The World of Ellen G. White

Chapter 9—Health and Health Care

Rennie B. Schoepflin

To make plain natural law, and urge the obedience of it, is the work that accompanies the third angel’s message to prepare a people for the coming of the Lord. —Testimonies for the Church 3:161. WEGW 143.1

The health and health care of early twentieth-century Americans bore little resemblance to that of antebellum years. Life expectancy had increased 20 years, and infant mortality rates had dropped by a third. Scientific medicine had solved numerous problems of therapeutic confusion by dramatically unifying medical theory and practice. Hospitals no longer served a merely custodial function, treating only the poor; they now provided the increasingly technological setting necessary for the medical treatment of all classes. WEGW 143.2

Personal habits of hygiene and diet had changed. Americans—the better classes, at least—bathed regularly, consumed a more balanced diet, and recognized the importance of functional clothing and adequate exercise. A public health movement had lobbied successfully for purified water supplies, new sewer systems, and keeping America’s streets cleared of garbage and filth. Seven decades of continued change have done little to efface the basic patterns of approach toward sickness and health that evolved during the last decades of the nineteenth century. WEGW 143.3

In the early nineteenth century, American patients and physicians shared a common understanding of health and sickness that contrasts sharply with that of most Americans today. Viruses, bacteria, and antibiotics were foreign to their model for the maintenance and restoration of health. WEGW 143.4

Before the last third of the nineteenth century, physicians knew of and used but few specific agents for the treatment of disease. Among those few agents, limes had cured and prevented scurvy since the mid-eighteenth century, and inoculation had provided a reasonably sound if less than perfect prevention for smallpox since the 1700s. Physicians had prescribed digitalis for various heart ailments since the early 1800s and indiscriminately had used quinine for various fevers in the 1820s (although cinchona bark, which contains quinine, had been used much earlier). Aside from these medications, physicians recognized few correlations between specific diseases and specific cures. WEGW 143.5

Instead, the common view pictured health as a state of balanced interaction between the environment and the body’s inherited constitution. Unfortunately, changes in weather, in disease makeup, and the trauma of the body’s growth and development (particularly puberty and old age) continually forced the body into states of imbalance—disease—that it struggled to correct. Patients and physicians believed that recovery followed nature-ordained pathways and that fever, diarrhea, vomiting, and other symptoms signaled the body’s progress toward that recovery. Physicians intervened in the body’s struggle by trying externally to regulate the body’s fluids and secretions through bleeding, purging, vomiting, and sweating. WEGW 144.1

Until late in the nineteenth century, physicians were dependent upon their senses in making a diagnosis. They carefully studied the tongue, the pulse, and the nature and extent of the body’s secretions for any hints as to the course of the disease. For treatment they drew upon the time-honored therapies of their predecessors. Using lancets, scarificators, and cups, most physicians, often called regulars or allopaths, bled their patients. They purged liberally with calomel, vomited with ipecac, and sweated with Dover’s powder, to name only a few of the standard powders, extracts, and tinctures in their armamentaria. WEGW 144.2

Although today we might attribute many of the “cures” to the self-limiting nature of most diseases, sometimes the administration of drugs coincided with the patient’s recuperation, further confirming the efficacy of the ancient model. WEGW 144.3

Under the far-reaching influence of the Philadelphia physician and teacher Benjamin Rush, a radical “heroic therapy” that built upon this ancient model of health, and advocated the energetic intervention of the physician in the natural disease process, engulfed allopathic medicine during the 1840s. WEGW 144.4

Especially concerned with the “violent morbid action” of a group of diseases called “fevers,” Rush copiously bled his patients to relax the vascular tension that he believed primarily responsible for them. The control of this body fluid, Rush claimed, held an important key to the physician’s successful intervention. Under his influence a generation of physicians set out to bleed Americans to health, often supplementing the work of their lances with doses of a powerful purgative, calomel. WEGW 145.1

Sociologist William Rothstein has illustrated the popularity of heroic therapy among regular physicians by noting that before 1850 almost two thirds of the patients at the Massachusetts General Hospital in Boston with acute lobar pneumonia were routinely bled and “almost every case was vomited and purged.” Rothstein further notes, however, that physicians’ practices began to change by mid-century, as evidenced by their bleeding of less than one third of the patients during the 1850s and their almost complete rejection of heroic therapy after 1860. WEGW 145.2

This does not mean that all heroic measures died out. Heavy doses of calomel remained a favorite remedy for many regular physicians, as witnessed by the uproar over the attempt by the United States surgeon general, William A. Hammond, to remove it from the Army supply table in 1863. WEGW 145.3

But heroic therapy did decline during the middle third of the century as physicians, especially younger physicians, slowly moderated their treatments by reducing the dosages of drugs and using bleedings only sparingly and mildly. Heroic therapy had always had its critics. In 1835 Jacob Bigelow, professor of materia medica at the Harvard Medical School, presented an address entitled “Self-limited Diseases,” in which he argued that certain diseases would not respond to a physician’s intervention and must be allowed to run their course under the care of nature’s own healing power. WEGW 145.4

Many physicians subscribed to this “nature-trusting heresy,” began to evaluate their former methods of treatment critically, and rejected heroic therapy. During the 1850s Edinburgh physician John Hughes Bennett further shook the heroic model by challenging the theoretical basis of bloodletting, thereby intensifying the need for some new therapeutic model. WEGW 145.5

Probably the most influential critics of heroic therapy, however, came from outside the ranks of the regular physicians. Homeopathic, Thomsonian, hydropathic, and other sectarian physicians touted their own theories of disease origin and cure and hurled abuse at their competitors. Sometimes the cures they offered the public tasted, smelled, or felt good, and regular physicians only had their own dubious authority to convince patients that the rigors of heroic treatment yielded better results. What could Americans who rejected the severe purgings and bleedings of the regular or allopathic physicians expect from the so-called sectarian or irregular physicians? WEGW 146.1

Many medical sects, almost too numerous to count, offered relief to the sick of nineteenth-century America. There were animal magnetizers, phrenomagnetizers, “rubbers,” clairvoyant physicians, faith healers, eclectics, and physiomedicals, to name only a handful. Furthermore, an enticing array of advertisements and testimonials lured Americans to patent medicines and quack devices and exploited their belief that every person could be an expert, even on matters of health. Lydia E. Pinkham’s Vegetable Compound provided women the perfect panacea for all female complaints, and “voltaic belts” restored the “vital power” frittered away by middle-aged men. WEGW 146.2

We give here a close look at three important sects—Thomsonianism, homeopathy, and hydropathy—to illustrate sectarian medicine’s diversity of doctrine and appeal. WEGW 146.3

Samuel Thomson, New Hampshire farmer, turned his knowledge of folk and Indian herbal remedies into a successful healing career. Under the belief that all disease was caused by cold, Thomson steamed, puked, and peppered his patients to increase the body’s natural heat. Relying heavily on lobelia (a powerful emetic), herbal purges, and a rejection of bleeding, Thomson’s system appealed to a long tradition of self-help, botanical medicine in America. WEGW 146.4

By the 1830s Thomson’s agents, often called “botanics” or “steamers,” had spread throughout America selling “family rights” to his system, which included membership in Thomson’s society and a copy of his New Guide to Health. By 1840 Thomson estimated that 3 million persons had adopted his system and eagerly diagnosed, prescribed for, and cured themselves. Although Thomsonians used many severe remedies, the naturalness of his herbs, the handiness of self-medication, and the one-time fee of $20 made botanical medicine an attractive alternative to regular therapy. WEGW 146.5

Through its purported success with the cholera epidemic from 1848 to 1852, a new medical sect, homeopathy, gained prominence and respectability in America. Whereas uneducated agents sold Thomsonianism primarily to poor clients on the frontier, educated homeopathic physicians catered to a wealthy, urban clientele and thereby represented a much greater threat to the prestige and financial well-being of regular physicians. WEGW 147.1

Samuel Christian Hahnemann, Vienna-trained German physician, invented the twin doctrines of homeopathy in the 1790s. His doctrine of similars stated that medicine that produced the symptoms of a disease in a healthy person could cure that disease. His second law declared that the smaller the dose of medicine, the stronger its effectiveness. WEGW 147.2

Homeopathy first reached America in 1825; by 1861 it had attracted nearly 2,500 practitioners through the active conversion of regular physicians and the graduation of homeopaths from educational institutions such as their medical college in Cleveland, Ohio. WEGW 147.3

Regular physicians, feeling the financial and philosophical pressures of physicians who denounced the theoretical and empirical bases of heroic therapy, retaliated by deriding the “foolish” doctrines of homeopathy and purging their organizational ranks of homeopaths. In response, some eager homeopaths turned to the sale of domestic homeopathic kits to spread their doctrines among all classes of Americans. Containing small vials of homeopathic remedies and checklists of symptoms, these kits allowed families to diagnose and painlessly dose themselves with the highly diluted homeopathic medicines. They thus avoided costly visits to a physician and the unpleasant treatments of heroic therapy. The rapid proliferation of these kits effectively propagated homeopathic doctrines, to the somewhat subdued delight of organized homeopathic physicians, who had agreed with the regulars that such competition could only hurt the prestige of their profession. WEGW 147.4

Whereas Thomsonians and homeopaths moderated the use of drugs, hydropaths eschewed the use of all drugs and appealed instead to the natural remedies of water, sunlight, fresh air, exercise, and good food. Primarily through the work of Joel Shew and Russell T. Trall, two regular physicians, and Mary Gove Nichols, a prominent health reformer, Americans reveled in a water-cure craze from the early 1840s until the onset of the Civil War. Through the therapeutic use of an astounding array of baths, soaks, packs, and douches, Americans sought to wash away their diseases. Leaders of the movement established numerous water-cure establishments, but as with homeopathy and Thomsonianism, domestic use held the greatest potential for advancement. WEGW 147.5

Hydropaths further enhanced the spread of their ideas by forging links in the 1850s with the amorphous health reform movement, whose members advocated, according to historian Regina Markell Morantz, the “prevention of disease through the teaching of the laws of physiology and hygiene.” WEGW 148.1

A reform spirit quickened Americans during the decades before the Civil War and led them to demand changes in areas as diverse as dress, work, prison, education, and health. Health reform first caught the attention of Americans when its key crusader, Sylvester Graham, prescribed his regimen of coarse vegetarian food, cold baths, and vigorous exercise to prevent contracting the feared cholera during the epidemic of 1832. WEGW 148.2

Women often assumed prominent positions of leadership in nineteenth-century reform movements; the crucial role that health reformers gave to wives and mothers in the education and supervision of proper health principles proved their movement no exception. Diet, water, and women linked health reform to hydropathy, which could boast that in an age of few women physicians, roughly one fifth of its professional practitioners were female. Ellen Gould White, cofounder of the Seventh-day Adventist Church, and Mary Gove Nichols both actively sought reform in dress, diet, and morals while practicing hydropathy. WEGW 148.3

No clear-cut measure of efficacy, no generally accepted therapy, guided the sick through the morass of competing healers. Left to their own wits, Americans chose as best they could, often accepting the testimony of friends and drawing upon their own experiences of trial and error. Persuaded by criticisms of heroic therapy and badgered by their competition, some physicians fell into a therapeutic nihilism that denied the efficacy of all therapies, but few physicians, confronted by importunate patients, could afford the luxury of such cynicism. WEGW 148.4

Regular physicians cast about for some unifying theory that could restore order to their discipline and lead to a resurgence in the status of their profession. Alcohol became one of the most widely used medications in the middle of the nineteenth century, as physicians experimented with a general therapy of tonics and stimulants that sought to build up, sustain, and stimulate the body. WEGW 149.1

Quinine became the fever panacea of the 1870s and 1880s, and analgesics, especially opium, relieved pain but unleashed the horror of addiction. Finally, two discoveries gave physicians the means to establish unambiguously their power in an important area of medical practice—anesthesia and germ theory. WEGW 149.2

Successful surgery requires a knowledge of anatomy, the skills to control bleeding and pain, and an understanding of the cause and prevention of infection. Antebellum American physicians understood anatomy and could control hemorrhage, and by the end of the Civil War had acquired a surgical skill equal to their European colleagues, but the inability of physicians to control pain consistently and to prevent infection limited the further development of surgery. WEGW 149.3

As early as the 1840s the anesthetic properties of nitrous oxide and chloroform became known to physicians, but their rapid and widespread use did not decrease the mortality rates of surgical patients or safely extend the surgeon’s knife into the abdomen, thorax, or cranium. Not only did physicians inadequately understand the safe use of anesthesia; they still could not cope with postoperative infections and only dimly correlated such infections with hospitals. WEGW 149.4

In 1865 the British surgeon Joseph Lister read Louis Pasteur’s work on spontaneous generation and concluded that infection spread to wounds by airborne germs. Choosing the highly toxic carbolic acid as their first antiseptic, Lister and his colleagues achieved partial success in the prevention of sepsis, but on account of improper use of the acid, or because of a rejection of germ theory, many physicians initially ignored antiseptic procedures. WEGW 149.5

Gradually physicians became more convinced of the validity of germ theory and recognized that germs transmitted by hand or instrument presented a greater hazard than airborne contaminants. Steam and dry-heat sterilization soon replaced carbolic acid, and finally asepsis rather than antisepsis became the goal of surgeons. By the 1880s and 1890s regular, homeopathic, and eclectic surgeons had adopted the new procedures and unified surgical practice under its new scientific ideals. WEGW 149.6

The bacteriological discoveries that led to the successes of aseptic surgery offered the hope that all medical therapeutics could be transformed. In 1876 the German physician Robert Koch isolated the anthrax bacillus; with the use of improved staining techniques and greater microscopic magnifications, bacteriologists isolated a plethora of other disease-causing organisms during the 1880s and 1890s. Unfortunately, these discoveries had little effect on medical practice until the 1890s, when scientists isolated antibodies for specific bacilli and produced antitoxin for general use by physicians. WEGW 150.1

Initially, physicians cautiously evaluated the bacteriological theories and discoveries, but soon they adopted the revolutionary therapeutics that correlated specific medications to specific diseases. The sectarian fragmentation that had characterized nineteenth-century medicine gave way to a unified scientific medicine, which absorbed those aspects of sectarianism that proved their efficacy in the laboratory or clinic, such as hydrotherapy, massage, and nutrition. WEGW 150.2

The new changes carried their liabilities as well, however, as physicians increasingly attended to their patients’ diseases in the laboratory and neglected the wholistic nature of human health. New twentieth-century medical sects such as naturopathy, osteopathy, chiropractic, and Christian Science replaced those of the nineteenth century and provided alternative treatments for large numbers of Americans. These new sectarians often attracted patients who had become disillusioned with the ineffective or inattentive care of the “scientific physician.” WEGW 150.3

Although scientific medicine unified medical theory and therapeutics to an extent that medicine had not enjoyed in decades, it would be far from the truth to say that it provided the solution for all of America’s health problems. More than just medical theory and physician practice influence a people’s health. Institutions, which today provide a major setting for health delivery, changed dramatically during the nineteenth century and illustrated the influence of a nation’s social and political ideals on health. Through the establishment of mental asylums, hospitals, and dispensaries, Americans institutionalized health care, significantly altering the way in which patients interacted with physicians, and providing a setting in which nurses could professionalize and numerous allied health professions multiply. WEGW 150.4

In the early 1870s America possessed fewer than 200 hospitals, about a third of which served the mentally ill, but by 1925 that number had ballooned to more than 6,000. What caused this rapid proliferation in the number of hospitals? Actually, there were two distinct periods of rapid growth. Instead of placing the insane in prison or letting them run loose to threaten society, most states and some cities in the 1830s and 1840s built hospitals to care for and treat the mentally ill. Historian David J. Rothman has argued that this rapid growth reflected the communities’ desire “to compensate for public disorder” and “to demonstrate the correct rules of social organization.” WEGW 151.1

No doubt the establishment of asylums did lead to a form of social control, but results are not always the same as motives. Physicians and reformers also believed that the insane could be cured through the use of a new therapy, moral treatment, which assumed that the stresses and strains of normal life caused insanity, and that the mentally ill could be cured by removing them from the community and placing them in an isolated environment with an ordered regimen. In addition, general attitudes of humanity and benevolence, which animated all antebellum reform movements, supplemented the motives of control and cure in the expansion of mental hospitals. WEGW 151.2

Most citizens of present-day industrialized nations identify the hospital as the institution for treatment of their acute medical and surgical needs, but in mid-nineteenth-century America most physicians treated the sick at home. Hospitals maintained social stability and contributed to community prosperity by providing free medical care for the poor, the old, and the transient. Anyone who could afford proper medical care avoided the hospital, which offered no treatment not available in the home but did offer the added danger of sepsis, known as “hospitalism.” WEGW 151.3

During the 1870s, however, the public image of hospitals began to change, as reformers cleansed them of their filth and disease. This initiated a second period of hospital growth. Often motivated by the belief that filth caused disease, followers of the “miasma” theory, such as Florence Nightingale, cleaned up hospitals and professionalized nursing to better care for the sick and maintain a clean environment. Those persuaded by the new “germ” theory also recognized a need for sanitation, and they joined the battle to free the hospital of filth and infection. WEGW 151.4

By the 1890s the physicians’ use of anesthesia and their acceptance of aseptic surgery made the hospital as safe as the home for surgical procedures. Although the causal relation remains questionable, there began a rise in the number of hospital surgeries during the early years of the twentieth century and a parallel increase in patronage by middle-class and well-to-do patients. Important demographic changes in industrial America further contributed to this wider use and multiplication of hospitals. Americans no longer found it easy, with changed working and living conditions, to attend the sick in their homes, and with improved transportation, mobile citizens increased their chances of becoming ill while away from home. WEGW 152.1

Although hospitals are the most visible medical institutions in America today, dispensaries, first established by philanthropists in urban America near the end of the eighteenth century, grew to provide the most important source of medical care for mid-nineteenth-century America’s urban poor. They also were a major source of clinical experience for young physicians. Many urban communities established a dispensary under the operation of a single apothecary or house physician. This person carefully applied his meager budget to the common ills of the neighborhood and formed the community’s major line of defense against epidemic diseases through his administration of vaccination. WEGW 152.2

Dispensary workers did not just push pills, however, but believed themselves responsible for the poor of society. They recognized, however dimly, a connection between their lack of food and clothing and their poor health. Thus dispensaries reflected not only America’s fear of disease but its benevolent intentions toward its resident and immigrant poor. WEGW 152.3

Dispensaries also served the educational needs of physicians. From the first third of the nineteenth century until their replacement by hospital internships and residency programs in the first decades of the twentieth century, dispensaries provided an important source of clinical training for physicians and an opportunity for young physicians to form important contacts with prospective patients and influential senior physicians. WEGW 152.4

Medical historians have long noted that, along with developments in medical theory and practice, the American people began to live longer throughout the nineteenth century. Although the data remain fragmentary prior to 1900, they still suggest a steady increase in life expectancy continuing well into the twentieth century. In 1830 the life expectancy at birth for both sexes was about 35 years; by 1915 it had climbed to 54.5 years; today it stands near 75 years. WEGW 153.1

Infant mortality rates dramatically symbolize the improving health of Americans. Infant mortality hovered near 150 infant deaths per 1,000 live births from 1865 to 1895, plummeted to nearly 100 deaths per 1,000 live births by 1915, and continued its precipitous decline to about 20 deaths per 1,000 live births in 1970. Unfortunately, not everyone partook equally of these increased years of life. Women and Whites consistently live longer than men and non-Whites. WEGW 153.2

Although historians’ recognition of increased longevity has been fairly universal, their explanations for that increase have not. To physician-historians filled with apostolic zeal for their science of medicine, the reasons are clear. Medical diagnosis and treatment became unified under the banner of science and enabled fearless doctors to dramatically cure diseases with their “magic bullets.” WEGW 153.3

But this view fails to recognize that life expectancies increased while the “fearless doctors” puked, purged, and bled their patients. The view also disregards the fact that scientific medicine had only limited effects on infectious diseases, which were the leading causes of death in the nineteenth century, until the advent of the sulphonamides and antibiotics in the 1930s and 1940s. Recognizing the limits of medical therapeutics as an explanation, a growing number of historians have gathered a persuasive body of evidence to support their belief that changes in personal hygiene, including diet, cleanliness, and dress, and the development of a public health movement contributed significantly to Americans’ improved health and increased longevity. WEGW 153.4

Antebellum American dietary habits differed greatly from those of today. Believing that all foods contain the important requirement for health—universal aliment—Americans bolted huge quantities of food and only introduced variety into their diet to please the palate. Farmers, who usually produced their own food, consumed notoriously rich diets of meats and desserts and avoided fruits and vegetables. Of course, the diet of city dwellers reflected directly their ability to purchase food, with the kitchens of the rich opulently arrayed and the sideboards of the poor woefully lacking. Corn and pork formed the staples of the rural diet, whereas urban populations probably consumed more bread and beef. Potatoes, turnips, cabbage, and later tomatoes completed the basic American diet. WEGW 153.5

Americans had been called to dietary reform ever since the 1830s, when Sylvester Graham began to advocate his vegetarian regimen as the cure for the sickness and immorality of society. But three midcentury technological innovations made widespread dietary reforms possible by increasing the distribution and year-round availability of perishable and seasonal foods. Nathaniel Wyeth’s invention of the ice cutter dramatically reduced the cost of refrigeration. When refrigeration was applied to the transportation of regional foods by rail, Americans suddenly enjoyed an enticing variety of fresh fruits and vegetables. The takeoff of the canning industry in the 1860s furthered the access of Americans to year-round variety by providing a cheap and safe way to preserve perishable foods. WEGW 154.1

As Americans learned basic principles of nutrition and increased the variety of their diet, their resistance to infectious diseases increased and the incidence of deficiency diseases declined. WEGW 154.2

Changes in bathing habits and dress contributed further to the health of Americans by dramatically improving their cleanliness. Although bathing did not become fairly regular among middle-class Americans until midcentury, the invention of convenient bathtubs and showers around 1800 greatly eased its difficulties. The insistence of Graham and the hydropaths during the middle third of the century on the health benefits of daily or weekly baths further encouraged many Americans to bathe regularly, but before 1850 many still followed the advice of physicians who judged winter bathing unsafe. Undoubtedly, aside from any perceived health benefits or dangers that accrued to regular bathers, many soon found their improved body odor sufficient motivation to continue the practice. WEGW 154.3

Few men or women who trudged behind a plow or wielded an axe to carve a living from the rich but hostile frontier fretted over the changing styles of American dress. They settled for warm, practical clothing that lasted and could be easily cared for. The poor, whether in city or country, made do with whatever they had; but the middle and upper classes of large cities and rural villages used fashion to define sex roles and advertise social standing. Men’s styles supported the Victorian ideal of masculinity by emphasizing strength, serious-mindedness, and aggressive activity. Women’s fashion drew attention to the frivolity, inactivity, and submissiveness valued by admirers of femininity. The ostentatious frills, ribbons, embroidery, and fine fabrics of the well-dressed woman, which obviously required the care of servants, advertised the wealth of the family and conspicuously announced their membership in the leisure class. WEGW 155.1

Women, more than men, even endured ill health by following the dictates of fashion. They acquiesced to costumes that restricted movement, weighed nearly 15 pounds, and dragged in the dirt and filth of the street. The popular practice of corseting, which accentuated the sexuality of the female shape and attracted the admiration of men, deformed the bodies and debilitated the health of women throughout the nineteenth century. WEGW 155.2

Angered by the social and intellectual restrictions implicit in women’s fashions, and fearful for women’s health and moral purity, feminists and health reformers of the 1850s campaigned for a warm, healthy, and practical costume. Some women chose to wear the reform dress, which included a short overskirt that hung loosely from the shoulders over a pair of pajamalike trousers. But they suffered public humiliation and ridicule, and within a few years most sacrificed the practice lest it by association weaken their other reform efforts. WEGW 155.3

By the 1880s and 1890s the reformers’ broader efforts bore fruit, as reforms in education and women’s suffrage greatly expanded social and economic opportunities for women. Under the demands of new job opportunities and the stimulus of the sports movement, which encouraged women to engage in vigorous physical activity such as bicycling, women’s clothing became plainer and more practical. WEGW 155.4

But transforming individual living habits was insufficient. During the last half of the nineteenth century, American urban centers underwent tremendous changes. They sprawled over ever wider chunks of the landscape as population, industry, and commerce exploded. This rapid growth multiplied the public health problems of the cities, for the expansion often went unchecked by planning or regulation. WEGW 155.5

Medical historian Judith Walzer Leavitt has aptly described the health problems of urban life with its “crowded, dark, unventilated housing, unpaved streets mired in horse manure and littered with refuse, inadequate or nonexistent water supplies, privy vaults that remained unemptied from one year to the next, stagnant pools of water, ill-functioning open sewers, and an overwhelming stench.” WEGW 156.1

The problems of public health reached critical levels when large waves of immigrants flooded American cities during the later decades of the nineteenth century. Huddled into high-rise tenements that absentee landowners felt no financial motivation to improve or maintain, tenants slept on bare floors, breathed stagnant air, consumed unpreserved food and unsanitary water and milk, and used inadequate public privies. WEGW 156.2

Many middle- and upper-class Americans recognized these problems and felt a moral obligation to improve public health. On the basis of their belief in miasma theory, which linked filth and disease, they advocated and supported efforts to clean up streets, water, and food and to maintain a healthy urban environment. WEGW 156.3

Colonel George E. Waring, a dynamic popularizer and propagandizer of miasmatic theory and public sanitation, may have done more than any other person to shape American attitudes toward public health during the last half of the nineteenth century. The devastating yellow fever epidemic that struck Memphis, Tennessee, in 1878, killing 5,000 persons unable or foolish enough not to flee the city, forced public officials to find ways to avoid similar tragedies. Colonel Waring argued that quarantine had failed in Memphis because the real source of the disease, “sewer gas,” permeated the city. City officials soon approved his plan for a complete sewer system for Memphis. WEGW 156.4

Similar projects rapidly sprang up across the country as cities sought to prevent epidemic diseases. Waring’s influence extended to street cleaning and garbage collection during his tenure from 1895 to 1898 as commissioner of street cleaning for New York City. Many of the programs and techniques he developed endured beyond his administration and provided an example of clean streets for other communities. WEGW 156.5

Nonmedical professionals, such as engineers and plumbers, continued to contribute to public health by designing and installing municipal water supplies. Although Philadelphia opened its system in 1801, it was 1842 before New York had recognized the benefits and established its own access to fresh water. Not until the 1850s and 1860s did Chicagoans solve the drainage problems of their location and ensure uncontaminated drinking water from Lake Michigan. WEGW 157.1

During the last third of the nineteenth century, Americans increasingly mandated a strong governmental role in the establishment and maintenance of public health. Citizens established municipal and state health departments and boards of health. These agencies enforced public health guidelines; inspected schools, hospitals, and food handlers; and quarantined and vaccinated against infectious diseases. Often critics decried these activities as invasions of private rights, but each agency in its turn survived such attacks and proved its benefit to the general welfare. WEGW 157.2

At the turn of the century, public health underwent a change of emphasis as its reforms shifted from a primary concern for sanitation to the control of the infectious agents of disease. The sanitarians had convinced Americans of the need to clean up their country, but the public health movement now focused on germs rather than miasma as the unseen source of disease. Most reformers had accepted the germ theory of disease, and their confidence in scientific medicine led them to concentrate their efforts in the laboratory rather than the general environment. Not until recent decades have Americans’ concerns about a polluted environment returned public health efforts to sanitation. WEGW 157.3

America’s engagement in two world wars taught many surgical lessons and hastened the development of antibiotics. No longer do infectious diseases pose the greatest threat to Americans’ health; the new challenges of heart disease, cancer, and cerebrovascular diseases have replaced them. We watch expectantly to see if the methods of scientific medicine, the roles of medical institutions, and the pressures of public health reform that proved their power at the turn of the century will meet the health needs of a new age. WEGW 157.4