History of Public Health and Sanitation in the West before 1700

Throughout most of the past, ideas about the means and necessity of providing for the health of the general community were based on notions of what ensured an individual's well-being. At this personal level, measures that we might consider motivated by aesthetic choices (rather than fully developed ideals of cleanliness and the health necessities of personal hygiene) were interwoven with practices designed to minimize exposure to disease and injury. In a narrow sense, public health practices refer only to the organization of care for the sick of a community and the implementation of epidemic controls. Public sanitation includes all collective measures taken to protect the healthy from disease. Yet even today many believe that what ensures the health of an individual should be reflected in the rules for maintaining the public's health.

Through much of the past and present, the view of "public" health has involved a compromise between available community resources and the ideals of health maintenance at the individual level. Thus, in order to examine the history of public health and sanitation before the 1700s, it is necessary to include some discussion of the ideas and ideals of personal hygiene along with the development of concepts that led to genuine public health practices. "Basic" sanitary organization largely comprised rudimentary sanitation and sanitary law, care of the sick poor, provision for public physicians, and epidemic controls.


Archaeological records testify to the antiquity of communal efforts to provide clean water and dispose of human and animal wastes. The engineering achievements of some peoples, such as the ancient Peruvians in the Western Hemisphere and the Etruscans in Europe, were most impressive. They managed extensive systems for refuse drainage and clear water conveyance. However sophisticated the outcome, the motivation for these projects probably lay in fears common among tribal societies - for example, the fear of pollution offending a god or gods, who in turn could send disease and disorder. Reflecting these aboriginal values, natural springs and wells were sites of religious activity for millennia. But independently of the health benefits, the maintenance of a reliable water supply and efficient drainage of agricultural lands permitted larger human settlements, and thus, whether or not the health benefits were perceived, these practices were copied or reinvented in all the early civilizations of the Mediterranean, in the valleys of the Yellow, Indus, Tigris, Euphrates, and Nile rivers, and in the Incan and Mayan civilizations.

The most celebrated early sanitary engineering achievements were those of republican and imperial Rome, c. 300 B.C. to A.D. 200. In fact, many of the conduits built by the Romans remained in use until the twentieth century. Basing drainage projects on the successes of Etruscan predecessors, who were able to construct extensive underground drainage channels because the loose, volcanic soil of southern Italy was easily worked, early Romans developed systems of wells, rainwater cisterns, and irrigation ditches that promoted rural, agricultural development. Before 300 B.C., the Romans seem to have associated the assurance of clean and abundant water with ordinary life, an ideal never specifically related to the maintenance of health, public or private. But when they began to build cities, aqueducts became a public symbol of the Roman way of life, as well as a symbol of Roman power and sensitivity to the general welfare. Frontinus, in On Aqueducts (c. A.D. 100), says that the first one was constructed in Rome in 312 B.C.

In rural areas, the prosperity of the "farm" or villa seems to have been the inspiration for securing a reliable water supply, a favorite topic for the pragmatic and aristocratic authors of treatises on Roman agriculture and medicine (Scarborough 1981). These authors fastidiously detailed the benefits and drawbacks of using plants and drugs, differentiated harmful from benign bugs, and analyzed myriad substances that promoted or undermined the well-being of the farm and the farmer. For Cato, Columella, Frontinus, Vitruvius, Varro, and Celsus, health benefits were the natural harvest of the well-managed farm, a pastoral ideal of Roman life that survived through the urban, imperial centuries.

Although Romans generally welcomed practical advice, the adoption of the Greek ideals of personal hygiene was delayed until after the period of early republican growth - a time of rapid development of architectural and administrative models for aqueducts, cisterns, cloacae, drains, and wells. Greeks and Romans, however, shared a passion for the details of personal hygiene, including a fondness for baths, cleansing agents for the skin, and oils, soaps, unguents, and other cosmetics used to maintain a good personal appearance and skin tone. Moreover, concern for personal hygiene went far beyond the realm of attracting sexual partners or performing religious cleansing rituals. Greeks and Romans worshiped health and consequently elevated in importance to their life-style the technical knowledge they believed would promote individual health and longevity.

Galen's Hygiene, written shortly after the death of Emperor Marcus Aurelius in A.D. 180, represents the acme of professional health theory and advice through which Greek medical thought and pragmatic Roman farm hygiene were united in late Mediterranean antiquity (Sigerist 1956). The Hippo-cratic theory of the four humors, describing health as a balance of the humors, which in turn represented the four elements of all material substance, dictated the fundamental ways of preserving equilibrium through an individual's natural changes in age, diet, season, and exposure to noxious influences. The emphasis was on prevention, and the health seeker needed to learn which foods were right for his or her constitution, when baths promoted or jeopardized health, what exercise was appropriate, when purgation was needed, and what substances and influences were lethal. Attention was to be focused on the fine details and management of the individual's environment.

Nonetheless, despite the foregoing, which seems an idealistic portrayal of health practices in antiquity, the stark reality is that 25 years was the average life expectation for most Greeks, Romans, Egyptians, and others in the vast ancient Greco-Roman Empire. Roman elites recognized the importance of effective disposal of human wastes and so constructed miles of sewers and cloacae, as well as public and private latrines, and collected the waste for use as fertilizer in rural areas (Scarborough 1981). However, an enormous gulf separated the privileged and the poor. The hovels and lean-to shacks of the destitute, home-lessness, and severe crowding (all of which mimic life in modern Western and Third World slums) dominated Roman life (Scobie 1986). The ideals promoted by the wealthiest citizens apparently had little impact on the public's health. De facto, the drainage systems installed in individual homes were seldom connected to street drains and sewers, as archeology at Pompeii has shown, and latrines were not provided with running water. Alex Scobie (1986) has detailed the multiple health problems attending the practical aspects of Roman public hygiene, observing that a city the size of Rome with a population of approxi mately 8 to 10 million in early imperial times would have produced about 40,000 to 50,000 kilograms of body waste per day. Arguing that only a fraction of that output reached the "public" collection sites, he shows that the emphasis in Roman public hygiene was the maintenance of the farm and an aristocratic life-style, whatever the adverse health costs to the general population. The emptying of public and private facilities enhanced agricultural productivity and provided a livelihood for armies of unskilled workers. The collection of urine aided the cloth industry, because fullers used urine as a mordant for certain dyestuffs. Roman literature does not adequately testify to the horrors of Roman cesspits "nauseating mixture(s) of the corpses of the poor, animal carcasses, sewage, and other garbage" (Scobie 1986).

Nor have the marvels of the aqueducts fared well under recent historical scrutiny. Frontinus sang the praises of the nine aqueducts that daily supplied the city of Rome (scholars have calculated that they provided about 992,000 cubic meters of water each day), but he tells us little about the distribution of water and whether there were any mechanisms to stem the flow of water into basins and tanks. Because of their malleability, lead pipes were commonly used in the plumbing of aristocratic homes, but we do not know whether the water they carried was soft or hard. (Hard water would have prevented much of the lead from seeping into the drinking water.) Ancient pastoral fondness for rainwater probably protected many Romans outside the great city from the multiple health hazards attending advanced urban sanitary technology.

The best and worst features of Roman public health, and of the Greek traditions and theories of personal hygiene, were passed along in the books and physical artifacts that survived the piecemeal dismantling of the Roman Empire. Thus, the strong aristocratic voice that determined the ideals of public and private health and their implementation remained relatively unchanged in the societies that inherited Roman custom, such as the Byzantine and Islamic empires. But in western Europe, retreat to a rural economic base, the effective disappearance of cities and market economies, and the introduction of Germanic customs interrupted the Greco-Roman public health tradition. It is true that in Benedictine monasteries upper-class monks constructed infirmaries, baths, latrines, caldaria, or steam rooms, and cold rooms in the best of Roman aristocratic tradition. (St. Gallen monastery in Switzerland, built in the eighth century, is one of the best surviving examples of this tradition.) But most Roman sanitary practices were adopted and gradually transformed only as Christian Mediterranean cities began to grow again in the eleventh and twelfth centuries.

In the European Middle Ages, cities grew to a maximum of 100,000 to 150,000 individuals by the early fourteenth century, only one-tenth the size of ancient Rome. The Roman legal principles holding individual property owners responsible for cleaning the streets in front of their homes dominated "public" sanitary intervention. Medieval Italians were far more willing than the Romans to specify what individual behaviors put others at risk and therefore to write new legislation prohibiting the pollution of public streets with animal carcasses, human refuse, and other noisome substances. Yet we do not know to what extent laws were actually enforced, and it is probable that medieval cities were even more squalid than those of antiquity. Nonetheless, there seems to have been a new ethic of communal, collective responsibility for public health. Some of the change may have come about with the Christianiza-tion of Europe, which among other things emphasized the physical and spiritual dangers of evil. Roman baths were used in common by the wealthier classes, but medieval laws dictated strict segregation of the sexes, treating as prostitutes, for example, women who strayed near the baths on a day when only men could use the facilities.

During the Middle Ages, urban dwellers could empty chamber pots into the streets as liberally as aristocratic Romans might have done, but medieval lawmakers often prescribed the times at which such wastes could or could not be evacuated or ordered i that words of warning be shouted to passersby below. For example, thirteenth-century residents of Siena were enjoined to cry "Look out!" three times before tossing the contents of a pot onto the street, and fines were specified for those who were found non-compliant. Medieval city governments, like their Roman predecessors, hired laborers to clean streets, cisterns, and sewers and to evacuate garbage. But unlike Roman officials, who appear to have adopted a laissez-faire attitude toward enforcement, they elected or appointed district supervisors to patrol both these employees and citizen behavior, and to report infractions to judicial authorities. The medieval belief that humans were sources of pollution (by the fourteenth century, lepers were forced to wear yellow to symbolize their danger to the community) had profound consequences for the development of epidemic controls, as will be discussed in a later section.

Leading the way for the rest of Europe, Italian and probably Spanish cities appropriated detailed Roman law and customs regulating the trappings of public sanitation - baths, sewers, fountains - as well as sanitary personnel and marketplace regulations, leaving most of these features unchanged, at least on paper, for hundreds of years. Public hygiene laws in 1700 strongly resembled those of 1300, with even the fines little changed. Those who could afford to follow all the recommendations of Galenic personal hygiene did so without questioning the basic premises of health maintenance, public or private. Only the creation of boards of public health, a very important late-medieval contribution to public health, and, late in the seventeenth century, medical attention to occupational disease represented significant advances in modern public health philosophy and practice.

Care of the Indigent and Public Physicians

The organization of basic health services within a community involves the provision of medical care to all members of that community and a conscious attempt to prevent or minimize disease. A relatively recent innovation is the appropriation of communal resources for hospitals devoted principally to medical intervention, that is, to hospitals that are something other than a refuge for the sick, the poor, or pilgrims. The earliest hospital in the modern Western sense was probably the Ospedale Maggiore of Milan. It was built in the mid-fifteenth century, funded by church properties, and managed by a lay board of governors, who in turn were appointed by state officials. Most medieval cities acknowledged the need for city hospitals, symbols of good Christian governance, and thus hospitals became as characteristic of this society as the aqueducts had been of Rome.

The public employment of physicians was another significant development in the history of public health before 1700. Even ancient Greece, where many physicians were itinerant healers forced to wander in search of patients, established political and economic centers and provided salaries and other privileges to individuals who would agree to minister to their populations (Nutton 1981). Yet wherever a settlement grew large enough to support ethnic, linguistic, or even economic diversity, it was more difficult to ensure a sufficient number of healers.

In some places, such as Mesopotamia, the provision of physicians could extend the power of rulers or of a religion if people were assured that the proper gods would be summoned when intervention was necessary. With politically or religiously less important illnesses, a patient's family could post the pa tient at their doorway or in the marketplace, giving passersby the opportunity to make a diagnosis or offer therapeutic suggestions.

In Egypt, India, and China where political upheaval was not as common as in Mesopotamia and Greece, highly individualized solutions to the communal responsibility for providing physicians were devised. Thus, Egypt may have developed a state system for the use of doctors as expert witnesses and provided a living allowance to all physicians, and by the period of the New Kingdom had established a formal hierarchy of doctors, the chief palace physician at its pinnacle. Similarly, in ancient India the king and other extremely wealthy individuals were obliged to provide medical care for their people by underwriting the services of priestlike Ayurvedic physicians (Basham 1976).

It was the Greek tradition that was ultimately transmitted to western Europe. From as early as the fourth century B.C., the Greeks had established a network of salaried physicians throughout the Hellenistic world. The terms of their contracts to individual communities varied widely, but the arrangement assured healers of some measure of personal stability. Unlike physicians in the more monolithic Egyptian society, who were natives subject to the same legal privileges and restrictions as their patients, physicians in the mobile Greek world were often foreigners who received salaries as well as tax immunities and special privileges (e.g., citizenship, the right to own land, rent-free housing, or even choice theater tickets) in return for contractual service to a community. This "system" - if indeed one can so call a functional solution to the provision of medical care - was adopted by the Romans in the designation of archiatri, or public physicians, whose duties were extended and to some extent redefined over the centuries. Later Renaissance European elaborations of the concept of public health mediated by public physicians was a rediscovery of ancient practices lost during the Middle Ages.

By the second century of the common era, large Roman cities designated up to 10 archiatri, their salaries set by municipal councilors, to minister to the poor. Physicians often competed for these communal posts, suggesting that there were financial rewards beyond the salary itself - most likely access to a wealthy patient population. Public physicians seem to have been selected by laymen. Sources are largely silent on how their performance was assessed or how they typically sought access to their clientele. It is unlikely that they had any responsibility for the maintenance of public health in other respects, such as epidemic control or sanitation. Other salaried physicians in the Roman Empire included physicians to gladiators (Galen began his professional career in such an assignment), to baths, and to courts or large households.

The financial privileges and immunities granted to public physicians may have ensured the survival of the office well into the early Middle Ages, for with inflation and the heavy fiscal demands on Roman citizens around A.D. 200, these inducements were considerable. In the early fourth century, the emperor Constantine the Great extended state salaries to teaching doctors irrespective of their medical services to the community, thus linking the interests of public physicians to those of local medical personnel. That association would become paramount in the later Middle Ages, leading to the monitoring and licensing of medical practice, ostensibly for the public good but equally obviously for the financial benefit of particular groups of healers. Under Emperor Theodoric, in the early sixth century, Roman doctors were given an overseer, an imperial physician called "count of the archiatri," who may have formed the first formal link between lay interests and medical elites because he could nominate and appoint physicians to a college of medicine. Specialized medical services, such as those of official public midwives, may also date from this period. The Islamic state, which replaced most of the Roman Empire in the Middle East, brought regulatory power over physicians under the control of the state, which paid the salaries of physicians appointed to hospitals and even administered licensing examinations (Karmi 1981).

The medical institutions of late Rome did not persist through the early Middle Ages, even in relatively urbanized Italy and Spain. The practice of community hiring of salaried physicians was not reestablished until the twelfth and thirteenth centuries. Vivian Nutton (1981) argues persuasively that early Italian interest in jurisprudence and their editions of Roman law texts led to the reestablishment of public physicians in Italy. Thus, the office acquired legal responsibilities not typical of the ancient world. Perugia's first medicus vulnerum (before 1222) probably had to provide expert testimony in cases of assault and battery. Public physicians in succeeding centuries typically had to judge whether a wound or injury had caused death. By the end of the fifteenth century, the system of hiring physicians was almost universal in Mediterranean western Europe, a system undoubtedly reinforced by the recurrence of plagues, which necessitated state interven tion to ensure medical care. Yet public physicians were not true public health physicians or medical officers of health, positions that Renaissance Italians seem to have invented. The institutions addressing communal medical responsibility for health surveillance arose instead from epidemic controls.

Richard Palmer (1981) has demonstrated that in large metropolitan areas the system of medici condotti, the Italian medieval name for archiatri, fell into disuse by the sixteenth century. But in small towns the system continued or even increased in popularity because it was a means of securing quality medical care without being at the mercy of itinerant quacks or "specialists."

The system of rural public physicians was able to absorb the late medieval expansion in the number of medical professionals, which brought about a more equal distribution of medical goods and services. Cities no longer needed to import physicians. The financial benefits they offered, the opportunities they provided for other, similarly trained practitioners, and often the presence of a university provided ample inducements for urban medical practice.

The major cities of Italy and Spain provided the prototype in medicine for the northern European cities of the seventeenth and eighteenth centuries: They developed local medical colleges dedicated to defending professional standards, restricting practice to the "qualified," regulating pharmacies, and mediating the state's charitable obligations to the poor in areas the church had abandoned (Lopez Pinero 1981; Palmer 1981). Tightening the restrictions on membership became common in Italy, foreshadowing the mercantilistic objectives of state medicine.

Epidemic Controls

Refuse disposal and the provision of clean water were regarded as aesthetic problems for growing cities as much as they were means to improve health. Nevertheless, by the thirteenth century, all Italian cities with statutes of laws had incorporated a system of sanitary provision modeled on ancient Roman patterns. The hallmarks of this system were maintenance of clean water sources, patrolling refuse disposal, and the posting of gatemen to identify potential sources of infection in the city. Two explanatory models underlay this approach to public health. The first was based on the assumption that polluted air caused disease by altering the humoral balance of humans and animals. The second was based on the knowledge that some diseases, such as leprosy, could be transmitted from one person to another.

The first of these two models was influential among public physicians when boards or offices of public health were created. The second model of contagion was not widely accepted during antiquity and the Middle Ages, at least among the educated elite. One exception, the practice of isolating lepers in special hospitals (leprosaria), is noteworthy because the custom was later adapted and justified as a means of epidemic control. Strict social isolation of individuals designated as lepers, whatever conditions may have been responsible for cases of advanced skin infection and/or physical deformities, was a practice derived from the Jews of antiquity. In biblical times priests identified those suffering from "leprosy" and used their authority to cast these people out of a settlement. Drawing on this practice, medieval Christian communities permitted priests to identify lepers and, at least in northern Europe, subject them to a ritual burial and banish them from the community.

Unlike Jews, medieval Christians accepted a communal responsibility for providing lepers with organized care - food, clothing, shelter, and religious services —but rarely medical care. The church and state cooperated in the construction and maintenance of residential hospitals for lepers. The peak of this building activity occurred in the period from 1150 to 1300.

Nonetheless, lepers were ostracized. Guards often kept them outside city gates. Those formally identified as lepers were made to wear symbols of their infection and perhaps to carry a bell or clapper to warn those who might get too near them. They could shop at markets only on designated days and hours, and could touch things only with a long pole. Moreover, practices such as these survived throughout the early modern period even when leprosaria were turned to other uses.

In other societies (e.g., Chinese and Muslim) in which leprosy was considered to be a communicable disease, social restrictions were often linked to legal restraints on lepers' activities. In Muslim lands, "mortal" illnesses, including both leprosy and mental illness, cast their victims into a state of dependency, somewhat like that of a child or slave. They lost the right to make and maintain contracts, including the right to continue a contract of marriage. Though a wide variety of behavioral responses to lepers existed across Islamic society, ranging from pity, to aggressive medical assistance, to isolation of the sufferers in leper hospitals, Michael Dols (1983) emphasizes the distinctiveness of Western Judeo-Christian tradition. In Europe, but not in the Middle

East, lepers were considered diseased in soul as well as body, were ritually separated from the community, were deemed fiercely contagious to others, and were subjected to religious penance and other punishments even after diagnosis and isolation.

Apart from exaggerated responses in the West to lepers (as well as to prostitutes, homosexuals, heretics, and Jews), collective action to protect public health was, as a rule, crisis-oriented. Plague and other epidemics may not have been the most important manifestations of disease in earlier societies in terms of mortality, but they were certainly the most visible. Recurrent bubonic plague epidemics evoked the greatest response, making plague what Charles-Edward Winslow (1943) called the "great teacher." Beginning with the wave now called the Black Death, plague appeared in Europe at least once every generation between 1348 and 1720. At the first outbreak of the disease, fourteenth-century government officials in Florence, Venice, Perugia, and Lerida called on medical authorities to provide advice on plague control and containment. Of these, only Lerida's adviser, Jacme d'Agramont, seems to have articulated a contagion model for the spread of disease. The Florentine and Venetian approaches to epidemic control may have been the most sophisticated: aggressive cleanup of refuse, filth, offal, and other sources of corruption and putrefaction on the city streets. They applied traditional health practices to meet an emergency, but created a novel bureaucratic unit to orchestrate public efforts. In these two republican city-states, small committees of wealthy citizens were appointed to oversee the administration of ordinary sanitary laws, to hire physicians, gravediggers, and other necessary personnel, to maintain public order and respect for property, and to make emergency legislation. These communities saw no need for the direct intervention of the medical guilds. By contrast, in Paris, which lacked a tradition of lay involvement in public health control, members of the university medical faculty collectively offered advice about surviving pestilence, a practice individual doctors elsewhere followed in providing counsel to their patients.

For whatever reason, during the following century there seems to have been no deliberate reappraisal of the sanitary methods used in the earliest plague epidemic, and no temporary re-creation of boards of health other than in Milan, the only northern Italian city not stricken during the 1348 epidemic. Most cities relied instead on maintaining order, particularly in the burial of bodies, acquiring information about cities that were havens from disease (or, con versely, cities that were stricken with plague), providing physicians and other service personnel, and transferring property and goods after the plague to heirs or to the state. Rarely, however, did cities specifically address the technical problems of public or community-level measures for containing plague even though the "corruption of the air" theory presumably should have dictated intervention. Purifying bonfires, the disinfection or destruction of the goods and clothing of plague victims, and fumigation or other cleansing of infected dwellings were practices first employed aggressively in Milan in the late fourteenth century. Elsewhere and later, antiplague measures based on either the contagion or the corruption model of plague were adopted. Cito, longe, tarde — "Flee quickly, go far, and return slowly" -was the advice most wealthy city dwellers followed during the first century of plague experience, thereby eschewing costlier and more direct measures against the disease.

The tiny Dalmatian colony of Venice, Ragusa (now Dubrovnik), invented the quarantine in 1377. This was a response to impending plague whereby a temporary moratorium on travel and trade with the town was decreed. The Ragusan practice, actually then a trentino, or 30-day waiting period, became standard maritime practice by the sixteenth and seventeenth centuries. Although the quarantine in common parlance has acquired a more aggressive meaning, in the maritime context it was a passive measure designed to prevent incursions of plague rather than to segregate active cases. Through reproduction of a typographical error in the early nineteenth century, many surveys of quarantine and public health have credited Marseilles with the use of the quarantine by 1483. In reality the Ragusan maritime quarantine was not widely used until the sixteenth century.

Another feature of what was to become regular plague control, the pest house, or lazaretto, was used during the first plague century, 1350 to 1450, but chiefly as a means of delivering medical care to the poor. After the 1450s both quarantine (passive, preventive isolation of the healthy) and active hospital isolation of the ill became more popular antiplague measures in city-states, which can be taken as evidence for the increasing acceptance of a contagion theory of plague. Finally, official boards of health were reestablished. Throughout the early modern period, these bureaucracies identified and handled human cases of plague and acted as arbiters of standard public health controls (Cipolla 1976; Carmi-chael 1986).

Only during the fourteenth century do descriptions of plague note the loss of many principal citizens. After that period, elites seem to have worked out effective patterns of flight, so that only those who remained in the cities were exposed to danger. Unfortunately, in urban areas, plague control measures may have inadvertently augmented the death tolls. Standard practices developed in Italian cities during the fifteenth century - practices that would be followed by northern Europeans during the late sixteenth and seventeenth centuries - included the house arrest or hospital confinement of all family members of plague victims as well as others who may have had contact with them, whether or not the others were sick. This led to the construction of ramshackle buildings, lazarettos, that could segregate as many as 5,000 to 10,000 individuals at a time. By the sixteenth century, larger urban areas were quarantining the still-healthy contacts of plague victims in one place, isolating the ill together with immediate family members in a medically oriented hospital, and placing those who recovered in houses or hospices for a second period of quarantine.

By 1500 many of the principal Italian city-states had created permanent boards of health to monitor urban sanitation and disease threats even when no crisis arose. Rarely were physicians members of these aristocratic boards, though in many cities the lay directors employed medical officers of health. Nevertheless, local colleges of medicine and university medical faculties assumed the responsibility of providing diagnostic and therapeutic advice when crises threatened. By the second half of the sixteenth century, boards of health routinely consulted members of the medical establishment, one group helping the other in publication efforts to dispense both health advice and sanitary legislation and in the provision of public "debriefings" after a plague had passed. During the sixteenth and seventeenth centuries, these basic principles of public health surveillance and epidemic control were adopted by states north of the Alps.

In Italy and the Mediterranean, generally, the boards of health developed into tremendously powerful bureaucracies, commanding sizable portions of state resources and the cooperation of diplomats in securing information about the health conditions in other states. Carlo Cipolla (1976) identifies both vertical and horizontal paths of transmitting such information, emphasizing the aristocratic character of health boards and their successes in superseding any authority that merchants might claim from the state. Detailed information about plague or other diseases thought to be contagious was gathered from the reports of ambassadors as well as from broad networks of informants and spies at home. Armed with these data, health magistracies could impose quarantine at will, confiscate goods, and impound, fumigate, disinfect, or burn them. Though they usually agreed to reimburse the owners at half to two-thirds the value of their property, dire necessity and heavy expenditures during great epidemics left many boards of health bankrupt in all but their broad judicial authority. In fact, despite all efforts and a rigorous interpretation of the contagion theory of plague, the plagues of the late sixteenth and seventeenth centuries were catastrophic in the Mediterranean countries, in terms of both human and financial losses.

Not surprisingly, with the sweeping powers Italian boards of health were given, permanent magistracies required greater justification for their existence and their policies than the control of plague. They could argue that plagues would have been even worse without their efforts, but the economic costs of quarantine and isolation policies were more than early modern populations could bear without the creation of widescale human misery. Yet as strong monarchies emerged, legislators, physicians, and concerned aristocrats of the seventeenth and early eighteenth centuries were able to weave some public health controls into the evolving theories of mercantilism. Apart from epidemic surveillance, medical "police" extended state medicine into the licensure of midwives, the control of drugs and markets for drugs, stricter control of nonlicensed practitioners, and a variety of other matters. The results were optimistically summarized at the end of the eighteenth century by an Austrian state physician working in Lombardy, Johann Peter Frank (Sigerist 1956).

Outside the Italian sphere, where state medicine and public health carried the longest and strongest tradition, public health boards and epidemic controls did not evolve into permanent magistracies concerned with all aspects of public health. As Caroline Hannaway (1981) has indicated, at the beginning of the eighteenth century, the French, British, German, and, ultimately, U.S. traditions of public health relied mainly on the traditional Galenic-Hippocratic discourse about what ensured an individual's good health. Superimposed on those interests was makeshift machinery of epidemic control borrowed from the Italians. Concern for the health of "the people," however, spurred by general mercantilist goals and the early Enlightenment passion for order and reason, was pan-European. During the eighteenth century, the impetus for change and reform in public health thus moved northward. Rejecting the political bases for state medicine that had led to the Italian boards of health, northern Europeans turned their energies to the production and consumption of health information: popular handbooks and manuals, such as those by William Buchann and S. A. Tissot; the proliferation of foundling homes, hospitals, and infirmaries; and the earliest efforts at systematic information gathering. As we move closer to the modern world, the rhetoric and rationale on which sanitation, care for the indigent, provision of public physicians, and epidemic controls were based before 1700 are blended into a new campaign for cleanliness and order, public and private.

Ann G. Carmichael


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