MEDICAL SOCIETY OF THE COUNTY OF
NEW YORK.

ADJOURNED STATED MEETING, Oct. 12, 1868.

DISCUSSION OF DR. ROGERS' PAPER.

(Continued from p. 404.)

In the few paragraphs which make any allusion to scientific questions, the same virulent and morbid tone is perceived. Shall we here refer to a few points that illustrate this characteristic in the discourse as it lies printed before us? It opens as a scientific discourse, with the subject of the hot summer. But at once, in the first column, we come upon this remark: "It is very much the fashion with our health authorities to give these malarial agents great prominence in the cauDR. HARRIS.-I would be obedient to your call, Mr. sation of infant mortality," etc. [The speaker here President, but I confess I am unprepared to enter upon read from the RECORD report, p. 337, the passage inthe discussion of a subject so broad, under the circuin- cluding extracts from Registrar's letters of July 14th stances which have attended the promulgation of this and 21st.] The quotations are correctly given; but we paper. I am wholly averse to any polemical discussion come now to the argument, and let us see what it is: of questions that depend upon accurate statistics and ex-"It is therefore manifest that carbolic acid and chloride act observations. It is well known to you, sir, that the of lime are not all that are required to prevent this anauthor of this paper has, from time to time, reported nual augmentation of mortality among infants in our upon the public health, as secretary of a committee of city," etc. [p. 338, first col.] Then, sir, opens an arguthis Society. Sitting in this room, I have heard state- ment to the effect that nuisances and stenches are not ments made by him that seemed to me incorrect in injurious. their statistics and in the deductions drawn therefrom, and yet have not thought it worth while to make any comment upon his statements. The Society could take his deductions for what they were worth, precisely as it might my own or any other gentleman's.

But when this paper was thrown before us, at our last meeting, I arose, hoping that I might possibly stay the tide that was sweeping it before the public without any attending statement. But the discourse had already been voted into type, and all discussion upon it suspended until medical journals and the daily press should have given it broadcast to the people. Now, after this course has been taken by the gentleman's paper, is it proper or desirable for the persons and the institutions, that have been thus attacked, to come forward and discuss the all-important subject of preventable causes of infant mortality upon the basis of that discourse? For one, sir, I must now decline to enter upon the discussion on such a basis, after the discourse has been a fortnight published in the daily papers.

This method of discourse goes on; and we escape from the defence of soap-boiling, nuisances, and stenches, as being not proved mischievous, into a very severe criticism [pp. 339, 340] upon a schedule of nine suggestions concerning the management of infants, which the author says were published by the Board-but erroneously, as explained at the previous meeting of this Society. [Dr. Harris said that he had then stated that the Board of Health failed to publish any such card of advice, though urged by several distinguished physicians; and that to one of the ablest teachers and authors upon the subject of infantile diseases, was due all the credit of the card of suggestions to mothers and nurses which the discourse so derided.] And yet we find the derision and the criticism concentrate upon the use of the phraseology "lump of sugar" and the advice to swathe the sick child's abdomen in light flannel; while the critic offsets against this homely advice from the experience and good judgment of our best physicians, his own discovery that "the true condition of an infant is perfect nudity."

From such criticisms and a labored defence of the great nuisances of the city, and with part of two columns in his discourse devoted to derision of disinfection and the cattle disease, the author of the discourse goes on to treat of the public institutions for the care of infants. He opens upon the new Hospital for Infants, under the Commissioners of Public Charities, by asserting-very incorrectly-that "no improvement is yet manifest there." He adds the remark that, "Whether the institution is doing a larger business this year, in both receiving and killing, the figures at the close of the year will tell."

Moreover, the discourse itself fails to supply the groundwork that is requisite for a proper discussion of the subject. It deals with the most important questions in an ex cathedra style; it deals largely in denunciations; and, sir, many of its statements are incorrect, its use of statistics is inaccurate, its deductions are unjust, and its arguments, like its style, are calculated to do harm. It purports to be a discourse upon preventable causes of infant mortality; and it is to be observed that the whole of it is taken up with criticisms and assaults upon whatever institutions and men at present chance to have any care for the sanitary interests of the infant population. From the delusions of sanitary officers in regard to the recent sickly season, the author The author of the paper has attempted to show that hastens to discuss the cattle disease; from the cattle dis- even the few deductions and lessons that the Bureau ease he turns to scorn the chemistry ruses of disinfect- of Vital Statistics ventures upon are erroneous, He ants; and then taunts the officers of the Board of Health quotes the remarks made by the Registrar, upon the with the charge of publishing canards. Lastly, the Com- nortality in the Sixth and the Twenty-second wards missioners of Public Charities, a noble and admirably last July, when in the latter ward the death-rate far conducted Board, are charged with flagrant neglect of surpassed that of the Sixth or any other ward in the duty. Then, too, in this last onset of criticism, another city; and he attempts to show that the Registrar's de nobl Board of Trustees-noble every one of them-ductions and statistics were erroneous. Now here is a the 17 Trustees of the Infants' Hospital, founded by the pious Mrs. Richmond-and watered with her tears for the fearful death-rate that prevailed in it-are denounced for having transferred the few survivors in that asylum to the more successful and effectually established Nursery and Child's Hospital in 51st street. Indeed, the author of the paper declares the action of those Trustees was criminal. Nearly the entire discourse is thus taken up with this kind of attacks upon our medical brethren and their best efforts.

diagram that shows the relative rates of mortality in those two wards, and the scale of their competition with each other, during the three summer months. [A scale diagram was here exhibited, to show the degree of excess in the Twenty-second ward.] Yet, as stated by the paper, facts, deductions, and principles are all erroneous. I would not pursue this subject farther. The attempt which the author made to throw discredit upon public institutions, statistics and men, we may safely leave to itself; but upon such

As to our tenement-houses, it was obvious that we must do away with every one of them.

DR. ČALKINS thought infants were too often drugged to death, or idiocy, with such opiates as paregoric or "Mrs. Winslow's Soothing Syrup." Mothers, as well as nurses, would thus relieve themselves of cradlerocking. DR. STONE felt that Dr. Harris had properly vindi

a foundation we cannot frame the good work that is needed to prevent the waste of infant life in our cities. [In conclusion, Dr. Harris remarked that it was not the personalities of the discourse, so much as its reckless and denunciatory spirit, that he deprecated. He had spoken frankly and fearlessly of these qualities, and he deeply regretted that duty compelled so free an expression of the reasons which led him to decline accepting that paper as the basis of any scientific or statistical in-cated himself and the Board of Health against the quiry.]

DR. BIBBINS deprecated all discussions of a personal nature, to the careful avoidance of which he traced the recent prosperity of the Society. He had not_come prepared to discuss the subject in extenso, but from a service of upwards of eleven years as Visiting Physician to the Demilt Dispensary, during which he had been visiting tenement-houses almost daily, he had come to consider inherited disease one of the chief causes of infant mortality among the lower classes. Many of the mothers were the victims of constitutional syphilis, said to be cured perhaps, but not cured. Was it any wonder that so many of these waifs of society died almost as soon as they were born-before birth, indeed, in very many cases, for abortion was becoming fearfully prevalent? Abortion was often attempted after the foetus was viable, and the premature infant was doomed to early death. Then, the mother was often intemperate and could not support her child; she wished it out of the way; had perhaps failed in the effort to get rid of it as a still-birth, so compassed the same end by neglecting it till ready to die, and then turning it over to some public charity. Improve the morals of the com-selves, for they would give us no help. If the tenemunity, and you would save much of its infant life.

Certain conditions were essential to the health of infants-pure air, cleanliness, proper clothing, exercise, good food, good attendance. As to the first, this city crowded more persons into one house than any other city in the country; and any physician visiting the upper stories of our tenement-houses, during the hot season, would appreciate the truth of Dr. Rogers' description. This evil of crowding had been greatly aggravated since the restrictions of the Tenement-House Law had discouraged the building of new tenement-houses. The matter should receive the careful consideration of the Board of Health. Bathing was a good thing, but it might be made a very bad one. If nurses were not watched they would put the child into water too hot or too cold, or even give it a douche under the Croton pipe. Babies demanded exercise; it was torture to them to be left in the cradle--not to be carried about the room and into the open air. One prolific source of infant mortality had not been mentioned--cold. Whoever had visited the tenement-house infants in winter knew that many of them died from exposure, bringing on pneumonia and other forms of chest disease. The upper stories and the damp basements showed a greater mortality than ever, from this cause, since the public authorities had stopped the gratuitous supply of fuel. With regard to ventilation, only those who had been called to visit the crowded dormitories in early morning could have any conception of their reeking atmosphere. The doctor might order the windows opened, but the moment he was fairly out of sight they would be closed again. Even in hospitals, the nurses could hardly be brought to obey orders in this matter.

DR. GARRISH rose, as a married man, to protest against the aspersions his bachelor friend had cast upon the poor Benedicts. Syphilis was not a prerequisite to matrimony, even in shanties; and to accuse the pauper babies of dying of such a disease was an insult to them and to their mothers. They all succumbed, of course, to cholera infantum, or some equally innocent affection.

erroneous charges that had been made. As a member of the Board, the speaker had taken the pains to investigate some of them. The "Rules for the Management of Infants" were never published by the Board, and he did not know how they got into print. But it did no good to inveigh against the Board of Health, which tried to do its duty, he believed. To develop a subject so vast, so obscure, so vitally important as that under discussion, required the cordial co-operation of all, It must be taken up in no captious spirit, and in no small way, but rather in its broad aspects and relations; and where all were ignorant, all must be willing to learn. The causes conspiring to affect the public health were numberless. Some of the more petty ones could be met at once, more or less effectually; but the grandest of them, those acting on the largest scale, must be modified only by the slow progress which is measured, not by years but by decades and generations. We might shut up the butchers' shops and the gut-factories, we might even clean the streets; but how deal with the terrible ignorance and indifference of the herding masses? They must be benefited in spite of themment-houses could be cleared out, and their dwellers scattered over, say, the whole of Westchester,county, a great step would be gained. After a practical experience of their bettered condition, they would hardly return to the old ways. But for this we must have railroads; and they were yet to be built. Then, too, the stable question was not a small one-how to escape the evils of keeping in our midst the herds of horses that the city business and pleasure demand. We should hardly solve it till our drays and omnibuses were all drawn by machinery.

DR. ELLIOT.--There is no topic, Mr. President, that has always interested me so deeply, appealed so warmly to my heart, so enlisted the best powers of my mind, as the prevention of infantile mortality. I was intimately associated with the organization of the Nursery and Child's Hospital; it originated in a conversation in my office with Mrs. Dubois. I have faithfully labored in that institution; but there, as well as in private practice, I have been condemned to feel, as a father and as a physician, that, do what we may, we cannot lay the spectre of the inevitable mortality of childhood. This discussion cannot be conducted in the elevated spirit that should characterize it, until full confession is first made of this inevitable mortality. You must not confine your view to one city, to one country, to one zone. Go through the whole world; take reports of exploring expeditions; examine the statistics of mortality in families placed under the most favorable hygienic conditions in the world; go among your own patients of the most favored classes-where is the family that has succeeded in raising all its children, even under the best conditions and with the best medical advice? By considerations of this kind, much of all that which has been deprecated in the paper and the discussion would be at once eliminated, and we could turn to the subject in the right spirit. Let any man devote himself to the care of a ward of neglected infants, bearing in their bodies traces of hereditary diseases which he cannot control, even with the best appliances all at his disposal, and he

will find it most disheartening. Then let him look at the physicians and fathers of families constituting the Board of Health, and--from my stand-point of full knowledge of the earnest, ardent, faithful spirit these men and the Commissioners of Charities have put into the effort to overcome these evils-I do not see how he can begin a discussion of this subject by upbraiding any one of them for his inability to prevent this inevitable mortality.

I am glad to see this subject brought to the notice of this Society and of the profession; and I trust that by united effort we may at length be able to achieve results less utterly discouraging.

Correspondence.

MEDICAL MATTERS IN PARIS.

(From our Special Correspondent.)

In herpes zoster, same distinctions in regard to the vesicles and antecedents; besides, the pains in arthritic zona are burning, deep-seated, muscular, and often disappear with the appearance of the eruption. In herpetic zona (that is, under the influence of the dartre), the pain is lancinating, neuralgic, and generally lasts after the eruption has disappeared.

In herpetic chronic pemphigus, the bullæ contain a transparent citrine colored fluid, are isolated, and equal in size. In the arthritic form, the bullæ are sero-purulent, unequal, and united in large erysipelatous patches. But the cachexia of pemphigus is the type of what M. Bazin calls the cachexia of dartre, arrived at its ultimate term, and this is true, however the début may be characterized by slight differences. Acute pemphigus, according to Hardy, is merely an accidental erythematous eruption, the bullæ being quite secondary to the erythematous patches upon which they appear, like the philycten in erysipelas.

A curious case of this affection entered M. Hardy's

THE PATHOLOGY, DIAGNOSIS, AND TREATMENT OF SKIN ward the other day. The patient was a man just re

DISEASES.

TO THE EDITOR OF THE MEDICAL RECORD.

SIR-The most remarkable instance of the application of Bazin's theory in the diagnosis of cutaneous affections is afforded by eczema. According to Hardy, this is always dartrans, and always-in its chronic forms at least to be treated by arsenic. For Dévergie it is a constitutional disease, belonging to no particular diathesis, but expressing a depuratory effort of nature, and consequently must not be cured, especially in children. Cazenave pooh-poohs this ideal, as in fact do almost all the other physicians, and declares eczema to be an accidental affection, whose principal characteristic is expressed in saying that it is a lesion of the sudoriparous glands. But M. Bazin divides eczematous affections into three great classes, belonging to scrofula, arthritis, and dartre. Syphilis is represented by a vesiculous eruption, or false eczema. Each affection requires a different treatment.

Urticaria, as a manifestation of dartre, is rather pale, and occurs under the influence of moral emotions. The arthrit.c variety is deep red, and occasioned by cold and gastric disturbance. It frequently complicates rheumatism, springing as it does from the same diathesis. The same distinctions may be made for acute pityriasis, as when arthritic complicates rheumatism, when herpetic is accompanied by sick headaches, and determined by moral emotions.

In arthritic herpes is noticeable the inequality of the vesicles, already mentioned as a characteristic of eczema. M. Bazin adds but very inappropriately-the peculiarity of occupying uncovered parts of the skin. He thus passes over the well-known fact that herpes labialis is an extremely frequent complication of fevers (other than typhoid), and thus may be found on individuals of all constitutions. The herpes of children is certainly much more frequently under the influence of dartre or scrofula than of arthritis, which rarely manifests itself at an early age.

covering from an attack of lead colic, and had been similarly affected with pemphigus at the same period of a previous convalescence from the same disease. On admission, he was as red from head to foot as a boiled lobster. The fiery patches were not absolutely coalescent, but so nearly so that the effect was almost as elevated in bull of different sizes. A slight febrile vivid. Upon the greater number the epiderm was movement accompanied the eruption. It was treated like an eruptive fever, let alone, and in a week had almost entirely disappeared, leaving brown stains in the place of the patches, that in their turn faded rapidly. The affection was therefore essentially distinguished from real pemphigus, by expending itself in a single eruption, whereas the more formidable disease is noted for the desperate tenacity with which fresh crops of bullæ continue to appear. M. Bazin has a little pet variety of chronic pemphigus-invented by himself—and entitled, Hydroa with little bullæ. This pretty name is applied to a variety almost as chronic as the ordinary form, but affording infinitely greater chance for cure. In fact, whenever a patient affected with pemphigus gets well, M. Bazin calls his malady Hydroa, But the objective feature is the small size of the bullæ, some of which are not larger than vesicles. They appear successively, but only one or two at a time, and are covered by very thin crusts. The general health of the patient does not suffer the deterioration so remarkable in ordinary chronic pemphigus.

Bazin professes to distinguish psoriasis, lichen and prurigo into arthritic and herpetic varieties, but the line is not very well defined. He observes that the old herpetic affections are always symmetrical, the arthritic almost always irregular, and not extending in large confluent patches. Certain horse-shoe and circular forms of psoriasis, with a shining coppery hue to the skin, instead of the raw ham look of the non-specific varietybelong to the cutaneous manifestations of syphilis. The diagnosis is evidently of the utmost importance. BeHerpes circinatus is regarded by all the St.Louis phys- either to arthritis or dartre, are certain others, peculiar sides these affections, containing varieties that belong icians, with the exception of Cazenave, as a parasitic disease, originating in a cryptogam, identical with that to one of these constitutional diseases. Erythema noproducing herpes tonsurans of the hairy scalp, and dosum, and papular erythema, are both arthritic, accordsycosis of the beard. The cryptogam is named trico-ing to M. Bazin. So also, St. Anthony's fire, or couphyton, and M. Hardy classes these three diseases to-perose, which he carefully distinguishes from the acne gether as one, tricophyte.*

Excuse me if I have mentioned the above idea somewhat dogmatically, as if on the supposition that it was entirely unknown at home, But Wilson does not mention this theory, and Cazenave disputes it, and as their works are the best known in America, I have ventured to be omewhat explicit.

rosacea, of which it is a frequent complication. But the pustules belong exclusively to the acne; the couperose is constituted by dilatations of the cutaneous capillaries. Acne is always either arthritic, or scrofulous, or syphilitic, never herpetic. The scrofulous acne develops on the face; the arthritic affection (except the in

experience, that it would return as soon as the treat-
ment was interrupted. She is still at the hospital.
The papular scrofulides are somewhat discutable.
Strophulus is certainly often an accidental affection.
Prurigo mitis, with large papules, and only a support-
able degree of itching, is considered scrofulous, while
prurigo ferox always belongs to dartre. Erythema pa-
pulatum can be distinguished by no objective char-
acters from arthritic erythema. I have mentioned
above that facial acne was always scrofulous, that is, the
varieties simplex and punctata, and occurring in young

durated form, which is facial and distinguished from
scrofula, principally by the antecedents, &c.), appears
on the back and shoulders; syphilitic acne is dissemi-
nated all over the body, and noticeable by the charac-
teristic color of the areola, and the fine epidermic scales
that remain after desiccation of the pustules. M. Bazin
insists upon this latter sign, and in his clinic mentions
cases where its absence has served to correct diagnoses
of syphilis obstinately applied to young persons whose
character was above reproach. Mentagra may be ar-
thritic or scrofulous (scrofulous sycosis), but is not her-
petic. The arthritic eruption consists of pustules, seat-persons.
ed on indurated tubercles, which occupy nearly the
entire thickness of the derm. The eruption is in cir-
cumscribed patches occupying the beard on the chin,
cheeks, or naso-labial sillon. The crusts are thin, brown,
and broken. In scrofulous sycosis, the crusts are yel-
low, thick and moist, the lips are swollen, and the face
generally occupied by acne indurata. The tubercles
are more superficial.

Syphilitic acne of the beard, which closely resembles the mentagra, is still more profound than the arthritic variety; the sub-cutaneous cellular tissue is inflamed and indurated. Finally, parasitic sycosis, constituted by the same cryptogamic vegetation as produces herpes tonsurans (the tricophyton), is noticeable for the alteration of the hairs, which become gray and lustreless in color, broken irregularly, and covered over the roots with a fine gray powder. On the other hand, nonspecific roseola is always considered as a manifestation of dartre; one of its early symptoms, as papular erythema of arthritis. A certain form of impetigo, which M. Bazin calls melitagra, is ranked as herpetic, and distinguished from scrofulous impetigo-which occupies the head, and appears in large confluent patches-by appearing symmetrically on the trunk and limbs, in psydracious pustules more or less isolated.

M. Hardy calls impetigo simply the second stage of eczema, of which pityriasis is the third, sometimes also the initial period.

Finally (for M. Bazin's dissertations on syphilis do not greatly differ from those of the rest of the world, and may be left out of the question), the great class of scrofulides, divided into benign and malignant, occupy the third place in the category of affections dependent on constitutional disease—the first, perhaps, in importance. It is unnecessary to repeat the symptoms of general scrofula, recognized by everybody. M. Bazin errs, perhaps, in absorbing into scrofula the lymphatic temperament, which, though tending towards scrofula, is distinct from it. As symptoms of the first period of scrofula, he reckons the benign scrofulous eruptions, classed as exsudative, erythematous, and papular, and distinguished from the malignant scrofulides by leaving no mark or cicatrice. In the first class (exsudative), are red gum, eczema, impetigo, and acne sebacea. The characters distinguishing eczema and impetigo have been mentioned above. All forms of sebaceous acne, whether fluid or concrete, are recognized as scrofulous. An interesting case of this troublesome affection was admitted to M. Bazin's ward a little while ago. A girl of sixteen, florid and stout, without, however, any appearance of scrofula elsewhere, or any derangement of health, had been unsuccessfully treated for a year in the attempt to remove a patch of concrete sebaceous matter, about three centimetres long, situated just above the right eyebrow. If this were scraped away it immediately reproduced itself, and constituted a disagreeable deformity, being a thick, yellow, unctuous mass, clinging like a plaster to the forehead. Treatment by cod-liver oil, and daily alkaline baths, removed the patch entirely, but the patient declared, from former

Among erythematous scrofulides M. Bazin counts chilblains; especially those accompanied by deepseated chronic inflammation of the subcutaneous tissue,-locality affected in preference by the scrofulides.

The following are the characters common to all the benign scrofulides:-Tenacity, persistence in the same place (in opposition to dartre, so noticeable for its mobility); début by the head, gradual extension to the ears, face, and body; inflammatory process secreting, suppurating or hypertrophic: participation of the lymphatic glands, and subcutaneous cellular tissue; absence of pain or of intense itching. This latter circumstance is due to the deep seat of the inflammation. If it chance to be superficial, itching becomes quite intense.

The malignant scrofulides (which, according to Cazenave, are all manifestations of hereditary syphilis) are remarkable for their extension to the deep layers of subcutaneous tissue, for their well-defined limits, and persistence in one place, for the absence of all pain or itching, and for a strong tendency to relapse after cure. These eruptions are divided into three classes: ulcero-crustaceous, tuberculous, and erythematous. The crustaceous scrofulide contains two important varieties, inflammatory-ulcerating, and ulcerating with fibro-plastic formations. The first commences with tubercles or pustules simply inflammatory, which degenerate into ulcers, that destroy surrounding soft parts, but are arrested by the bones. These ulcers cover themselves with thick, green crusts, imbedded in the skin, and formed of superposed and concentric layers. Impetigo rodens and rupia are here included. After the crusts have fallen, and the ulcers healed, there remain white, irregular cicatrices, retracting the tissues like those of a burn, and adherent to the bones. In the second variety, the tubercles are fibro-plastic, caused by a proliferation of the cellular tissue, and the ulcers attack the bones as well as the soft parts. It is to this variety that M. Bazin especially applies the name of lupus vorax, which is considered an independent disease by some other dermatologists. He admits the title also in the second class, or tuberculous scrofulides. The primitive element is in this case the same as in the other, an inflammatory or fibro-plastic tubercle, but it remains stationary, without ulcerating on the surface. Curiously enough, however, the cicatrices are produced precisely as in the case of open ulcers, new fibrous tissue being called upon to fill up the place left vacant by the subcutaneous destruction of cellular tissue. Cure is only obtained at the expense of such cicatrices.

The same is true of the third class, erythematous scrofulides. These appear as a circumscribed patch of erythema, at first seeming to be as innocent as the ordinary ephemeral eruptions. But it presently reveals its real nature by its long persistence, its dull, pale red color, the pasty suboedematous feeling on pressure of the subcutaneous tissue, the absence of all burning, itching, pain or fever-finally, the appearance of a white irregular cicatrix in the centre of the patch, which gradually extends to the circumference.