Chapter V: Front Matter (5)

8. Washing the floors of houses with a solution of alkaline salts in water, has been recommended by Dr. Mitchell, as an antidote to malignant fevers. As yet, I believe, there are no facts which establish the efficacy of the practice, when they are produced by exhalations from decayed vegetable and animal substances in a putrid state.

9. Large fires have sometimes been made in cities, in order to destroy the miasmata of pestilential diseases. They were obviously hurtful in the plague of London, in the year 1665. Dr. Hodges, who relates this fact, says, "Heaven wept for the mistake of kindling them, and mercifully put them out, with showers of rain."

I cannot conclude this head, without lamenting the want of laws in all our states, to compel physicians to make public the first cases of malignant fever that come under their notice. The cry of fire is not more useful to save a city from destruction, than the early knowledge of such cases would be to save it from the ravages of pestilential and mortal epidemics. Hundreds of instances have occurred, in all ages and countries, in which they might have been stifled in their birth, by the means that have been mentioned, had this practice been adopted. But when, and where, will science, humanity, and government first combine to accomplish this salutary purpose? Most of our histories of mortal epidemics abound with facts which show a contrary disposition and conduct in physicians, rulers, and the people. I shall mention one of these facts only, to show how far we must travel over mountains of prejudice and error, before we shall witness that desirable event. It is extracted from the second volume of the Life of the late Empress of Russia. "The Russian army (says the biographer), after defeating the Turks, on entering their territories were met by the plague, and brought it to their country, where the folly of several of their generals contributed to its propagation, as if they thought by a military word of command to alter the nature of things. Lieutenantgeneral Stoffeln, at Yassy, where the pestilence raged in the winter of 1770, issued peremptory orders that its name should not be pronounced; he even obliged the physicians and surgeons to draw up a declaration in writing, that it was only _a spotted fever_. One honest surgeon of the name of Kluge refused to sign it. In this manner the season of prevention was neglected. Several thousand Russian soldiers were by this means carried off. The men fell dead upon the road in heaps. The number of burghers that died was never known, as they had run into the country, and into the forests. At length the havoc of death reached the general's own people: he remained true to his persuasion, left the town, and went into the more perilous camp. But his intrepidity availed him nothing; he died of the plague in July, 1771[21]."

[21] The above disease appears to have been the camp fever, the origin
and character of which will be noticed in the next article.

III. Let us now consider, in the last place, the means of exterminating malignant and other forms of summer and autumnal disease, by removing their causes. These means are,

1. The removal or destruction of all those putrid matters formerly enumerated, which are capable of producing fevers. Many of the institutions of the Jewish nation, for this purpose, are worthy of our imitation. The following verses contain a fund of useful knowledge upon this subject.--"Thou shalt have a place without the camp, whether thou shalt go forth abroad; and shalt have a paddle upon thy weapon, and it shall be when thou wilt ease thyself abroad, thou shalt dig therewith, and shalt turn back, and cover that which cometh from thee; for the Lord thy God walketh in the midst of thy camp to deliver thee, therefore shall he _see no unclean thing in thee_, and turn away from thee." Deuteronomy, chapter xxiii. verses 12, 13, and 14. "But the flesh of the bullock, and his skin, and his dung, shalt thou _burn with fire without the camp_." Exodus, chapter xxxix. verse 14. The advantages of thus burying and removing all putrid matters, and of burning such as were disposed to a speedy putrefaction, in a crowded camp, and in a warm climate, are very obvious. Their benefits have often been realized in other countries. The United Provinces of Holland hold their exemption from the plague, only by the tenure of their cleanliness. In the character given by Luther of Pope Julius, he says, "he kept the streets of Rome so clean and sweet, that there were no plagues nor sicknesses during his time." The city of Oxford was prepared to afford an asylum to the royal family of Great-Britain from the plague, when it ravaged London, and other parts of England, in the year 1665, only in consequence of its having been cleaned, some years before, by the Bishop of Winchester. In a manuscript account of the life of Doctor, afterwards Governor Colden, of New-York, there is the following fact. It was first communicated to the public in the daily gazette of the capital of that state, on the 30th of October, 1799. "A malignant fever having raged with exceeding violence for two summers successively in the city of New-York, about forty years ago, he communicated his thoughts to the public, on the most probable cure of the calamity. He published a little treatise on the occasion, in which he collected the sentiments of the best authority, on the bad effects of _stagnating waters_, _moist air_, _damp cellars_, _filthy shores_, and _dirty streets_. He showed how much these nuisances prevailed in many parts of the city, and pointed out the remedies. The corporation of the city voted him their thanks, adopted his reasoning, and established a plan for draining and cleaning the city, which was attended with the most happy effects." The advantages of burning offal matters, capable by putrefaction of producing fevers, has been demonstrated by those housekeepers, who, instead of collecting the entrails of fish and poultry, and the parings and skins of vegetables, in barrels, instantly throw them into their kitchen fires. The families of such persons are generally healthy.

2. In the construction of cities, narrow streets and alleys should be carefully avoided. Deep lots should be reserved for yards and gardens for all the houses, and subterraneous passages should be dug to convey, when practicable, to running water, the contents of privies, and the foul water of kitchens. In cities that are wholly supplied with fresh water by pipes from neighbouring springs or rivers, all the evils from privies might be prevented by digging them so deep as to connect them with water. Great advantages, it has been suggested, would arise in the construction of cities, from leaving open squares, equal in number and size to those which are covered with houses. The light and dark squares of a chequer-board might serve as models for the execution of such a plan. The city of London, which had been afflicted nearly every year for above half a century by the plague, has never been visited by it since the year 1666. In that memorable year, while the inhabitants were venting their execrations upon a harmless bale of silks imported from Holland, as the vehicle of the seeds of their late mortal epidemic, Heaven kindly pointed out, and removed its cause, by permitting a fire to destroy whole streets and lanes of small wooden buildings, which had been the reservoirs of filth for centuries, and thereby the sources of all the plagues of that city[22]. Those streets and lanes were to London, what Water-street and Farmer's-row are to Philadelphia, Fell's-point to Baltimore, the slips and docks to New-York, and Water-street to the town of Norfolk.

[22] A proposal was made to replace the houses that had been burnt, by
similar buildings, and upon the same space of ground. Sir
Christopher Wren opposed it, and with the following argument: "By
so doing, you will show you have not _deserved_ the late fire!"

3. Where the different forms of summer and autumnal disease arise from marsh exhalations, they should be destroyed by drains, by wells communicating with their subterraneous springs, or by cultivating upon them certain grasses, which form a kind of mat over the soil, and, when none of these modes of destroying them is practicable, by overflowing them with water.

I have met with many excellent quotations from a work upon this part of our subject, by Tozzetti, an Italian physician, from which, I have no doubt, much useful information might be obtained. The Rev. Thomas Hall, to whom I made an unsuccessful application for this work, speaks of it, in his answer to my letter, in the following terms. "It is in such high estimation, that the late emperor Leopold, when grand duke of Tuscany, caused it to be re-printed at his own expence, and presented it to his friends. The consequence of this was, it influenced the owners of low marshy grounds, in the neighbourhood of the river Arno, to drain and cultivate them, and thereby rendered the abode of noxious air, and malignant fevers, a terrestrial paradise."

4. The summer and autumnal diseases of our country have often followed the erection of mill-dams. They may easily be obviated by surrounding those receptacles of water with trees, which prevent the sun's acting upon their shores, so as to exhale miasmata from them. Trees planted upon the sides of creeks and rivers, near a house, serve the same salutary purpose.

5. It has often been observed, that families enjoy good health, for many years, in the swamps of Delaware and North-Carolina, while they are in their natural state, but that sickness always follows the action of the rays of the sun upon the moist surface of the earth, after they are cleared. For this reason, the cultivation of a country should always follow the cutting down of its timber, in order to prevent the new ground becoming, by its exhalations, a source of disease.

6. In commercial cities, no vessel that arrives with a cargo of putrescent articles should ever be suffered to approach a wharf, before the air that has been confined in her hold has been discharged. The same thing should be done after the arrival of a vessel from a distant or hot country, though her cargo be not capable of putrefaction, for air acquires a morbid quality by stagnating contiguous to wood, under circumstances formerly mentioned.

All these modes of removing the causes of malignant and yellow fevers, and of promoting strict and universal cleanliness, are of more consequence in the middle and northern states of America, than in countries uniformly warm, inasmuch as the disease may be taken as often as our inhabitants are exposed to its sources. In the West-Indies, a second attack of the yellow fever is prevented by the insensibility induced upon the system, by its being constantly exposed to the impressions of heat and exhalation. After a seasoning, as it is called, or a residence of two or three years in those islands, the miasmata affect the old settlers, as they do the natives, only with mild remittents. Nearly the same thing takes place at Madras, in the East-Indies, where, Dr. Clark says, the exhalations which bring on bilious fevers, colic, cholera, and spasmodic affections in new comers, produce a puking in the morning, only in old residents. But very different is the condition of the inhabitants of the middle and northern states of America, in whom the winters prevent the acquisition of habits of insensibility to the heat and exhalations of the previous summers, and thus place them every year in the condition of new comers in the West and East-Indies, or of persons who have spent two or three years in a cold climate. This circumstance increases the danger of depopulation from our malignant epidemics, and should produce corresponding exertions to prevent them.

In enumerating the various means of preventing and exterminating the malignant forms of fever, it may appear strange that I have said nothing of the efficacy of quarantines for that purpose. Did I believe these pages would be read only by the citizens of Pennsylvania, I would do homage to their prejudices, by passing over this subject by a respectful and melancholy silence; but as it is probable they will fall into the hands of physicians and citizens of other states, I feel myself under an obligation to declare, that I believe quarantines are of no efficacy in preventing the yellow fever, in any other way than by excluding the unwholesome air that is generated in the holds of ships, which may be done as easily in a single day, as in weeks or months. They originated in error, and have been kept up by a supine and traditional faith in the opinions and conduct of our ancestors in medicine. Millions of dollars have been wasted by them. From their influence, the commerce, agriculture, and manufactures of our country have suffered for many years. But this is not all. Thousands of lives have been sacrificed, by that faith in their efficacy, which has led to the neglect of domestic cleanliness. Distressing as these evils are, still greater have originated from them; for a belief in the contagious nature of the yellow fever, which is so solemnly enforced by the execution of quarantine laws, has demoralized our citizens. It has, in many instances, extinguished friendship, annihilated religion, and violated the sacraments of nature, by resisting even the loud and vehement cries of filial and parental blood.

While I thus deny the yellow fever to be the offspring of a specific contagion, and of course incapable of being imported so as to become an epidemic in any country, I shall admit presently, that the excretions of a patient in this disease may, by confinement, become so acrid as to produce, under circumstances to be mentioned hereafter, a similar disease in a person, but from this person it cannot be communicated, if he possess only the common advantages of pure air and cleanliness. To enforce a quarantine law, therefore, under such a contingent circumstance, and at the expence of such a profusion of blessings as have been mentioned, is to imitate the conduct of the man, who, in attempting to kill a fly upon his child's forehead, knocked out its brains.

From the detail that has been given of the sources of malignant fevers, and of the means of preventing them, it is evident that they do not exist by an unchangeable law of nature, and that Heaven has surrendered every part of the globe to man, in a state capable of being inhabited, and enjoyed. The facts that have been mentioned show further, the connection of health and longevity, with the reason and labour of man.

To every natural evil the Author of Nature has kindly prepared an antidote. Pestilential fevers furnish no exception to this remark. The means of preventing them are as much under the power of human reason and industry, as the means of preventing the evils of lightning and common fire. I am so satisfied of the truth of this opinion, that I look for a time when our courts of law shall punish cities and villages, for permitting any of the sources of bilious and malignant fevers to exist within their jurisdiction.

I have repeatedly asserted the yellow fever of the United States not to be contagious. I shall now mention the proofs of that assertion, and endeavour to explain instances of its supposed contagion upon other principles.

FACTS,

INTENDED TO PROVE

_THE YELLOW FEVER_

NOT TO BE CONTAGIOUS.

When fevers are communicated from one person to another, it is always in one of the following ways. 1. By secreted matters. 2. By excreted matters. The small-pox and measles are communicated in the former way; the jail, or, as it is sometimes called, the ship, or camp, and hospital fever, is communicated only by means of the excretions of the body. The perspiration, by acquiring a morbid and irritating quality more readily than any other excretion, in consequence of its stagnation and confinement to the body in a tedious jail fever, is the principal means of its propagation. The perspiration[23] is, moreover, predisposed to acquire this morbid and acrid quality by the filthiness, scanty, or bad aliment, and depression of mind, which generally precede that fever. It is confined to sailors, passengers, soldiers, prisoners, and patients, in foul and crowded ships, tents, jails, and hospitals, and to poor people who live in small, damp, and confined houses. It prevails chiefly in cool and cold weather, but is never epidemic; for the excreted matters which produce the fever do not float in the external atmosphere, nor are they communicated, so as to produce disease, more than a few feet from the persons who exhale them. They are sometimes communicated by means of the clothes which have been worn by the sick, and there have been instances in which the fever has been produced by persons who had not been confined by it, but who had previously been exposed to all the causes which generate it. It has been but little known in the United States since the revolutionary war, at which time it prevailed with great mortality in the hospitals and camps of the American army. It has now and then appeared in ships that were crowded with passengers from different parts of Europe. It is a common disease in the manufacturing towns of Great-Britain, where it has been the subject of several valuable publications, particularly by Dr. Smith and Dr. John Hunter. Dr. Haygarth has likewise written upon it, but he has unfortunately confounded it with the West-India and American yellow fever, which differs from it in prevailing chiefly in warm climates and seasons; in being the offspring of dead and putrid vegetable and animal matters; in affecting chiefly young and robust habits; in being generally accompanied with a diseased state of the stomach, and an obstruction or preternatural secretion and excretion of bile; in terminating, most commonly, within seven days; in becoming epidemic _only_ by means of an impure atmosphere; and in not furnishing ordinarily those excretions which, when received into other bodies, reproduce the same disease.

[23] The deleterious nature of this fluid, and its disposition to
create disease, under the above circumstances, has been happily
illustrated by Dr. Mitchill, in an ingenious letter to Dr. Duncan,
of Edinburgh, published in the fourth volume of the Annals of
Medicine.

I have been compelled to employ this tedious description of two forms of fever, widely different from each other in their causes, symptoms, and duration, from the want of two words which shall designate them. Dr. Miller has boldly and ingeniously proposed to remedy this deficiency in our language, by calling the former _idio-miasmatic_, and the latter _koino-miasmatic_ fevers, thereby denoting their _private_ or _personal_, and their _public_ or _common_ origin[24]. My best wishes attend the adoption of those terms!

[24] Medical Repository, hexade ii. vol. i.

I return to remark, that the yellow fever is not contagious in its simple state, and that it spreads exclusively by means of exhalations from putrid matters, which are diffused in the air. This is evident from the following considerations:

1. It does not spread by contagion in the West-Indies. This has been proved in the most satisfactory manner by Drs. Hillary, Huck, Hunter, Hector M'Lean, Clark, Jackson, Borland, Pinckard, and Scott. Dr. Chisholm stands alone, among modern physicians, in maintaining a contrary opinion. It would be easy to prove, from many passages in the late edition of the doctor's learned and instructive volumes, that he has been mistaken; and that the disease was an endemic of every island in which he supposed it to be derived from contagion. A just idea of the great incorrectness of all his statements, in favour of his opinion, may be formed from the letter of J. F. Eckard, Esq. Danish consul, in Philadelphia, to Dr. James Mease, published in a late number of the New-York Medical Repository[25].

[25] For February, March, and April, 1804.

2. The yellow fever does not spread in the country, when carried thither from the cities of the United States.

3. It does not spread in yellow fever hospitals, when they are situated beyond the influence of the impure air in which it is generated.

4. It does not spread in cities (as will appear hereafter) from any specific matter emitted from the bodies of sick people.

5. It generally requires the co-operation of an _exciting_ cause, with miasmata, to produce it. This is never the case with diseases which are universally acknowledged to be contagious.

6. It is not propagated by the artificial means which propagate contagious diseases. Dr. Ffirth inoculated himself above twenty times, in different parts of his body, with the black matter discharged from the stomachs of patients in the yellow fever, and several times with the serum of the blood, and the saliva of patients ill with that disease, without being infected by them; nor was he indisposed after swallowing half an ounce of the black matter recently ejected from the stomach, nor by exposing himself to the vapour which was produced by throwing a quantity of that matter upon iron heated over a fire[26].

[26] Inaugural Dissertation on Malignant Fever, &c. published in June,
1804.

To the first four of these assertions there are some seeming exceptions in favour of the propagation of this fever by contagion. I shall briefly mention them, and endeavour to explain them upon other principles.

The circumstances which seem to favour the communication of the yellow fever from one person to another, by means of what has been supposed to be contagion, are as follow:

1. A patient being attended in a small, filthy, and _close_ room. The excretions of the body, when thus accumulated, undergo an additional putrefactive process, and acquire the same properties as those putrid animal matters which are known to produce malignant fevers. I have heard of two or three instances in which a fever was produced by these means in the country, remote from the place where it originated, as well as from every external source of putrid exhalation. The plague is sometimes propagated in this way in the low and filthy huts which compose the alleys and narrow streets of Cairo, Smyrna, and Constantinople.

2. A person sleeping in the sheets, or upon a bed impregnated with the sweats or other excretions, or being exposed to the smell of the foul linen, or other clothing of persons who had the yellow fever. The disease here, as in the former case, is communicated in the same way as from any other putrid animal matters. It was once received in Philadelphia from the effluvia of a chest of unwashed clothes, which had belonged to one of our citizens who had died with it in Barbadoes; but it extended no further in a large family than to the person who opened the chest. I have heard of but two instances more of its having been propagated by these means in the United States, in which case the disease perished with the unfortunate subjects of it.

To the above insolated cases of the yellow fever being produced by the clothing of persons who had died of it, I shall oppose a fact communicated to me by Dr. Mease. While the doctor resided at the lazaretto, as inspector of sickly vessels, between May, 1794, and the same month in 1798, the clothing contained in the chests and trunks of all the seamen and others, belonging to Philadelphia, who had died of the yellow fever in the West-Indies, or on their passage home, and the linen of all the persons who had been sent from the city to the lazaretto with that disease, amounting in all to more than one hundred, were opened, exposed to the air, and washed, by the family of the steward of the hospital, and yet no one of them contracted the least indisposition from them.

I am disposed to believe the linen, or any other clothing of a person in good health that had been strongly impregnated with sweats, and afterwards suffered to putrify in a confined place, would be more apt to produce a yellow fever in a summer or autumnal month, than the linen of a person who had died of that disease, with the usual absence of a moisture on the skin. The changes which the healthy excretions by the pores undergo by putrefaction, may easily be conceived, by recollecting the offensive smell which a pocket-handkerchief acquires that has been used for two or three days to wipe away the sweat of the face and hands in warm weather[27].

[27] See Van Swieten on Epidemic Diseases, Aphorism 1408.

3. The protraction of a yellow fever to such a period as to dispose it to assume the symptoms, and to generate the peculiar and highly volatilised exhalation from the pores of the skin which takes place in the jail fever. I am happy in finding I am not the author of this opinion. Sir John Pringle, Dr. Monro, and Dr. Hillary, speak of a contagious fever produced by the combined action of marsh and human miasmata. The first of those physicians supposes the Hungarian bilious fever, which prevailed over the continent of Europe in the seventeenth century, was sometimes propagated in this way, as well as by marsh and other putrid exhalations. Dr. Richard Pearson, in his observations upon the bilious fevers which prevailed in the neighbourhood of Birmingham, in England, in the years 1797, 1798, and 1799, has the following remark: "In its first stage, this fever did not appear to be contagious, but it evidently was so after the eleventh and fourteenth day, when the _typhoid_ state was induced[28]." As this protracted state of bilious fever rarely occurs in our country, it has seldom been communicated in this way.

[28] Page 13.

It is not peculiar, I believe, to a bilious and yellow fever, when much protracted beyond its ordinary duration, to put on the symptoms of the jail fever. The same appearances occur in the pleurisy, and in other, of what Dr. Sydenham calls _intercurrent_ fevers, all of which I have no doubt, under certain circumstances of filth, confinement, and long duration, would produce a fever in persons who were exposed to it. This fever, if the weather were cold, would probably put on inflammatory symptoms, and be added, in our nosologies, to the class of contagious diseases.

From the necessary influence of time, in thus rendering fevers of all kinds now and then contagious by excretion, it follows, that the yellow fever, when of its usual short duration, is incapable of generating that excretion, and that, instead of being considered as the only form of bilious fever that possesses a power of propagating itself, it should be considered as the only one that is devoid of it.

4. Miasmata, whether from marshes, or other external sources, acting upon a system previously impregnated with the excreted matters which produce the jail or ship fever. Mr. Lempriere informs us, that he saw what were supposed to be cases of yellow fever communicated by some sailors who brought the seeds of the ship fever with them to the island of Jamaica. The fevers which affected most of the crews of the Hussar frigate, mentioned by Dr. Trotter[29], and of the Busbridge Indiaman, described by Mr. Bryce[30], appear to have been the effect of the combined operation of foul air in those ships, and human excretions, upon their systems. The disease was barely tinged with bilious symptoms, and hence the facility with which it was cured, for the jail fever more readily yields to medicine than the yellow fever. The former was probably excited by some latent exhalation from dead matters in the holds of the ships, and hence we find it ceased on shore, where it was deprived of its exciting cause. It is true, great pains were taken to clean the hold and decks of the Busbridge, but there are foul matters which adhere to the timbers of ships, and which, according to Dr. Lind, are sometimes generated by those timbers when new, that are not to be destroyed by any of the common means employed for that purpose. Of this Dr. Kollock has furnished us with a most satisfactory proof, in his history of the yellow fever, which prevailed on board of the frigate General Greene, on her voyage to the Havanna, in the year 1799. "The air in the hold of the vessel (says the doctor) was so contaminated, as to extinguish lights immediately, and candles in the cockpit were almost as useless from the same cause. The fish were thrown overboard, and the decks washed and scoured, the ventilator and wind sails put in motion, and every measure of purification adopted that their situation allowed; notwithstanding these precautions disease invaded us. The men were unceasing in their exertions to purify the ship; washing, scouring with vinegar, burning powder and vinegar, old junk, and sulphur, added to constant ventilation, proved unequal even to the amelioration of their calamities, while they were in the latitude of _great heat_. After the removal of the sick, the ship was disburthened of her stores, ballast, &c. cleansed and white-washed throughout; still new cases occurred for nearly two months. Some days, two, three, or four were sent off to the hospital, which would seem to indicate the retention of some portion of this noxious principle, which was lodged beyond the reach of the cleansing process." That this noxious principle or matter existed in the ship, and not in the bodies of the crew, is evident from its not having been communicated, in a single instance by a hundred of them who were sent to an hospital on Rhode-Island, notwithstanding an intercourse sufficient to propagate it was necessarily kept up with the inhabitants. Even their nurses did not take it[31].

[29] Medicina Nautica, p. 360.

[30] Annals of Medicine, vol. i. p. 116.

[31] Medical Repository, vol. iv. No. 1.

5. A fifth instance in which contagion has been supposed to take place in the yellow fever is, where the exhalation from the excretions of a patient in that disease acts as an _exciting_ cause, in persons previously impregnated with the marsh, or other external miasmata, which produce it. The activity of this exhalation, even when it is attended with no smell, is so great, as to induce sickness, head-ach, vertigo, and fainting. It is not peculiar to the exhalations from such patients to produce morbid effects upon persons who visit them. The odour emitted by persons in the confluent small-pox has been known to produce the same symptoms, together with a subsequent fever and apthous sore throat. This has been remarked long ago by Dr. Lind, and latterly by Dr. Willan, in his Reports of the Diseases of London[32]. That the yellow fever is often excited in this way, without the intervention of a supposed specific contagion, I infer from its sometimes spreading through whole families, who have breathed the same impure atmosphere with the person first infected by the fever. This is more especially the case where the impression made by the exhalation from the sick person is assisted by fear, fatigue, or anxiety of mind in other branches of the family. In favour of this mode of exciting the yellow fever, Dr. Otto communicated to me the following fact. In the autumn of the year 1798, it prevailed upon the _shores_ of the Delaware, in Gloucester county, in New-Jersey. A mild remittent prevailed at the same time on the _high_ grounds, a few miles from the river. During this time, the doctor observed, if a person who had inhaled the seeds of the yellow fever in Philadelphia afterwards came into a family _near_ the river, the same disease appeared in several instances in one or more branches of that family; but where persons brought the fever from the city, and went into a family on the _high_ grounds, where the mild remittents prevailed, there was not a single instance of a yellow fever being excited by them in any of its members. This fact is important, and of extensive application. It places the stimulus from the breath, or other exhalations of persons affected by the yellow fever, upon a footing with intemperance, fatigue, heat, and all the common exciting causes of the disease; none of which, it is well known, can produce it, except in persons who have previously inhaled the putrid miasmata, which in all countries are its only remote cause. The city of Philadelphia has furnished, in all our yellow fever years, many additional proofs of the correctness of Dr. Otto's remark. In the months of July and August, when miasmata are generally local, and float chiefly near to their hot beds, the docks and holds of ships, persons who are affected by these miasmata, and sicken in other parts of the city, never communicate the disease; but after the less prepared and heterogeneous filth of our whole city has been acted on by an autumnal, as well as summer sun, so as to emit pestilential exhalations into all our streets and alleys, the fever is now and then excited in the manner that has been mentioned, by a single person in a whole family. The common intermittents of the southern states are often excited in the same way, without being suspected of spreading by contagion. Even the jail or hospital fever is vindicated by Dr. Hunter from the highly contagious nature which has been ascribed to it, upon the same principle. His words, which are directly to my purpose, are as follow: "In considering the extent and power of the contagion [meaning of the jail or hospital fever], I am not inclined to impute to this cause the fevers of all those who are taken ill in one family after the first, as they are all along exposed to the same vitiated air which occasions the first fever. In like manner, when a poor woman visits some of her sick neighbours, and is taken ill herself, and afterwards some of her children, I would not impute the disease to infection alone; she and her family having previously lived in the same kind of vitiated air which originally produced the fever. If the cases in which the infection meets with the poison already _half formed_ be excepted, the disease in itself will be found to be much less infectious than has been commonly supposed[33]." By the modes of communicating the yellow fever which have been admitted, the dysentery, and all the milder forms of autumnal fevers, have been occasionally propagated, and perhaps oftener than the first-named disease, from their being more apt to run on to the typhus or chronic state. Of this I could adduce many proofs, not only from books, but from my own observations; but none of these diseases spread by contagion, or become epidemic from that cause in any country. A contrary opinion, I know, is held by Dr. Cleghorn, and Dr. Clarke; but they have deceived themselves, as they formerly deceived me, by not attending to the difference between secreted contagions and morbid excretions from the body, produced by the causes which have been enumerated, and which are rare and accidental concomitants of bilious or summer diseases.

[32] Page 13 and 113.

[33] Medical Transactions, vol. iii. p. 351.

6. The last instance of supposed contagion of the yellow fever is said to arise from the effluvia of a putrid body that has died of that disease. The effluvia in this case act either as the putrified excretions mentioned under the first head, or as an exciting cause upon miasmata, previously received into the system. A dead body, in a state of putrefaction from any other disease, would produce, under the same circumstances of season and predisposition, the same kind and degrees of fever.

The similarity of the fever induced by the means that have been enumerated, with the fever from which it was derived, has been supposed to favour the opinion of its being communicated by a specific contagion. But let it be recollected that the yellow fever is, at the time of its being supposed to be thus received, the reigning epidemic, and that irritants of all kinds necessarily produce that disease. The morbid sweats which now and then produce an intermitting fever, and the alvine excretions which occasionally produce a dysentery, act only by exciting morbid actions in the system, which conform in their symptoms to an immutable and universal law of epidemics. It is only when those two diseases generally prevail, that they seem to produce each other.

Thus have I explained all the supposed cases of contagion of the yellow fever. To infer from the solitary instances of it thus excited, is to reason as incorrectly as to say the small-pox is not contagious, because we now and then meet with persons who cannot be infected by it.

From the explanation that has been given of the instances of supposed contagion of the yellow fever, we are compelled to resort to certain noxious qualities in the atmosphere, as the exclusive causes of the prevalence, not only of that fever, but (with a few exceptions) of all other epidemic diseases. It is true, we are as yet ignorant of the precise nature of those qualities in the air which produce epidemics; but their effects are as certainly felt by the human body as the effects of heat, and yet who knows the nature of that great and universal principle of activity in our globe?

That the yellow fever is propagated by means of an impure atmosphere, at all times, and in all places, I infer from the following facts:

1. It appears only in those climates and seasons of the year in which heat, acting upon moist animal and vegetable matters, fills the air with their putrid exhalations. A vertical sun, pouring its beams for ages upon a dry soil; and swamps, defended from the influence of the sun by extensive forests, have not, in a single instance, produced this disease.

2. It is unknown in places where a connection is not perceptible between it, and marshes, mill-ponds, docks, gutters, sinks, unventilated ships, and other sources of noxious air. The truth of this remark is established by the testimonies of Dr. Lind and Dr. Chisholm, and by many facts in Lempriere's excellent History of the Diseases of Jamaica. Dr. Davidson furnished me with a striking confirmation of their remarks, in the following extract from a letter, dated November 12th, 1794. "I have mentioned (says the doctor) an instance of the remarkable good health which the 66th regiment enjoyed at St. Vincents for several years, upon a high hill above the town, removed from all exhalations, and in a situation kept at all times cool by the blowing of a constant trade wind. They did not lose, during eighteen months, above two or three men (the regiment was completed to the peace establishment), and during eight years they lost but two officers, one of whom, the quarter-master, resided constantly in town, and died from over fatigue; the other arrived very ill from Antigua, and died within a few days afterwards."

In the United States, no advocate for the specific nature or importation of the yellow fever, has ever been able to discover a single case of it beyond the influence of an atmosphere rendered impure by putrid exhalations.

It is no objection to the truth of this remark, that malignant bilious fevers sometimes appear upon the summits of hills, while their declivities, and the vallies below, are exempted from them. The miasmata, in all these cases, are arrested by those heights, and are always to be traced to putrefaction and exhalation in their neighbourhood. Nor is it any objection to the indissoluble connection between putrid exhalations and the yellow fever, which has been mentioned, that the disease sometimes appears in places remote from the source of miasmata in _time_ and _place_. The bilious pleurisies, which occur in the winter and spring, after a sickly autumn, prove that they are retained in the body for many months, and although they are sometimes limited in their extent to a single house, and often to a village, a city, and the banks of a creek or river, yet they are now and then carried to a much greater distance. Mr. Lempriere, in his valuable Observations upon the Diseases of the British Army in Jamaica, informs us, that Kingston is sometimes rendered sickly by exhalations from a lagoon, which lies _nine_ miles to the eastward of that town[34]. The greater or less distance, to which miasmata are carried from the place where they are generated, appears to depend upon their quantity, upon the force and duration of currents of wind which act upon them, and upon their being more or less opposed by rivers, woods, water, houses, wells, or mountains.

[34] Vol. i. p. 84.

3. It is destroyed, like its fraternal diseases, the common bilious and intermitting fevers, by means of _long-continued_ and _heavy_ rains[35]. When rains are heavy, but of short duration, they suspend it only in warm weather; but when they are succeeded by cold weather, they destroy all the forms of bilious fever. The malignant tertians, described by Dr. Cleghorn, always ceased about the autumnal equinox; for at that time, says the doctor, "Rain falls in such torrents as to tear up trees by the roots, carry away cattle, break down fences, and do considerable mischief to the gardens and vineyards; but, after a long and scorching summer, they are very acceptable and beneficial, for they mitigate the excessive heat of the air, and give a check to epidemical diseases[36]." There are facts, however, which would seem to contradict the assertion that miasmata are suspended or destroyed by heavy rains. Dr. Lind, in his Treatise upon the Diseases of Hot Climates, mentions instances in which they suddenly created fevers. It is probable, in these cases the rains may have had that effect, by disturbing the pellicle which time often throws over the surface of stagnating pools of water, and putrid matters on dry land. I was led to entertain this opinion by a fact mentioned in a letter I received from Dr. Davidson, dated November 4th, 1794. "Being ordered (says the doctor) up to Barbadoes, last November, upon service, I found that the troops had suffered considerably by that formidable scourge, the yellow fever. The season had been remarkably dry. It was observed, a rainy season contributed to make the season healthier, excepting at Constitution-Hill, where the sixth regiment was stationed, and where a heavy shower of rain seldom failed to bring back the fever, after it had ceased for some time. I found the barrack, where this regiment was, surrounded by a pond of brackish water, which, being but imperfectly drained by the continuance of the drought, the surface was covered with a green scum, which prevented the exhalation of marshy putrefaction. After a heavy shower of rain, this scum was broken, and the miasmata evolved, and acted with double force, according to the time of their secretion."

[35] Clarke on the Diseases of Long Voyages to Hot Climates, p. 116.

[36] Diseases of Minorca, p. 8.

4. It is completely destroyed by frost. As neither rains nor frosts act in sick rooms, nor affect the bodies of sick people, they must annihilate the disease by acting exclusively upon the atmosphere. Very different in their nature are the small-pox and measles, which are propagated by specific contagion. They do not wait for the suns of July or August, nor do they require an impure atmosphere, or an exciting cause, to give them activity. They spread in the winter and spring, as well as in the summer and autumnal months: wet and dry weather do not arrest their progress, and frost (so fatal to the yellow fever), by rendering it necessary to exclude cold air from sick rooms, increases the force of their contagion, and thereby propagates them more certainly through a country.

5. It is likewise destroyed, by intense heat, and high winds. The latter, we are sure, like heavy rains and frost, do not produce that salutary effect by acting upon the bodies, or in the rooms of sick people.

It is worthy of notice, that while the activity of miasmata is destroyed by cold, when it descends to frost; by heat, when it is so intense as to dry up all the sources of putrid exhalation; by heavy rains, when they are succeeded by cool weather; and by high winds, when they are not succeeded by warm weather; they are rendered more active by cool, warm, and damp weather, and by light winds. The influence of damp weather, in retaining and propagating miasmata, will be readily admitted, by recollecting how much more easily hounds track their prey, and how much more extensively odours of all kinds pervade the atmosphere, when it is charged with moisture, than in dry weather.

It has been asked, if putrid matters produce malignant bilious fevers in our cities, why do they not produce them in Lisbon, and in several other of the filthiest cities in the south of Europe? To this I answer, that filth and dirt are two distinct things. The streets of a city may be very _dirty_, that is, covered with mud composed of inoffensive clay, sand, or lime, and, at the same time, be perfectly free from those _filthy_ vegetable and animal matters which, by putrefaction, contaminate the air. But, admitting the streets of those cities to abound with the filthy matters that produce pestilential diseases in other countries, it is possible the exhalations from them may be so _constant_, and so _powerful_, in their impressions upon the bodies of the inhabitants, as to produce, from habit, no morbid effects, or but feeble diseases, as was remarked formerly, is the case in the natives and old settlers in the East and West-Indies. But if this explanation be not satisfactory, it may be resolved into a partial absence of an inflammatory constitution of the air, which, I shall say presently, must concur in producing pestilential diseases. Such deviations from uniformity in the works of Nature are universal. In the present instances, they no more invalidate the general proposition of malignant fevers being every where of domestic origin, than the exemption of Ireland from venomous reptiles, proves they are not generated in other countries, or that the pleurisy and rheumatism are not the effects of the alternate action of cold and heat upon the body, because hundreds, who have been exposed to them under equal circumstances, have not been affected by those diseases. There may be other parts of the world in which putrid matters do not produce bilious malignant diseases from the causes that have been mentioned, or from some unknown cause, but I am safe in repeating, there never was a bilious epidemic yellow fever that could not be traced to putrid exhalation.

It has been asked, if the yellow fever be not imported, why does it make its first appearance among sailors, and near the docks and wharves of our cities? I answer, this is far from being true. The disease has as often appeared first at a distance from the shores of our cities as near them, but, from its connection with a ship not being discovered, it has been called by another name. But where the first cases of it occur in sailors, I believe the seeds of it are always previously received by them from our filthy docks and wharves, or from the foul air which is discharged with the cargoes of the ships in which they have arrived, which seeds are readily excited in them by hard labour, or intemperance, so as to produce the disease. That this is the case, is further evident from its appearing in them, only in those months in which the bilious fever prevails in our cities.

It has been asked further, why were not these bilious malignant fevers more common before the years 1791, 1792, and 1793? To this I answer, by repeating what was mentioned in another place[37], that our climate has been gradually undergoing a change. The summers are more alternated by hot and cool, and wet and dry weather, than in former years. The winters are likewise less uniformly cold. Grass is two or three weeks later in the spring in affording pasture to cattle than it was within the memory of many thousand people. Above all, the summer has encroached upon the autumn, and hence the frequent accounts we read in our newspapers of trees blossoming, of full grown strawberries and raspberries being gathered, and of cherries and apples, of a considerable size, being seen, in the months of October and November, in all the middle states. By means of this protraction of the heat of summer, more time is given for the generation of putrid exhalations, and possibly for their greater concentration and activity in producing malignant bilious diseases.

[37] Account of the Climate of Pennsylvania, vol i.

It has been asked again, why do not the putrid matters which produce the yellow fever in some years produce it _every_ year? This question might be answered by asking two others. 1st. Why, if the yellow fever be derived from the We st-Indies, was it not imported every year before 1791, and before the existence, or during the feeble and partial operation of quarantine laws? It is no answer to this question to say, that a war is necessary to generate the disease in the islands, for it exists in some of them at all times, and the seasons of its prevalence in our cities have, in many instances, had no connection with war, nor with the presence of European armies in those and in other sickly parts of the globe. During the seven years revolutionary war it was unknown as an epidemic in the United States, and yet sailors arrived in all our cities daily from sickly islands, in small and crowded vessels, and sometimes covered with the rags they had worn in the yellow fever, in British hospitals and jails. I ask, 2dly, why does the dysentery (which is certainly a domestic disease) rise up in our country, and spread sickness and death through whole families and villages, and disappear from the same places for fifteen or twenty years afterwards?

The want of uniformity in the exhalations of our country in producing those diseases depends upon their being combined with more or less heat or moisture; upon the surface of the earth being completely dry, or completely covered with water[38]; upon different currents of winds, or the total absence of wind; upon the disproportion of the temperature of the air in the day and night; upon the quantity of dew; upon the early or late appearance of warm or cold weather; and upon the predisposition of the body to disease, derived from the quality of the aliments of the season. A similar want of uniformity in the annual operations of our climate appears in the size and quality of grain, fruits, and vegetables of all kinds.

[38] In the Account of the Yellow Fever of 1793, the different and
opposite effects of a dry and rainy season in producing bilious
fevers are mentioned from Dr. Dazilles. In the autumn of 1804, I
have elsewhere remarked, after a summer in which there had fallen
an unusual quantity of rain, the bilious fevers appeared chiefly
on the high grounds in Pennsylvania, which were in a state of
moisture, while scarcely a case of them appeared in the
neighbourhood of marshes, or low grounds, owing to their being so
completely covered with water, as to be incapable of generating,
by putrefaction, the miasmata which produce those forms of
disease.

But the greater violence and mortality of our bilious fevers, than in former years, must be sought for chiefly in an inflammatory or malignant constitution of the atmosphere, the effects of which have been no less obvious upon the small-pox, measles, and the intercurrent fevers of Dr. Sydenham, than they are upon the summer and autumnal disease that has been mentioned.

This malignant state of the air has been noticed, under different names, by all the writers upon epidemics, from Hippocrates down to the present day. It was ascribed, by the venerable father of physic, to a "divine something" in the atmosphere. Dr. Sydenham, whose works abound with references to it, supposes it to be derived from a mineral exhalation from the bowels of the earth. From numerous other testimonies of a belief in the influence of the insensible qualities of the air, altering the character of epidemics, I shall select the following:

"It is certain (says Dr. Mosely) that diseases undergo changes and revolutions. Some continue for a succession of years, and vanish when they have exhausted the temporary, but secret cause which produced them. Others have appeared and disappeared suddenly; and others have their periodical returns."

The doctor ascribes a malignant fever among the dogs in Jamaica (improperly called, from one of its symptoms, hydrophobia), to a change in the atmosphere, in the year 1783. It was said to have been imported, but experience, he says, proved the fact to be otherwise[39].

[39] Treatise upon Tropical Diseases, p. 43, 44.