In rheumatic fever, also, Dr. Todd has considered it his duty to protest against the too prevalent practice of large bleedings; other evacuants, he says, being as capable of modifying the fever, without the risk of doing ulterior mischief, and opium being more effective in relieving pain. The mistura guaiaci, as employed by Dr. Seymour, is a most useful medicine in this affection.

A work of considerable merit.

AUSTRIA ITS LITERARY, SCIENTIFIC, AND MEDICAL INSTITUTIONS, &C. By W. R. Wilde, M.R.I.A.

The object of this work is stated by Mr. Wilde to be twofold: first, to afford information to the medical and general scientific reader in this country, on topics of considerable importance not hitherto inquired into, with respect to the state of medicine, the arrangement of hospitals and sanatory institutions, and the admirable system of education and clinique in a large portion of Europe. Secondly, this work may be found useful as a hand-book, in its particular province, to a country with which we are daily becoming more and more acquainted and connected.

We will notice a few points of interest as they arise.

Division of the Medical Profession in Austria.-At present, the medical profession in Austria is divided into the first class physicians and first class surgeons; the town and country surgeons, analogous to the general practitioners in Great Britain; those who practise specialities, as accoucheurs, oculists, dentists; the pharmaceurs, who are divided into the apothecaries and the doctors of chemistry; and, lastly, the veterinary surgeons-a class very superior to any other of a similar calling in Europe, and a large portion of whom are at the same time physicians and surgeons of the first grade. Each of these classes undergoes a certain fixed course of study. The education for the first class, physicians and surgeons, requires five years, and none are permitted to attend the lectures upon these subjects but those who have obtained, at the final examina tions of their philosophical studies, a certificate of first-class in all the obligatory courses. They only are eligible to become doctors of medicine and surgery.

The second class surgeons, however, are in a far inferior position, being degraded, not only in letter but in spirit, to the mere barbers and dressers of wounds a position from which they can never rise, no matter what their talents or abilities. Every Wundarzt (one of this class) is obliged by the law of the land to shave for a couple of kreutzers, exhibit the basin and striped pole, and keep open a barber's shop. And although many of these surgeons in the larger cities do not themselves manipulate upon the jaws and chins of the inhabitants, yet are they obliged to keep a servant or an apprentice to do so, as hair-dressers or any other class of the community, except the Wundärzte, are not permitted to perform this operation. These general practitioners are not allowed to sell medicine, but to them is committed the performance of all the minor chirurgical parts of the profession, such as usually falls to the lot of the apothecary with us; as for instance, bleeding, cupping, the application of leeches, and the dressing of simple wounds and fractures, &c. They cannot prescribe medicine, except a few simples, unless in cases of immediate danger, and when a physician or doctor of surgery is not at hand; they form, however, the principal practitioners in the distant country parts.

Great General Hospital at Vienna.-This most magnificent institution, the greatest either here or upon the Continent, contains within its walls 3,477 persons, and treats upwards of 30,500 patients annually. The object of this establishment is three-fold. First, to afford a comfortable asylum for those able to pay all, or a portion of their expenses; secondly, to provide in-door medical

relief gratis for those unable to pay any portion of their cost; and, thirdly, to maintain a school of practical clinical medicine. The hospital is divided into three great departments-the medical and surgical hospital, the lying-in institution, and the lunatic asylum. There are 389 medical attendants to 3,025 beds, or one for every eight, independent of the different clerks and general servants not in immediate attendance upon the sick.

This hospital, however, with the exception of the lying-in department for females illegitimately with child, and its attendant institution for the foundlings born there, together with the female venereal wards, affords little or no gratuitous relief. The expences are defrayed by the patient himself or his friends, or in default of these, by the parish or district to which he belongs. In the event of a foreigner being obliged to seek medical relief in this or any other Austrian hospital, his ambassador is served with the bill of his expenses, which his country is obliged to discharge.

State of Disease in Vienna.-"Scrofulous diseases, particularly in the tubercular form, are more frequent in Austria that any other country I have visited. General surgery has but little to offer to the attention of the French or English student, except, perhaps, a lesson upon adhesive inflammation to the former. The want of machinery and manufactures, as well as the few heavy-wheeled carriages, and the sober quiet deportment of the inhabitants, compared with London, Paris, or Dublin, no doubt assists in lessening the number of accidents.

"Calculus and bladder affections are also comparatively less frequent than with us. I cannot praise the dressing and bandaging-it is neither neat nor scientific. The surgical divisions most deserving a visit, are those of Drs. Schuh and Moisisowitz, the most rising surgeons in Vienna. Rheumatism is a most frequent and dangerous affection in Vienna. Diseases of the skin are not very common in this part of Austria: there is a separate division set apart for their treatment, which is chiefly by baths and fumigations; but to those who have seen St. Louis, at Paris, it offers little attraction.

"The fever wards are usually crowded, especially in the cold season, and their mortality is very great; generally a third die; ulceration of the intestines, and scrofulous tubercular deposits in the abdomen, being the most usual pathological appearances. The visitor will have here a good opportunity of witnessing, on a large scale, the Nerven fieber, or true typhus abdominalis of the east of Europe. The treatment is more of the expectant than the anticipating plan, and consists, as indeed does the treatment of most diseases in this hospital, of some one line already marked out, and only deviating to meet symptoms as they present themselves, but never venturing upon new and unexplored ground. Stimulants are never used even in the advanced stage of this disease."

Dr. Skoda's Clinique.-This is purely a stethoscopic clinique for diseases of the chest, and is perhaps the best school for acquiring a knowledge of the diagnosis of such affections that the foreigner can visit. As an auscultator, Dr. Skoda possesses an unrivalled reputation, and certainly his diagnosis of heart and lung affections is astonishingly correct. It is entirely in this latter branch of knowledge that this clinique is so remarkable; for the treatment pursued there has in it nothing peculiar except that it is by no means good. It is purely antiphlogistic-consisting of blood-letting, leeching, and blistering, with the use of a few simples-such as tartarised antimony and the tinctura digitalis-administered in large doses. In pleuritic effusion he practises paracentesis much more frequently than any other physician, and does so even in acute cases; for he maintains that it must be performed early if at all, otherwise the lung having become collapsed and shrivelled up by the long-continued pressure of the fluid, will not again expand. He has also punctured the pericardium several times and with various success. In acute rheumatism he employs the constant application of iced water to the inflamed extremities, even where there is severe pericarditis present.

Syphilis. The venereal affections in Austria appear generally to be of a milder nature than in Great Britain. This is probably owing to the sanatory police regulations, to the peculiarity of the climate, the temperate habits of the people, the non-use of mercury, and the non-existence of unqualified practitioners to attempt its treatment. True chancre is very rarely seen, and phagedenic and sloughing ulcers of the genitals are comparatively unknown. Among the secondary forms of syphilis, affections of the throat and papular eruptions are the most common, but syphilitic rheumatism and nocturnal pains are rare and less severe than in this country. Rupia, nodes, caries, the pustular form of eruption, the spreading syphilitic sore, diseases of the bones and testes, &c. and other severe secondary and tertiary forms are very seldom seen: indeed rupia appeared to be only known from English descriptions of it, and during six months Mr. Wilde did not see a single case of syphilitic iritis. Condylomata are very prevalent; these are supposed by the medical men there to constitute a primary affection, and to form in many instances the only symptom.

Inoculation with syphilitic virus, as practised by Ricord at Paris, is not permitted in Vienna. Infantile syphilis is exceedingly rare, and abortions from that disease are hardly known.

Imperial Lying-in Hospital.-This is probably the most curious institution in Europe. Pregnant women of every description can avail themselves of the advantages of this asylum; the poor and destitute are admitted gratis, and the rich by paying a certain stated sum. Every comfort is supplied-no visitor can intrude-no law affect, and no authority reach its inmates-nay more, the very fact of their having been delivered there is inadmissible either as documentary or personal evidence in a court of justice. The principle of secresy is imposed as one of the strictest duties on all those in any way engaged in the institution. Should a female desert her family, and take refuge here, the vigilance of the police or the inquiries of her friends may trace her to the door of the Gebäranstalt, but no further. Indeed in many instances, and in almost all the cases occurring among the highest class, a female may enter, accomplish her delivery, and depart from the hospital without her name being known, or even her face seen by the physician or any of the attendants. Persons are allowed to appear masked, veiled, or otherwise disguised; they may enter at any time previous to their delivery, and remain as long as they wish; they may carry their infants away with them or send them to the foundling hospital through the medical attendant. The names and address of persons admitted into this division are not required, but each female must write her name and residence upon a billet, which she seals, and on the back of which the physician inscribes the number of the room and bed she occupies. This ticket is then placed in a small locked-up cabinet beside her bed, and at her departure it is returned to her unopened; its object being, that in case of her death, the institution may inform her friends, or be able to produce this testimony of her decease on the demand of her relations or the police.

A considerable portion of the work is devoted to the consideration of the state of ophthalmic surgery in Vienna, but as this has been already noticed in this Journal*, we shall not again refer to it.

The volume is one of very considerable interest.

* No. 71, page 262.

Spirit of the Foreign Periodicals.

PATHOLOGY OF PHLEGMASIA DOLENS-DISCUSSION AT THE ROYAL

ACADEMY-REMARKS.

Ar a recent seance of this learned body, M. Capuron read an elaborate report on a memoir by M. Drousard on the disease known by the name of Phlegmasia Alba Dolens, and in which the author has attempted to prove that it is generally, if not always, connected with an inflammation of the crural and other veins of the affected limb. The question, it will be seen, gave rise to much discussion and difference of opinion; some assenting to this view of the subject, and others expressing their decided dissent. The result of the whole seems to be, that there are different forms of the disease, and that these are most probably owing to the operation of different causes.

M. Breschet objected to the opinion, expressed in the report just read, that phlegmasia alba dolens is in all cases the result of an inflammation of the veins in the affected parts. According to his experience, the lymphatic vessels are usually as much implicated in the morbid process as the veins. The phenomena of genuine phlegmasia are certainly not the same as those of ordinary phlebitis ; and this, among other reasons, he considered a strong argument against the opinion of M. Capuron.

M. Capuron, in reply, said that he had by no means denied that the lymphatic vessels may be inflamed in this disease; but only that they are not primarily and necessarily so.

M. Blandin :-" It has been long imagined that Phlegmasia alba is a disease peculiar to women. This is not strictly correct; for, although of much more frequent occurrence in females, it is certainly not peculiar to them. When the disease was first recognised and described, it seems to have been regarded as a mere form of ædema; but, in proportion as its phenomena and cause were more attentively studied, it was found that in some cases the veins, in others the lymphatic vessels, and in others still the nerves were in a more or less decided state of inflammation at the time:-this M. Dance shewed in his interesting memoir on the subject. Subsequently however it has been discovered that the inflammation of the veins and that of the nerves are not of a necessary, but only of an occasional, coincidence in phlegmasia; and that the only essential pathological character of the disease is an inflammation of the absorbent vessels of the limb. We must admit, however, that the inflammation of the veins sometimes precedes that of the absorbents, and we are therefore obliged to dissent from the opinion of our colleague, M. Breschet, who seems to regard the lastnamed vessels as invariably the seat of the disease in question."

M. Velpeau." Twenty years ago, when I published my first observations on this disease, it was almost universally maintained that the pathological cause was an inflammation of the lymphatic vessels of the limb. In consequence of several post-mortem examinations, I felt convinced that the veins were often more or less affected, and I expressed this opinion publicly. About the same time, Dr. Davis came to nearly the same conclusions in England. I have had very many opportunities, since that time, of studying the diseases of the venous and lymphatic systems, and have treated not a few cases of phlegmasia alba, and I now feel assured of the truth of the following two propositions: first, that the opinion of M. Dance and others, as to the nerves being in some cases inflamed, is utterly erroneous; and secondly, that the disease is primarily seated in the lymphatic vessels of the thigh; that a phlebitis is not necessarily existent; No. LXXVIII. I 1

and, when it is, that it is only of consecutive or secondary development. But while I say this, I must also distinctly state that, in almost all post-mortem ex. aminations of the affected parts, both sets of vessels have been found more or less seriously diseased. The phenomena of the disease in its first stage tend much to shew that it is rather an angeioleucitis than a phlebitis that we have to deal with. There is then a general engorgement of the limb, with patches here and there of diffused redness, and irregular uneven nuclei or nodules of tumefaction, which are not necessarily found along the trajet of the veins, as in genu. ine phlebitis. The constitutional symptoms too, in proper phlegmasia dolens, are certainly not the same as in phlebitis; and it is only when both sets of vessels happen to be simultaneously implicated that we ever meet with the symptoms which denote the occurrence of purulent resorption and infection. În conclusion, I will briefly repeat my opinion that genuine Phlegmasia alba dolens is attributable to an angeioleucitis or inflammation of the lymphatic vessels, accompanied with an inflammation of the adjacent cellular tissue, and occasionally also with inflammation of one or more of the veins of the limb."

M. Capuron here reminded the Academy that the opinion now expressed by the preceding speaker differs in almost every essential particular from that which he expressed not long ago, and pointed out the striking contradiction between M. Velpeau's present sentiments and those which he has published in his writings.

M. Cloquet.-"I agree with M. Blandin in the sentiment which he has expressed in his remarks, that phlegmasia alba is not necessarily or invariably met with in the female sex; as cases of it have unquestionably occurred, in my own practice, among youths and men. I have experienced no little difficulty in forming any exact or definite opinion as to the etiology of this disease. If I were to trust exclusively to the results of the post-mortem examinations which I have made, I should indeed be utterly perplexed what to say; but, by having carefully watched the progress of many cases from their first stage, I have been enabled to form clearer and more accurate notions, as I think, on the subject under consideration. The result of my observations is that, as a general remark, the cellular tissue is primarily the seat of the cedematous swelling; that an inflammatory engorgement, accompanied with effusion, takes place at first; and that it is only consecutively that either the lymphatic vessels or the veins become affected. In my opinion we may regard Phlegmasia alba as a specific exhalant inflammation of the cellular tissue, with or without an accompanying inflammation of the veins or lymphatic vessels of the part."

M. Moreau (the eminent obstetrical physician) took nearly the same view of the aetiology of phlegmasia alba as M. Cloquet. In his opinion, it is a specific disease which should not be confounded with an inflammation either of the absorbents or of the veins. "Phlebitis is always a serious, and often a most dangerous, disease; phlegmasia alba, when uncomplicated with other lesion, is comparatively mild and innocuous. In proof that there is something special about the disease, we have only to bear in mind the circumstances which usually give rise to it. Is it not remarkable that often it does not occur for 15, 18, or 20 days after delivery, when the usual exciting causes of suppuration have entirely passed away? Does not this circumstance alone suffice to shew that the disease depends most frequently on the neglect of certain precautions on the part of women who have been recently delivered? According to my own experience, it is generally owing to checked perspiration under such circumstances. At first there seems to be nothing but an indolent swelling, a simple engorge ment; this, if not relieved, is apt to be followed by inflammation of the absorbents, and in some cases of the veins also. It is only when the last-named lesion is present, that there is any cause for alarm as to the issue of the case. I should define the disease in its primary stage to be une veritable inflammation exhalante du tissu cellulaire."