A treatise on the synochus icteroides, or yellow fever; as it lately appeared in the city of Philadelphia. : Exhibiting a concise view of its rise, progress and symptoms, together with the method of treatment found most successful; : also remarks on the nature of its contagion, and directions for preventing the introduction of the same malady, in future.
Currie, William, 1754-1828., Mifflin, Thomas, 1744-1800, dedicatee.
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A TREATISE ON THE Synochus Icteroides, OR YELLOW FEVER; AS IT LATELY APPEARED IN THE CITY OF PHILADELPHIA.

EXHIBITING A CONCISE VIEW OF ITS RISE, PROGRESS AND SYMPTOMS, TOGETHER WITH THE METHOD OF TREATMENT FOUND MOST SUCCESSFUL; ALSO REMARKS ON THE NATURE OF ITS CONTAGION, AND DIREC|TIONS FOR PREVENTING THE INTRODUCTION OF THE SAME MALADY, IN FUTURE.

BY WILLIAM CURRIE, FELLOW OF THE COLLEGE OF PHYSICIANS, AND MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY.

PHILADELPHIA: PRINTED BY THOMAS DOBSON, No. 41, SOUTH SECOND-STREET.

M,DCC,XCIV.

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TO HIS EXCELLENCY THOMAS MIFFLIN, Governor of Pennsylvania.

SIR,

NOT the splendor of your sta|tion, but the qualities of your heart, so conspicuously displayed during the prevalence of the late destructive malady in this city, in|duce me to inscribe the following Page  iv treatice to your excellency. You are therefore requested to accept it; not as a compliment, but as a tribute to which you are justly en|titled, from

Your most sincere, And very humble servant, THE AUTHOR.

PHILADELPHIA, January 20th 1794.

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PREFACE.

AS every invention, discovery, or improve|ment, is more or less useful and interesting, in proportion as it contributes to the preservation of health, life, prosperity, and satisfaction; and as the author of the following pages is persuaded, that very material improvements were made in the treatment of the synochus icteroides or yel|low fever, which lately prevailed in this city, and proved so destructive and distressing to its in|habitants, he thinks it his duty to lay the same before the public, together with his observa|tions and sentiments on other circumstances, relative to that disease; that if it should ever appear here again (as there is too much rea|son Page  vii to apprehend, unless much caution is ob|served to prevent it, from our constant inter|course with the West Indies, where strangers are seldom long exempt from it) physicians may not again be at a loss for a directory, deri|ved from actual experience and observation. He however does not pretend to have been the improver of the treatment, or the discover|er of the means most effectual in the cure, which is recommended in the following pa|ges. On the contrary, he believes they were adopted from the joint deliberations of the col|lege of physicians, in consequence of some of its members having observed their good effects when the disease first appeared, and was mista|ken for a higher grade of the bilious remittent fever of the autumnal season. Instead of at|tending to systematic arrangement in the fol|lowing little production, he has contented him|self with enumerating symptoms and circum|stances as they occurred to him, while enga|ged in practice; and offering his sentiments in the order in which they happened to arise. Page  viii By this method he hopes to escape the imputa|tion of pedantry: and though those who pre|fer the studied and formal arrangement of the schools, to the simplicity and order of nature, may condemn his manner, he hopes the mat|ter it contains, and the importance of the sub|ject, will secure him the approbation of all those who prefer utility to formality and fa|shion. To men of taste indeed, some apology is due for the imperfections of its style and composition; but if want of leisure and fre|quent interruption are ever admitted as an a|pology for a trespass of this nature, he is cer|tainly entitled to some indulgence on the pre|sent occasion; especially as he can assure them, that truth has been his aim, his end the public good.

JANUARY 24th, 1794.

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A SKETCH OF THE RISE AND PROGRESS OF THE DISEASE.

THE disease which we are about to de|scribe, made its first appearance in Wa|ter street between Mulberry and Sassafras streets, the beginning of August 1793, and ap|pears to have been imported by a vessel which arrived in this port, and lay at a wharf in that neighbourhood the latter end of July.*

Page  2 From this source it spread gradually by contagion over the greatest part of the city; and was more or less rapid in its progress, ac|cording as people had more or less intercourse with the sick, and according as the weather was more or less cold: for though it was pro|pagated by contagion, the sensible qualities of the atmosphere had a surprising effect in ren|dering the contagion more or less active, as well as in its influence on the symptoms of those labouring under the disease.

The greatest number confined with the disease, was about the middle of October; but as the weather became cold and frosty, its de|clension was so rapid that it appeared as if ex|tinguished by a miacle: for by the tenth of November, there was scarcely a person to be found with it.

The whole number that died of this disease in the city, appears from the registers of deaths kept by the different religious societies, to have Page  3 been about 3500. In the registers of the deaths which have been kept by those socie|ties, there is no discrimination made between those who died of the yellow fever and of o|ther diseases; and the whole number of deaths appears to have been 4048, from the 1st of August to the 10th of November; of which above 00 are supposed to have died of other diseases. At one period there appears to have been more than eight thousand persons confi|ned by it at the same time; though at that time near twenty thousand of the inhabitants had retired from the city.

That the long continuance of heat and drought which preceded this disease had no share in its generation, is certain, from its be|ing confined for some time to that part of the city where it commenced: for almost every case which occurred for the first week or two, could be traced to that source, and was pro|pagated to others in succession.

Page  4 This fever corresponded in most of its lea|ding and characteristic symptoms, with the synochus icteroides occidentalis, or yellow fe|ver of the West Indies. A fever of the same kind has prevailed here three times before, viz. in the years 1740, 1747 and 1762.

In the year 1740, it was introduced by means of a trunk of wearing apparel, which had belonged to a gentleman who died of it in Barbadoes. The family to whom the trunk was sent first took the disease; and from them it spread into the town, and destroyed above two hundred people; as we are informed by the celebrated LIND, in his treatise on fevers and infection.

The only account I have been able to obtain respecting its appearance in 1747, is what is contained in Mr Lardner's letter, of which the following is a copy.

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PHILADELPHIA, Sept. 3d, 1747. (O. S.)

SINCE my last, a contagious fever has raged amongst us, which admits of no relief, cure, or abatement; never intermitting to the last moment of life. It has carried off three of my most intimate acquaintance; among which are my dear friends Andrew Hamilton and Mr Currie. Philadelphia has been a melan|choly place, and many whose business and fa|mily would permit them, have fled the city. But the air is now become much cooler, and those under the disorder revive. The symp|toms (a pain in the head and back, vomiting, &c.) are less violent, and the fever gradually abates. Messrs. Allen and Turner's family are yet under the disease; the one having lost a near relation, and Mr Allen himself not out of danger.

September 24th. The yellow fever is still amongst us: yesterday was buried young Sa|muel Powell who died of it.

Page  6 It is astonishing that the physicians of that time left nothing on record respecting so de|structive a malady. Perhaps if the notes of Doctors Zachary, Graham, Kearsley, and Cad|wallader were inspected, some important facts might yet be discovered. Dr Griffiths' mo|ther who had the disease at that time is still a|live.

The third time of its appearance it was in|troduced (according to the notes of Dr Red|man of this city) about the latter end of Au|gust, by a mariner from the Havanna: it came to its height about the 25th of September, and from that time gradually declined, and was en|tirely extinguished by the middle of October. Neither the state of the weather, nor the num|ber of deaths which occurred at that time, are known, no register having been preserved.

The fever at that time was circumscribed to Pine or Union street Northerly, and three or four squares from thence Southerly, and Page  7 extended from Water street, to Third or Fourth street Westerly. Its first and greatest ravages were about the New Market, which lay near the source where the disease origi|nated. It spread at that time, as the one we are about to describe did, from family to fa|mily, as they happened to have intercourse one with another.

A fever of the same kind, also prevailed at Charleston, South Carolina, in the years 1732, 1739, 1745 and 1748; an account of which has been given by Dr. Lining, and published in the second Vol. Physical and Li|terary Essays of Edinburgh. The disease each time that it prevailed in Carolina, was traced to some person lately arrived from some of the West India Islands.

We are also informed by Dr Lind, in his treatise on hot climates, that a similar disease occurred in Cadiz, in Spain, the latter end of the summer of 1764, of which an hundred Page  8 persons sometimes died in a day; that its ra|vages were at that time entirely confined to that city, and that those who retired to the country escaped it.

Though the disease we are about to describe was highly contagious, the influence of the contagion was circumscribed to a narrow sphere, for none but those who approached near to the sick, or to such articles as had been in contact with them, or within the sphere of their effluvia so as to be impregna|ted thereby were affected.

All that shut themselves up in their houses, retired into the country, or avoided entering into infected houses, and all intercourse with the sick, or infected substances, or with those who visited the sick (for the idle curiosity of servants, particularly of the hired girls, was the means of propagating the disease more than any other circumstance), though con|stantly abroad in the open streets, escaped the Page  9 disease without exception. The prisoners in the jail and work house—the pensioners in the poor house, and the patients and attend|ants at the hospital, from whence all inter|course with the infected was excluded, also entirely escaped the disease.

There was something however, in the state of the atmosphere in the city, or in the con|stitutions of the inhabitants, peculiarly fa|vourable to the operation of the contagion, very different from that of the country; for when any person with the disease was remo|ved a few miles into the country, and even died of it, there is scarce an instance of its ha|ving been communicated to any person in the same house, whereas when any one in a family took it and remained in the city, o|thers, and sometimes the whole of the family, soon after took the disease*.

Page  10 Those exposed to the contagion generally began to be affected between the third and eighth day; we recollect several that were certainly attacked on the fifth day, one on the third, and two not till the tenth day after ex|posure. These were ascertained by such cir|cumstances, as could not have deceived us. Those who had retired into the country, and again returned to the city during the preva|lence of the disease, were affected more rea|dily and earlier than others, after such ex|posure.

The state of the mind seems to have had great influence, in hastening or retarding the effects of the contagion; those under the in|fluence of fear, which was the case with the majority, were sooner affected after exposure to the contagion, than those who were less concerned. Every other debilitating power had a similar affect, such as an abstemious regimen, too much fatigue, frequent purging, blood-letting, and exposure to the night air, Page  11 without exercise sufficient to keep up a vi|gorous circulation. But a lax state of the bowels, and a moderate tone of the solids, appear to have contributed to render the dis|ease more mild when it did attack those who were not greatly under the influence of terror. Neither age nor sex were exempt, not even infants at the breast—but those that were fat, corpulent and indolent, were most susceptible of the contagion, and suffered accordingly.

While this formidable disease was making such ravages in the city, the country for some miles around was never more healthy, espe|cially in dry and elevated situations. In the low and marshy grounds, indeed, this was not the case; for at Harrisburgh on the Sus|quehanna, at Dover on the Delaware, and a few other places, bordering on rivers or large creeks, whose channels were almost exhaust|ed of their waters, by the long continuance of heat and drought, bilious fever, choleras, dysenteries and cholics, were never known to be so prevalent and mortal.

Page  12 The French West Indians, particularly those from St. Domingo, who had taken shel|ter here, from the storms of a sanguinary war, almost to a man escaped the disease, though they made no use of any precaution for the purpose; while those from France were as liable to it as the Philadelphians.

The reason that the West Indians were not liable to it, is perhaps owing to the resemblance of the season to that of the climate from whence they came; and to the effects produced by the frequent excretions of bile to which they are particularly subject, rendering the duodenum and biliary ducts insensible to the poison. For it is a singular though a notorious fact, that the disease seldom or ever affects any but stran|gers or new comers from a colder or more tem|perate climate, in the West Indies; as we are informed by almost all the writers on the sub|ject. But we were strangers or new comers to it to all intents and purposes, with this diffe|ence, that it was brought to us instead of our and Page  13 being taken to it; and for that reason were subject to its influence. There are however some instances mentioned by Hillary of its be|ing communicated by contagion at Barbadoes, and of a few Creoles being affected by it. But this he says was very rare, and after the dis|ease had become very malignant.

*The negroes that were natives of Ameri|ca Page  14 were also liable to it, though not in the same proportion as the whites. This was not the case, according to the observations of Dr Lining, when it prevailed in Charleston; for at that time there was not an instance of any negro being affected by it, though as much exposed to the contagion as the whites. This with some exceptions, is also the case with re|spect to the negroes in the West Indies; tho' Dr. Blane says he saw a black woman die with all the symptoms of it at Barbadoes, ha|ving caught it from nursing some seamen that were ill of it. The same author is of opinion, that the disease cannot be generated in any Page  15 place, unless the heat has been for some time above 75 degrees. It is asserted by Dr Li|ning, that those who have once had the dis|ease, cannot take it a second time: but we have seen several instances of its occurring a second time here, where the circumstances were so unequivocal, that it could not be fairly ascri|bed to a relapse.

As soon as the contagion had reached the central part of the city, the disease spread with astonishing rapidity. In the course of August, there were more than 300 funerals; towards the close of the month, twenty were buried of a day. During the greatest part of this month, the mercury in the thermometer ran|ged from 80 to 90°, in the afternoons; the sky generally clear, and the winds Westerly. From the 25th to the end of the month the weather was cloudy, and a small quantity of rain fell.

In September, the disease increased ama|zingly. Page  16 In the course of the month, about 1400 citizens were added to the list of mor|tality; towards its close, from 50 to 90 were buried of a day, though the mercury now seldom rose above 80°. The weather was mostly fair; a few days were cloudy, but there was no rain. The wind still westerly. Throughout the month the heat was general|ly moderate, and the weather uniform, ex|cept from the 19th to the 23d, when it was unusually calm, "deprived of the refreshing breeze," during which the mortality was great|er than at any other period in that month.

From this time to the middle of October, the disease proceeded with an increase of mor|tality, owing to the enlargement of the circle of contagion. From the 1st to the 17th, more than 1400 fell victims to the malady—but from the 17th, to the 1st of November, the bills of mortality lessened rapidly, though not regularly. The whole number of the deaths in this month, amounted to near 2000, Page  17 though one third of the inhabitants had for some time before deserted the city, and retired into different parts of the country, as choice or chance directed.

The thermometer was very variable all this month, generally below 80°, but above 50° until the 27th, from which time to the end of the month, it was always below 50°, and one day below 40°. The weather for the most part fair, though some rain fell on the 12th and 31st, and it was cloudy from the 25th to the end of the month. The wind ge|nerally from the N. and N. W. till the latter end of the month, but from that time N. N. E. Towards the last of the month, the con|tagion declined apace, the funerals being re|duced to between 12 and 20 a day. From this time the weather became more wet, cold and frosty, and the disease declined so rapid|ly, that on the 9th of November, the fune|rals in all the grave yards only amounted to six. From this time every thing seemed to Page  18 sink into that kind of placid calm, which gene|rally succeeds a dying storm. The citizens who had retreated from the danger, now ventured back, and the streets and various departments of business, immediately resumed their former life and energy—commerce again spread her white wings, and pensive mourning melan|choly, has since given place to the cheerful face of joy.

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DEFINITION.

The SYNOCHUS ICTEROIDES or YELLOW FEVER, derives its name from the inflammatory symptoms, with which it begins, becoming putrid in its progress; and from the yellowness in the eyes and skin, with which it is gene|rally accompanied.

DESCRIPTION OF SYMPTOMS.

THE disease (whose symptoms are now to be delineated), was generally preceded by a slight indisposition, such as muscular de|bility, and sense of lassitude, on exercise or motion, drowsiness, slight pain and giddiness in the head, pain in the back and loins, defec|tive Page  20 appetite, dyspeptic symptoms, such as flatulent eructations, loss of appetite, &c. After this prelude, which seldom continued more than 6 or 8 hours, and sometimes with|out any such prelude at all, a chilly fit, al|ternated with glowing flushes of heat, came on, generally in the after part of the night, or ore part of the day; which, after a dura|tion, for the most part short, though some|times of 12 or 14 hours continuance, gave place to those symptoms which designate a confirmed fever of the inflammatory type, which increased in violence as the day ad|vanced; and continued with little or no vari|ation, till towards morning, when some alle|viation with respect to violence was generally observable, but in scarcely any instance was there so much abatement as could be proper|ly called a remission.

The pulse, after the feverish state became established, was generally quick and tense, and during the exacerbation, it was also full Page  21 and strong. In the carotid and temporal arte|ries in particular, it was strong and throbbing; respiration hurried; the skin very hot and dry; and the face highly flushed; the eyes re|markably red, hot, and painful, as if irritated by small grit or sand; accompanied with a tor|turing pain in the head, back, loins, and large joints, shooting from temple to temple, and extending from the loins to the hips and down the thighs; the thirst considerable, but not in|satiable; the tongue white, moist, and clam|my; the bowels either costive, or discharging thin, watery, and sometimes bloody, stools; the urine high-coloured, cloudy, and small in quantity; the stomach distended, painful, ten|der, and irritable, especially after taking any kind of drink or aliment; frequently affected with sick qualms, and more or less propensity to puke, but seldom bringing up any thing; a sense of stricture and oppression at the pre|cordia, as if tight bound with a belt; great rest|lessness, with moaning and sighing; and fre|quently shifting of posture in search of ease; Page  22 some confusion of the intellects, attended with constant pervigilium; but seldom so much de|rangement of the reasoning faculty as to a|mount to violent delirium; frequent hemor|rhages from one or both nostrils, during the afternoon exacerbations in young persons of both sexes; and in those of one of the sexes at two different periods of life. In some the head was most affected; in others the stomach. In persons under puberty, symptoms of hy|drocephalus internus frequently occured in the course of this stage. In men verging on old age, the disease usually began with symptoms resembling apoplexy, unless prevented by a discharge of blood from the hemorrhoidal ves|sels.

When stools were procured by art, the first were generally soft and white, but seldom bi|lious. The contents thrown out from the stomach were generally the drinks or aliment last received. Sometimes mixed with matter of a sea-green colour and bitter taste, but of|ten Page  23 without either. The suffusion and infla|med appearance of the eyes, constantly increa|sed in proportion to the violence of fever and date of the disease.

The preceding symptoms which may be considered as limiting the first stage of the dis|ease, continued with more or less violence from one to three days, and sometimes longer; and then abated suddenly, succeeded soon after by the appearance of a yellow tinge in the eyes, face, and neck, or by a copious evacuation of bilious matter by stool; and the patient spee|dily recovered, except that his stomach remain|ed weak, and his appetite defective for some time: or no bilious stools taking place at the time, or soon after the icteroitous appearance became observable, the disease proceeded to the second stage, in which there was a diminution of force in some of the symptoms; an increase in others; and an accession of new ones. The inflammatory symptoms which before, in many respects resembled those of the idiopathic gas|tritis,Page  24 now became mixed more or less with symptoms of nervous affection. The pulse though still quick, was no longer full or tense; the respiration also continued quick and hur|ried; and the skin, though less hot, was more dry and parched, except during the act of vo|miting, and then the moisture was only par|tial, chiefly about the neck and forehead. The tongue now appeared more dry and foul, par|ticularly in the middle; the thirst became in|satiable; the stomach so irritable, and the reach|ing and propensity to puke so constant, that no|thing could be retained on it, but was cast up the instant it was swallowed, accompanied with vio|lent straining and noise; but the matter thrown up appeared very little if any changed in ap|pearance, except being mixed with mucus and more ropy than when drank: the stomach was also constantly affected with a constant burn|ing heat, which occasioned the most excruci|ating agony and distress. The anxiety at the precordia also hourly increased, and soon be|came insupportable torture: the sighing, rest|lessness, Page  25 and tossing to and fro became perpe|tual; the eyes and countenance were expres|sive of the deepest anguish and despair; and a delirium resembling mania was by no means uncommon. As these symptoms became more distressing, the yellowness which before was faint and partial, assumed a deep orange or saffron colour, and extended itself over the whole surface of the body; so that the patient resembled one with an obstinate and invete|rate jaundice. When these symptoms had continued with increasing violence to the end of the second, or beginning of the third, day, sometimes earlier, and sometimes later, they all suddenly vanished, and left the patient for a time perfectly easy and tranquil. But this fa|lacious truce, so flattering to the inexperien|ced, as well as to the patient, was soon succeed|ed by a different, and though less acutely pain|ful, more hopeless and desperate train of symp|toms, which marked the third and last stage of this domestic tragedy. The whole surface of the body now became of a cadaverous cold|ness, Page  26 with the pulse slow and soft, in some not exceeding 40 strokes in a minute, but as regu|lar as in health. The respiration was slow and deep; and the yellowness of the eyes and skin appeared of a deep tawny or dull copper-colour; the tongue much cleaner and moister than in either of the former stages; the vomit|ing was also less frequent, but in a much lar|ger quantity when it did occur; and the pati|ent always had some respite after emptying his stomach, till a large quantity of fluid was again accumulated; when it was again spout|ed up in an enormous quantity, and general|y of a dark colour and turbid consistence, re|sembling coffee-grounds; and when stools oc|curred at this time, they generally had the same appearance; but sometimes resembled tar or molasses. The patient was generally at this time affected with a kind of cheerful delirium, imagining himself well: he could seldom be retained in bed, but walked about till exhaust|ed with fatigue. The delirium was generally succeeded, the day following, or the day after, Page  27 by coma, from which the patient was occasi|onally roused by vomiting and uneasy dreams; and when roused, started up, and attempted to get out of bed; and when prevented, immedi|ately sunk down again into a state of slumber|ing insensibility; and if asked, when rou|sed from his coma, how he did, his constant reply was "very well!" As the debility in|creased, the face and breast became spotted, as if sprinkled with ink; and a deep dusky yel|low and purple colour, resembling blood set|tled in a bruised part, pervaded the whole sur|face of the body. The respiration now be|came deep and slow, frequently interrupted by a sobbing kind of sighing and constant hiccup. These were succeeded by dimness of vision—difficulty of swallowing—loss of speech—rat|tling in the throat—short and convulsive breathing—sunk and irregular pulse—cold sweats—and finally death.

But in more protracted and less violent cases, instead of the black vomiting and co|ma, Page  28 the patient frequently became affected with symptoms resembling those which are commonly met with in a protracted and inve|terate scurvy: In these the countenance ap|peared bloated and livid, as well as yellow, and blood perpetually oozed from different parts of the body; particularly from the nose, gums, and hemorrhoidal vessels. Some had apthae or superficial ulcerations, in the roof of the mouth, and in the throat, and parts which had been blistered; and some had a frequent vomiting, or rather gulping up of dark grumous blood from the fauces and sto|mach, or a discharge of it by stool. Several in this situation, lived many days without any other morbid appearance, except a constant and distressing watchfulness; sitting up or walking about constantly, but without any appetite or extraordinary thirst, or apparent delirium; till, exhausted by a sudden hemorr|hagic discharge, or by a more gradual drain of blood, they sunk insensibly into the arms of death, without a struggle or a groan.

Page  29 When the disease terminated favourably, it was generally before the fifth day, frequently on the second or third; and when it termi|nated fatally, it was generally on the fourth, fifth, or sixth day; sometimes earlier and sometimes later; but when the patient survi|ved the seventh day, without the accession of the black vomiting, coma, or scorbutic symp|toms, or great and increasing debility, the disease generally terminated favourably.

This was the most usual appearance and pro|gress of this formidable and too often fatal dis|ease, through its several stages. But there were very surprising variations in the appearance it assumed, both in respect to the duration of the several stages, and the state of the symp|toms, according to the particular constitutions and temperaments of different patients, the state of the weather, the manner of treat|ment, &c.

A sketch of these we shall now proceed to Page  30 enumerate. In some cases signs of debility in all the functions, and a putrescent tendency in the whole system, were apparent at a very early period of the disease. In these cases the anxiety at the precordia was constant, the sighing frequent—the yellowness of the eyes and skin became conspicuous very early—the exacerbations and remissions of fever scarcely perceptible—the pulse quick and weak, skin dry and parched, restlessness and pervigilium great, vomiting constant, and on the second or third day of a black colour—the stools also black and gelatinous—the stomach constantly affected with a violent cardialgia, or a burn|ing heat, which the miserable sufferer said felt as if scalded or burnt by a coal of fire; no posture gave ease, and whatever was swallow|ed, except very small draughts of toast and water, weak barley water, or simple spring water, increased the agony to the most exqui|site torture. It was in this form of the dis|ease, that the method published by Dr Kuhn, particularly applied. And it was the form Page  31 in which the disease most frequently appear|ed all the month of August.

In other cases the generality of the symp|toms resembled those of the autumnal remit|tent, combined with jaundice—and in some no yellowness or black vomiting occurred at all; but in these the eyes were almost always highly inflamed for a day or two, but when a diarrhoea, accompanied with a discharge of bile spontaneously occurred, or was procured by purgatives or glisters, the yellowness or icteroitous appearance was frequently pre|vented.

It was often difficult to distinguish this dis|ease at the beginning from the influenza, which was prevalent in the city, and spread over all the Southern states and over the Western ter|ritory, before the yellow fever had made much progress in the city. The influence of terror also occasioned great variation in its symp|toms. That the usual disease of the season, Page  32 the remitting fever, was often blended with this disease, is by no means improbable. For though two epidemics arising from a change or alteration in the sensible qualities of the air, or from any invisible miasma diffused abroad to a considerable extent in the atmosphere, cannot exist together, yet there s nothing more certain than that a contagious disease, and a disease depending on climate, season, and soil, may exist at the same time and in the same place. Of this we have several exam|ples in the works of Lind, Russel, &c.

A preternatural discharge of bile, was by no means a common circumstance in any form or at any period of the disease, as has been already observed. Dissections made not only at Cadiz and the West Indies, but also in this city, demonstrate that this is owing to an inflammatory affection of the stomach, du|odenum and ductus choledochus: And it is more than probable, that the black matter brought up by vomiting, was the sphacelated surface of those parts mixed with coagulated Page  33 blood, bile, and the contents last taken into the stomach. The white colour of the stools so common in the beginning of the disease, also indicated an obstruction to the excretion of bile. When the fever was protracted, ac|cumulations of bile frequently took place, as was evident from the tension of the right hypochondrium, and the foetid and copious discharges coloured with that fluid, which fre|quently appeared after an active purge.

Dr. Jackson relates that while he resided in Jamaica, between the years 1774 and 1782, he opened several persons who died of this disease, and observed that the stomach and in|testines had a dirty yellow appearance, and were highly putrefied, and much distended with wind—the liver and spleen generally enlarged in size, and the colour of the liver often of a deeper yellow than any other part of the abdominal viscera—the gall bladder for the most part moderately full, and of a thick consistence and black colour—the bilia|ry Page  34 ducts enlarged and filled with a similar flu|id, while the vessels of the liver bore the marks of uncommon distention. A dark coloured turbid fluid was always observable in the ca|vity of the stomach, similar to that usually thrown up in the last stage of the illness; and the villous coat of that organ was also abraded in various places, and at the same time, spots were observed on different parts of its surface, which appeared to be incipient mortifications. The superior portions of the intestinal canal, had also frequently a similar appearance. From these and other dissections, much light has been thrown upon the seat, and nature of this disease.*

Page  35

PROGNOSIS.

IN THE FIRST STAGE.

The favourable Signs were,

HEMORRHAGES from the nose, with relief of the head during the exacerbations. A gradual reduction of the pulse, heat, and oppression at the precordia. A diarrhoea or laxative stools, mixed with bile coming on before the third day.

When in the decline of this stage, there was a constant retching to vomit, without bringing up any thing or vomiting the drinks only, accompanied with a burning heat and tenderness at the stomach, with pain or op|pression; it was almost a certain indication that the yellowness, or bilious effusion, would Page  36 soon make its appearance. When the allevi|ation of the symptoms, especially of the op|pression and weight at the precordia or epi|gastric region took place, and were accompa|nied with, or succeeded by, a bilious diarrhoea, it always afforded a favourable prognostic.

Unfavourable Signs.

STRONG, hard, and quick pulse, with ferocious delirium, and pervigilium; or quick, small and irregular pulse, with low delirium, great muscular debility, exquisite pain at the stomach, oppression and sense of stricture at the precordia, great thirst, constant nausea and retching, and restleness; obstinate costive|ness, and the stools when procured of a soft consistence, in lumps, and of a whitish colour. A want of action in the bowels, and great in|sensibility to purges and glysters, also gave room for much apprehension.

Page  37

IN THE SECOND STAGE.

The favourable Signs were,

AN abatement of the vomiting, anxiety and oppression at the precordia—relief from the burning pain at the stomach—natural heat in the forehead and limbs, open bowels and natural coloured stools—turbid urine, &c.

Unfavourable Signs.

AN increase of muscular debility, oppres|sion, anxiety, incessant vomiting, a rapid in|crease of the icteroitous aspect, restlessness and frequent sighing, costiveness or bloody stools, accompanied with a painful tenesmus; hollow eyes, shrunk countenance, and shrill feeble voice; an obstinate and painful pervigilium; Page  38 the patient continuing wide awake, in a state of the most uneasy agitation, with his senses and reason but little impaired. But the symp|toms expressive of the greatest danger were, an invincible irritability of the stomach, which prevented it from retaining any kind of drink, aliment, or medicines, and a gradual recession of heat from the surface of the body.

IN THE THIRD STAGE.

Favourable Signs.

A GRADUAL return of heat to the sur|face of the body, cessation of delirium, and change of colour in the matter vomited up.

Page  39
Unfavourable Signs.

ALMOST all the symptoms in this stage indicated a fatal event, particularly the sudden cessation of pain and fever; coldness of the face and limbs, and the black vomitings, or black stools; constant singultus, coma, and hemorrhagy; a sense of great weight and stric|ture about the epigastric region; deep and fre|quent sighing; and great failure of strength de|noted danger in every stage. When in this stage deep coma took place, it generally deno|ted a speedy dissolution.

Page  [unnumbered]

OF THE METHOD OF CURE.

FROM the preceding account of the various forms in which the synochus icteroides appear|ed, the reader will at once perceive, that no one mode of treatment could be with propri|ety pursued; but that it was requisite to vary it, as the symptoms indicated an inflammatory or putrid type, as well as to adjust it to the se|veral stages of the disease. But in all cases which began with inflammatory symptoms, whether they ended in those which indicated putridity or not, the following treatment was found most certain and successful. Blood-let|ting Page  41 generally afforded relief in all cases, when the activity of the arterial system was evident; and the head and epigastrium were at the same time much affected: and this operation was found serviceable when repeated every six or eight hours, for the first twenty-four or thir|ty-six hours after the establishment of the pa|roxysm; and in every subsequent exacerbation so long as those symptoms continued in any considerable degree*. To those who con|demn bleeding under such circumstances, we may say with Sydenham, when speaking of the plague, "they either did not bleed early enough, or too sparingly." To those accus|tomed to see frequent cases of idiopathic gas|tritis, where the danger is seldom indicated fully by the pulse, the propriety of this prac|tice will be at once obvious. In conjunction Page  42 with blood-letting, mercurial purges were found more certain in their effects and more serviceable than any other kind; especially when exhibited in doses of from six to twelve grains, and repeated every six or eight hours till a copious discharge by stool took place; and more especially when their opera|tion was promoted by mild laxative enemas, administered three or four hours after each dose of the mercurial purge. Those who have not had an opportunity of observing the good effects of this practice, will perhaps think it a very hazardous one. But when they consider the difficulty of retaining the saline and less active purges on the stomach, and the very great difficulty of procuring copious evacua|tions by stool, without which the topical affec|tion which obstructs the passage of the bile could not be removed, nor the propensity to puke relieved; they will change their sen|timents; for, notwithstanding the inflamed and irritable state of those parts, calomel in large doses, passed the pybones, and occasion|ed Page  43 less irritation till it had reached the intes|tines, and was less liable to be cast up than a|ny other purgative.

But, however preconceived theories might influence others, we who were not prejudiced in favour of any particular hypothesis, and who had daily opportunities of seeing its ef|fects, not only in our own practice, but in that of others, are convinced that it was more certain in its operation, and in general as safe as any other.

In a few persons of delicate or infirm con|stitutions, indeed it proved injurious; and particularly when administered after the in|flammatory symptoms had subsided. When it proved injurious before the inflammatory symptoms were removed, it appeared to have induced an inflammation in the intestines, and a very painful and troublesome tenesmus. And when it proved injurious in a later stage, it was in consequence of the debility occasion|ed Page  44 by its operation or the ptyalism, which too frequently succeeded the too frequent and in|judicious exhibition of it. Unless speedy and decided measures are taken in this stage of the disease, all our future endeavours to remove it, will generally be ineffectual. And surely, in a disease which had foiled every method formerly employed, some innovation was jus|tifiable. These cases, however, were very rare in comparison with those wherein it ope|rated gently, and to good effect. As we ne|ver administered it when putrid symptoms were prevalent or the debility very great, or in any stage of the disease, but the first; we cannot speak with any certainty of its effects, under any other circumstance or period.

We seldom had occasion, even in the first stage of the disease, when inflammatory symp|toms were prevalent, to exhibit mercurial purges after copious evacuations were procu|red, but found those of a milder kind, such as sal. cath. crem. tart. or castor oil, generally Page  45 sufficient to keep the bowels in a laxative state, when the stomach would bear them, and when it would not, glisters made of an infusion of senae leaves, manna and common salt, with the addition of a little oil, generally answered the purpose. We found the most difficult part in the treatment, consisted in putting the stomach in a condition to retain any thing; the saline draught in the act of effervescence, so useful for that purpose in other fevers, sel|dom produced any permanent effect in this; magnesia taken in a draught of sweetened wa|ter, seemed to have a better effect when im|mediately followed by a draught of acid be|verage; but there was nothing so certain as a copious diarrhoea when it could be procu|red.* When on the first or second day of Page  46 the disease the face was greatly flushed, the vessels of the tunica adnata very red and tur|gid, and the patient was affected with feroci|ous delirium, resembling that which occurs in phrenitis, he generally died in a short time, unless immediately and copiously blooded, purged and restricted to a cooling and abste|mious regimen.

The antiphlogistic regimen was always found to agree better than that of the vinous or cordial kind; not only while the pulse con|tinued full and active, but when it was low and quick, previous to the accession of typhous symptoms. The patient was accordingly di|rected to drink toast and water, lemonade, ta|marind-water, barley-water, and any other diluting, mild, sedative drink, that was grate|ful to the palate, and rested easiest on the sto|mach.

Fresh air was constantly admitted into the sick room, and cold vinegar and water fre|quently Page  47 sprinkled upon the floor. This was found much more refreshing than flashing gun-powder, or burning nitre and charcoal in the chamber; as these latter, though they fur|nish a quantity of pure air, always increased its heat; and thereby counterbalanced the good effects that might otherwise have been derived from them. The bed and body-linen were also directed to be changed every day, or eve|ry second day at farthest.

When a repetition of blood-letting during the first and second day of the complaint, did not remove the pain in the head and back, and the distress at the stomach, and when every thing was vomited up as soon as taken; re|course was immediately had to purging cly|sters, and to the application of epispastics to the stomach and legs, or to the back and in|side of the thighs: the latter method is prefer|ed by Dr Hume of Jamaica, to any other; from a supposition, that an inflammation rai|sed on an inferior part, always relieves that Page  48 subsisting in a superior one. At present it is supposed to be owing to a change of action, from one part of the system to another.

Opium was also frequently employed in a solid form as directed by Hillary of Barbadoes, with a view of relieving the vomiting; but in general was found to aggravate it. The sa|line draught given in the act of effervescence, or magnesia as already mentioned, had a bet|ter effect, but was by no means certain: nor in fact was any thing else found to have any permanent effect on this symptom, except gly|sters, brisk purges, and blisters. But these when judiciously and early applied seldom failed of affording relief.

Baths of various kinds were occasionally employed, but seldom with such manifest ef|fect as to induce us to say much in their fa|vour, except washing the limbs with simple water of tepid warmth, to keep the skin soft, and take off stricture and resistance from the Page  49 surface. When the topical affection of the stomach was relieved, a solution of Rochelle salts, in thin veal or fowl broth, with the ad|dition of a little common marine salt, was in general more certain and less irritating than any other laxative. (A drachm of this salt requires about two ounces of boiling water to dissolve it perfectly.) The inflamed state of the stomach deterred us from employing eme|tics, or any antimonial preparations: but from the trials of others, we are convinced that they seldom were of service, but often the reverse. When purges produced copious, foetid and bi|lious stools early in the disease, it generally terminated favourably and speedily.

In the second stage of this fever, (which however, seldom took place when the reme|dies beforementioned were early and judici|ously employed and duly persisted in), we found a very different treatment proper, from that which was necessary in the first stage; for the inflammatory state now, for the most Page  50 part, rapidly verged towards gangrene; and the muscular weakness was such as to render bleeding inadmissible; and the irritable state of the stomach precluded all expectation from purgatives, as they were rejected as well as every thing else the instant they reached the stomach. Our only resource, therefore, was in warm antiseptic fomentations, applied by means of flannel cloths to the stomach, thighs, legs and hands, sinapisms to the feet, aroma|tic and essential oils, or spices stewed in bran|dy to the stomach; or the application of blis|ters, and the frequent exhibition of laxative glisters; and after a free evacution, the injec|tion of bark decoction, and a few drops of laudanum, with some farinaceous or mucila|ginous liquor, into the intestines—(here per|haps, washing the patient's whole body with cold water, and afterwards wrapping it in a blanket wrung out of a hot decoction, and the subsequent application of blisters, would have been beneficial; but we were afraid to try them). Vinous and cordial drinks as Page  51 well as all kinds of aliment, invariably aggra|vated this symptom, and encreased or produ|ced the cardialgia; but small draughts of cold water generally gave instant case. When by these means the topical inflammation of the epigastric region was removed, all the symp|toms gradually subsided, and the patient reco|vered. But when these means failed, and the black vomiting came on, accompanied with coldness, and a cadaverous appearance of the extremities, and a dark yellow and purple aspect of the countenance, our practice was to employ a strong decoction of peruvian bark—an infusion of camomile flowers, and toast and water lightly acidulated with the elixir of vitriol, and in some cases a mixture of brandy and water—and to direct glisters com|posed of a strong decoction of bark, with the addition of fifteen or twenty drops of lauda|num, to be administered every two or three hours; applying at the same time, sinapisms and jugs of hot water, to different parts of the patient's body. We also directed all the Page  52 drinks to be given in a tpid state. Hot spi|ced wine, wine and water, and various other liquors were often tried, but in general with such bad success, that we cannot recommend them in such circumstances. Hot brandy toddy, however, with the addition of a large quantity of powdered nutmeg, in conjunction with external heat and acrid stimulating ap|plications, often had evident good effects.

When indeed the disease began with great prostration of strength, and other symptoms which denote a typhous diathesis, we found wine not only safe, but more useful than any other article. In these cases also, the early use of the bark in various forms, together with the liberal use of laudanum and volatile salts were of service; but that which was most particular|ly so, was the shower-bath of salt-water, ap|plied quite cold three times aday, the patient sitting in an arm chair, in a large tub for the purpose, his head being previously shaved or covered with a thin bathing cap of oiled cloth. Page  53 But after the accession of this stage, in which the black vomiting and coldness of the limbs were the most predominant symptoms, all at|tempts to relieve were generally ineffectual.*

Page  54 When the disease did not appear to be confined more particularly to any one part of the system than another, but was universally diffused; and when nervous symptoms with great prostration of strength, were conspicu|ously predominant, which was frequently the case during the greatest part of the month of August, the treatment recommended by Dr Edward Stephens, a physician of great repute at St Croix, was employed with more success than any other; of which the following is an abstract. "The nausea and vomiting may be relieved by an infusion of camomile flowers, given frequently until the stomach is suffici|ently emptied of all crude matters. Small do|ses of a cordial mixture composed of the oil of peppermint and compound spirits of laven|der, may then be taken until the sickness a|bates. 〈◊〉 notwithstanding, the irritability of the stomach should continue, recourse must be instantly had to the cold bath, which must be used every two hours or oftener if the urgen|cy of the symptoms should require it: after Page  55 each immersion a glass of old Madeira or a lit|tle brandy burnt with cinnamon may be ad|ministered.

Flannel cloths wrung out of spirit of wine, impregnated with spices, may be applied to the pit of the stomach and changed frequently. An injection containing an ounce of powdered bark, mixed with thin salep or sago, to which a tea-spoon-full of laudanum has been added, should be administered. These injections may be continued every two or three hours, omitting the laudanum after the first—as soon as the stomach can bear medicines and nou|rishment, the bark may be administered in small doses—and as much madeira wine may be given as the patient can bear, without af|fecting his head or heating him too much. All emetics and violent cathartics should be avoid|ed. If the bowels should not be sufficiently open, a laxative clyster may be necessary, or a few grains of powdered rhubarb added to each dose of bark, until the desired effect is Page  56 produced. If diarrhoea should prevail, it must be checked by starch injections, blended with laudanum, by the tincture E. kino, Japonica, or a decoction of cascarilla; for a diarrhoea, especially when profuse, is always injurious when the disease is in an advanced stage, or when the debility is great.

If stupor, coma, or delirium should come on, a large blister should be applied between the shoulders, small ones to the thighs, and stimulating cataplasms to the soles of the feet. When hemorrhages appear, the elixir of vi|triol may be joined with the bark, but great care should be taken to prevent it from affect|ing the bowels.

If the pulse should be much sunk, the pro|stration of strength great, and subsultus tendi|num take place, small doses of the liquor mi|neralis Hoffmanni, or even vitriolic aether, di|luted with water may be given. Musk and camphor in this situation, have also proved Page  57 effectual. Upon the whole this outline may be summed up under the recited circumstan|ces, by saying that the cold bath, bark and wine, a spacious well ventilated room, fre|quent change of bed and body linen, and at|tention to rest, and quiet if properly perseve|red, is all that can be done with any prospect of success."

We were led with other physicians of this city, to make trial of mercurial purges in the early stage of this disease, from having obser|ved their good effects in bilious remittents, when symptoms of accumulated bile were present; and are surprized that the West In|dia practitioners never made trial of it in a dis|ease, which the generality of them acknowledge is the most desperate and mortal to which mankind are liable, and which has heretofore baffled all their skill; especially as some of them imagine it to be only a higher grade of the bilious remittent, of tropical climates; and as mercurial cathartics are recommended oc|casionally Page  58 for the removal of bilious accumu|lations, by several modern authors, particu|larly by Balfour, Blane and Clark. Dr. Wil|liams indeed, (who published as treatise on the yellow fever at Jamaica in 1750), though he makes no mention of mercury, says he found jallap or seammony in doses of 20 or 30 grains, given after an antiemetic draught, and repeated as often as it was thrown up till it operated freely by stool, more effectual, not only in relieving the incessant propensity to puke at the beginning of the disease, but in mitigating every painful and febrile symptom, and adds that though he can adduce no mo|dern authority in support of is practice, he can recommend it from his own experience. We can say the same of mercurial purges, with this addition, that when they operated copiously, which was generally the case when a laxative glyster was injected, a 〈…〉 after them, the vomiting or the propensity thereto became more moderate, and in many cases was entirely removed.

Page  59 With respect to blood-letting, there is much contrariety of sentiment among the West In|dia physicians; the generality of them re|straining the operation to the first and second days, from the commencement of the disease, and to a very sparing quantity: whereas Dr. Mosely advises it without limitation, even ad|deliquium, and a repetition so long as the pulse continues preternaturally quick, and the skin; exhibits much feverish heat. And Williams advises opening the temporal artery, when the pain in the head is great, and the fever high. But though Mosely is of the same opinion with Williams, with respect to purg|ing for relieving the irritability of the stomach, so long as the feverish heat is evident, with|out regarding the state of the pulse, he makes no mention of mercurial purges, but places his chief dependence on a solution of vitrio|lated tartar and emollient glysters; and as soon as that is accomplished, has immediate re|course of the bark in various forms, as may be most grateful to the stomach.

Page  60 Blane and Jackson have given a more ac|curate description of the disease, but Mosely certainly understood its nature and treatment better than either, though he may perhaps sometimes have carried his plan too far for the constitutions of the generality of citizens. For hardy athletic mariners we believe it was the best mode of treatment that was known at the time he practised in Jamaica.

Page  [unnumbered]

OBSERVATIONS ON THE ORIGIN AND NATURE OF THE CONTAGION.

THERE is no disease on which the influ|ence of climate and season is so conspicuous as on the yellow fever.

In the islands and countries within the tro|pics, where the disease is generated, the physi|cians who practice in those parts have no idea of its being contagious; but because it rarely attacks the natives of that climate, and is con|fined to foreigners from a colder climate, they Page  62 ascribe it to the effects of fatigue and heat, ex|posure to night air, or to some irregularity, &c. Numerous observations however prove, that it is highly contagious when conveyed to other countries, especially in populous cities with close built streets, when the heat of the weather is e|qual to, or exceeds that of, tropical climates. For examples of this, the reader is referred to Lind on Hot Climates; to Lining's account of its several occurrences at Charleston, published in the 2d volume of the physical and Litera|ry Essays of Edinburgh; and to the history of its rise and progress as it lately appeared in Philadelphia, published by Mr Carey. For|mer observations also shew, that the contagion has always been so effectually destroyed by cold and frosty weather, that it has never been known to revive the following spring or sum|mer.

As the contagious miasmata, or deleterious corpuscles of this contagion, or whatever else it may be supposed to consist of, is neither vi|sible nor can be rendered cognizable to the Page  63 senses by any means hitherto invented, we can only determine its existence and judge of its nature from its effects. And as the source from whence it is ••rived, and the means by which it is generated, have never been investi|gated or even suspected as we know of, we can only form a judgment of that circum|stance from analogy, which at best is but a problematical guide.

The yellow fever, though it agrees with the typhus, jail or hospital fever, and the pes|tilence in being capable of affecting sound persons under certain circumstances, who hap|pen to approach within a certain distance of its source, or of substances which have already been within that distance, and imbibed the contagious effluvia, differs materially from the former, in not being capable of producing any morbid effect in cold and frosty weather, un|less the heat of the chamber where it may chance to lurk, be raised and continued for some hours above fifty or sixty degrees, or ac|cording Page  64 to the learned and observing Blane, 75 degrees—and from the latter in not losing its power, and declining as the heats of sum|mer, in countries where they are very hot come to the•• height, as well as by the cold of winter—and from both in the manner of its attack, and the appearance of the symptoms in the progress of the disease. And though it resembles the influenza in the suddenness of attack, it differs from it materially in the faci|lity of communication, the rapidity of its pro|gress, and the extensiveness of its sway—the one being confined to cities, and taking some months to finish its progress—the other spread|ing over whole continents, in the course of as many weeks.

Nor does it agree in its effects with the mi|asmata, which arise from putrefying substan|ces, or from a marshy soil in any one circum|stance, except being extinguished by cold and frosty, and perhaps rainy weather.* For the Page  65 miasmata of marshes, are diffused through the atmosphere to a considerable distance from their source, and affect numbers at the same time, and the diseases produced thereby, are not contagious; whereas the miasmata which occasion the yellow fever, are confined to a very narrow sphere, and only affect those that happen to come within that sphere, or in contact with, or near to such persons, or such substances as have been within that sphere, so as to receive the contagious effluvia; and the disease produced by these miasmata is conta|gious, and propagated in succession from one to another, in proportion as there is more or less intercourse between the sound and the sick, provided a state of the atmosphere, with respect to heat and some other circumstances, exist at the same time favourable for propaga|ting the contagion. What these circumstan|ces are, will be mentioned in the sequel. But if this disease is neither a modification of the Page  66 pestilence—the typhus—the influenza—or a higher grade of the bilious remittent fever.—What is it? From what source does it origi|nate, or by what means is it generated? That it originates within the tropics, and seldom if ever in any other climate is generally admit|ted—but from what source or how generated, is the question.

It is well known to every one conversant with medical subjects, that other contagious miasmata are frequently generated in close crowded or unventilated places, particularly in jails, hospitals and ships of war, unless the body and bed clothes are frequently changed and kept clean, and the air frequently renew|ed, in consequence of the effluvia constantly issuing from the lungs and pores of the skin, at the same time that a portion of the pure and vivifying principle of the air, is gradually exhausted by the same circum|stance. It is also a fact well established, that persons thus circumstanced, frequently com|municate Page  67 a disease to those who chance to come into the same place, or in contact with such substances as have been within a certain distance of them, so as to imbibe a quantity of the effluvia issuing from them, especially when rendered volatile by heat, without being in any apparent degree affected in their health themselves.*

May not the contagion of the yellow fever therefore be generated in the dirty, confined, and suffocating cabins of the unfortunate slaves, (who are deprived of the means as well as the relish for cleanliness and agreeable appearance, which actuates the minds of independent free|men), exalted into a pestilential quality by long continued heat; and may not the consti|tutions of the inhabitants from the same cause, in conjunction with the purity of the air from constant ventilation, be rendered incapable of Page  68 being affected by it; while strangers, whose constitutions are differently disposed, seldom escape?

The putrefaction of dead animal matter can, have no share in generating the disease, as it gives out nothing but a little hydrogen or in|flammable air different from vegetable sub|stances in that process.

To suppose with Drs Warren and Desportes that the contagion by which the disease is pro|duced and propagated, was first introduced into the Islands by a crew of sick persons that arrived there about the year 1730, from Si|am in the East Indies; and that it has been fostered there ever since, as the small pox has been in other countries, would have some ap|pearance of plausibility, if like that disease it made no distinction between natives and fo|reigners; and a greater or less number of the inhabitants were always affected by it: but as that is not the case, such an opinion must be Page  69 groundless. For instead of affecting the na|tives, it is almost entirely confined to mari|ners from long voyages, and foul and crowded ships; and to soldiers confined in hospitals, or crowded together in huts or barracks. And when it happens to be conveyed to other coun|tries, its influence is entirely exerted upon the inhabitants of cities; and is observed to be most contagious in those parts where the air is most confined and impure—when the days are very hot and the nights cool. Hence it appears, that in order to give effect to the contagion of this fever, it is necessary that there should be a certain constitution of the air, in conjunction with great heat.

Let us therefore enquire into the circum|stances which give this morbific constitution to the atmosphere, that if the contagion should ever be introduced here again, we may not only escape its effects by retreating into the country, but if possible, disarm it of its power, and prevent it from spreading, and affecting those who remain in the city.

Page  70 That all contagious diseases receive their full force from a particular constitution or con|dition of the atmosphere, appears certain, from a multiplicity of concurring observations made by different authors at different periods and in different countries. In what this particular constitution of the atmosphere consists, which in one year and in the same situation favours the spreading of contagion, and in another year in the same season and in the same place, checks or extinguishes it, has been variously explained by different writers: but as no ex|planation hitherto attempted is perfectly satis|factory, we beg leave to offer one which we think less exceptionable.*

During a long continuance of dry and hot weather, the atmosphere becomes more or less charged with exhalations from various sour|ces, in proportion to the moisture of the soil, &c. which are more or less injurious to health, Page  71 in proportion to the quantity of animal and vegetable substances in a state of putrefaction, which cover or are mixed with the soil, the respiration of animals, the combustion of fuel, &c. while it is at the same time robbed by these processes of a considerable portion of its vivifying principle, at present known by the name of oxygen gas, or pure air.. It is cer|tain that the air is saturated by some other sub|stance, or deprived of a portion of its vivify|ing principle by some means or other; other|wise we know from the most unquestionable observations, that it would always neutralize, correct, dissipate, or precipitate the matter of contagion, however minute and subtle the cor|puscles may be of which it consists. For it is well known that no contagious disease can spread, or become epidemic, on mountains, or on open and extensive plains, where the soil is dry, cleared, and cultivated; whereas it is with difficulty it can be prevented in populous ci|ties, with close built streets and narrow alleys, or in low champaign countries, where venti|lation is obstructed by surrounding woods.

Page  72 In populous cities in sultry weather the ex|halations, from the vaults, privies, sinks, sew|ers, gutters, shambles, slaughter-houses, tan-yards, from respiration, and the combustion of fuel, and a variety of other processes of na|ture and art, are inconceivably great. Nor can such exhalations fail of filling the air with a noxious mass of invisible corpuscles; at the same time that the process by which they are generated spoliates the same atmosphere of a principle, on the presence of which, both life and flame depend for their continuance.

—"It is not air
That from a thousand lungs reeks back to thine.
Sated with exhalations rank and ell,
The spoil of dunghills, and the putrid thaw
Of nature; when from shape and texture, she
Relapses into fighting elements:
It is not air, but floats a nauseous mass
Of all obscene, corrupt, offensive things;
Which still ranker grows with sickly rest,
And poisons the balsamic blood."

ARMSTRONG on Health.
Page  [unnumbered]

MEANS FOR PREVENTING THE INTRODUCTION OF CONTAGION INTO SEA-PORT TOWNS.

THE most effectual means of preventing the introduction of contagious diseases into a|ny sea-port town, is to erect at a convenient distance therefrom, four separate hospitals, with large airy apartments. One of these hos|pitals to be appropriated for persons with du|bious symptoms. A second for persons ma|nifestly infected. A third for convalescents from the disease. A fourth for purifying the body, the wearing apparel, and bed clothes: Page  74 this last should be provided with bathing tubs, and materials for fumigating. A bath|ig chamber and fresh clean apparel should al|so be provided near to each hospital, for each patient, before his admission into either; ex|cept his weakness or fever should make the bath hazardous. Each apartment should be separated by means of a partition, to prevent any effect from each other; and should have windows that will both slide up and down, for the admission of fresh, and expulsion of foul, air. (For the manner of constructing these, see Mackiterick's Medical cautions.)

These hospitals should be at some distance from each other, on as elevated and dry a si|tuation as can be conveniently found. When a suspected ship arrives, the whole crew should be compelled by law to perform qua|rantine for 14 days at least; the sound to re|main on board; the sick or indisposed in a marine hospital or infirmary. By this it would be ascertained with certainty, whether there was contagion on board or not.

Page  [unnumbered]

MEANS FOR PREVENTING THE SPREADING OF CONTAGIOUS DISEASES, WHEN THEY HAPPEN TO BE IN|TRODUCED INTO A CITY.

WHEN a contagious disease breaks out in a city, the most certain means of prevent|ing it from becoming epidemic, or from spreading, is to prohibit all intercourse be|tween the sound and the infected; and to commit the diseased to the care of persons commissioned for that purpose. As soon therefore, as the disease appears in any fami|ly, both the sound and the sick should be im|mediately separated and removed to other a|partments, at some distance from the town, Page  76 and a considerable distance from each other, and the house where the disease appeared should immediately be purified by the means hereafter directed.

Infirmaries for this purpose should be built at the public expence, on dry and elevated si|tuations, particularly on the high and gravelly banks of rivers or constant streams of water, open on all sides to the free access of the air, provided with every necessary, and supported at the public expence. But persons in afflu|ent circumstances though compelled to leave the city, should be allowed to retire to private infirmaries at their own expence, provided they conformed to the rules of the public infirmaries, in every other respect.

Every family in the neighbourhood where the infection prevailed, should also be obliged under a heavy penalty, to remove to another part till all danger from contagion be over; and no person be permitted to return to an Page  77 infected house, or to use any article where the contagion existed, till purified by the means hereafter directed. Nor should any person who has recovered from the disease be permitted to return to the city, or to his own house, till he has after such recovery, repeat|edly undergone the ablution of both the warm and cold bath, changed every article of his cloathing, and performed a quarantine of at least 14 days, so as to render his return per|fectly safe to the community.

If proper attention had been paid to these directions, which have been collected from the most respectable sources; and the substance of which was earnestly advised by the college of physicians, the calamity by which all descrip|tions in this city so lately suffered, would have been prevented. And that a strict and punc|tual observance thereof in future, will prevent the like calamity, we are as certain as we are of any axiom in natural philosophy.

Page  78 In a letter from Dr Waterhouse, the present respectable professor of the theory and practice of medicine in the university of Cambridge, Massachusetts, dated September 28th, 1778, we find the following information respecting the means which have been found effectual for preventing the small pox from spreading among the inhabitants of Newport, the capi|tal of Rhode-Island, when it happened to be introduced there, by means of any vessel; and will apply equally well in preventing any o|ther contagious disease from becoming epide|mic.

When a vessel arrives in the harbour with the small pox on board, every person with the disease is immediately taken by officers ap|pointed for the purpose, to Coaster's harbour, a little island about three miles from Newport, where there is an hospital and every necessary provided for their reception and accomoda|tion. And the vessel having a jack hoisted in her shrouds, is obliged to perform quarantine.

Page  79 None of the bedding or wearing apparel made use of by the patients during their stay at the hospital, are permitted to be brought away; nor are the patients who recover from the disease, allowed to leave the hospital, till they have undergone several ablutions in warm water, and till at least one week has elapsed af|ter their recovery, let the disease be ever so light.

When any person in the town is suspect|ed of having taken the infection, the family is obliged, under a heavy penalty, to give im|mediate notice to one or more inspectors. If these, in conjunction with a physician, pro|nounce the disease to be the small pox, the fa|mily has little more to do with the patient; but he is from that time to the termination of the disease, wholly under the direction of these officers, who remove him to Coaster's harbour. Formerly they carried the sick person on a sleigh in a box in form of a large chest, with a small bed in it; the cover of which was per|forated with holes sufficient to supply the pa|tient Page  80 with air. But the inhabitants percei|ving that this formidable apparatus had all ill effect on timorous minds, discontinued the box, and substituted a sedan chair. It has hap|pened more than once, that the disease was so far advanced before it was known to be the small pox, that the patient could not be remo|ved without the greatest hazard. In that case the street was boarded up; an advertisement published in the news-papers, and guards pla|ced to prevent any person from approaching within a certain distance of the house.

MEANS FOR DESTROYING CONTAGION.

HEAT, fumigation and lime-washing ap|pear to be the most effectual means of destroy|ing the contagion adhering to the walls, floors, Page  81 and furniture of houses, and to bedding, wear|ing apparel, and to other materials which have been exposed to it.

For this purpose the bedding and wearing apparel being hung on lines across the room, iron pots placed on bricks in the centre, and at each corner of the chamber or apartment should be nearly filled with alternate layers of powdered sulphur or nitre, and charcoal; and a piece of oakum dipt in tar, to serve as a match, being placed in each pot, the fire-place being previously closed, and the windows shut down, is to be set on fire, and then the door to be shut; observing to let in fresh air occa|sionally, and to relight them when extinguish|ed; but cautiously avoiding going in till the door and windows have been for some time opened to prevent suffocation.

When this process has been continued for three or four days, the door, windows, and chimney are to be opened, and left open day and Page  82 night for at least a fortnight. By this time every particle of contagion will be perfectly extinguished, especially if the air of the room had been greatly heated immediately before the admission of fresh air: for by great heat it is attenuated and dissipated, and by cooler and pure air entirely changed in its nature and qualities, if there is any faith to be put in the experiments of the committee of physicians ap|pointed by the empress of Russia, to super|intend the hospitals, when a pestilential fever prevailed at Moscow in the year 1771, related by Mertens in his medical history of that dis|ease: or if the observations of the experienced Lind, and the intelligent Russel, are to be cre|dited.

For greater security, the walls of the house where infected persons have lain, should al|ways be white-washed with lime, and a quan|tity of the same article should be thrown into the privies, as it is a certain corrector of conta|gion and putrefaction, as well as destructive to every species of animalcule.

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APPENDIX.

Copy of the report of the College of Physicians, in answer to the Governor's enquiries, respec|ting the origin of the late epidemic; and their directions for extinguishing latent in|fection.

SIR,

IT has not been from a want of re|spect to yourself, nor from inattention to the subject, that your letter of the 30th ult. was not sooner answered; but the importance of the questions proposed, has made it necessary for us to devote a considerable portion of time and attention to the subject, in order to ar|rive at a safe and just conclusion.

No instance has ever occurred of the dis|ease, called the Yellow Fever, having been ge|nerated in this city, or in any other part of the United States, as far as we know; but there have been frequent instances of its ha|ving been imported, not only into this, but Page  84 into other parts of North America, and pre|vailing there for a certain period of time; and from the rise, progress, and nature of the ma|lignant fever, which began to prevail here a|bout the beginning of last August, and ex|tended itself gradually over a great part of the city; we are of opinion that this disease was imported into Philadelphia, by some of the vessels which arrived in the port after the middle of July. This opinion we are fur|ther confirmed in, by the various accounts we have received from unquestionable autho|rities.

TO PURIFY THE CITY FROM LATENT INFECTION,

WE beg leave to recommend, that every house, particularly those in which there have been any sick, should be thoroughly cleansed and kept open for some weeks, so as to ad|mit fresh air through every aperture. The walls should be white-washed, and gun-pow|der burned in all the apartments. The beds Page  85 and woollen apparel of the infected, should either be destroyed or smoaked with gun-pow|der in a close room, and afterwards exposed to the open air and rain. Unslaked lime should be thrown down the necessaries; the streets should also be kept clean, especially in the confined parts of the city.

In answer to your last question, permit us to observe, that we trust the early attention of the legislature will be directed to the port, with respect to the officers and other necessa|ry arrangements, and on such an occasion the College will ever cheerfully co-operate with them, in their endeavours to prevent the in|troduction of contagious maladies in future.

By order of the College of Physicians.

JOHN REDMAN, President.

NOVEMBER 26th, 1793.