Sewers and scapegoats: spatial metaphors of smallpox in nineteenth century San Francisco.

Medical geography is slowly including more social and cultural theory in its analysis of health issues. Yet there is still room for theoretical growth in the discipline, in areas such as historical inquiry, metaphoric landscapes of disease, and the role of disease and its interpretations in the production of place. With the example of four smallpox epidemics in nineteenth century San Francisco, application of these concepts is illustrated. Each successive epidemic in San Francisco brought stronger association of the disease with Chinatown, until an almost complete metonymy of place and disease had occurred by the last decades of the century. The articulation of biased medical theory onto a landscape of xenophobia engendered this metaphorical transformation of Chinatown into a pustule of contagion threatening to infect the rest of the urban body. A less metaphoric mapping of smallpox focused on the sewer. According to 19th-century miasmatic theories of epidemiology, sewers were the most dangerous urban topographical feature. In an increasingly class-stratified city, they undercut attempts of the upper classes to escape disease by carrying smallpox-causing miasmas across class and ethnic boundaries. A reinvigorated sanitation movement was the result. Both reactions to smallpox epidemics had significant influence in shaping San Francisco's landscape, real and symbolic.