Book Review

Naples in the Time of Cholera, 1884 –1911

Cholera in Post-Revolutionary Paris: A cultural history

N Engl J Med 1996; 335:1164-1165October 10, 1996

Article

Naples in the Time of Cholera, 1884 –1911
By Frank M. Snowden. 478 pp. New York, Cambridge University Press, 1996. $59.95. ISBN: 0-521-48310-7

Cholera in Post-Revolutionary Paris: A cultural history
(Studies on the History of Science and Culture. Vol. 25.) By Catherine Kudlick. 293 pp. Berkeley, Calif., University of California Press, 1996. $40. ISBN: 0-520-20273-2

The complex relations among disease, science, attitudes, beliefs, and society are richly documented in Frank Snowden's fascinating book Naples in the Time of Cholera, 1884–1911. In 1884, science was just beginning to have an impact on the understanding of cholera. In 1852, John Snow had reported his classic epidemiologic studies wherein he removed the handle from London's Broad Street pump to prevent access to the contaminated water supply. Robert Koch had just reported his discovery of the cholera vibrio in 1883. The debate between the proponents of contagionism (the theory that disease was spread from person to person) and anticontagionism raged on with dire consequences. Strict quarantine measures were adopted by the Italian government against the advice of both Italian and international advisory committees, but were driven by the government's realization of the extreme vulnerability of the poor, due to neglect of hygiene and the virtual absence of a public health infrastructure in Naples. The quarantine measures not only failed to contain the epidemic, but also produced profound social and economic consequences. Riots broke out among the poor when ill family members were forcibly removed to die in inaccessible hospitals and were buried in unknown mass graves, with their personal possessions confiscated and destroyed. The burning of sulfur to purify the air of the slums only added to the suffering. Although the germ theory of disease was coming into acceptance by physicians and scientists, the miasmo–contagionism theory of von Pettenkofer was accepted by government officials. This theory proposed that the cholera bacteria permeated the sewage-soaked soil of Naples and produced a poison that contaminated the air and caused cholera.

Although the epidemic of 1884 killed more than 14,000 people in Naples, its economic impact throughout Italy is what led to national funding of a massive reconstruction plan in Naples. This brief review cannot do justice to Snowden's detailed account of the reconstruction. The Neapolitan government created a redevelopment plan to clear the slums and improve the sewerage and water systems. Based on the miasmo–contagionism theory, it focused primarily on removal of the sewage from the subsoil so that the miasma would be stopped. Providing pure water was secondary. In spite of this faulty logic, the plan represented a major advance. Owing to prior government failures, the reconstruction was turned over to private enterprise. Snowden's account of how the lack of government control and the greed of the private sector severely compromised the program should be carefully read by proponents of unfettered free enterprise.

It appears that the main lesson learned by the Italian government from the 1884 epidemic was that cholera caused widespread economic and social chaos. Consequently, officials responded to the 1911 cholera epidemic by covering it up. This is the only known major cholera epidemic that has been systematically concealed. Snowden's fascinating account of the methods used to accomplish this formidable task reveals the collusion by the press and other governments, including that of the United States, which had tapped a rich vein of cheap labor in the form of Italian immigrants. The deceit was in direct opposition to a widely accepted and trusted international treaty. The cost of the coverup included extensive spread and prolongation of the epidemic. For example, many unnecessary deaths were caused by the suppression of Leonard Rogers' newly discovered, successful rehydration therapy for cholera.

Catherine Kudlick's Cholera in Post-Revolutionary Paris focuses on the cultural history of the epidemics of 1832 and 1849. These epidemics occurred in a more stable, noncontroversial scientific period, although it was a socially and politically volatile time in French history. Dr. Kudlick explores the dynamics of the process by which a disease acquires different social and cultural meanings over a relatively short time. She explains the contrast between the riots and uprisings associated with the 1832 epidemic and the relative calm of the 1849 epidemic in terms of the cultural changes of the bourgeoisie. The role of the medical profession and, especially, the positive impact of military medicine and the hygienists will be of interest to some Journal readers. However, to us the book seems more focused on French history than on cholera.

We were both hooked by Snowden's ability to invoke our senses to experience the smells, sights, and sounds of cholera while awakening our sensibilities to the culture of the times and the parallels with today's attitudes about disease. The description of Naples in the late 19th century awakens images of major cities in developing nations where AIDS is seen as religious retribution, resulting in inappropriate prevention methods; where the lack of care for the poor, including undocumented immigrants, results in economic devastation for the entire country; and where the greed of some jeopardizes major attacks on societal problems. Much can be learned from the story of cholera, and much has not.

Parker A. Small, Jr., M.D.
University of Florida College of Medicine, Gainesville, FL 32610

Natalie S. Small, Ph.D.
Shands Hospital, Gainesville, FL 32610