Physiologic diagnosis, not only because remedial or surgical meas- or rather biologic reasoning, pivoting on an abundant ures might be more successful, but so you can warn and thoroughly worked-up material of chemic analyses their friends of possible line of conduct such cases may prepared the way for a rational supervision and correc pursue. This man, before his condition was known to tion of infantile nutrition. the public, feeling so wealthy, burned notes and money, gave too much change in return and other unbusiness like methods until he became bankrupt. As a result numberless lives have been saved, which owing to accidental and casual trifles would otherwise have had no chance of asserting their claim on life by successfully struggling for it. It is this very point that I would like to emphasize, in an age, which only too much looks for laurels and triumphs by carefully preserving and fondly nursing waste and refuse. Not in the everyday sense of the word the work done in this direction has been a benefit to mankind; there is none of that common, sickly, weakly humanity and philanthropy about it, but it really tends to advance the standard of the human race as an adjuvant to the natural and and normal course of selection. The next case is L. K., aged 32, butcher, duration two years, syphilitic, intemperate, no heredity and a Keely graduate. We have about five cases of paresis who have taken some one of these "whisky cures" and the "cure" is often blamed by their relatives for causing the insanity, but I believe the soil has already been pre pared by the syphilis, by the years of intemperance and excessive venery, and that they would have developed paresis anyway. Again, if it is due to the "cure" why is it the other forms of insanity do not develop? Why should my cases who have taken the "whisky cure" Still, however deep science may have delved into the each give a history of syphilis and intemperance; the intricacies and complications of infantile metabolism, a very causes of most cases of paresis, if the "cure" is the great deal as may be supposed, remains to be done. The causative factor? I give this only as my own limited immensely high importance of these questions (growing experience; other observers may have had a different the more important, the more unnatural and complex our so-called civilized and cultured life is tending to be) is generally conceded. So I may hope that a small contribution to this field will be kindly received. one. This patient has an exaggerated patellar reflex, quite opposite to the others, this being due to the involvement of the inhibitory fibers which pass from the cortex to the anterior columns of the chord. He also has contractures and ankle-clonus, so that the lateral columns are also involved, and that reminds me, I had a very in teresting case of ascending or spinal paresis to show you, also a case in prodromatic stage, but both were re moved on furlough a few days ago. I thank you gentlemen for your attention, and Prof. Brower, I feel both grateful for and honored by your presence. By the term, "Infantile Dysauxesis," I propose to designate a complex of symptoms or better an often met-with condition in nursing, breast fed infants, for which a comprehensive name hitherto was missing. Being fully aware of the odium that clings to the creating new termini technici I looked around for some terminus already in use that would square the condition in question, the latter being in short, what everyday language expresses by saying: "The baby does not thrive." A great number of different symptoms occur under this head, and in the majority of cases medical science has been able to trace them back to the etiologic factor (the About a Hitherto Unrecognized Cause of different forms of diarrhea, intestinal tuberculosis, fat Infantile Dysauxesis. BY C. FISCH, M.D., ST. LOUIS. starvation, etc.). But everywhere and always a number of cases are left behind, where a healthy, strong baby, in spite of the seemingly most favorable conditions begins to cease gaining in weight and to show general signs of ill health, a state, which by and by only too often settles down into However great the attainments of modern medicine in diagnosing and treating the ailments of early infancy may be, still every now and then even the experienced a marasmus like condition. It is the rule in these cases, observer will meet with a case which as to its etiologic that no very definite symptoms appear; great restlessand diagnostic features remains shrouded in mystery, ness and irritability are almost always present, the apand where, in consequence, his treatment, like any treat petite is only sometimes impaired, the babies nurse regment lacking a rational basis, will most likely prove en-ularly and even the intestinal tract seems to be little tirely futile and useless. It is particularly the large affected, though more or less pronounced diarrhea (of group of digestive and assimilatory troubles that I am the nervous type) may be occasionally observed. Slight here alluding to, and towards the elucidation of which elevations of temperature occur, but may be entirely the efforts of American and German writers have been absent; anemia sets in to a moderate degree, but usually directed during the last decade. Better than ever be no flabbiness of the skin, nor pinching of the face are fore we understand the intentions of Nature, to put it seen. The most painstaking physical examination, a in the anthropomorphous old fashion, thus being en- close scrutinizing research of the surroundings, investi only accidentally present or really inhabit the gland-tis. sue seems by the researches of Bumm, Cohn, and Neumann to be decided in favor of the latter alternative. Pyogenic bacteria, too, have been repeatedly found, mostly staphylococcus pyogenes albus. Some cases are on record, where staphylococcus pyogenes aureus and even streptococcus pyogenes were present. gation into the mother's milk according to the hitherto ing, that here perhaps is a fruitful field for research. used clinical methods, examination of the blood of The much mooted question, whether these bacteria are mother and child (here too it has become the last refuge to talk about malarial infection!) etc., all of these means of diagnosis usually fail; so does of course our treat ment. The number of cases showing these general ap pearances is by no means a small one; to group them under the head of malnutrition or dyscrasia, etc., would encroach on the definite meaning of these terms; so I venture to introduce my word "dysauxesis" as covering all features of the condition mentioned and conveying only a general idea, not that of a specific and well-defined symptom-complex. It is not an uncommon observation to see cases like these improve rapidly on weaning and substituting rational artificial feeding, a measure resorted to whereever the condition of the mother seems to give the slightest indication, though on examination her milk may prove not to deviate considerably from the average. But unfortunately very often there is nothing in the appearance and general health of the mother calling for this step, and the physician is rather inclined to search for an explanation in the very opposite direction. Nevertheless I have, until now, in seven cases been able by an examination of the resp. breast-milk to clear up the etiology of such a dysauxesis, and from the reports of the physicians, under whose care these cases have been, I learned that by adopting appropriate means the little patients have been restored to perfect health. To be sure, these examinations were conducted on a principle differing a little from the one usually followed, inasmuch as the microscope came in for a good share of the work to be done. By some strange misconception the idea prevailed that the microscopic characters of milk were so uniform, as not to yield any valuable hints as to its nutritive value. Rotch even goes so far, as to intimate that microscopic examinations of milk may prove to be misleading. Unfortunately, when looking up the resp. literature we find that it is not accompanied by clinical notes, while other investigations were made in pronounced cases of acute and infective diseases, which by their very nature fall outside the limits of our present topic. But, as a matter of fact, in the breasts of even perfectly healthy women there is not very seldom during lactation for a longer or shorter period or at intervals going on a suppurative exudation caused by the action of the just named micro organisms, which, since no external signs betray its presence, usually is entirely overlooked. Right here I want to lay stress upon the fact, that this condition has nothing to do with puerperal complications, nor with the conditions known as mastitis, abscess, etc., being strictly localized and limited to so small an area as not to reflect on the general health or to produce any changes in the external appearance of the organ. The cases, that I examined, were all of them strong, vigorous women, by which remark I would like to insinuate, that in individuals of minor resistance more general affections might arise as sequelæ. As a matter of course the presence of small suppurative foci in my cases could only be inferred from the presence of a considerable number of pus cells and micrococci in the milk; cultures of these cocci, made with observation of all necessary cantelæ, in all of them re sulted in a luxuriant growth of the aureus, which in none of the other milk-specimens (more than fifty) was found. Only in one case the place of the staphylococcus pyogenes aureus was taken by the Fraenkel-Weichelbaum diplococcus. Indirectly the prominence of these bodies (pus-cor. puscles and cocci) from the gland itself, though, in the absence of any and whatsoever signs of pyemic Infec tion, hardly another place of origin could be thought of, became confirmed to me through the good luck of being enabled to examine some secretion from a case of ab This is a gross mistake, and from my own experience, which now comprises samples of milk from about fifty different individuals, I do not hesitate to believe that even the size and number of milk-globules will in the near future be resorted to as a means of diagnosis. At all events, it is certain, that much oftener than is usually expected, the microscope reveals the presence of foreign bodies in milk, in the first place pus corpuscles or leucocytes, and pyogenic and saprophytic bacteria (staphy-scess in the axillo superior quadrant of the gland. Not lococcus pyogenes aureus for instance in six and Fraenkel-Weichelbaum's pneumonia-diplococcus in one of my seven cases). This is by no means a new discovery; leucocytes, pus, blood-corpuscles and epithelial cells have been found before in quite a number of more or less acute cases of breast-disease (mastitis, abscess, etc.), while as to the so-called bacteriology of the milk we possess a list of micro-organisms which are apt to be met with now and then. Since, however, we are not in the least entitled, to either assert or deny that their presence or absence influence the character of the milk, we may for the present leave them alone, only observ only the very same microscopic findings, but even certain chemic characteristics in the composition of these pus-containing secretions, about which I am going to speak later, were noticed. On the other hand with the disappearance of pus the chemical norm would be again approached. In order to give an approximate idea of the amount of pus-corpuseles in these diseased milks, I may mention, that in a specimen of a thinly spread drop with medium power there could be in one field very often counted as many as twenty-five to thirty and more of them; of course in other cases there were less. For the obvious reasons mentioned I was compelled in trying to establish the pathologic anatomy of the condition to conduct my researches on material taken at random from the post-mortem table. The object in view was, to find evidence of intraglandular (miliary I might say) suppurative inflammation, or of ulceration. It is a well known fact to every pathologist, that the ducts of the glands opening on the surface as well, as of the glands of the intestinal canal (even the small Lieberkuehn's follicles present very frequently beautiful illustrations of this fact) on close examination are decorated with scars, which show that they victoriously stood the brunt of bacterial assaults. Moreover the struggle itself in favorable instances may be observed in any of its stages. In other words, we very often see along the ducts and even penetrating into the gland tissue proper minute suppurative foci, wherever in a locus minoris resistentia the pyogenic micro-organisms found a chance to set to work. Not seldom from such microscopic foci more extensive inflammations originate; in most cases, however, they remain limited and are in due time isolated and made innocuous by the cus tomary fibrous tissue barriers. These scars often appear in the shape of miniature strictures. It is self. evident that the continuity of the epithelial lining is not always restored, the bare stretches remaining as lasting landmarks of the bout. Such exactly is the condition, too, in the glandular tissue of the female breast; it is safe to say, that lesions similar to the ones described are met with in a great percentage of the female sex. I found them twice in material derived from twelve different individuals, all of them multiparæ. I could not find them in material from two virginal cases and from one case of marasmus senilis; but this last case showed a so extensive retro grade development of the whole glandular tissue, that hardly anywhere along the collapsed ducts intact epi thelium remained demonstrable. I must eonfess, that only in one of the above two cases there was evidence, that the individual died during lactation, but since in both of them the phenomena were identical, I may well talk of them collectively. only a small piece of the whole glandular structure could be examined. There is no doubt, the alleged facts can only be used as circumstantial evidence, but in my opinion they are stringent enough, to allow of drawing a conclusion as to similar processes in the above cited cases of pus-containing milk. The etiology of these lesions is easily understood, when we remember that the openings of the ducts in the nipples form a gateway, especially during lactation, easily accessible to micro-organisms, and that, on the other side, there exist a great number of conditions (pressure from corsage, etc.), which are apt to produce the locus minoris resistentiæ required. Certain it is, that even very slight suppurative processes exert a decided influence on the chemical nature of the secretion of a gland, be it by directly alternating the secretive quality of the functional tissue, or by the simple admixture of the products of metabolism of the pyogenic bacteria, of toxalbumins or whatever they be. And with this remark I have approached the chemical side of the subject under discussion. Thanks to the splendid work done of late in milk analysis our views as to the importance and value of the single components of breast milk have been revolutionized and the method of artificial feeding was placed on a rational basis. More and more the necessity of examination of the mother's milk in obscure cases has been acknowledged, but unfortunately at the same time an effort made itself felt to simplify and to reduce them to so-called clinical tests. A great many valuable hints are, therefore, necessarily lost, which like in the cases discussed here may prove to be of decisive importance. For it is not only the percentage of fat, proteids and sugar, that afford these hints; but for instance the relative proportions of water and solids, the amount of mineral matter, especially of iron, the proportion of casein to lactalbumin, etc., ought to command our at tention just as well. The accompanying table will serve to illustrate this assertion; it contains the analyses of normal milk with the variations considered to be concordable with perfect quality, the analyses of my seven cases of dysauxesis and of one case of breast abThe lesions themselves were distributed along the scess. To Case 5 is attached a particular interest, since ducts and sometimes reached down as far as to the it was first without success treated for fat starvation, smaller galactophorous branches. I never saw them oe until at last the real cause was discovered and recovery cupy the ampullæ, the reason for this being most likely ensued. In Case 3 I succeeded to locate the suppurathe more flattened epithelium and the massive bands of tion in the left breast; the milk of the right breast was fibrous tissue, which inclose them. They appeared perfectly normal and with mixed feeding the baby got either in the shape of cicatricious tissue and moderate along splendidly. For comparison the last analysis is narrowings, or even as active suppurative foci, that taken from a real case of fat starvation. means minute spaces of ulcerating surface. Without At one glance it becomes apparent that we have to any exception in the latter a staphylococcus species was demonstrated, a fact, which in default of a reliable history of my material I should like to accentuate. As to the frequency, with which these lesions were encountered, I would not like to commit myself by making an estimate, but I may simply state, that they were by no means rare, since naturally in every case deal here with a condition of things, which even chem. ically might be diagnosed with a certain amount of reliability. In everyone of the cases we find a highly decreased amount of casein, an (in two cases enormous) increase of the percentage of albumin and a very low amount of mineral matter. The variation of fat is not so marked, nor is it constant, while the total amount of solids only in two cases exceeds the normal. The most constant element, too, in these cases is the sugar. A problem of the highest interest is given by the low figures for ashes; it would be exceedingly important to know, whether the amount of lime is decreased accord ingly, because thereby some light would be thrown on the low percentage of casein, the latter, as is well known, being held in its colloidal semi-dissolved condition only by the presence of, or the association with, lime. Since no peptones were present or at least only minute traces of them a conversion of casein into peptones, like that which takes place in milk on standing, was to be excluded. Fat. 3.78 are entirely different; but since the peculiar relation be. tween casein and lactalbumin as well as the appearance of more or less numerous colostrum corpuscles (the latter are often mistaken pus corpuscles) form the most salient points of the nature of colostrum, and on the other side are paralleled by pus-containing milk, the suspicion is aroused, that cases of the latter type have been mistaken for anomalous colostrum-secretion. The clinical histories, too, confirm this conjecture. I have not had an opportunity yet of seeing a case, in which this alleged recurrence of colostrum-secretion could be verified. But of course, I mean to give these remarks as a mere possibility; it only looked improba. ble to me, that a derangement so characteristic as the one described by me, should have been hitherto overlooked. I may be allowed to conclude this article with a few words on some technicalities in examining milk. In the first place a microscopic examination must never be confined to the simply testing a drop of milk. I always let the milk stand for a few hours and then by means of a pipette collect some from the bottom of the vessel. This sample, then, is subjected to rapid and prolonged rotation on a centrifugal machine, after which process a drop of the sediment is spread in the usual manner on a cover glass, dried, fixed and hardened in equal parts 1.76 First treated for of alcohol and ether, and finally stained after one of the methods in vogue. Of the latter I prefer the so-called neutral stain, a combination of eosine and methylene. blue. The method of hardening specimens by heating is not practicable for milk. 6.90 2.85 Left breast. 3-4 0.10 7.10 2.8 0.13 7.10 3.1 6.62 6.80 3.14 2.05 0.17 6.13 3 50 1.85 0.15 6.50 2.36 1.25 1.36! 0.34 6.91 1.84 fat-starvation. Be that as it may, the above analyses form a very characteristic feature of this pyogenic dysauxesis. To obviate, however, any possible misconceptions I will distinctly remark, that I do not connect directly the pathologic condition of such infants with the just mentioned anomalies of the combination of the constituents of their food. In fact, it seems to me, that already too much stress has been laid on the exact percentage of the different components of infantile food; in my cases, too, I am inclined to rather attribute a part of the phe nomena constituting the disease to the effect of germ produced toxines. Anyhow, in some cases, I am told, improvement did not immediately follow weaning and artificial feeding, but was only noticeable after a mild antiseptic treatment. At least I call minute doses of lactic acid antiseptic treatment, however doubtful this assertion may be. As an incidental observation I will mention, that in so prepared specimens of cow's milk it is a comparatively easy task to, after properly staining them, find tubercle bacilli; in the milk offered for sale by three different dairies of this city I have been able to demonstrate them, and not in very small numbers either. It is perhaps interesting, too, to know that very seldom cow's milk does not contain pus-cells. Bacteriologic examinations of such milk, as furnished by the different dairies, is for obvious reasons without value. But while in this way it could seem, that the much ventilated question as to the occurrence of tubercle bacilli in milk might be easily decided upon even without the help of animal experiments, there is on the other hand one fact, which has been hitherto entirely overlooked and which is apt to cause the observer unacquainted with it to become the instigator of unjust annoyance and even heavy damage. The fact, too, that I am going to describe now, shows in a very striking manner, how careful we have to be in establishing and accepting differential characters based on some artificial proceeding. Should my suspicions prove to be correct cases of pyogenic dysauxesis have been every now and then recorded in the pediatric literature under the head of recurrence of colostrum-secretion. If we look compar- The morphologic appearance of the so called tubercle ingly at our figures and those of a number of colostrum-bacilli is, though characteristic to a degree, not so disanalyses, we are bound to notice a certain resemblance tinguishing as to allow of a reliable discrimination between them, especially as far as the low percentage of against other forms of bacteria on that ground. We casein and the increase in the amount of lactalbumin know quite a number of these organisms, that resemble are concerned. Other features, it must be confessed, them very closely, and were it not for the differential |