demic, and they interchanged type just as is observed among the fevers of the country.

From all these facts I am led to the conclusion, that the disease we have been considering, originated from local causes, in conjunction with an extraordinary constitution or condition of the atmosphere existing at the time.

THE CAUSE, PATHOLOGY AND TREATMENT OF YELLOW FEVER.

The unexpected length to which this report has already been drawn, together with the fact that I am at this moment busily engaged noting the rise and progress of another epidemic which has broken out at New Orleans, preclude the possibility of my entering upon a full consideration of the above important topics on the present occasion. In short, I can give them but a passing notice, hoping to discuss them more fully on a future occasion.

I have already expressed the belief that yellow fever originates from the combined influences of decomposing animal and vegetable matters, and a peculiar, unknown constitution of the atmosphere; but I confess this is only a conjecture, and shall not attempt now to give the grounds of my belief in it. So far as I have been able to ascertain, the true and real cause of this disease is as yet unknown. Whatever it may be, however, long and careful observation of its effects has led me to the conclusion that it is most probably a subtle material poison, that floats in the atmosphere, and enters the human system by respiration; first, getting into the current of the circulation, and thereby carried to all parts of the body. This, too, is but a theory, that cannot be demonstrated by positive proof, yet it may be strongly supported by the analogous effects of certain known poisons upon the system. It appears to me that the phenomena observed in an attack of fever, bear a strong resemblance to a conflict between the vital powers and certain poisons which we have known to be introduced into the system; that in some instances these powers are capable, unaided, of resisting or overcoming the poison,of doing so in many cases with the aid of medical skill; but in others they are totally unequal to the task, with whatever aid they may receive; and that in such, death must be the inevitable result.

I have known yellow fever to run through all its stages and terminate in recovery, without medical aid. I have, more frequently, seen cases thus unaided terminate in death. Such cases as these are valuable to the medical observer, as showing the natural history or course of the disease. I have seen many cases cut short and cured in the first stage of the disease, thus making an

abortion of its natural course. On the other hand, I have seen attempts to produce this result fail, and the effects sometimes prejudicial.

I have seen a great many cases of yellow fever conducted to a favorable termination by medical skill, which I confidently believe would have died without such aid. On the other hand, I think I have seen cases that were injured instead of being benefitted by the treatment pursued.

I have known cases which appeared to be doomed victims from the moment of attack, and which I believe could not have been saved by any remedial means now known.

In addition to these observations, I may say I have seen persons whose systems were capable of resisting the morbific cause, and never experiencing its deleterious effects, although fully exposed to it, and witnessing the deaths of thousands around them. Some escape through violent epidemics, such as the last in this city, and are attacked subsequently, when but little of the disease is prevailing; several instances of which I have recently witnessed.

Our theory being, then, that yellow fever consists in a series of morbid phenomena and lesions, produced by an aerial poison that finds its way into the human system, the sum total of these phenomena must constitute the pathology of this disease. The symptomatology of yellow fever has been most accurately given by many acute observers. The same may be said respecting the post mortem appearances of all parts of the body excepting the blood. So far as I know, the changes that take place in this fluid, from the beginning to the end of the disease, have not yet been satisfactorily demonstrated; but the chemist and microscopist are engaged in the work, and we may hope for important results from their labors in the course of time. I am not aware that examinations of the dead body have thrown much light upon the true pathology of yellow fever, or afforded as much assistance in the selection of the most beneficial remedies.

TREATMENT. In regard to the treatment of yellow fever, the grand object and aim of all our investigation, I am quite at a loss as to what I should say. Almost every imaginable plan of treatment was pursued in the late epidemic, from the mildest to the most heroic, and with results as various as the plans. It would bę impossible for me to describe all the different plans pursued, and I must therefore confine myself to a few general remarks upon this topic.

Some cases were known to recover without any medical aid

whatever. Many physicians say they succeeded best with a comparatively mild or gentle course of treatment, taking the range of all the most approved remedies in this disease, but using them in moderate doses, and according to the indications apparent in the natural course of the disease; whilst others, again, boldly undertook to cut short and cure the fever by the prompt use of powerful remedies. From 1847 to 1853, I succeeded in doing this myself, as did several other physicians in New Orleans, in a very satisfactory manner, by large doses of the sulph. quiniæ and opium at the onset, followed by moderate doses of calomel or blue mass. These were the chief remedies relied on, though others of less force were used as adjuvants. In my published accounts of this practice, I admitted that the type of yellow fever thus so readily mastered was mild, and that it remained to be seen whether it would succeed equally well in a more malignant type of the disease. Candor requires me now to state that this abortive practice did not answer my expectations in the late epidemic, and that after giving it a fair trial I abandoned it, and fell upon a milder course of treatment, which proved more satisfactory. I finally dropped the sulphate of quiniæ altogether, and resorted to the ferro-cyanuret, combined with blue mass and, sometimes morphia. Experience has taught me that quiniæ is most beneficial in the first stage, and that it should rarely be ventured on even so late as the end of the second day. I do not recollect ever to have seen good effects from it when given in large doses after the second day; but often the contrary. I believe that quinine operates in two ways: first, as a specific antidote to the fever poison; and secondly, as a powerful depurator of the blood, by the copious perspiration it induces. Now, if this view be correct, it may readily be conceived why this remedy should produce its happiest effects in the first stage of the disease, as it is then that the supposed poison is floating in the current of the circulation,—then the perturbation of the system is chiefly, if not entirely, functional, and has not continued long enough to cause organic lesion of any important part. That quinine, when administered by the mouth, the rectum, on blistered surfaces, and even by inhalation through the lungs, does readily find its way into the blood, and is eliminated in the urinary secretion, has been completely demonstrated, and must be admitted as a fact. In regard to the perceptible effects of quinine on the human system, we see none that may not be equally or even more powerfully produced by other remedies; yet none of these medicines display such decided curative power in the treatment of fevers as quinine; hence we are led to the inference, that quinine must possess specific virtues in

these affections. Dr. Boling, of Alabama, and others, have asserted that quinine is highly beneficial in pneumonia and some other inflammatory diseases occurring in miasmatic districts; and so have I; but I have not observed like good effects from this remedy in the inflammations that commonly supervene in the course of idiopathic fevers, such as cerebritis, gastritis, gastroduodenitis, etc. When these organic lesions set in, they require special attention. I know of no remedy but cinchona that possesses specific virtue in the cure of our Southern endemic fevers. We may bleed, sweat, puke, purge, stimulate, depress, heat, cool, and vesicate; and, doubtless, the judicious application of such means often affords very great assistance to the constitution in its struggles against the deadly assaults of these fevers; but that is all they can do. But we find in cinchona a remedy, which, if introduced into the system early enough and in sufficient quantity, possesses the power of curing these diseases in a great many instances, without any other aid whatever.

So early as the year 1800, two distinguished Spanish physicians, Drs. Lafuente and Bobadilla, (the former consulting physician to the royal armies), discovered and published to the world, that the malignant yellow fever prevailing in Spain at that day could be completely cut short and cured by from six to eight ounces of Peruvian bark, taken within the first forty-eight hours from the attack. Their dose was two or three drachms repeated every two hours, commencing immediately after the chill. At first, they gave a gentle emetic to "clean the stomach;" but this practice was abandoned, because it often left the stomach so irritable that it could not retain the bark. They then gave some cream of tartar with the first doses, for the purpose of opening the bowels; but this was afterwards found useless; and, finally, the bark was relied on alone, and the success was extraordinary.

"Of ninety-seven persons who were attacked with this fever in the village of Barreos, and who took these six or eight ounces of bark within forty-eight hours of the attack, commencing from the first to the eighth hour, all quelled the disorder in its origin, one excepted, who perished, having at the same time an attack of the gout. Of eight who took the same quantity, commencing from the eighth to the tenth hour, all were cured. Of five who began to take it from the tenth to the twenty-fourth hour, three recovered and two died. Of seventeen, who began the third and fourth days, eight recovered and nine died; and, finally, of eightynine, who were treated as they chose, but in a different manner (including the sudorific plan,) only twenty recovered."

*New Orleans Med. and Surg. Journ., vol. iv. p. 248. Extract from Philadelphia Medical and Physical Journal for 1808.

This would appear to show, not only the wonderful powers of cinchona in the cure of yellow fever, but also, that the physicians of the present day were anticipated by a long period in their practice of curing yellow fever with the alkaloids derived from that article. But I must hasten to a close.

I do not maintain that quinine is the only remedy that is beneficial in yellow fever, or that what is called "the quinine treatment" is the only method that can be relied on; on the contrary, I have not the least doubt but that the skillful use of other remedies, together with careful nursing, may enable nature to overcome the disease in a great majority of cases, without the use of a single particle of quinine. A few years ago, the late Dr. Luzenberg, and several of our French physicians, treated yellow fever quite successfully, almost with the lancet alone. Some of our physicians who were formerly much prejudiced against quinine in yellow fever, now prescribe it freely; whilst others, who once considered it almost a sovereign remedy in this disease, now prescribe it very cautiously. That this invaluable medicine was often injudiciously prescribed, and sometimes produced injurious effects in the late epidemic, cannot be denied; but this is not sufficient cause for condeming it entirely. On such grounds, every potent remedy in the materia medica would be ostracised

at once.

Let us now endeavor to lay down something like the principles of practice in yellow fever. Before this can be done, we must have definite and correct ideas of the nature or pathology of the disease, of its natural course from the beginning to the close of an attack, and of the manner in which it terminates, whether it be in convalescene or death. The changes produced in the organisni by the morbific cause, may be discovered by examination after death. In these examinations, however, we see only the results of morbid action; and, as before stated, I am not aware that these discoveries have thrown much light either upon the modus operandi of the morbific cause, or the best method of counteracting its baneful effects.

We

We are called to a patient, I will say within two or three hours after he is attacked, and are told that he was taken with a chill, accompanied by headache and pain in the back and limbs; and that on going to bed, and covering up warmly, this condition was soon followed by the symptoms now before us. find him with violent pains in the head and back; his skin is burning; countenance flushed and swollen; eyes red; pulse frequent, full and bounding; thirst intense; stomach uneasy; sometimes nausea and vomiting, restlessness, &c. We recognize this