Epidemics in Western Society Since 1600

HIST 234 - Lecture 9 - Asiatic Cholera (I): Personal Reflections

Chapter 1. Asiatic Cholera in Naples in 1911 [00:00:00]

Professor Frank Snowden: Good morning. We can get started. And this morning will be a slightly different style of lecture. You’ll notice that you don’t have handouts, and that wasn’t an oversight. It was actually because you won’t need them this morning. What we’re going to be doing is something of an experiment, which is that it seemed to me that it was useful, when you were reading various historical works, that sometimes the author of one of them should explain and discuss with you how they came to be as they are. So, that was one of the reasons that I put my own book, this one, on Naples, on the reading list. And I thought this morning I’d try the experiment of a different kind of lecture, where I talk to you about how it came to be the work that it is.

We’re moving on now from the material on the Paris School and on plague and smallpox, to our next major epidemic disease, which was the great feared disease of the nineteenth century, which was Asiatic cholera, which hit Europe — it wasn’t an endemic disease — it hit Europe for the first time around 1830, and returned in a series of pandemics in various waves. And normally the official historiography has it that about the last epidemic in Western Europe was in the 1890s. And the statistics of the WHO in the various countries of Europe support — and the literature as well — support this conclusion, that Asiatic cholera, after the 1890s, returns again to Western Europe only in tiny little outbreaks, the last of which was 1973.

So, there really isn’t supposedly a history of cholera in the twentieth century in Europe. And it’s that that I want to challenge and to talk with you about this morning. Now, as I began — and here we can start into how the book came to exist at all. I, at the time — well, one, there’s this sort of, as I started doing research on a very different topic, I had, in a sense perhaps, been primed for an interest in cholera. I had been primed because I had lived through an outbreak in Rome in 1973, and I had noticed a number of things that had captured my attention — because this was Italy, this world seventh industrial power at the time — and I remember some strange phenomena.

Being in Rome — the epidemic had started and found its epicenter in the city of Naples. And cars had, at that time, license plates that bore the province of origin of the vehicle, and cars in Rome that had Naples license plates were being stoned by the citizens of Rome. It was also true that in the fish and vegetable markets near the apartment where I was living, that the stalls of the fish and vegetable sellers were attacked and overturned by crowds. So, this seemed something that captured my imagination very clearly. And then the minister of health went on television and said that you really didn’t need to worry because all you had to do was to squeeze — because the Vibrio, the bacterium that causes Asiatic cholera, is highly susceptible to acid; so all you have to do is squeeze a little lemon juice on your raw mussels, and then you can quite happily eat them; which I wouldn’t advise any of you.

In any case, it was also true that this prime minister and the minister of health visited Naples and the infectious diseases hospital there. And there’s an Italian magazine in which pictures of them appeared, and you could see them almost running down the wards, as they were visiting the patients, and behind them they had their hands — you can imagine them trotting — with this gesture, which is a gesture to ward off the evil eye in Italian culture. So, this seemed rather strange in the world’s seventh industrial power. In a sense I had, then, this subliminal message that came from an earlier experience.

But there I was, a decade or so later, and my project was — I thought that I was interested in political philosophy and social history, and I was working on the disappearance of the European peasantry under the press of economic circumstances, and major transformations in the countryside, and the coming of the commercial revolution in agriculture, urbanization and the Industrial Revolution. But I began to have my imagination captured by numbers of references that I began to find around the early twentieth century to cholera in Italy around 1910. And that seemed a little surprising to me, and it really began — I began to read more about it. And it seemed to illustrate how people’s lives were lived, and their standard of living, much better than the project that I originally began with.

Chapter 2. Concealment? [00:06:22]

And, so, I let this medical project have a life of its own, and this is what eventually became my book. As I was working more on cholera, however, something else came to the forefront of my attention, and that was a conflict between what I read about cholera in the literature and what I was beginning to find in my own research. The literature said that there wasn’t a major epidemic in the twentieth century in Europe, the last major one being in the 1890s. But I was beginning to find odd references to some very strange events, particularly in the summer of 1911, and I began to think that perhaps a very interesting policy of concealment was taking place; that is, an epidemic that was concealed by the authorities. And Naples once again was a very interesting place.

Now, Naples is, if you’re interested in cholera in the West, Naples is a very interesting place because it was the city — it was the largest city in Europe in the nineteenth century, and it was scourged the most often by this affliction. And I’m going to be arguing that it was scourged also in times that aren’t recorded in the standard historiography of the subject, and in particular in 1911. It also is an extraordinary place because it has something happen that you won’t find elsewhere, and that is this is a city that was actually, after the dreadful epidemic of 1884, was rebuilt in order to make the city cholera-proof, so that it wouldn’t return.

So, we see an extraordinary — we talk about the impact of infectious diseases, and here we see a case study of a place where the city itself is reconstructed specifically as result of an epidemic catastrophe, in order not to make another one possible. We can directly see in bricks and mortar, and in the sewers underground and the buildings above, and in the layout of the city, you can see the impact of cholera and of the idea of miasma. Because the miasmatic interpretation was the one under which had guided the reconstruction of the city, which happened in the wake of the 1884 catastrophe. But in 1911, there was no public record of a major epidemic. I had a whiff of the fact that there was, but I couldn’t prove it.

So, how do you go about demonstrating an epidemic that doesn’t have a literature? I thought that the first thing that would be useful to do would be to visit Naples, and in particular to visit the Naples Cemetery. The cemetery is a very large one — you can visit it yourselves — and it’s a very monumental grand cemetery. And I went in the middle of the week with the idea that I would go to the registry and perhaps there find records of burials, and that I would also be able to see in stone the victims of a major epidemic. In other words, the first idea I had was that you can’t — in order to prove that there was an epidemic, you would have to have a sudden bulge in mortality in the summer months of 1911. And I thought I could demonstrate that by visiting the Naples Cemetery, and if there wasn’t a sudden excess of death in the summer, then I would know that I was actually on the wrong trail entirely and I should abandon my project.

Well, as I was walking through the monumental cemetery — I think it was a Wednesday or a Thursday — I suddenly had a car pull up alongside me, and the man inside said, “Get in, get in.” I don’t know exactly how you would have reacted. I hesitated; particularly as it was a cemetery in which on a Wednesday and a Thursday I found myself completely alone, except for this strange request that I get in a car with someone I had never seen before. Well, it turns out, as we talked, that he was the director of the cemetery, and he had come to rescue me. And, so, I did eventually get in, and he took me out of the cemetery, scolding me and telling me that I was obviously a stranger, an outsider and a foreigner who knew nothing, and that, in fact, the Naples cemetery is the most dangerous place you can be in the city, which has a long history of organized crime, because during the week this was, in fact, where the local mafia did its drug deals, and that everyone in Naples knew this except me, and he was possibly saving my life by removing me.

It wasn’t that I wasn’t welcome. I was welcome to come back on Saturday and Sunday, because that’s when all the people of Naples do come to pay their respects to their relatives, and there are flower stalls and gazillions of people frequenting the cemetery then, and the registry office with the records was also open then. I also discovered that there was, in fact — by reading the newspapers surrounding the time of my visit, that that very summer there was the — I was doing a little checking up, and it turns out that the rector of the cemetery wasn’t kidding me at all — that there was a major drug bust in this very cemetery. And the way they had done it was that they had wired the tombstones, and in this way they had pulled off a major move against the Camorra, which is the local, if we like, subset of the organized crime families in Italy, and one of the most important crime syndicates in the world, in modern times.

Chapter 3. Search for Evidence [00:13:27]

So, that was — that brought me back on a weekend. And on the weekend I discovered that there was, in fact, a big mortality bulge; that there were lots of people who’d been buried in the summer of 1911, well in excess of the year before, 1910, 1909, or the years that were succeeded, 1912 or 1913. And there was a book that registered the deaths and burials, and there was a huge bulge in 1911. So, I knew something had happened. And something was interesting, because one of the features of the book that’s the register of burials is that they provide the neighborhood from which the deceased was resident. But in this case they, instead of the usual record of a neighborhood, they had the marking Cotugno Hospital, was the last place that the deceased had been. And the Cotugno Hospital, then as now, was the infectious diseases hospital of the city.

I suddenly knew that there was this great excess of mortality in the summer of 1911, and that the mortality was from infectious diseases, because the people had been buried in vast numbers from the Cotugno Hospital as their last port of call. Then the next thought — and I think a lot of historical work is a bit like detective work — and I found myself playing a sort of detective role. So, my next place to visit was the Cotugno Hospital of Infectious Diseases. And I made two findings there that were confirming me in my vision of what might have happened; that they were — there was in the library of the hospital, the hospital itself had preserved its own records, patient records. And after some persistence, I was allowed to look at patient records in the hospital, and found something interesting and mysterious, and that was that there were records of the patient records through 1908, ‘09, ‘10, and the first half of 1911, and then suddenly there were no records at all.

There was a mysterious disappearance of the records of the patients of the hospital. Then I went to the library of the Infectious Diseases Hospital, where there was a second interesting thing, which was that the hospital had its own research journal that it published, recording the research findings of its own physicians, its own house physicians and interns and residents. The result of that was to discover that for surprise, surprise, in the summer of 1911 the physicians of the Cotugno Hospital were doing lots and lots of research on therapeutics for Asiatic cholera. They were experimenting with giving patients ice, and lots of other therapeutic procedures that we’ll talk about in a couple of minutes. So, I now knew that the physicians of the Infectious Diseases Hospital were enormously preoccupied with Asiatic cholera.

Then the next place was to go to the local archives, where I was told that my idea was impossible, there was no such thing; that there also — the local records had been moved during the Second World War out of the city for safekeeping, to the Sanctuary of Monte Cassino, an abbey outside of the city. But I think a number of you have heard of Monte Cassino. It became a major battle site in the war, and so the abbey itself and all of the archives went up in flames, and so all the records of the city for the period I was interested in were destroyed. And I was told that a project of the kind that I was imagining was inconceivable and also couldn’t be carried out. So, what do you do next if you think there’s a major epidemic and you want to demonstrate its existence?

The next thing that happened was that I had the idea that this was a time, in 1911, that was the height of mass emigration of Italians — that is, I’ve said that I had been studying the disappearance of the European peasantry and its transformation into workers or urban dwellers, and a part of that was the extraordinary story of Italian transoceanic migration, in large part to this country, but also to Australia and other places. So, I thought if there really was a mass movement — and Naples is and was then a port. It was one of Europe’s, along with Hamburg, major port cities. And what Naples specialized in — if Hamburg specialized in goods and services, Naples specialized in the export of people, and in particular Italian emigrants to New York City.

There was enormous transoceanic migration. I thought well, if this is true, and these thousands, hundreds-of-thousands of emigrants are moving through the city of Naples, and there is a major cholera epidemic, and they’re arriving at Ellis Island, well surely some of them will have been afflicted with the disease, and there would be records there of that, at Ellis Island. Well, as it turns out, this was true. There were records. Cholera did break out on a series of emigrant-bearing ships in the summer of 1911, and people were quarantined for the disease — Italians, that is, who had last been in Naples — were quarantined for the disease on Ellis Island. And indeed, there had been a number of people who were released from quarantine and fell ill on the mainland. And, so, there are perhaps a dozen cases of people who fell sick in New York State and not on Ellis Island itself. So, we know that there was then — there were Italian emigrants coming to the United States who were afflicted with the disease.

Chapter 4. Advances in Cholera Therapeutics [00:21:05]

This led me to think, well, I do have a project, and now the point is to prove it further. What can I find out about its reasons? What are the politics of concealment, and so on? And I was lucky then because I was interested in a physician called Leonard Rogers, who was one of the world’s experts in tropical medicine at the early years of the twentieth century. And it was he who in 1908 [correction: 1909] made a major discovery. In terms of the therapeutics of Asiatic cholera, down to 1909, there was nothing that physicians could do that was effective and helpful for their patients, and so the case fatality rate was something like fifty percent for Asiatic cholera. In 1908 and 1909, Leonard Rogers, who was a British physician working in India, had found that he could reduce the mortality from fifty to fifteen percent — the first major advance in therapeutics — and he did it, one by a simple building on something that had been observed from the 1830s, and that is to say that cholera kills by dehydration.

The bodily fluids flow out of the rectum and the mouth through vomiting, at an extraordinary rate, so that human beings lose up to three-quarters of the fluid portion of their blood serum. And, so, from the 1830s onward, one of the therapeutic ideas was why not simply replace the fluids? There were major attempts early on to get people to drink lots of liquid. That doesn’t work because you simply vomit it up. It has no effect, except to make the patient weaker. So, having discovered that, there were attempts by physicians to replace the fluids intravenously. The problem early on was that there was not a knowledge — there were several problems. How much liquid do you actually administer? And many patients died of heart failure from an excess of fluid. It was also a time before the discovery of the germ theory of disease, and so although they were given drips that had clean water, it wasn’t sterile and patients died of septicemia.

It was also true that another discovery, which was that the patients — what made people persist with rehydration is that this administration of liquid caused the patients to feel much better briefly. For a few hours they seemed to recover. They would sit up in their beds and feel infinitely better. So something clearly positive was going on. But what it was wasn’t understood. And what happened was that the administration of fluid was trying to replace fluid that had the same salinity as the blood in the body. Unfortunately, that is not retained by tissues, and it merely pours out of the body again. And, so, the patient who had momentarily, for a few hours, felt better, relapses, and even the continuing of this therapeutic attempt had no positive effect.

Well, Leonard Rogers discovered in 1909 a number of things. He measured the amount of fluid loss. He used distilled water, and he made it a hypertonic — that is, much more saline than the blood fluid. And the result of that was that it was retained — through mechanisms that aren’t very well understood, the fluid was retained. And, so, Leonard Rogers was able to save the lives of the vast majority of the patients he treated for Asiatic cholera in India, and he wanted to — the problem was this was a time in medical history when there were racial ideas of disease, and it was thought the fact that he had discovered this with Indian bodies would have nothing to do with European bodies.

So, partly for humanitarian reasons and partly for scientific reasons, he was looking for an outbreak of cholera in the West, in which he could apply his therapeutics and demonstrate their ability to save life, any human life. And in 1911, because he was watching very closely, he realized that there was an epidemic afoot in Italy, and he sought permission to go to Naples to demonstrate the efficacy of his new procedures. Soon I had Leonard — I was in contact with Leonard Rogers’ family — and I had access to his papers, and his discussion of what happened to him in the summer of 1911. Which was that to admit him to the hospital at Naples to train physicians in saving lives, the best available practice, the only therapy that had any effect, would be to admit the presence of an epidemic.

And, so, he wasn’t allowed to come to mainland Italy. Instead he was allowed a two-week visit to Sicily, where the disease spread as well. And the Italian physicians there called him the “prince of medicine,” because they had a survival rate, under his direction and his new rehydration method, of eighty-five percent, which was extraordinary by international standards. He had discovered the first effective therapy, one that is in fact the basis of present-day therapy for cholera, which is oral rehydration. Leonard Rogers’ methods have been perfected, but he was the one who found an effective rehydration system.

Chapter 5. Concealment in Conflict with Patient Care [00:27:39]

Soon we knew, then, that the state in Italy, for various reasons, was preserving a secret and denying its own citizens the most effective, the only effective available system of care. So, Leonard Rogers left Italy in great disappointment, after only being allowed to visit the cholera wards in Sicily, and was denied by the state the ability to visit Naples, which was the epicenter of what was happening. The next thing I was able to discover was that the records for this epidemic — there were records, but they existed not in the usual places that scholars would think of to study public health. The first files on this that I discovered were in police records. And they happened in an odd way, which was that the prime minister of Italy ordered the state police in Italy to deal with a new offense, which was sanitary defeatism. And in order to preserve silence and not promote sanitary defeatism, they began tapping the telephone lines used by physicians, and censoring and opening physicians’ mail.

In the city of Venice in 1911, there were actually the police records that demonstrated the following: which was to say that the Venice Medical Society decided quite sensibly in the summer of 1911 that it would save lives and enable people to protect themselves by publishing pamphlets and distributing them, about Asiatic cholera and how you can protect yourself against it. And they printed thousands of these, and wall posters as well, to put up on the walls of Venice. Instead, the Medical Society was visited by the police, who confiscated and burned all of the pamphlets and all of the wall posters, and told the physicians of Venice, the city, that to propagate health and sanitary defeatism would be fatal to their careers. So, this was all preserved in the records of the police regarding the summer of 1911 in Venice.

The next place that I visited then was the National Archives here, and discovered that Italy had signed, in 1903 — and this means that all of the things that I’m telling you about marked a violation also of international law. Because in 1903 there was a Paris Sanitary Convention, which made the full disclosure of infectious diseases mandatory for — Italy and the United States were both signatories, along with a series of other countries. And the physician who represented the United States in 1903, a major cholera expert named Henry Geddings, was now stationed at Naples with the U.S. Embassy, directing the medical service there. Why Naples? Because Naples was the center of mass emigration from Italy to the United States, and there were health inspections that took place in the city before departure, and Henry Geddings was therefore in charge of protecting the health of the United States by heading off infectious diseases before people even boarded the ship.

Well, in 1911, there’s an extensive correspondence, and a very unhappy correspondence, by Henry Geddings and people in the United States, including his superiors and his family, about his experiences in the city, where he tried to report to the United States Government that there was a major epidemic of Asiatic cholera. He found that his life was threatened in the city of Naples, and his superiors in the United States were not at all enthusiastic about receiving his message of what was taking place, and so the United States Government — you’ve met [U.S. Surgeon General] Walter Wyman in your study of the bubonic plague and the Barbary plague in San Francisco. Well, we meet him here again, actually colluding with the Italian government in the suppression of knowledge about this important major infectious disease, against international law that the United States had actually signed.

Then there were — in addition to that, I then went back to the police files and discovered that there were also health statistics that were coming in to Rome, reporting events in the Italian provinces, and they included statistics for Asiatic cholera. But the prefects, who were the highest authority for law and order in each Italian province, today as then, were actually sending back, to help officers in the various provinces, the statistics they were receiving, saying that, “These aren’t good statistics; we don’t want them, send us something better.” And, so, you actually see the process by which the state manufactured the health statistics that were subsequently published, and are the basis for the historiography. And you can read those statistics in World Health Organization reports, and Italian Government reports, and in U.S. Government reports of the summer of 1911.

Chapter 6. Why Conceal? [00:33:49]

Now, why is this true and why was this so sensitive? This meant that I needed to go back in time. My first idea was to write the second half of the book, about concealment. And I’m introducing that — I think that’s important in our course — because we’re talking about various strategies of public health, and so far we’ve looked at plague regulations and we’ve looked at vaccine. But there’s — as you will remember probably from the SARS outbreak, that China practiced a policy of concealment at the outset. What I’m trying to say is that concealment is also a style of public health policy. And I think our newspapers rather misled us in leading us to believe that this was simply unique to China, something very unusual. I would argue as well that this is probably something that’s been resorted to a number of times, and this epidemic of 1911 is a good example and a good case study in which one can find the actual documents of the concealment, and the reasons that it took place.

Well, why this pressure? Why does the prime minister of Italy collude, and why the United States, the Surgeon General of the United States, also colluded with that? Indeed, I would tell you another little anecdote, which was that Walter Wyman had a friend who was — friends, a couple he knew — who were the parents of young Johnny, who just finished his B.A. degree in 1911 — I’m sorry not here in New Haven, but rather at that other unmentionable place in Cambridge, Mass. And having finished his degree in 1911, as a newly minted Bachelor of Arts, he was planning a grand tour, which was going to take in Italy. And Italy had — this was the fiftieth anniversary of Italian unification, and there was a major fair with a grand U.S. pavilion, and Johnny was planning to visit; until, that is, he got a letter from his friend, the U.S. Surgeon General, who wrote to Johnny’s parents that this trip simply wasn’t on in the summer of 1911, because due to infectious diseases it wasn’t safe to visit Italy.

At the U.S. Pavilion, also, the people, the organizers, wrote back to Washington, saying that they were scandalized and horrified because American citizens were not being warned that in fact there was cholera rampant in Italy and their health was at risk, and there was no knowledge of this and no coverage of it in the press. Well, why would this be happening? The first thing is that by this time there was an enormous stigma associated with Asiatic cholera. Asiatic cholera in Western Europe and in North America was supposedly vanquished by the bulwarks of sanitation and public health. Cholera is spread by the ingestion — in only one way — which is the ingestion of food and water contaminated with fecal matter. And, so, it really is an indictment of sanitary standards. And therefore one of the features was a matter of national pride for Italians not to admit that there, in fact, there were these deficiencies in sanitary standards, in a nation that was supposedly advanced and, as they would have said, civilized.

So, part of it then is avoiding stigma; this was an important part of what happened. But in addition, there was a patriotism involved, because this was the fiftieth anniversary of Italian unification, and the whole world was descending on Italy; or so it seemed, and Italians hoped. And to destroy the festivities by putting them off, by warning the world that cholera was rampant in Italy at this time, would have had enormous economic repercussions for tourism, a major industry. It also would have had major repercussions in terms of Italian pride in canceling the whole of the celebrations, a second feature. Another feature has to do — is the fact that I’ve just said, that the Italian economy and Italian standards of living were dependent in part on the export of people at this time. These were emigrants who came to these shores, and to South America, and then sent back very large-scale remittances that were very important to the Italian economy. And what would’ve happened if the 1903 Sanitary Convention terms had been enforced, in Italy as it should have, and was legally committed to doing, had announced the presence of Asiatic cholera, that would have stopped emigration to these shores and to South America. And that was something that Italians did not want to risk. And this also could have had repercussions in terms of civil disorder.

There was a fear that, then, too — cholera, as we’ll see, is much associated with social tension and disorder, and that was another fear that was very much in the minds of Italians. But then there’s something very specific, and that is that — as I said in the beginning of our talk this morning — that Naples had been made supposedly cholera-proof after the summer of 1884, when a catastrophic epidemic had ravaged the city, and massive commitment of funds — Italian but also Neapolitan and from abroad — had been devoted to this rebuilding of the city. The problem is — I’ve already said that Naples was the center of the Camorra, of a major criminal syndicate, and was a place where funds often disappeared in mysterious channels. And one of the features of the rebuilding project was that the money largely went into undisclosed and corrupt channels.

Here we have a city, which has supposedly been built like the Titanic, just hitting another iceberg and discovering that, in fact, the funds that were to have made it safe have been misspent. And there was an opposition to this municipal government in Naples, which was using health as one of the complaints of the opposition parties. The opposition parties in Naples at the time were republicans, socialists, anarchists. And so part of the danger then, from the standpoint of the government of the day, was that to admit this would lead to a major local scandal, and would, if you like, legitimate the complaints and accusations of a radical leftwing opposition. So, a consideration of political stability was also part of the calculation. And this, in fact, was a motivating factor for the U.S. Surgeon General and the U.S. Government; that here was a friendly government that was being lampooned and lambasted by a radical, very left-wing opposition, and it was better to cooperate then with the government, the legitimate government, in the face of this opposition.

Well, this concealment then went forward, and it was orchestrated at the very highest levels. The press was censored. Health defeatism actually then became something that the police regarded as an infringement and repressed. We’ve seen the way in which physicians and public health authorities were censored and were threatened. In addition, it was not discussed in parliament, and it wasn’t even discussed in the Naples Municipal Council. And if you read the reports — and I read the discussions of what was being discussed in Naples in the summer of 1911 — you see a discussion of the need for hiring lots and lots of nurses, the need for many more doctors. And you see that they’re importing massive quantities of snow from the Apennines and the Alps into the city, and it’s taken to the Cotugno Hospital. And there, if you correlate that with what the physicians were doing, they were giving ice to cholera patients on the ward to deal with the tremendous thirst that they had, and to replace, they hoped, some of the fluid that they were losing through the course of the disease.

So, that was all — this conspiracy then is not a casual one. It’s organized from the top down, and is a very major and well-organized plot to conceal the existence of this epidemic. In addition then, what were the consequences of concealment? I want to argue that — throughout this course — that public health is dependent on accurate and timely information. We’ll see that today, in that a major feature of public health policies is surveillance and monitoring, and the availability of information, nationally and internationally, is vital to contain and prevent pandemic afflictions. So, one of the features — and I think 1911 is a good example of what happens if you don’t provide information.

Chapter 7. Effects of Concealment [00:44:59]

A first thing that happened was that this disease spread through many provinces of Italy. It was not contained domestically. Fortunately, it did not spread to these shores and to Argentina and to other places where large numbers of Italians went. But I think that was no thanks to the Italian government, it had to do with serendipity and good luck. What I could say was that the Italian government, with the collusion of the U.S. government, was placing the health of this country, and the health of Argentina in particular, at risk. It was placing at risk the health also of international visitors to Italy, tourists and people who came to see the celebrations of 1911. And one of the truly unfortunate parts of the concealment effects is that it led to thousands of deaths of Italians. Because the patients on the wards of the Cotugno Hospital, and elsewhere in Italy, were systematically denied what was then the best available international practice, which is the administration of rehydration therapy, as developed by Leonard Rogers, and Italian doctors weren’t allowed to know that this was the state-of-the-art and the way in which it was possible to save Italian lives, reducing mortality from fifty to fifteen percent, or something like that.

If you look at the Cotugno ward, what were the physicians doing instead? Well, instead, because cholera patients become tremendously cold and look as though they’ve been cadaverized, they were immersing cholera patients in hot tubs. Because for the same way as their energy was failing, they were administering them stimulants, caffeine. And there were various experiments with other things that were meant — because there wasn’t a therapy that was known to work, there were lots of experimental therapies that were being tried. Strychnine, which you know better as rat poison, was also administered to cholera patients, in an attempt to revive their energy and their flagging health. Also there were attempts at rehydration therapy. But this took the form that was now outdated, after 1908, of trying to get the patients to suck on ice, or to drink, or to be injected with isotonic saline solutions; that is, of the same content of salt, same salinity as the blood, which by 1908, through a century of experience, was known to be entirely useless. And these were the kinds of therapies that were being practiced, plus simply supportive nursing care. And as I said, the hospital was recruiting very large numbers of nurses.

So, nursing care and various experimental and sometimes heroic interventions that led to a very high mortality rate, when in fact it was possible to save about eighty-five percent of patients. Well, I’ve run out of time, and so I’ll just say then that this is how this particular book came to be. And I ended up writing, adding on, that in order to understand 1911, it was absolutely crucial to see 1884 and the steps that had been taken, unfortunately not so successfully, to make Naples cholera-proof by the early twentieth century, when sadly it wasn’t. And I think there’s a story there of concealment as a public health policy that I wanted to alert you to as yet another style of public health, and one that has very — it’s not good for your health — and has very dire consequences. So, thank you.

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