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Part 5

Table of Contents


Three Wars -The Sanitary Reform
Movement (1812 - 1860)

(18 JUNE 1812-21 JANUARY 1815)

When the disputes between the governments of the American Republic and Great Britain resulted in the War of 1812, there was no central organization of the Medical Department of the Peace Establishment of the Army of the United States. For many years, the medical personnel had consisted of a few regimental surgeons and their mates, scattered at isolated posts, with no official medical chief. Dr. James Mann (1759-1832), Hospital Surgeon of the Army, who served from the start of the war until it was technically closed by the Treaty of Ghent on 24 December 1814, and militarily finished by General Andrew Jackson's victory over the British at the Battle of New Orleans on 21 January 1815, bewailed the fact that physicians and surgeons of the Revolutionary Army, with the exception of Dr. Benjamin Rush, had neglected to record and transmit their experiences and observations (88). Uninterested in military medicine, the civilian physicians and surgeons of the day were ignorant of the diseases incident to armies, unfamiliar with the police and hygiene of camps, and inexperienced in the operation of military hospitals. In the flux of war, a medical organization had to be devised; and efforts had to be made, under hard conditions and with scant knowledge, to solve old but unenvisioned problems. These problems in varied forms recurred in the wars of 1812, 1848, 1861, and 1898.



As usual, there was a general neglect of sanitation and much sickness among the troops in the north and in the south. The chief diseases were typhus (called "Lake Fever" along the northern border), diarrhea and dysentery, and pneumonia, especially a form known as "peripneumonia notha." Although no new principles were introduced, some remarkable achievements, significant for preventive medicine, were attained.

On 11 June 1813, the venerable, respected, and forceful Dr. James Tilton was recalled from retirement and appointed Physician and Surgeon General of the United States Army. In February of that year, he had published his informative and forthright book "Economical Observations on Military Hospitals and Cure of Diseases Incident to an Army." The opinions expressed in this treatise were having an influence upon congressional thought about the reorganization of the medical department, resulting in the issuance on 1 May 1813 of "Rules and Regulations for the Army," which defined the duties of the Physician and Surgeon General. The appointment of Tilton to that position is regarded as one of the starting points in the establishment of the definitive Medical Department of the Army. Tilton served in this capacity until 15 June 1815, when he retired permanently to his farm near Wilmington, Delaware.

The Burlington Hospital (1812-1814).-In addition to Dr. James Mann, Dr. Joseph Lovell, later to become the first Surgeon General of the War Department, performed duties superbly during the War of 1812. In the first year of the war, Lovell established at Burlington, Vermont, a hospital which became a model, under the direction of himself and his successors, as chiefs, Drs. Walter W. Wheaton, James Mann, and Henry Hunt. Mann (89) included in his "Medical Sketches" details of the regulations which brought the Burlington Hospital to a high state of efficiency, "where," according to Mann, "in no instance from its first establishment, even when the monthly reports counted from six to nine hundred men [distributed in 40 wards], was an infectious disease gener-



ated or propagated." The regulations through which this salutary result was accomplished embodied all of the empirically determined measures that were included in the broad concepts of cleanliness, ventilation, isolation of febrile patients, attention to diet, and the location of the hospital on high grounds, 60 or 70 feet above the nearby water. At Burlington during the first 4 months of 1814, there were 2,412 admissions and 75 deaths. The record made by this model hospital was a demonstration that infectious diseases could be considerably controlled, and lives saved, by application of sanitary measures devised without the benefit of microbiology long before the bacteriological era.

Vaccination.-Finally, it is to be recalled for emphasis, that War Department General Orders, issued on 26 May 1812, required that all troops be vaccinated against smallpox, and that, on 3 March 1813, the Congress passed a law establishing an agency for the provision of Jennerian vaccine matter to citizens of the United States. Bearing on the issuance of this General Order in 1812 and the law passed by Congress in 1813, it is undoubtedly of significance that the two successive Secretaries of War during the period from 1801 to 1817 were well-educated physicians, distinguished Army officers, and statesmen. There was first Dr. Henry Dearborn (1751-1829) who was Secretary of War in the cabinet of President Thomas Jefferson throughout both terms from 1801 to 1809. The second was Dr. William Eustis (1753-1825), Secretary of War from 1809 to 1816, in the cabinet of President James Madison. Both were in position to hear much about Jenner's discovery and the success of his method of vaccination against smallpox and to influence the passage of both the regulation and the legislation.


On 14 May 1818, an Act passed by Congress reorganized the staff departments of the Army, provided for a Medical



Department, and for one Surgeon General. From the passage of this law developed the modern Medical Department of the United States Army. Its general significance was comprehensive. Its special significance for military preventive medicine was determinative, because it established a permanent central military medical organization within which a preventive medicine service could be developed, over the years, with conceptual continuity that persisted through periods of error, administrative failure, financial deprivation, changes in knowledge, and through wars.

Fortunately, a medical officer with vision, talent, and learning was available to occupy the newly created post of Surgeon General. This medical officer was Dr. Joseph Lovell (1788-1836), who was appointed Surgeon General, to date from 18 April 1818 (fig. 17). On 30 June 1817, Dr. Lovell, then Hospital Surgeon of the Northern Division, addressed to Maj. Gen. Jacob Brown a communication entitled (90): "Remarks on the Sick Report of the Northern Division for the Year Ending June 30, 1817."

Although this report by Lovell has been referred to often, the citations have been usually in clinical and administrative contexts. It has not been appreciated as a basic document in the history of preventive medicine in the United States Army, although about 90 percent of it deals with military hygiene. Emphasis is placed upon investigations of the causes of diseases and upon preventive measures based upon knowledge, or ideas, of the causes of these diseases. Knowing nothing about microbial causes of infections, Lovell reasoned along the lines of the current concepts of the injurious effects of cold and wet climates, and in words suggestive of the theories of epidemic constitution of the atmosphere, advised taking precautions against unfavorable weather "which no ordinary care can prevent."

Medical police for camp sanitation.-Realizing that surgeons and line officers could not change the weather, Lovell specified ways of safeguarding soldiers by such measures as proper clothing, a liberal supply of dry socks,



FIGURE 17.- Joseph Lovell (1788-1836), Surgeon General of the United States Army (1818-1836). Vigorous supporter of preventive medicine, he instituted medical police for the cleansing and sanitation of camps and hospitals. In 1818, he required Army surgeons to keep meteorological records and to investigate the relation of disease incidence to climate and weather (climatology). These "Meteorological Registers" led to the establishment of the United States Weather Bureau in 1870 through the efforts of a medical officer, Brig. Gen. Albert James Myer (1828-1880), who had created the Signal Corps during the Civil War. In 1836, Lovell founded the Library of the Surgeon General's Office, which became the National Library of Medicine in 1956. In 1819, Lovell initiated a system of reports and publications of vital statistics of the Army, invaluable for the epidemiological basis of preventive medicine. (Photocopy of a painted portrait, courtesy of the Armed Forces Institute of Pathology, photograph negative No. WW-390.)



laced shoes, warm housing, salubrious situations of camps, and finally the institution of "a proper Medical Police" for the cleansing and sanitation of camps and hospitals. He recommended that the surgeon attached to the headquarters of a division be made "Inspector of Hospitals" or Medical Director, in effect, a Chief Sanitary Officer, since "none but the medical staff can be competent" to supervise such matters.

"Meteorological Registers."-Out of these ideas came the War Department's Regulations of the Medical Department, issued in September 1818, which among other requirements ordered surgeons to keep meteorological records, and investigate the relation of disease incidence to climate and weather. As time passed, the annual records were published in four large volumes (91) as "Meteorological Registers," one under the direction of Surgeon General Lovell in 1826, and three under the direction of his successor, Surgeon General Thomas Lawson, in 1840, 1851, and 1855. These collections and publications of meteorological data were of value not only to the medical service, including epidemiology and preventive medicine, but also to national and international interests. They led directly to the establishment of the United States Weather Bureau in 1870, through the efforts of a medical officer, Brig. Gen. Albert James Myer (1828-1880), "founder of the Weather Bureau," and, as Chief Signal Officer in the Civil War, "father of the Signal Corps of the Army."

Surgeon General Lovell introduced selection of medical officers on the basis of competence, and elevated the status and efficiency of the Medical Department. He instituted physical standards for the acceptability of recruits. He secured a regulation requiring smallpox vaccination of recruits who had not had smallpox or had not been vaccinated. He encouraged and supported Army Surgeon, Dr. William Beaumont (1785-1853), from 1824 to 1833 in his original investigations of the gastric juice and physiology of digestion in the famous case of Alexis St. Martin.

Library of the Surgeon General's Office.-In 1818, Surgeon General Lovell began to provide medical and scien-



tific books for surgeons at Army posts, retaining at least one copy of each book for his office. This collection grew and formed the nucleus of the great Library of the Surgeon General's Office, which dates its founding as 1836. Among its many functions, it has powerfully supported both civilian and military hygiene and preventive medicine. After passing through other stages designated as The Army Medical Library and The Armed Forces Medical Library, in 1956 this vast collection of books, journals, documents, and manuscripts became the National Library of Medicine, under the administration of the Public Health Service of the U.S. Department of Health, Education, and Welfare (92).

Vital statistics of the Army.-In 1819, Surgeon General Lovell, in collaboration with The Adjutant General, had made provision for the collection of records of the sickness and mortality of troops to all Army posts and stations, according to specific plans. One of the first of Dr. Thomas Lawson's major undertakings after he succeeded Dr. Joseph Lovell as Surgeon General of the Army, in 1836, was to supervise the assembling, collation, and condensation of these data. The first volume prepared under the supervision of Surgeon General Lawson was published in 1840, embracing the 20-year period from 1819 to 1839. This was followed by two more large volumes, one in 1856 and one in 1860 (93).

The pages of these publications are devoted to the investigation of the comparative influence of various systems of climate upon the organization of man. They are "medico-topographical" studies intended to disclose "the laws of nature in regard to external influences upon healthy and diseased conditions of man." The detailed descriptions of posts include the location (latitude and longitude, and geographical), topography, meteorological conditions, case reports, surgeons' reports, and numerical data on morbidity and mortality by diseases. Strength figures are given (94). Many of the narrative vignettes are as vivid as Col. John E. Gordon's "Epidemiologic Case



Reports" from the European Theater of Operations in World War II.

The compilers and supervisors clearly appreciated the general import of these statistical studies and their specific value for preventive medicine. With regard to the latter aspect it is stated in the introduction of the first volume: " * * * Military hygiene-the knowledge of maintaining the health of soldiers, and of promoting their efficiency-is another subject which should not only be carefully studied by medical and all other officers, but receive the special attention of Government."

Climatology.-Combining material from the meteorological registers and the statistical reports on sickness and mortality in the Army, Forry, formerly an Army surgeon who collated and condensed the compilations used in the first statistical volume, produced an original treatise (95) on "The Climate of the United States and Its Endemic Influences." In this, he traced out the medical relations of the observed principal physical phenomena of climate. His publication was the first American book on climatology. By numerical (statistical) investigations of diseases, he built firmly one of the piers of modern epidemiology.

THE MEXICAN WAR (1846-1848)

Through the victories gained by Brig. Gen. Zachary Taylor, from Matamoras in April 1846 to Buena Vista in February 1847, and by Maj. Gen. Winfield Scott, from Vera Cruz in March 1847 to Mexico City in September of that year, the United States acquired from the Republic of Mexico a vast addition to its territory. The lands ceded by Mexico in the Treaty of Guadalupe Hidalgo, signed at Mexico City on 2 February 1848, extended from the mouth of the Rio Grande westward across New Mexico to the Pacific Coast as far north as the upper limit of California. The Mexican War, fought with high courage, endurance, and military skill, succeeded in spite of shortages of supplies and equipment, and in spite of much sickness and



mortality from disease, the consequences of lack of knowledge of military hygiene, poor management, and the failure to apply generally such rudiments of sanitation as were known. The military achievement was a brilliant contrast to the dismal sanitary deficiencies.

In describing the main medicomilitary episodes of General Taylor's campaign in northern Mexico, Duncan (96), writing in 1921, cited instances of the prevalence of diarrheas and dysenteries, and commented that: "The care of food and water, disposal of waste, and other functions were carried on in a primitive manner or generally ignored."

In his commentary on General Scott's campaign to the city of Mexico in 1847, Duncan (97) assessed the medical activities as follows: "Few encomiums can be passed on the Medical Department in Mexico. Nor do the officers appear to have learned or developed anything of importance in military sanitation, medicine, or surgery. * * * All did honest and faithful work, but none originated anything. They left the service about as they found it. * * * they did as well as they knew."

Duncan drew most of the material for his narrative from Amy Surgeon John B. Porter's accounts of his experiences during the whole campaign and a period after July 1848 when the troops returned to East Pascagoula, Mississippi (98). These are largely surgical and medical reports, but do contain a number of descriptions of the filthy conditions in camps and hospitals, the horrors of the widely prevalent chronic dysentery, and a disquisition on the author's conviction that yellow fever was not a contagious disease. On the positive side, however, Porter noted that there was no smallpox among the troops, an exemption which he attributed to vaccination; that General Scott (acting perhaps on the advice of Surgeon General Thomas Lawson who accompanied him in person, as an adviser) moved the troops out of Vera Cruz in time to avoid the yellow fever season; and cited examples showing that the regular regiments had better-policed camps, and were healthier, than the volunteer regiments.



Garrison (99), drawing on both Porter and Duncan, dealt with the Mexican War in a sharp, brief paragraph, from which the first sentence is quoted:

The Mexican War (1846-1848) is highly instructive to Americans as a campaign of small dimensions, entered upon caravan-wise with boyish, meridional enthusiasm, waged in an unknown country without forethought or adequate preparation, by an army equipped on a peace footing, and carried to a successful issue in spite of untold suffering from lack of clothing, supplies, rolling stock and adequate medical administration.

The reports of The Surgeon General for the years 1846-1849 do not contain anything which contradicts these statements and opinions; indeed, little or nothing is said in them about sanitary conditions. Few details of sickness and mortality are given in The Surgeon General's reports because his office was often out of touch with surgeons in the field in Mexico, and such returns as were received from them were often incomplete and incorrect.

Disease and battle casualty statistics-To fight the War with Mexico, approximately 100,454 North American men were mustered into the United States Army (100). They were in three main categories; namely, (1) Old Establishment; Old Regulars, 15,736, (2) Additional Force; New Regulars, 11,186, and (3) Volunteer Force, 73,532 (regiments and corps, 73,260 and General Staff, 272) making the total 100,454. Of the total Army, 1,549 were killed in battle or died of wounds, and 10,970 died of disease, a ratio of 7 deaths from diseases of the camp (chiefly dysentery) to 1 death caused by battle injury. Duncan (97) calculated that the mortality rate for deaths from disease in the Army in Mexico was 110 per 1,000 per annum, which may be compared with rates of 65 and 16 per 1,000 per annum in the Civil War and World War I, respectively. How many thousands were temporarily sick or incapacitated for various periods is unknown. It has been stated in a number of writings that the losses due to disease alone exceeded 33 percent of General Scott's command. The losses by disease in the volunteer corps were nearly twice as high as in the Old Establishment (Regulars).



Civil affairs-military government and public health.-In chapter I, volume VIII, of the preventive medicine history series, it has been pointed out that some of General Winfield Scott's plans, orders, and operations during the final phases of the Mexican War constituted the earliest large-scale venture of the United States into military government and civil affairs, and put into effect principles which became fundamental to American practice in those fields. These activities in Mexico, instituting procedures for trials and punishment for crimes outside those defined in the Articles of War, provided justice and protection for both Americans and Mexicans. They began with General Scott's General Orders No. 20, issued at Tampico on 19 February 1847, declaring martial law. The General-in-Chief reissued the order at Vera Cruz and Puebla, and a final edition of it, General Orders No. 287, "with important additions," at Headquarters, National Palace of Mexico, on 17 September 1847. At first, and for nearly a century thereafter, civil affairs-military government, as it came to be called, was only incidentally concerned with public health activities. In World War II, however, public health activities became such a large and pressing part of the program that the War Department and the Office of The Surgeon General authorized and maintained distinct and strong organizations to carry them out. Taking appropriate action, on the recommendation of Brig. Gen. James S. Simmons, a special Civil Public Health Division was established in 1944 in the Preventive Medicine Service. In addition, the function was represented in all the main theaters of operations. In view of the importance of the subject, an entire volume in this series, Volume VIII, has been devoted to "Civil Affairs-Military Government Public Health Activities," with due acknowledgment of the foresight and wisdom of General Winfield Scott (101).

Rank for medical officers.-At the beginning of the Revolutionary War, surgeons and physicians serving in the Medical Department, or "Hospital" of the Continental Army, had no military rank. Although many attempts



were made to rectify this situation during the succeeding 75 years (approximately), rank for medical officers was not secured until Surgeon General Lawson, constant and vigorous fighter for the improvement and strengthening of the Medical Department of the Army of the United States succeeded, through the War Department, in gaining favorable Congressional action upon the issue, on 11 February 1847. On that date, Congress (102) passed an Act (9 Stat. 123) which not only added several surgeons and assistant surgeons to the medical staff of the Regular Army of the United States, but also granted military rank, with appropriate pay and emoluments, to medical officers. This Act of obvious general importance elevated the position of medical officers concerned then, and in the future, with military hygiene, sanitation, and preventive medicine. The Surgeon General himself was advanced to a high grade. On 30 May 1848, Dr. Thomas Lawson was given the rank of brevet brigadier general in recognition of his meritorious service in the Mexican War.

The Act contained a proviso "That the medical officers shall not in virtue of such rank be entitled to command in the line or other staff departments of the army." As medical officers did not wish to exercise such command function, this proviso, while serving as a protection of the anxious and jealous line, was not a hindrance to their work. Medical officers had been placed at last upon a footing of military association with the commanders whom they were to advise, and with the line officers and men whose training in preventive medicine and sanitation they would thereafter be able to directly influence.

(14 SEPTEMBER 1854-12 JULY 1856)

Losses from disease in British and French troops.-The Crimean War, fought by allied forces composed chiefly of English and French armies against a Russian army, was mainly concentrated in the siege of Sevastopol, from mid-September 1854 to the capture of the city on 9 September



1855. The occupying troops were withdrawn by 12 July 1856. It was a campaign in which courage, valor, and endurance of the soldiers and their leaders triumphed not only over the enemy but also over unpreparedness and poor administration. Immeasurable suffering resulted from shortages of food, clothing, and shelter, and from sickness due to dysentery, cholera, scurvy, and typhus fever. Losses by death from disease were excessive, reaching rates above 200 per 1,000 at times. After citing the "terrible losses" from disease among the British and French troops, Garrison (103) pointed out: "* * * the war was an object lesson in the evils resulting from lack of sanitary preparedness and in those resulting from gradual slackening of the eternal vigilance which is necessary to good sanitation * * *."

Garrison based this conclusion upon statistics and statements in Dr. Andrew Smith's official sanitary history of the Crimean War-the first medical and surgical history of a war to be published by a government-and upon statistics compiled and discussed by Chenu, Longmore, and Myrdacz (104).

Beneath this overcast of evils, however, a number of beneficial medical and sanitary achievements made during the Crimean War, or as a result of the war, exerted an influence upon the evolution of military preventive medicine in the United States Army. These positive contributions, rather than a detailed narrative, will be the subjects of this brief section.

Sanitary contrasts.-Sir Thomas Longmore, Surgeon General of the British Army, writing in 1883, described the remarkeable contrast that occured in the mortality from disease in the British and French armies before Sevastopol in 1854-1855 and 1855-1856. He wrote (105):

The situation of the French and British armies during the siege of Sebastopol was so similar in respect to soil and locality, the climatic influences to which they were exposed, and the nature of the work in which they were engaged, were so thoroughly alike, that practically the two armies might almost be regarded as parts of one and the same force. * * * there was no similarity between



them in respect to their conditions of health. * * * the British part of the Allied Force before Sebastopol was remarkably unhealthy during the first period of the siege, and as remarkably healthy during the second period of the siege; while a precisely opposite state of things existed in the French part of the force, which was in a generally good condition of health during the first period, but in an extremely unhealthy condition during the second period.

From statistics presented in Longmore's publication, from which deaths from cholera were omitted by the author, the following tabulation shows sanitary contrasts between British and French armies before Sevastopol:

Average effective strength

Four-monthly periods

Deaths from disease

Death rates from disease, per 1,000

British Army:





1854, Sept. to Dec.




1855, Jan. to Apr.




1855, Sept. to Dec.




1856, Jan. to Apr.



French Army:





1854, Sept. to Dec.




1855, Jan. to Apr.




1855, Sept. to Dec.




1856, Jan. to Apr.



The explanation advanced for these contrasts is that in the first winter the British troops were inadequately clothed, fed and sheltered, and had poor sanitation, while in the second winter, after the Parliament and the public had become aroused by reports of the scandalous conditions under which British troops were fighting, all aspects of sanitation of the army were vastly improved. In contrast, the French troops which were relatively well clothed, well housed, and well fed during the first winter, suffered from shortages, exposure, and deteriorated sanitation during the second winter. The healthiness of the British soldiers during the second winter-said to be healthier than the Guards in London-showed what could be done for the preservation of the health of soldiers in the field by attention to proper housing, clothing, feeding, and cleanliness, even in ignorance of the microbial causes of disease before the bacteriological era.



Florence Nightingale.-The most versatile, powerful, and steadfast figure of the period of the Crimean War, and afterwards, was Florence Nightingale (fig. 18). Her contributions to medicine and hygiene were surpassingly important. At the Barracks Hospital at Scutari, she created the modern profession of civilian and military nursing (106). But, as Bishop (107) has justifiably stated, "Florence Nightingale's ideas and achievements in the fields of public health and hygiene, hospital construction and management, medical statistics, and Indian and colonial health and welfare, have far wider implications than her work for nursing."

Acclaiming Florence Nightingale as a "great pioneer," Winslow (108) has emphasized her significance for military hygiene, her vision of the nurse as a "health missioner," her conception and establishment of district nursing coupled with teaching of public health in the home and in the community and region, and finally her conception of the public health nurse, a specially trained agent invaluable to programs of civilian and military hygiene.

The specialty of Army health.-Lewis pointed out (109) that: "The appointment of health officers in the [British] Army was one of the many measures which stemmed from the upsurge of public opinion following the revelation of the appalling sanitary conditions suffered by the British soldier in the Crimea."

The Royal Commission of 1857 recommended that medical officers be given powers of advising commanding officers on all matters pertaining to the health of troops, and a provision to this effect became incorporated in British army regulations, representing a type of similar provision in regulations of the United States Army.

The Royal Army Medical School.-As a result of recommendations made by the Royal Commission and by Florence Nightingale, the Royal Army Medical School was established in England, at Fort Pitt, in 1860. Among its educational and training programs, courses in military hygiene were developed, most notably during the professorship of Edmund A. Parkes (110), whose "Manual



FIGURE 18- Florence Nightingale (1820-1910). At the Barracks Hospital at Scutari in the Crimean War (1854-1856), she created the modern profession of civilian and military nursing, including public health nursing, and made later important contributions to public health and preventive medicine. (Photocopy of portrait drawn by T. Cole, The Century, November 1882. Courtesy of the National Library of Medicine, photograph negative No. 5039.2.)

of Practical Hygiene," prepared especially for use in the Medical Service of the Army, went through 19 editions between 1864 and 1900 and was known in the United States as well as in England. It was a standard textbook of the Civil War times. Undoubtedly, the model and experiences of this British military medical school had some influence, as a prototype, upon the planning and establishment of the United States Army Medical School, envisioned by



Surgeon General Hammond in 1862-1863, and established by Surgeon General Sternberg in 1893.

Further influence of sanitary experience of Crimean War.-At the outbreak of the Civil War, the experience of the Crimean War was fresh in the memory of many persons who became concerned in the health and welfare of soldiers of the Union Army. This experience, containing important lessons in military hygiene, exerted a determinative influence upon the establishment and activities of the United States Sanitary Commission, to which this narrative will return later in this volume, in the section dealing with the Civil War.


At this point, it is necessary to give almost exclusive attention to the civilian public health affairs of the mid-19th century. To do so may seem a digression. But, on the contrary, this is not a departure from the main subject of this volume because civilian public health envelops military hygiene and influences military preventive medicine in many ways, some direct and many subtle.

The sanitary movement abroad.-"The Great Sanitary Awakening," to use the term employed by Winslow (111) and others, took place during the first half of the 19th century. Actually, the awakening in Europe began in 1777-1778 with the work of Johann Peter Frank (1745-1821), "the true founder of modern public health [and preventive medicine] in Europe," according to Smillie (112). It was initiated in England in the last quarter of the 18th century by John Howard (1726-1790) through his reports on conditions in prisons, hospitals, and lazarettos (113).

Chadwick, Farr, Simon, and Smith.-The sanitary reforms in England were carried forward chiefly by four men-three laymen: Edwin Chadwick (1800-1890), William Farr (1807-1883), and Sir John Simon (1816-1904), and one physician: Dr. Southwood Smith (1788-1861). Of these four, the greatest was Chadwick, who, in 1842, pub-



lished his classic "General Report on the Sanitary Conditions of the Labouring Population of Great Britain," and who was influential in securing the passage by Parliament of the Public Health Act of 1848 and the establishment of the first true Board of Health. These events marked the legal birth of sanitary reforms and the beginning of the correction of the horrible, unhealthy, and inhumane conditions of living that had developed under the Industrial Revolution. The English example had a strong effect on the public health movement in the United States (114). The man who was to become the leader of this movement in America, Mr. Lemuel Shattuck (fig. 19), was thoroughly familiar with the writings of Chadwick, Farr, and their associates.

The sanitary movement in the United States; Lemuel Shattuck's Report (1850).-The event which heralded the emergence of sanitary reform and development-"the sanitary era"-in the United States was the publication of the Shattuck Report in April 1850 (115).

This Report is famous as the first concrete and comprehensive plan for an integrated State program of public health in the United States. In his summary and analysis of the Shattuck Report, Smillie (116) characterized it as "the cornerstone of the splendid edifice of public health in this nation." It dealt with almost every aspect of public health administration-housing, construction of factories and buildings, ventilation heating water supplies, waste disposal, sewerage, milk and food products, control of nuisances, pollution of the atmosphere, pollution of streams, nursing schools, public health training, control of communicable diseases, and innumerable additional philosophical and administrative aspects of preventive medicine. Although the "Report" was largely opposed and neglected by laymen and physicians for nearly 20 years, Winslow (117) has pointed out that "of the fifty recommendations [in the "Report"]- * * * no less than thirty-six are now [in 1948] universally accepted practice-not only in Massachusetts but throughout the Union." In his opinion, only 4 of the 50 recommendations were unimpor-



FIGURE 19.- Lemuel Shattuck (1793-1859), pioneer leader of the sanitary reform movement in the United States (1850). (Photocopy of portrait, courtesy of the National Library of Medicine, photograph negative No. 6151-A.)

tant or, in some degree unsound, and the remaining 10 were as sound as the 36 but remained as challenges to the public health profession of 1948.

Considering that Shattuck had no knowledge of the microbial causes in infectious diseases, or of the modes of their transmission, or of human carriers and arthropod vectors of these agents, his "Report" stands out all the more clearly as a masterpiece of careful observation and sound thinking, of intelligent use of statistics, and the formulation of wise conclusions. It was far from "fumbling in the dark," as some writers regard public health activities before the bacteriological era.

Toward the end of the period under consideration, there



was one impressive demonstration of a control measure derived from epidemiological observations and logical reasoning. John Snow (1813-1858), who had stated in 1849 that cholera was waterborne and taken into the body through the mouth, in 1854, stopped an epidemic of cholera in London by removing the handle of the Broad Street Pump.

It is not the intention of the writer of this monograph to elaborate the details of the public health movement of the 19th century. His purpose in these brief notes and comments has been to record the facts that by the middle of that century modern civilian public health and preventive medicine had gained great impetus, and that the ideas, programs, and activities of those days are still influencing present day administration of public health. Although it is not possible to show specifically what, how, and when, measures of the civilian movement became incorporated in the precepts and activities of military hygiene and military preventive medicine, it is nevertheless obvious that such incorporations have occurred. That this should be so is inevitable from the reciprocal relations between civilian and military practices in this field.