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May 2002
Vol. 5, No. 5, pp 51–55.
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the time line
Apostles of cleanliness
The 19th-century Sanitary Movement denied the germ theory of disease, yet created our public health infrastructure.

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National Library of Medicine
Most residents of the United States take public sanitation for granted. They expect their drinking water to be free of disease-causing microorganisms and their streets to be clean. Yet it was not always so. Until the early 20th century, the living conditions in many, if not most, U.S. cities were far from healthy. An organized effort to safeguard public health was essentially nonexistent.

Public health became a civic problem as urban population density increased. While the urban population was never high in early America, the Industrial Revolution and increased immigration caused a population boom in American cities. From 1840 to 1920, the U.S. urban population grew from about 1.8 million to more than 54 million. This influx of new city dwellers increased human and industrial waste, and strained the minimal resources used to deal with refuse.

Contagious diseases swept through urban areas. In the early 19th century, the reigning explanation for the spread of disease was the miasmic, or anticontagionist, theory. This theory held that disease was caused by sewer gas, garbage fumes, and poor sanitation. While we now know this to be false, the earliest bacteriological research, which led to the germ theory of disease (also called contagionism at the time), did not have an impact on American sanitary practices until the late 19th century. The anticontagionist theory gave impetus to the Great Sanitary Awakening, the rise of organized public movements to improve sanitation in urban Europe and the United States.

Snow and water
John Snow, physician to Queen Victoria of England, was a staunch proponent of the germ theory who pinned down the cause of cholera. While investigating a local cholera epidemic in London in 1854, Snow deduced that all the cases could be traced to a single contaminated well. By having the water pump handle removed, he managed to stop the spread of the disease. Although this was one of the first epidemiological studies, and Snow isolated what would eventually be proven to be the causative bacterium, Vibrio cholerae, Chadwick and other anticontagionists remained convinced that it was the befouled water and not a microorganism that was at fault. Both sides of the debate saw Snow’s study as a confirmation, however, of the importance of sanitation.
The Sanitary Awakening began in England during the last quarter of the 18th century, spurred by John Howard’s reports on the poor condition of prisons and hospitals. The greatest British sanitary reformer was Edwin Chadwick, whose research was influential in securing the passage of the Public Health Act of 1848. Chadwick published the now classic General Report on the Sanitary Conditions of the Labouring Population of Great Britain, and he was behind the movement to establish the first British Board of Health. His views were antithetical to those of the contagionists, especially his contemporary, John Snow (see box, “Snow and water”).

Chadwick’s example inspired reformers in the United States. In April 1850, Lemuel Shattuck, a teacher and amateur genealogist, wrote the first comprehensive plan for an integrated state program of public health in the United States. His report dealt with the construction of buildings, waste disposal, the pollution of streams and the atmosphere, the control of communicable diseases, and other aspects of the hitherto neglected field of preventive medicine. Like his British predecessors, Shattuck believed in the miasma theory of disease. He had no knowledge of bacteriology and no formal training in the sciences. Yet of the 50 recommendations in his 1850 report, more than 36 were universally accepted public health practices 100 years later.

Scientific proponents of bacteriology dismissed the theories of Shattuck and other anticontagionist sanitarians, but the Sanitary Movement had a prodigious impact on public health in the United States.

Spreadin’ the news
Mid-19th century sanitarians in New York City expended much energy promoting the passage of a metropolitan health bill that would address miserable living conditions there. At this time, New York had a higher mortality rate than most cities in the United States and Western Europe. Members of the New York Sanitary Association were convinced that the diseases that contributed to this high rate were primarily due to the absence of proper sanitary practices and could be prevented. Sanitarians wanted to improve public health law and educate the populace about proper hygiene.

In 1864, the New York physician Stephen Smith organized and directed a sanitary survey of New York City, a landmark event in the history of American public health. Many students of public health still consider this survey to be among the most comprehensive ever made. It contains vivid descriptions of living conditions unimaginable to contemporary Americans. The inspectors wrote about overflowing privies, slime-covered streets filled with horse manure, and slaughterhouses and fat-boiling establishments dispersed among overcrowded tenements. One inspector reported that blood and liquid animal remains flowed for two blocks down 39th Street from a slaughterhouse to the river. It was common knowledge that youngsters could earn nickels by standing along Broadway and sweeping a path through the muck for those who wanted to cross the wretched boulevard.

The New York survey was responsible for immediate improvements. Smith testified before the New York Senate and Assembly, and just over a year later New York passed the first comprehensive health legislation in the nation. The newly established Metropolitan Board of Health was the first government agency dedicated to truly professional sanitary reform in the United States, and New York’s sanitary legislation served as a model for other local and state bills. Smith’s work in New York City also led to the formation of the American Public Health Association, on whose board he served.

While the mortality rates in New York were higher, the city of Chicago was not free of sanitation crises in the 19th century. In the 1850s, Chicago endured a succession of cholera and dysentery epidemics, incited primarily by the city’s random waste disposal methods. In response, the Illinois legislature appointed Boston city engineer Ellis Sylvester Chesbrough to be chief engineer of the Chicago Board of Sewage Commissioners. Chesbrough immediately submitted a plan for a sewage system designed to solve Chicago’s waste disposal problems. At that time, not one U.S. city had a comprehensive sewage system, although most had sewers. In devising a system that would best serve Chicago, Chesbrough visited several major European cities and studied their sewage systems.

The sewage project transformed the look of the city itself as streets were raised, buildings torn down, and vacant lots filled. Chesbrough’s innovations decreased epidemics and greatly improved public health, although he and his peers still worked within the miasmic paradigm of disease.

“Waring” away at filth
The most important 19th-century sanitarian was also an anticontagionist, Colonel George E. Waring. A farmer, agricultural and drainage engineer, and cavalry officer in the Union army, Waring helped to establish sanitary engineering as a profession. After the Civil War, Waring developed a reputation as an expert on scientific agriculture. He published popular books and articles on sanitation (such as Draining for Profit and Draining for Health) and even acquired a financial interest in a British-designed earth closet (a toilet that was similar to a soil-composting system). Indeed, Waring initially criticized water closets (standard flush toilets) as threats to public health because they exuded the “sewer gas” thought to be a primary cause of disease. But after earth closets failed to sell in America, the colonel switched his position and advocated the universal adoption of the water closet!

In the 1870s, Waring expanded his advocacy of the water closet to a broad-based crusade against sewer gas and the diseases it was thought to cause. Throughout the late 19th century, Waring’s views on disease were endorsed by much of the medical profession and by most of the general public. He traced disease outbreaks to putrid house drains and stagnant ditches. The remedy to such disease-producing miasma, Waring argued, was the installation of proper sanitary fixtures, which would remove the sources of “bad air”. The complete prevention of disease relied not simply on the protection of individual houses but on the sanitary reform of entire communities.

Like Chesbrough, Waring recognized the importance of comprehensive sewage systems. In the wake of the 1878 yellow fever epidemics in Memphis, TN, President Rutherford B. Hayes appointed him to a commission directed to establish a plan for the sanitary improvement of that city. Waring developed a plan for a complete sewage system and then, ever the salesman, hired himself out to the city of Memphis to build it. He had obtained the American rights to the “separate” sewage system of England’s Chadwick and capitalized on his prominence to promote this system throughout the nation. While he reaped the financial rewards of his engineering work, Waring also consulted on sewage projects all over the world and advised the U.S. president on the sanitary condition of the White House.

Waring’s tenure as New York City’s Commissioner of Street Cleaning, from 1895 to 1898, was probably his most famous position in the sanitary movement. He completely renovated his department’s street-cleaning and garbage-collecting procedures and equipment and transformed New York’s streets from the dirtiest to among the cleanest in the world at the time. Although the return to power of the Tammany Hall political machine cost Waring his job, he would be remembered in the city as the “apostle of cleanliness”.

Muddling past miasmas
By the turn of the 20th century, the anticontagionist position had been all but completely undermined by bacteriological research. Waring died of yellow fever in 1898 after visiting Havana, Cuba, to help end the epidemic there. Ironically, this epidemic discredited the partisans of the miasma theory. While the city was completely cleaned and made free of “sewer gas”, following Waring’s recommendations, yellow fever raged on. The contagionists, led by Major Walter Reed, demonstrated that “filth” played no causative role in the disease and proved that the disease was transmitted by the Stegomyia mosquito.

While the future of public health was in the hands of researchers like Reed, Waring and his anticontagionist forebears had made a significant contribution. The miasma theory of disease may have been inaccurate, but the public health solutions begun to combat “filth” and “sewer gas” would have abiding, salutary effects. The anticontagionists built a public health infrastructure and professionalized its management, improving the lives and safeguarding the health of millions. The sanitarians’ science was wrong, but their activism in the name of the public good benefited all Americans. Indeed, most medical historians believe that the sanitation movement, and its attendant improvements in urban health and food safety, contributed far more to the increase in Western life expectancy in the 20th century (primarily through the prevention of infectious diseases) than did much of modern medicine. The turnaround in mortality rates came well before the rise and general use of vaccines and antibiotics.

Further reading
Melosi, M. V. The Sanitary City: Urban Infrastructure in America from Colonial Times to the Present; Johns Hopkins University Press: Baltimore, 2000.
Sickness and Health in America: Readings in the History of Medicine and Public Health; Leavitt, J. W., Numbers, R. L., Eds.; University of Wisconsin Press: Madison, WI, 1985.


Richard A. Pizzi is a freelance writer with an M.A. in history, currently working on a Ph.D. at Indiana University. Send your comments or questions regarding this article to mdd@acs.org or the Editorial Office by fax at 202-776-8166 or by post at 1155 16th Street, NW; Washington, DC 20036.

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