But, whether we accept this view or not of the corrective or antiseptic powers of ammonia in septic fevers, repeated observation has convinced me that, in certain cases, its administration is highly advantageous; and if I were to indicate the particular cases in which it is preferable to the mineral acids, I should say, those in which the vital prostration is very great on the one hand, and those in which there is an inflammatory tendency on the other. To administer it effectively, however, it must be given in the manner recommended by Dr. Peart, to whom we are mainly indebted for our knowledge of its efficacy in malignant fevers, viz., in full, concentrated, and frequentlyrepeated doses; whilst I would in all cases advise it be given, with a view to depuration, in a little fresh infusion of senna. So administered, I can indorse the opinion that it possesses the power of increasing the strength of the arterial action, at the same time that it diminishes its frequency; that it supports the vis vitæ, without increasing the heat or irritability of the system, and, by such means, counteracts the tendency to malignancy in low fevers. I have elsewhere adverted to the antiseptic powers of creasote, and would merely add that, in the form of vaginal injection, it should be daily employed throughout the whole course of the form of phlegmasia dolens we are now considering.

Reparative Treatment. The last general indication points to the renovation of the blood, and the restoration of constitutional power; a principle to be effected by the steady and sustained administration of suitable food, wine and stimulants to an extent commensurate with the demands of the case. But here I would observe that, in the fulfilment of this indication, we have a powerful auxiliary in quinine, which, in combination with the mineral acids and proper evacuants, may be beneficially given throughout the whole course of septic fever. When much febrile

heat or inflammatory irritation exists, its administration should, in my opinion, be temporarily withheld; but, otherwise, it is not incompatible with the ordinary symptoms which attend every stage of such fever, operating, as it does, beneficially upon the nervous system, whose powers it recruits, and through whose agency it exercises a favourable influence upon the blood and secretions. Guided by these considerations, its employment may be commenced with the earliest manifestation of the febrile movement, and it may be continued, in gradually increased doses, to an extent commensurate with the tolerance of it by the system; and, so given, it cannot, I think, be doubted that it both curtails the duration of the fever, and powerfully assists in the restoration of strength.

These, then, are the more important remedial agents-evacuants, the mineral acids, or ammonia, and quinine, which would appear to be the remedial means best adapted for the fulfilment of the three principal indications which present themselves in the treatment of septic fevers, viz., the depuration, correction, and reparation of the blood; and upon their judicious combination and employment must our success in the treatment of such fevers mainly depend. Their action should, of course, be assisted by a suitable regimen ; and it may be necessary, in certain cases, to combine measures for the relief of inflammatory complications; but these I need not enlarge upon, inasmuch as their right selection and application must depend upon the circumstances peculiar to each individual case.

Neither need I enter upon a consideration of the various local, or, as I have elsewhere termed them, secondary indications of treatment in relation to this form of the disease; inasmuch as they have been fully treated of under the preceding, or inflammatory type, and require no particular modification in the present.

There is, then, but one other point to which I have to allude before concluding the treatment of the septic forms of phlegmasia dolens; and that is, the necessity for the freest ventilation in these, as well as in all forms of septic fever. In doing so, I avail myself of the opportunity of remarking that this, one of the most important remedial measures inculcated by sanitary writers of the present day, was one as fully recognised in the days of the past as of the present generation; and by no one more so than by the eminent physician in whose name these lectures are addressed to you. For if you look into the writings of Lettsom, and more especially his Medical Memoirs, you will find that, in his treatment of fever, he carried this principle to the fullest possible extent; directing that the windows and doors of the patient's apartment should be kept open throughout the day, in order that he might be exposed to, and receive the fullest current of fresh air that could be admitted. There is no nearer approach to this practice, that I am aware of, than that which is inculcated by Miss Nightingale, in her recent work upon nursing; and, taking her as the exponent of the advanced school of sanitary reformers, and her work as reflecting the most recent advances in sanitary science, we may see how in this, as in many other instances, the learning of the present day is but a reflex of the past,—with this difference perhaps, only, that that which is empirical in one generation becomes, by the advancement of learning and of science, to be rational in another.

And now, gentlemen, I have fulfilled, to the best of my ability, although very inadequately to my wishes, the task I proposed to myself on undertaking the duties of your

Lettsomian lecturer on midwifery. In the discharge of those duties I have addressed myself to you as to a jury empannelled to consider and decide upon certain weighty questions appertaining to medical science-questions bearing upon the nature of a disease of the highest pathological importance, as it is of the greatest social interest-upon one which has the most intimate relations with every puerperal malady, and more distant relations with a wide range of non-puerperal diseases; and, in the discharge of those duties, I have endeavoured to lay before you such evidence as would lead to the development of truth, rather than to the attainment of victory. For, believe me, however interested I may feel in the establishment of the truth of the doctrines I have submitted to you in relation to the pathology of phlegmasia dolens,-identified, as they are, with much anxiety and labour on my part,-I can with candour affirm, that I wish for them no further recognition than that which, on the closest scrutiny, they may be deemed fairly entitled to. But, whatever may be your verdict in regard to them,—whatever may be the opinion of our contemporaries, or of posterity, concerning them, I cannot finally take leave of the subject without thanking you, and the Fellows of the Medical Society of London generally, for the great kindness and consideration with which you have listened to my case, and the facts and arguments by which I have endeavoured to support it.

INDEX TO THE CASES ANALYSED AND TABULATED IN THE FOREGOING LECTURES.

The numbers in the Text will be found to correspond with those in

5. Medico-Chirurgical Transactions, vol. xii, p. 437

6. American Journal of Medical Sciences, vol. xvi, p. 48

7. Lee; Diseases of Women, p. 134

19. Edinburgh Medical and Surgical Journal, vol. xxvii, p. 14

34. Hardy and M'Clintock; Midwifery and Puerperal Diseases, p. 52

35. Ditto

36. Trye; Essay, etc., p. 15

ditto

P. 54

K