The scientific background

of the lnternational Sanitary

Conferences
1851-1938

Norman Howard-Jones
~ 1 'I

Formerly Director, Division of Editorial and Reference Services,

World Health Organization

WORLD HEALTH ORGANIZATION

GENEVA
1975
 HISTORY OF INTERNATIONAL PUBLIC HEALTH, No. 1

This study originally appeared in

WHO Chronicle, 1974, 28, 159-171, 229-247, 369-348,
414-426, 455-470, 495-508.

©World Health Organization 1975

Publications of the World Health Organization enjoy copyright protection in accord-
ance with provisions of Protocol 2 of the Universal Copyright Convention. For rights
of reproduction or translation of WHO publications in part or in tofo, application should
be made to the Division of Publications and Translation, World Health Organization,
Geneva, Switzerland. The World Health Organization welcomes such applications.
The designations employed and the presentation of the material in this publication
do not imply the expression of any opinion whatsoever on the part of the Director-General
of the World Health Organization concerning the legal status of any country or territory
or of its authorities, or concerning the delimitation of its frontiers.
The author alone is responsible for the views expressed in this publication.
 CONTENTS

Page

Preface . . . 7
lntroduction . 9
The first conference: Paris, 1851 12
The second conference: Paris, 1859 . 17
The third conference: Constantinople, 1866 23
The fourth conference: Vienna, 1874 . 35
The fifth conference: Washington, 1881 42
The sixth conference: Rome, 1885 . 46
The seventh conference: Venice, 1892 58
The eighth conference: Dresden, 1893 66
The ninth conference: París, 1894 71
The tenth conference: Venice, 1897 78
The eleventh conference: Paris, 1903 81
The founding of the Office international d'Hygiene publique, 1907 86
The twelfth conference: Paris, 1911-1912 . . . . . . . . . . 89
The thirteenth and fourteenth conferences: Paris, 1926 and 1938 93
Conclusion . . . . 99
Bibliographical notes 101
Index . . . . . . . 105

10s816
 ILLUSTRATIONS

Page

The facies in cholera, Vienna, 1831 10

Europe in 1851 . . . . . . . . 13
Ber/iner Cho/era-Zeitung, 1831 . . 14
Treatment of cholera by heat, 1831 16
Cholera in Paris, 1832 . . . . . 18
"A Court for King Cholera '', 1852 19
Michael Faraday and Father Thames, 1855 21
Proceedings of the third Conference, Constantinople, 1866 . 24
Clot's "proof" of the non-contagiousness of plague, 1835 . 26
Filippo Pacini (1812-1883) 28
William Farr (1807-1883) . . . . 29
August Hirsch (1817-1892) . . . 33
Max von Pettenkofer (1818-1901) 36
Opening of the Suez Canal, 1869 41
Carlos Finlay (1833-1915) . . 44
Robert Koch (1843-1910) . . . 48
Sir Joseph Fayrer (1824-1907) . 53
Sir John Burdon-Sanderson (1828-1905) 59
Sir Charles Sherrington (1857-1952) 60
Zum gegenwiirtigen Stand der Cho/erafrage . 62
The first International Sanitary Convention to come into force 65
Heat sterilization of faeces, St Petersburg, 1892 67
The Ka'ba, Mecca . . . . . . . . 72
The El Tor quarantine station, 1892 . . . . . 73
Alexandre Yersin (1863-1943) . . . . . . . . 79
Albert Calmette (1863-1933) and Camille Guérin (1863-1933) 80
Ion Cantacuzino (1863-1934) 81
Adrien Proust (1834-1903) . . . . . 82
Emile Roux (1853-1933) . . . . . . 83
William Crawford Gorgas (1854-1920) 84
Coffins of plague victims at Harbin, 1911 94
Hideyo Noguchi (1876-1928) . . . . . 97
Adrian Stokes (1887-1927) . . . . . . 98
The first and last International Sanitary Conferences 99
 PREFACE

It is almost thirty years since the nations decided that the World Health Organiza-
tion should be founded as the single agency for directing and coordinating intergovern-
mental health activities. Subsequent developments have been very fully documented in
two WHO publications respective/y on thefirst and second decades ofthe Organization's
existence and in the series of annual reports that started in 1948. But WHO did not come
into being as a result of sorne process of spontaneous generation. As it exists today, it
represents the culmination of over 120 years of strivings, at first with very limited
objectives, towards intergovernmental cooperation in understanding and solving health
problems. For the first four decades, international agreement was frustrated by lack of
scientific knowledge. Since then, every gain to knowledge won by medica! research has
increased the possibilities of fruitful international cooperation for the benefit of ali
mankind.
In 1943 Sir Edward Mellanby wrote:
"The work of Government Departments ... ofmedical men .. ., and ofnursing staff
in controlling disease can only be as good as knowledge allows it to be, and this know-
ledge has come, and can only come by medica! research."
There is no more striking demonstration of Mellanby's assertion than that
provided by the early history of international health cooperation, for which medica!
research provided the missing link. In the future, every advance made by medica!
research will facilitate the broadening of the scope of WHO's activities.
The present study is largely based on work done during the tenure in 1971-72 of an
appointment as visiting scientist, National Library of Medicine, National Institutes of
Health, Public Health Service, Department of Health, Education and Welfare, USA.
The author wishes to acknowledge his indebtedness to Dr Martin M. Cummings,
Director of the National Library of Medicine, and Dr John B. Blake, Chief of its
History of Medicine Division, for having facilitated access to the superb historical
resources of this great library.

7
lntroduction
About two centuries ago Samuel Johnson, the proof of their real etiology and epidemiology. For
English philosopher, wit, and lexicographer, said: sorne four decades these conferences produced no
" Whatever .makes the past, the distant, or the result, and it says much for the early pioneers of
future, predominate over the present, advances us international health cooperation that they had the
in the dignity of thinking beings." But, beyond tenacity to pursue their deliberations. But as the
this, a study of the historical evolution of present etiologies of cholera, then plague, and then yellow
scientific ideas and institutions helps to place them fever were unravelled, the pace of international
in perspective, to measure the progress made, and, health cooperation quickened, leading to the
by extrapolation, to predict future trends. foundation, one after the other, of the Pan American
While it was not until 1948 that the World Sanitary Bureau, the Office international d'Hygiene
Health Organization carne into being, it represents publique, the Health Organisation of the League of
the culmination of efforts at international health Nations, and, finally, the World Health Organiza-
cooperation that started almost a century before tion, which incorporated all its predecessors.
when the first International Sanitary Conference The records of the International Sanitary Con-
opened in Paris on 23 July 1851. Ten such confer- ferences show not only how long and uphill was
ences took place during the nineteenth century, and the road that eventually led to WHO but also how
the seventh of them was the first to produce any scientific knowledge that has been painfully won
tangible result. Nevertheless, these conferences may be forgotten and, decades later, rediscovered.
provided a unique forum for the international Thus, in the 1960s the concepts of convalescent
exchange of ideas between medica! administrators cholera carriers, of mild or inapparent infections,
and medica) scientists of different nations and and of the gall bladder as a reservoir of cholera
cultures. Their printed proceedings are of extra- vibrios were trumpeted as new discoveries. Yet the
ordinary scarcity, as only a few copies were issued records show that all these concepts were universally
for distribution to participating governments. Two accepted sorne sixty or more years ago. That they
libraries-the library ofthe World Health Organiza- faded into oblivion for so long is doubtless because
tion and the National Library of Medicine, cholera had been unknown for many years in the
Bethesda, Md.-are probably the only ones in the countries where medica! research and teaching
world with the complete series, either in the form of were most advanced. The increase in the amount
originals or photocopies. And the completion of the and speed of air travel has changed all that, and
holdings of these two libraries was achieved as late public health authorities in all countries must now
as 1971 by the mutual exchange of duplicates and be alert to the possibility that arriving passengers,
photocopies. often returning tourists, may be harbouring the
That these printed records should be so inacces- disease.
sible is to be regretted, for they constitute a living During the nineteenth century, cholera was the
history of the different conceptions of the nature of main or the sole subject of discussion at most of
epidemic diseases held during the latter half of the the International Sanitary Conferences. It was the
nineteenth century and immediately after. The disease that, more than all others combined, sti-
discussions at these international confrontations mulated the nations to persist in their efforts to
vividly refiect medica! thinking as it really was, and reach agreement on the measures to be taken to
provide a salutary corrective to the foreshortened limit the spread of epidemic diseases.
and romanticized accounts of individual discoveries The background to the first of the International
that often pass for medica! history. They also show Sanitary Conferences may be briefiy sketched as
very clearly that all hopes of international agree- follows. Asiatic cholera first reached the fringes of
ment on preventive measures against epidemic dis- Europe when it broke out in 1829 at Orenburg, at
eases were illusory as long as the partisan confiict the south-eastern extremity of the Russian Empire,
between rival hypotheses did duty for scientific having slowly travelled overland from India via the

9
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.__:/f'l',.-:J/U'V1('_,' //lt'.'t't'ff'" r / V i / (.··o¡.,¡w,ff~JN,'ffN"(.:..:4'e/i•,.í''d,,.
.e;¡(;.: }i r/.:r;.t't'./'C/ dVt't:?l/-:~ir~ .~7IU1 1·7,;·.-

WHO photograph from original

in the author's possession
Cholera made its European début in Russia and rapidly spread to Poland and then to Austria. Other European countries
that were as yet unaffected sent governmental medica! missions to investigate and report on this frightening new pestilence.
Among these was a two-man mission sent by the Royal Academy of Medicine of Paris in June 1831 on behalf of the French
Government to Russia, Prussia, and Austria, the members of which were Auguste Gerardin and Paul Gaimard. 1 On their
way to St Petersburg they stopped for a few hours at Weimar, where they had the" signa! honour "ofbeing" most graciously"
received by Johann Wolfgang von Goethe, then in his 82nd year, who spoke of the newly discovered coral islands of the
South Sea. In their published report to the French Minister of Commerce and Public Works and to the Royal Academy
of Medicine, Gerardin and Gaimard include the above portraits. The originals are in colour and show on the left a buxom
young Austrian woman of 23 with a strawberries-and-cream complexion. In the portrait on the right the complexion has
turned to a livid blue-green, allegedly one hour after the subject had been stricken by cholera and three-quarters of an hour
before her death. In England the disease was often known as "the blue cholera ". Early European observers of cholera were -
also particularly struck by the mummified appearance of victims of the disease, due to the draining of fluid from the soft
tissues. Despite the fact that the cause of death in cholera is massive dehydration, doctors firmly believed that patients should
be treated by bleeding. Often the loss of fluid was so great that the blood was of a tarry consistency, and the opening of a
vein would produce no result. In such cases, the next step would be to try opening an artery. In 1831 a famous German
surgeon, J. F. Dielfenbach, even inserted a catheter into the left ventricle of the heart via the brachial artery in a desperate
-but unsuccessful-attempt to obtain blood. • This is the first recorded example of cardiac catheterization. The patient
" rendered up his soul " sorne minutes later. In those days, the cholera patient most likely to survive was the one who
could not afford a doctor!
1
Gerardin, A. & Galmard, P.(1832), Du cholera-morbus en Russie, en Prusse et en Autriche pendant [es années 1831 et 1832, Paris,
2
Dieffenbach, J. (1832), Cholera-Archiv, Bd 1, Ht 1, 86-105.

10
Asian Steppes. In the following year there was an de la santé ", who would read it without touching
outbreak at the annual fair of Niiniy N ovgorod it. Letters from the unfortunate sick or suspect
(now Gorkij), and despite elaborate precautions it passengers confined to a lazaret had to be thrown
soon reached Moscow-the first major European for a distance of ten paces, retrieved with long
city to be attacked by the disease. In the following tongs, plunged into vinegar, and then passed
years cholera spread to most other European coun- through the flame and smoke of ignited gun-
tries, causing calamitous epidemics. At that time powder. The personnel of the lazaret wore wooden
quarantine regulations had been devised mainly as clogs and oilskin jackets, trousers, and gloves.
a protection against the importation of plague from Very similar precautions were prescribed in
the Levant. Earlier, yellow fever had made ephe- regulations promulgated in 1835 by the French
meral appearances on the western seaboard of Minister of Commerce. 6 Article 614 stated that
Europe but had not for sorne time given cause for where there was need for surgical intervention,
alarm. Even plague had been kept at hay for a surgical student should be " invited " to be
almost a century but was still endemic within the incarcerated with the patient-students presumably
borders of the Ottoman Empire, and the European being more expendable than doctors. The latter had
Powers took elaborate but varying precautions to to be separated from patients with " contagious "
prevent its importation by maritime traffic with the diseases by "at least twelve metres " (Article 617),
Levant. As the etiology and mode of spread of and if the patient was too ill to approach the limit
plague and cholera were equally shrouded in mys- of this no-man's land the doctor would prescribe
tery, similar quarantine precautions were applied supposedly suitable remedies on the basis of the
to both of them. Such precautions resulted in report made by the student (Article 618). But
onerous delays and expenditure occasioned by the another article (616) provided that a surgeon ciad
immobilization of ships, the incarceration of their in oilskin garments could operate with special
crews and passengers in lazarets, and the destruction long-handled instruments provided that he carried
or spoilage of cargoes. with him a brazier for burning aromatic herbs.
In the early 1830s the Secretary of the Conseil It was firmly believed that low spirits predisposed
supérieur de Santé of France, P. de Ségur Dupeyron, to epidemic diseases, and Papon cites with apparent
was charged by the Minister of Commerce with the approbation the case of a doctor who was " very
responsibility of reporting on the sanitary regula- careful " to drink a few glasses of wine from time to
tions of the Mediterranean countries. In his report 3 time when attending a potentially dangerous
in 1834 he pointed to the needless difficulties that patient. " He <lid not get drunk," says Papon,
arose from differing quarantine requirements by "but he became merry." 7 For the involuntary
different countries, and proposed that an inter- inmate of a lazaret, the visit of a half-tipsy doctor
national meeting should be convened with a view to ciad from head to foot in oilskins and bearing
standardizing protective measures against the long-handled instruments and a portable brazier
importation of exotic diseases. According to can hardly have been reassuring !
Tardieu, writing twenty years later, 4 the French While these elaborate precautions imposed in-
Government accepted Dupeyron's proposal and tolerable constraints upon travellers, what govern-
attempted unsuccessfully to convene an inter- ments found most irksome were the often disastrous
national conference. But a further French initiative hindrances to international commerce, and it was
in 1850 succeeded and in this way the long series of this concern that finally prompted the European
International Sanitary Conferences began that were nations to meet to discuss to what extent these
ultimately to lead, almost a century later, to the onerous restrictions could be lifted without undue
founding of WHO. risk to the health of their populations. If, in the
1t is of interest to cite sorne of the procedures old colonial days, it was true that " trade follows
that were in force, as described by Papon in 1800. 5 the flag", it was equally true that the first faltering
On disembarking, the Master of an infected or steps towards international health cooperation
suspected ship was required to stand before an iron followed trade.
grille, swear on oath to tell the truth, and then
'Dupeyron, P. de S. (1834) Rapporl adressé a Son Exc. le Ministre du
throw the ship's bill of health into a basin of Commerce, Paris.
vinegar. An official would then plunge the bill 'Tardieu, A. (1854) Dictionnaire d'hygii!ne publique et de salubrité,
vol. 3, Paris.
beneath the surface with the aid of iron tongs and, 5 Papon, J. P. (1800) De la peste ou les époques de ce fléau et les moyens

when it was judged to have been well soaked, de s'en préserver, vol. 2, Paris.
6
Toy~ J. (1905) La réglementation de la défense sanitaire eontre la peste.
remove it by the same means, lay it on the end of le choléra et la fievre jaune d'apres la Convention de Paris 1903, Paris.
a plank, and thus present it to the " conservateur 7
"Il ne s'enivroit pas; mais il se mettoit en gaité.n

11
The first conference · París, 1851
Eleven European States and Turkey were repre- rnajority view, far from approaching unanimity,
sented at the first of the International Sanitary that plague and yellow fever were in some way
Conferences. Four of them-the Papal States, communicable from the sick to the healthy, but it
Sardinia, Tuscany, and the Two Sicilies-were to was otherwise with cholera-the only one of the
becorne only a few years later part of a uni:fied three diseases that had been a recent and terrifying
Italy. The rernaining States were Austria, Great scourge. Early in the debate, the Austrian medica!
Britain, Greece, Portugal, Russia, Spain, and, of delegate, G. M. Ménis, declared that he was under
course, France, in the dual role of convenor and instructions from his government to discuss only
host. plague and yellow fever. Austria, he said, had tried
Each participating country was represented by quarantine measures against cholera which, " far
two delegates-a physician and a diplornat-and it frorn opposing the ravages of the disease, only
was agreed after sorne discussion that each govern- made it more frightening and fatal", and it was
ment would be entitled to two votes. However, the the opinion of the most eminent physicians of the
conference also decided that voting should not be Austrian Empire that cholera was " a purely epi-
by country but by individual delegates. This curious demic disease ". In these contentions Ménis received
system was maintained also at the third Inter- strong support from J. Sutherland, the British
national Sanitary Conference and often resulted in medica! delegate, who stated that in England
the anomaly that two delegates of the sarne country cholera was also believed to be " purely epidernic "
would vote in opposite senses, thus effectively and that quarantine measures therefore had " no
disfranchizing the governments they represented. effi.cacity " against it. That, only two years before,
In convening this conference, the French Govern- John Snow of London and Williarn Budd of
ment was inspired by the eminently reasonable Bristol had, alrnost sirnultaneously, postulated that
desire that international agreement should be cholera was transrnitted by faecally contarninated
reached on the standardization of quarantine water was not considered worthy of mention by
regulations aimed at preventing the importation of Sutherland.
cholera, plague, and yellow fever (smallpox was To the modern reader the term " a purely epi-
then such a universal disease that it was not to be dernic disease " must, in such a context, ring a
brought within the scope of international sanitary strange note. But to Ménis, Sutherland, and many
legislation until 76 years later). The situation at the of their conternporaries epidemic diseases were not
opening of the conference on 23 July 8 was that directly or indirectly comrnunicated frorn the sick
plague had long been only a theoretical danger in to the healthy but sirnultaneously affected large
Europe, and this was even more true of yellow nurnbers of persons under the irrfluence of certain
fever, whose European appearances had been, atmospheric, climatic, and soil conditions, to which _
though more recent, ephemeral. Cholera, on the " filth " was often added, the whole forming an
other hand, had within the previous twenty years "epidernic constitution ". The idea of the trans-
twice caused havoc and panic not only in Europe rnutability of epidernic diseases was widespread,
but also in the Americas. and sorne held that plague, yellow fever, cholera,
Admirable as was the objective underlying this malaria, and typhus were all the same disease,
French initiative, its outcome was compromised by manifesting itself in different guises according to the
inherent and insuperable diffi.culties; the delegates, reigning epidemic constitution.
whether physicians or diplomats, were equally The question of whether or not cholera was a
innocent of any knowledge of the etiology or mode disease against which quarantine measures could
of transmission of the diseases under discussion.
Such lack of knowledge was no bar to the holding 'In the second edition of International Hea/th Organlzations (1971) by
N. M. Goodman the date is given as 27 July (a Sunday). This is indeed
of convictions that were, within each country, as the date that appears on the cover of the printed proceedings. However,
the minutes of the inaugural session are clearly dated 23 July, which was
strong as they were contradictory. There was a also referred to during the closing session as the opening date.

12
 In 1851, when the first lnternational
Sanitary Conference opened, the
face of Europe wore a very different
aspect from that of today. The
twelve participating governments
were those of Austria, France, Great
Britain, Greece, Portugal, Russia,
Spain, Turkey (then officially known
as " the Sublime Port ") and of four
Sovereign States that were shortly
afterwards to combine to form a
united Italy-the Kingdoms of
Sardinia and of the Two Sicilies,
the Papal States, and Tuscany. The
borders of Sardinia then extended
as far north as to include part of
what is now a suburb of Geneva.
This was essentially the Europe as
mapped out by the Congress of
Vienna in 1815. Opening the 1851
Conference, the French Foreign
Minister referred to the lnterna-
tional Exhibition in London in the
same year as heralding a new age
of industrial cooperation between
nations. In the same year also,
telegraphic communications were
established between London and
París.

have any effect was too thorny for immediate in certain cases, and contrary to the end for which
discussion in plenary session and the conference they were intended ".
therefore appointed a committee of seven members The conference was to last for no less than six
-four physicians and three diplomats-to study months. Exactly two months after its opening it
and report on it. Introducing the committee's met in plenary session to discuss the committee's
report, its secretary, Melier, of France, stressed at report and decide whether cholera was susceptible
the ninth plenary session of the conference that it to quarantine measures and therefore eligible for
had excluded not only all political questions but inclusion in the proposed intemational sanitary
also any discussion of scientific theory. (One can regulations. This discussion, lasting three and a
only wonder what was left !) Indeed, he said, the half hours, took place on 23 September 1851, and
words contagian and infection, " which had oc- it was agreed to adjoum it until four days later,
casioned so many arguments elsewhere ", had not when Melier summarized the rival points of view
_ even been mentioned. If, in preparing the agenda as follows. Three of the four Italian Powers-the
for the conference, Melier explained, France had Papal States, Tuscany, and the Two Sicilies-
included cholera with plague and yellow fever as advocated quarantine measures against cholera.
one of the diseases to be subject to quarantine, it For them, epidemicity was nothing, and importa-
was not because of a belief that this served a useful tion everything. The fourth-Sardinia-was in the
purpose but " as a satisfaction given by France to opposite camp, as were Austria, Britain, and
an opinion that still prevails elsewhere ". Melier France, which were unanimous in declaring the
then summarized the conclusions of the committee. impotence of cordons sanitaires and of maritime
By a majority of four to three it had decided that, in quarantine against cholera.
the case of cholera, it was " humanly impossible to At this point, the Spanish medica} delegate,
do anything useful or efficacious against such a Pedro F. Monlau, intervened. Admitting that
scourge ", which " fell like a storm on the country cholera was not " constantly, essentially, and
that it reached ". Quarantine measures against universally contagious ", that quarantine caused
cholera were "impossible, illusory, even dangerous loss of time, and that, as the English said, " time

13
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. i'>a~· .
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~~rd? fr_eddlt ~Í!dJfi.1df1iu9lít~ <tt·~~~ttiffc btr ~tft1tllt!l¡1srn1
~cn~fungm tmb. <!ifer~fil~ct ~!e' •ti'rt'. fortfudprmt> ~ut ~mt•
m1iiti{ _¡..,.¡. ~>tfhp • •wrt..i>l"dtt~k' m1-:,,:,,a~~....r.t .lii :·;;~;,:,,,.~ .

The dramatic impact of cholera is strikingly illustrated by the sudden vast output of publications on it during the
successive occasions when it overran Europe. As early as 1831, Jaehnichen of Moscow wrote: "Since Divine Providence
has delivered the town from the scourge of cholera, its inhabitants find themselves affiicted by another calamity: the works
that authors rush to publish, one by one, on the fatal disease." The third volume of the first series of the lndex-Catalogue
of the Library of the Surgeon-General's Office (1882) lists 15 journals solely devoted to cholera, of which 12 were started
in 1831 or 1832. The illustration shows one of these. On the first page of each issue the word DESINFICIRT (" disinfected ")
was printed. The same volume of the Index-Catalogue lists separately publications on cholera before and after 1817-the
year when the first cholera pandemic started. For the years 1666-1816 there are 66 publications, most of which have nothing
to do with the disease that we now know as cholera. For the years 1817-1881 there are 150 pages of entries representing
over 7000 publications.
Photo by courtesy of the National Library of Medicine,
Berthesda, Md., USA

is money ", he pointed out that "public health is lt seems to me that there is an obstinate determination on
gold ", and in a long peroration pleaded that the part of sorne of our honourable colleagues to persist in
cholera should not be excluded from quarantine the routine path of practices that are outmoded, useless,
ruinous to commerce, and harmful to public health, in that,
regulations. Then followed Anthony Perrier, the
instead of enlightening the peoples on the true means of •
British diplomatic delegate, who enumerated the guaranteeing themselves against epidemics, they inspire, on
names of no less than twenty-six distinguished the contrary, a false sense of security that prevents them
French physicians who had declared themselves from raking the only sanitary precautions that can offer real
against the communicability of cholera, and cited guarantees. In short, I seem to see sorne serious and respect-
examples of anti-contagionist opinions in Austria, able men who, instead of spreading the light unveiled by
Russia, and Spain. In England, he asserted, a the progress of science, would Iike to revive and perpetuate
report was in preparation in which it would be practices followed under the influence of past centuries. God
said that " contagion is nota fact, but an hypothesis will that I am mistaken, that the fear of a deplorable cleavage
has exaggerated the evil in my eyes, and that the truth may
invented to explain a number of facts that, without
finish by triumphing.
this hypothesis, would be inexplicable". To the
modern reader, an hypothesis that explains other-
wise inexplicable facts would have sorne claim to Perrier concluded his eloquent appeal with the
attention. Not so for Perrier, who said: hope that the conference would not finish by " an

14
 abortion that would cover it with ridicule in the had spoken of its " horrible torments " as being
eyes of the civilized world ". " of equal potency with the gallows as a dissuasive
Spanish, Greek, and Tuscan delegates then to vice, certainly far more terrible than transporta-
pronounced themselves in favour of quarantine tion for life ". For Blane, it was the duty of doctors
against cholera, while the medica! delegate of to ad vise the clergy of" the power of the instrument
Portugal proposed one of those harmless non- which is put into their hands ". 9
resolutions that are not entirely foreign to modern The conference discussions continued but were
international affairs. Lamenting the lack of under- interrupted by the arrival, over ten weeks late, of
standing of the disease "that God seems to have the Turkish medica! delegate, who coolly requested
1< sent us to confound the pride of human know- that the debate be adjourned to enable him to
ledge ", he suggested that quarantine for cholera study the documents. This request was accorded,
should be " optional " and " of a duration less than and the conference resumed its work two days
that for yellow fever ". Further, "suitable mea- later. After a brief discussion the Chairman put to
sures " should be taken to destroy the epidemic the vote the question whether or not cholera should
constitution of the disease " to the extent that is be subject to quarantine regulations. Of twenty-
possible ". The adoption of such a resolution three delegates present, fifteen voted in the affirma-
would have given cause to wonder why the con- tive, four were against, and four abstained. Thus,
ference had ever been held ! after fierce opposition, did cholera gain admission
It was now the turn of the Russian medica! to the quarantine club.
delegate, Carlos O. R. Rosenberger, who referred The practica! result of this majority decision, as
to the first invasion of his country by cholera of all the decisions of the conference, was nil.
in 1829-32. Very severe quarantine regulations Agreement was reached on the text of a draft
were then in force but nevertheless almost 290 000 Sanitary Convention (Projet de Convention sani-
Russians had perished from the disease. This taire) and annexed draft International Sanitary
appalling mortality had discredited quarantine Regulations (Projet de Reglement sanitaire inter-
measures. However, during the second invasion by national) consisting of 137 articles, but these were
cholera-from late 1846 to 1849-when quarantine pieces of prose that committed none of the particip-
was not enforced, more than 880 000 Russians had ating governments unless they subsequently ratified
succumbed to the disease. These statistics, and them.
apparently clear instances of communication of the At the closing session of the conference the
disease from the sick to the healthy, had caused the French Minister of Foreign Affairs congratulated
Russian Government to think again in terms of the delegates on having " gloriously accomplished "
quarantine precautions. their mission. The fact that they had taken six
This was too much for Ménis, of Austria, who months to achieve what was in reality nothing
outdid even Perrier in his anti-contagionist elo- showed that they had understood that time was
quence. The great difference between plague and precious, and they had completed in this short
cholera, he said, was that the former attacked all time-" illuminated by the torch of science "-
~orts and conditions of people. Cholera, on the a task that might well have taken years.
other hand, selected principally the dregs of society, On 27 May 1853 the Emperor Napoleon III of
including the intemperate, the debauched, decrepit France issued an Imperial Decree promulgating
old men, those languishing from long illnesses, the the " International Sanitary Convention concluded
insane,. and the imprudent and timorous. The best between France, Sardinia, and various other
, weapons against it were courage, resignation, maritime Powers ". 10 It is clear from the text of this
spiritual calmness, and faith. Cholera could be decree that Sardinia was the only country to have
thought of as a divine wind sent on earth to punish exchanged-on 18 May 1853--'acts of ratification
, those who did not know how to look after their with France (which were denounced a few years
own health. Properly considered by governments later). Adrien Proust, one oftheleading participants
and doctors, it could serve to make men better by in the International Sanitaty · Conferences, stated
reforming their morals and habits. It was a scourge in 1873 that Portugal also ratified the convention,
sent not to wipe out humanity but to punish and citing as his authority the Imperial Decree of
correct it. He concluded by declaiming that quaran- 27 May 1853.11 Severa! later writers have repeated
tine against cholera was not only useless but
eminently dangerous to the conservation and the • B!ane, G. (1831) Warning to the British public against the a/arming
approach of the lndian cho/era, London.
civilization of peoples. Ménis was not alone in 1 º France. Ministere de I' Agricu1ture, du Commerce et des travaux

attributing a beneficent infl.uence to cholera. publics. Acte et instructions pour l'exécution de la Convention sanilaire
lnternationa/e [Paris, 1853].
Twenty years before, Sir Gilbert Blane in England 11 Proust. A. (1873) Essai sur /'hygiene internationale, Paris.

15
,-
¡
In 1831 Professor H. Scoutetten
of Strasbourg was sent by his health
department to Berlin to investigate
the cholera epidemic raging in that
city. In his published account of his
findings he includes this plate,
which represents a special bed for
treating cholera patients by heat. 12
The funnel-shaped device protrud-
ing from the foot of the bed con-
tains a spirit lamp with four wicks,
as shown in the cross-section
lettered M. The base of the device
contains many perforations, as
shown in K. P and O are respec-
tively a bowl and tripod that could
be placed over the lamp for
vaporizing aromatic herbs or sulfur.
While sorne doctors believed in
treating cholera by the app!ication
of heat, others were equally con-
vinced that cold should be applied.
The latter gave their patients ice to
suck and cold enemas, and some-
times even hosed them with cold
water. Whether a patient was
roasted or refrigerated depended on
his choice of medica! attendant.

WHO photograph from original

in the author's possession

Proust's statement, but in fact although Portugal ation was for many years to be limited to defensive
signed the decree it did not ratify its signature. quarantine measures. The French Government of
Thus, from the point of view of practica! results, the time had planted a seed that was not to germi- _
the first International Sanitary Conference was nate for sorne forty years and then, after a com-
a fiasco. Everyone went on doing in their own way plicated cycle of development, to blossom more
what they had done before. Yet there was more to than half a century later into the World Health
it than that. The fact that the conference took Organization.
place established the principie that health protec-
tion was a proper subject for international con- 12
Scoutetten, H. Relation historique et médica/e de l'épidémie de choléra
sultations even though international health cooper- qui a régné a Berlín en 1831. Paris, 1832.

16
 The second conference · Paris, 1859
¡
i In the eight-year interval between the first and pathogen, once remarking bitterly that his country-
second of the International Sanitary Conferences men would accept his discovery only when a
there appeared two publications that, taken togeth- foreigner had repeated it. He was not so pessimistic
er, provided the complete answer to the enigma as to foresee that the foreigner who did repeat the
of cholera. It was to be many years before the discovery would get the sole credit for it.
crucial importance of one of them was to be Pacini was not alone in identifying the cholera
generally recognized, while the other has been vibrio in 1854, for in that year a London ínicro-
almost universally overlooked. The authors of these scopist, Arthur Hill Hassall, reported to the Medica]
pioneer observations were Filippo Pacini (1812- Council of the General Board of Health, strangely
1883) of Florence, a microscopist, and John Snow enough using the same expression as Pacini's, that
(1813-1858) of London, an anaesthetist and, in his he had seen " myriads of vibriones " in " every drop
spare time, an epidemiologist. of every sample of rice-water discharges ". 14 How-
While in all the standard works on bacteriology ever, neither he nor the General Board of Health
and medica! history Robert Koch is credited with appreciated, as did Pacini, the etiological signifi-
the incrimination of the cholera vibrio as the cance of the vibrios.
pathogen of the disease, Pacini anticipated him by Also in London, the epidemiological investiga-
thirty years when he published in 1854 (in Italian) tions of John Snow provided the perfect comple-
his " Microscopic observations and pathologic ment to Pacini's pioneer microscopical researches.
deductions on Asiatic cholera ". 13 In this mono- His 1849 publication had been a mere pamphlet of
graph Pacini described numerous vibrios seen in the 31 pages, 15 but the so-called second edition that he
intestinal contents of three cholera victims and, in published in 1855 was in fact a new book in which
a fourth victim, he was struck by their " enormous he reported much more elaborate and refined
quantity ", especially in the fiocculi consisting of epidemiological investigations correlating cholera
mucus and desquamated epithelial cells. " When I incidence and water supplies in London in 1854. 16
pulled these masses of cells apart a little under the Snow's work has long been recognized as a classic,
microscope, myriads of vibrios emerged ... ". and it would be superfiuous to summarize it here.
Referring to the characteristic appearances of the But it is difficult to understand how his impeccable
small intestine in cholera victims, Pacini added: reasoning could have made so little impact on his
" ... in spite of the most precise and meticulous contemporaries. William Farr considered Snow's
search, we have not come across anything that observations to be of importance, but regarded
could be considered capable of producing the epi- them as pointing to one possible mode of trans-
thelial desquamation [now considered a post- mission of cholera. In a report to the General
.mortem change] and other changes but the millions Board of Health, the great John Simon referred
· of vibrios that are found in the intestines ". in 1858 to Snow's" peculiar doctrine (first advanced
Pacini recognized that there were morphologically in 1849) as to the contagiousness of cholera ...
similar vibrios that could live in various parts of Against this doctrine almost insuperable arguments
.the human body without apparent harm, but he have been stated. . . Dr Snow's illustrations are
considered that what he called the " vibrio cholera " very far from proving his doctrine: but they are
was an unusual species that was constantly asso- valuable evidence of the danger of drinking fecal-
ciated with the disease. He emphasized, in capital
letters, that a contagion was an " ORGANIC, LIVING,
"Pacini, F. (1854) Gazz. med. ita/. tose., 2nd ser., 6, 397, 405.
SUBSTANCE OF A PARASITIC NATURE, WHICH CAN
'' Hassall, A. H. (!855) In: Great Britain, General Board of Health,
COMMUNICATE ITSELF, REPRODUCE ITSELF, AND Report of the Committee for Scientific Enquiries in relation to the Cholera
THEREBY PRODUCE A SPECIFIC DISEASE ". For many Epidemic of 1854, London.
"Snow, J. (1849) On the mode of communication of cho/era, London.
years Pacini fought a Ione and unsuccessful battle "Snow, J. (1855) On the mode of communication of cho/era, 2nd ed.,
for the recognition of the vibrio as the cholera London.

17
 SOUVENIRS nu CHOLÉRA-MORBUS.

A census made in 1831 showed that the inhabitants of París numbered 785 862. On 26 March 1832 cholera struck the city
for the first time in its history, the infection having come from England. In April 1832 alone there were 12 733 deaths from
cholera in Paris. This was more than half the average annual number of deaths from ali causes for the previous ten years,.
andan intolerable strain was placed upon public services. There was a penury not only of gravediggers but also of transport
to take the dead to the burial grounds. An attempt was made to rernedy the latter deficiency by pressing rnilitary wagons
into service, but this solution had to be abandoned for two reasons: the vehicles were unsprung, and the noise that they
made at night in the cobbled streets of the city deprived the inhabitants of sleep and added to the reigning atrnosphere of
terror. Moreover, the vibration was such that the coffins disintegrated and foul fluids escaped from the corpses. This
experirnent was abandoned after only one day. The epidemic ended in Septernber, having claimed a total of 18 402 victims. 17
Thanks to cholera, deaths in París in 1832 jumped from an expected 23 000 to 44 119. In this drawing by a famous artíst,
Daumier, the man in the foreground has collapsed in the street from cholera. In the background, two men are carrying
a coffin while a hearse drives by b~ring another. On the left, a terrified woman rushes into the house, while on the right
even the dog has its tail between its legs.
11 Rapport sur la marche et les effets du choléra..morbus dans París et les commun.es rurales du département de la Seine, París, Imprimerie Royale, 1834.

18