Medical geography is slowly including more social and cultural theory
in its analysis of health issues. Yet there is still room for theoreti
cal growth in the discipline, in areas such as historical inquiry, met
aphoric landscapes of disease, and the role of disease and its interpr
etations in the production of place. With the example of four smallpox
epidemics in nineteenth century San Francisco, application of these c
oncepts is illustrated. Each successive epidemic in San Francisco brou
ght stronger association of the disease with Chinatown, until an almos
t complete metonymy of place and disease had occurred by the last deca
des of the century. The articulation of biased medical theory onto a l
andscape of xenophobia engendered this metaphorical transformation of
Chinatown into a pustule of contagion threatening to infect the rest o
f 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 incr
easingly class-stratified city, they undercut attempts of the upper cl
asses to escape disease by carrying smallpox-causing miasmas across cl
ass and ethnic boundaries. A reinvigorated sanitation movement was the
result. Both reactions to smallpox epidemics had significant influenc
e in shaping San Francisco's landscape, real and symbolic.