The SARS epidemic recalls the great plagues of the past, the panic that accompanied those tragic events and the measures adopted to limit contagion.
Most measures adopted today to check SARS are the same as those resorted to centuries ago to fight the plague and other great epidemics such as smallpox and cholera.

Man’s history is marked by great epidemics that influenced his development and historical course. When population density and mobility increased, the premises were created to spread epidemic diseases that could strike many individuals in a short time. It is not always easy to spot the disease behind each epidemic.
The term “plague” that today designates a special disease was used to speak of all widespread diseases with a high mortality. The words plague and contagion struck people with terror because they were immediately linked with death.
From time immemorial plague was considered the scourge of God, hence it was exorcised by resorting to the intercession of saints like San Rocco or the Virgin Mary.
In 1600 Venetians built Santa Maria della Salute, whose image was used as a logo for the 1st European Conference on Travel Medicine (ECTM1), Venice 1998, to thank Our Lady for having permitted the plague to end in Venice.
Besides being considered a divine punishment, pestilence was interpreted by resorting to astrology (the conjunction and opposition of planets) or to the theory of poisoning (Jews, lepers and “anointers” [plague-spreaders], as Manzoni wrote in the Promessi Sposi concerning the 1630 plague, were believed responsible for the Black Plague in 1300). All these interpretations clearly expressed a rooted feeling of powerlessness and certainty. The terrible mortality of epidemics was well known and sadly and fatally expected.

The need for reliable and timely information

All those institutionally appointed to rule cities were interested in the health of fellow citizens. They realized the need for updated information concerning the health of neighbouring populations, as they were aware that only timely information on the appearance of any epidemic hotbed presented the most effective premise for preventive measures.
In centuries gone by land and sea travellers were the channels of information authorities could make use of as they collected information at post houses or in ports. These travellers could be considered unaware health ambassadors or sentries of the epidemiological watch implemented at the time. At times authorities assigned reliable officers or doctors to officially or secretly visit neighbouring towns or bordering states where some contagious disease was suspected, to bring back reliable information to their native land.
From mid-1500 authorities exchanged information on health issues, committing themselves not to conceal the truth, increasingly convinced that this reciprocal loyalty was the most reliable guarantee of protection of reciprocal health.
Many magistrates and Congregations for Health thus sent foreign establishments punctual and updated circular sisters but, in practice, doctors did not always agree on the nature of the epidemic of certain diseases, authorities were incredulous before a doctor’s diagnosis or they intentionally concealed the gravity of the situation from the population so as not to cause alarm. It often happened that the population was alarmed out of all proportion or remained dangerously calm. It also happened that many scare stories were intentionally spread, forcing authorities to a formal denial.

Banishment

One of the most demanding measures implemented by all states to protect themselves from plague was to put a ban on a city or a country where a contagion hotbed was suspected. Banishment was strictly related to another protection measure: the establishment of a cordon sanitaire on land and at sea to avoid contagion.
Putting a ban was considered the most frequent means used to try to prevent an epidemic. It involved interrupting all commercial relations and communications with the place or country that was considered the potential source of contagion.
Countries belonging to the Ottoman Empire and Africa were often banished as they were considered a danger. Civil and health authorities used people called “criers” to spread the warning of a risk and advice to interrupt journeys towards places or countries. Criers had to spread this message among the territory’s population, which was mainly illiterate. The order given through criers was called Proclamation, Edict, Injunction or Decree.

Letter disinfection

For centuries mail was considered a dangerous vehicle of contagion: paper was in itself believed liable to receive, preserve and convey contagion. Hence we can easily imagine the suspicion felt by those who, even before the addressee, had to touch a letter during the journey it made to reach destination. Disinfection of mail (letters, manuscripts, despatches, newspapers) was one of the commonest measures adopted to prevent the spreading of contagion. Letters could be disinfected on the outside or both inside and outside. Stations for Disinfection were located along consular roads or however along the postal route. At these stations a certain number of gloved operators with oilskin aprons used long tongs to take the letters, place them on a table, open them, disinfect them and then collect and burn every fragment of paper that remained.
Methods o
f disinfection varied by area and period.
For centuries the purifying virtues attributed to fire calmed the fears of those appointed to disinfect letters. Scented wood, aromatic substances and brushwood were also used. Unfortunately paper burnt easily hence letters were passed over the fire with great care. The end of a wooden rod opened lengthwise and the sheet to be passed over the flame was inserted in the gap. Immersion in vinegar was also believed a very safe method of disinfection. Letters were opened, sprayed with vinegar and dried. This system too had its drawbacks because not all ink resisted vinegar and some manuscripts became illegible: an irreparable damage when they were business letters or bank statements. To avoid at least some of the abovementioned mishaps operators tried to reduce immersion time as far as possible.
Both methods of disinfection required letters to be opened thus permitting the violation of the secret of correspondence. In certain Stations for Disinfection, the operation was performed before a Foreign Affairs’ officer or a Police Officer.
Only in 1886, following the discovery of the aetiological agent of cholera and the Health Congress held in Paris in 1855, letters were considered foreign to the possibility of spreading diseases and their disinfection was suspended some time later. It is paradoxical that after such a long time contagion could take place with the very tool wrongly considered dangerous for over 400 years, as occurred in the US when anthrax spores were spread as a bioterrorist act.

Health offences and related punishments

In the past strict laws on matters of health were always announced very clearly.
Hence it was easy to call one who broke the law guilty and it was hard to escape the severe regulations. The most recurrent offences, such as crossing the limits prescribed by the cordon sanitaire, can be traced back to those expressly specified in many Health Regulations.
Punishments were particularly severe and often involved death sentences, maiming and torture. Ships were often responsible for serious health offences. At times punishments were also extended to relations.
The “Story of the shameful pillar”, related by Alessandro Manzoni, is well known: this pillar was built in Milan in 1630 on the site of a demolished saloon belonging to a barber who had been condemned as plague-spreader, so that all could remember the event and the exemplary sentence. Betrayal was the order of the day. Not always dictated by a legitimate fear, it was at times related with some particular interest or as revenge. On the steps of the Basilica Palladiana, Vicenza, today we can still admire the large marble mask in whose mocking mouth every citizen could insert his secret exposure of health issues.
Health Documents for journeys by land and by sea In times of contagion restrictive measures were enforced to protect virgin communities. The arrival of people, goods and animals was looked on fearfully and all sought protection from these possible vehicles of infection. One of the most ancient preventive measures, also the most widespread and best documented, was the institution of Health Certificates.





Certificates were compulsory to those who began a journey by land and they “certified” the health conditions of the traveller’s country of departure and subsequently of the traveller himself. The health certificate, a real health passport, was considered such an important document that authorities, fearing deception, carefully followed it from the moment it was printed till it was handed to the person who had to fill it out. The equivalent document for ships, the Health Permit, was necessarily issued by port authorities (by a Delegation for Health charged with great authority), while the health certificate was issued in small towns too. Health permits often had beautiful prints with the well-known health seals, while certificates were often small, simple, handwritten sheets filled out by a municipal clerk.
Certificates had to report their owner’s somatic features and all other information useful towards certain identification. On long journeys travellers certainly came upon health control points along the way where the document was disinfected and notes were added confirming the places the traveller had visited. Every ship about to set sail had to have certain documents, which varied according to its tonnage, type of sail, port of embarkation, cargo and nationality.

Papers also numbered the health permit, which was considered the most important document during epidemics. Some special purpose permits were printed in advance: some for the transport of salt, others for fishing boats and still others accompanied passengers who had embarked or goods and animals that filled the hold. Permits had to be written in ink and had to carry the seal of the issuing authorities.
All Health Magistrates, as a sign of respect towards foreign countries, undertook to note on the permits they issued the sad possibility of early cases of contagious diseases. Officers and doctors in charge of health control carefully checked health permits. If ships came from ports that were considered suspicious and if pirates attacked a boat during navigation, the crew, its passengers and cargo were placed in quarantine. At the end of the quarantine period the doctor once again visited the crew and passengers and gave his possible approval to proceed with the journey.
Generally 17th – 18th century permits reflect the piety of seafaring people as they often depict Christ, the Blessed Virgin and other patron saints.

Lazarettos

This term designated those hospitals that once treated lepers. Then it marked those fenced in areas near seaports where ships, seafarers and their goods were subject to periods of quarantine when a pestilence was suspected. Depending on the period and the place, lazarettos acted as shelters for the very seriously ill or places where men, animals and goods remained isolated during the entire quarantine period.
The City/State of Venice, the Repubblica della Serenissima, was the first to introduce a lazaretto and quarantine measures at the end of the 14th century. Some large lazarettos were built by famous architects and can still be admired: the one in Ancona in the Marches and in San Gregorio, Milan, famous due to the role played during the 1576 plague.

Lazarettos’ regulation specified, as for example the one in Nitida (Naples), a division in three classes according to the price paid. The lazaretto’s staff comprised doctor, chaplain, caretaker, curate, captain and guards. They all had to report to a Director. Quarantine lasted forty days because, according to Hippocrates’ doctrine of critical days, the fortieth was the last day an acute disease, the plague to be precise, could express itself.
The premise for quarantine measures was the need to avoid the total paralysis that followed banishment. In the seafaring world for many years this resulted in refusing entrance to ships arriving from infected countries, especially from the Ottoman East, which was considered an inexhaustible source of contagion.
The term quarantine was first used to point out that isolation lasted forty days and it remained thus when quarantine was limited to “three fourths of the moon’s cycle” (22 days) or two weeks. Endless dissertations on the duration of quarantine help us understand the difficulties experienced by those who had to guarantee peace and health to the populace without penalizing commerce.
In the 18th – 19th centuries a journey to America or to Northern Europe could last over a month, hence it took the crew many months to return to the port of departure where another month of quarantine awaited them. Sailors would at times take advantage of the night to escape, though perfectly aware of the risks they ran. Animals and goods too were placed under quarantine.
Some lazarettos had large barns.
The expense of quarantine for those journeying by land was charged to the traveller, while sea travellers’ expenses were charged to ship owners. Besides quarantine in lazarettos, during epidemics people’s homes could be seized, especially if they lost a family member due to the epidemic that raged at that moment.

Doctors

Doctors were in the frontline during epidemics. The plague’s dreadful infectiousness spared nobody who had relations with plague-stricken patients, hence doctors too died together with thousands of people who perished under the plague or other epidemics. The fear of not having any doctors left was so great that they were at times invited to live in country homes, considering the risk of contagion and death.
At times doctors, aware that they were risking their life, chose to escape, attracting the scorn and anger of the populace and of health and civil authorities.
Pressed by the disease people sought the best doctors, the promptest and most helpful. Physicians working in lazarettos were the most exposed to contagion. They were disliked by the population, which looked upon them as potential sources of contagion.
During plagues doctors obviously adopted individual measures of protection such as masks with the typical hooked beak and robes that covered most of their body.

Remedies

Man has always looked for some remedy against pestilential diseases and 15th – 18th century treatises offer advice that was given when there was no knowledge of the aetiology and pathogenesis of diseases.
Patients were bled, rubbed and administered evacuating treatment, just to state a few methods. A thousand other remedies that were more or less encoded enriched doctor’s therapeutic resources during epidemics.
There also existed a type of folk medicine that generously handed out remedies based on superstition and magic. Some resorted to patron saints or practices meant to cure those struck by the plague or to protect others from contagion.
During the next few weeks an exhibition on the remedies of folk medicine will be held in the premises of the Museum of Anthropology and Ethnology, University of Florence.

Walter Pasini
OMS Centre -TRAVEL MEDICINE

Traslated by INTERPRES SAS