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[22]Milestones of Medicine | [23]Disease
The 432-year-old manual on social distancing
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(Image credit: Bildagentur-online/Alamy)
The Cholera in Spain, Fires for disinfecting the Streets of Granada by
William Heysham Overend (Credit: Alamy)
By Zaria Gorvett8th January 2021
In this spookily prescient booklet, people are advised to keep six feet
apart, avoid shaking hands and only send one person per household out
to do the shopping.
I

It was the dead of night in mid-November 1582. A sailor [26]stepped
onto the dock at the port of Alghero, Sardinia, and took in the view of
the city for the last time.

The unfortunate mariner is thought to have arrived from Marseille,
447km (278 miles) across the Mediterranean Sea. The plague had been
raging there for a year – and it seems that he had brought it with him.
He was already delirious, and suffering from the characteristic
swellings that marked out the disease, known as buboes, in his groin
area.

And yet, somehow the sailor managed to get past the plague guardians,
or Morbers, whose job it was to stop those who had any symptoms. He
made it into the city. Within days, he was dead and an outbreak had
begun.

At this point, many of the people of Alghero were already doomed. Based
on official records from the time, one 18th-Century historian estimated
that the epidemic led to 6,000 deaths, leaving only 150 people alive.
In reality, it's thought that the epidemic killed 60% of the city's
population. (The exaggeration may have been an attempt by the
government of the time to avoid tax.) [27]Mass graves sprung up, some
of which remain to this day – long trenches filled with the bones of up
to 30 people at a time.

You might also like:
* [28]The history of pandemics
* [29]How global outbreaks are contained
* [30]Why people object to life-saving laws

It could have been worse, however. The surrounding districts were
largely spared – unusually, the contagion remained in Alghero and
vanished within eight months. It's thought this was [31]all down to one
man and his prescient conception of social distancing.

"It is perhaps a bit surprising to find this knowledgeable doctor in
this rather parochial town," says Ole Benedictow, emeritus professor of
history at the University of Oslo, who co-authored a paper on the
subject. "You would expect for measures to be introduced more strictly
in the big commercial towns, such as Pisa and Florence. But this
doctor, he was in the front of his time. It's quite impressive."

Live chickens and urine

The most notorious plague episode in history was of course, The Black
Death, which swept across Europe and Asia in 1346, killing an estimated
50 million people worldwide.

In Florence, the Italian poet Francesco Petrarca didn't think future
generations would be able to grasp the scale of the devastation. He
[32]wrote: "O happy posterity, who will not experience such abysmal woe
and will look upon our testimony as a fable." The remains of the
plague's victims are regularly unearthed as part of tunnelling projects
today, such as [33]Crossrail in London. Records suggest that there are
[34]50,000 bodies hidden under Farringdon alone.
The medieval city of Alghero is now a popular holiday destination, but
it was the epicentre of a devastating plague outbreak in 1582 (Credit:
Milosz Galezowski/EyeEm/Getty Images)

The medieval city of Alghero is now a popular holiday destination, but
it was the epicentre of a devastating plague outbreak in 1582 (Credit:
Milosz Galezowski/EyeEm/Getty Images)

But though the plague was never quite so catastrophic ever again, it
remained a regular visitor in the coming centuries. It was reportedly
present in Paris for [35]one out of every three years until 1670, while
in 1563 it's thought to have [36]killed 24% of London's population.

This was a time before modern science, when the current understanding
was that diseases were caused by "bad air" and vinegar was a
cutting-edge antiseptic. Treatments for the plague ranged from the
revolting, such as [37]bathing in one's own urine, to the bizarre – one
popular method was to attempt to draw the "poison" out of buboes by
rubbing them with [38]the rump of a live chicken.

Plague knowledge

As Benedictow and his co-authors explain, Alghero itself was not
well-set-up for an epidemic. The city was burdened with poorly
organised sanitary systems, a handful of badly-trained medics and a
"[39]backwards" medical culture. It had its work cut out.

Enter Quinto Tiberio Angelerio, a 50-something doctor – Protomedicus –
from the upper classes. He had trained abroad, because there were no
universities at the time in Sardinia. Luckily for the residents of
Alghero, he was fresh from Sicily, which had endured a plague epidemic
of its own in 1575.

Years later, he published a booklet, Ectypa Pestilentis Status Algheriae
Sardiniae, detailing the 57 rules he had imposed upon the city

Alghero's patient zero arrived with buboes and, later, two women died
with distinctive bruises on their bodies – another feature of the
disease. Angelerio knew immediately what was happening. His first
instinct was to ask for permission to quarantine the patients, but he
was thwarted again and again – first by indecisive magistrates, then by
a senate which rejected his report and put his concerns down to
apocalyptic visions.

Angelerio became desperate. "He had the courage or the guts to turn to
the viceroy," says Benedictow. With their agreement, he set up a triple
sanitary cordon around the city walls, to prevent any trading with
people outside.

Initially, the measures were extremely unpopular, and the public
[40]wanted to lynch him. But as more people died, they came round – and
he was fully entrusted with the task of containing the outbreak. Years
later, he published a booklet, Ectypa Pestilentis Status Algheriae
Sardiniae, detailing the 57 rules he had imposed upon the city. Here's
what he did.

Lockdowns

First, citizens were advised not to leave their houses, or move from
one to another. Along these lines, Angelerio also forbade all meetings,
dances and entertainments – and stipulated that only one person per
household should leave to do the shopping, a rule that should be
familiar to many enduring pandemic restrictions today.

Lockdowns were not unique to Alghero. "In Florence, for example, they
imposed a total quarantine of the city in the spring of 1631," says
John Henderson, a professor of Italian Renaissance history at Birkbeck,
University of London. And just as today, rule-breaking was common.

"Over the year from the summer of 1630 to the summer of 1631, I found
something like about 550 different cases that people were prosecuted
for, for various infringements of the public health regulations," says
Henderson. For most of that time, the city wasn't in full lockdown, but
people were expected to self-isolate for 40 days if a member of their
household was suspected of having the plague, and taken to hospital.
This is where the word "quarantine" comes from – "quaranta giorni"
means "40 days" in Italian.
The plague spread most rapidly in cities, where it was transmitted via
contact with fleas, infected tissues or droplets in the air (Credit:
Pictorial Press/Alamy)

The plague spread most rapidly in cities, where it was transmitted via
contact with fleas, infected tissues or droplets in the air (Credit:
Pictorial Press/Alamy)

"Obviously people got impatient," says Henderson. In the days before
smartphones, streaming services, or even affordable books, people
innovated ways to get around the total boredom of being confined to the
house. "And so the court cases provide an extraordinarily lively
account of the type of reactions that people had when they were locked
up," he says.

Sometimes people were just unlucky – in one example, a woman rushed out
of the front door after her chicken, which had made a bid for freedom
onto the street. "As she runs back having caught it, a member of the
Health Board comes along and arrests her for breaking the plague
regulations"," says Henderson. She was taken to prison, but soon
released by a sympathetic judge who explained that her offence was very
minor.

In another, a woman whose son lived in the apartment beneath sent a
basket down to him, in which he placed a pair of socks that need
repairing. Then she hauled it back up. "Then a Health Board officer
comes along, having seen what she was doing, and takes her off to
prison," says Henderson.

But other people are more culpable. "Some people climbed along the
roofs on contiguous terraced houses, and met friends to play the guitar
and drink together, again breaking the plague regulations against
people mixing together from different households," he says.

Physical distancing

Next up was the six-foot-rule, in which Angelerio instructed that – as
translated by Benedictow's team – "People allowed to go out must bear
with them a cane measuring six feet long. It is mandatory that people
keep this distance from one another."

It turns out the 16th-Century policy may have been on the right side of
science

Here Angelerio really marks himself out as an expert social distancer –
none of the experts I spoke to had heard of this happening elsewhere.
And yet, at the beginning of the Covid-19 pandemic, many countries
around the world adopted an uncannily similar policy, recommending that
people remain two metres (6.6ft) apart where possible.

In many places, including the UK, France, Singapore, South Korea and
Germany, the minimum distance has since been reduced to [41]one or one
and a half metres. But it turns out the 16th-Century policy may have
been on the right side of science: one study estimated that the risk of
transmitting Covid-19 at one metre could be [42]between two and 10
times higher than the risk at two metres.

And Angelerio went further. He also specified that a large rail, or
parabonda, should be added to the counters at shops in which foods are
sold, to encourage people to keep their distance – and recommended
that, during mass, people should be careful when shaking hands.
Many countries now require people to keep two metres apart at all times
– roughly the same as that recommended in 16th-Century Sardinia
(Credit: Jamie Lawton/Getty Images)

Many countries now require people to keep two metres apart at all times
– roughly the same as that recommended in 16th-Century Sardinia
(Credit: Jamie Lawton/Getty Images)

"I think he is more goal-oriented, with respect to the anti-epidemic
measures that he wishes to introduce [than other doctors of his era],"
says Benedictow. "I think it's mainly a question of degree and being
early in his understanding of the required measures."

Washing your shopping

The Renaissance is popularly remembered as a golden age of classical
philosophy, literature and especially art, when Michelangelo,
Donatello, Raphael and Leonardo (da Vinci) – the Italian artists, not
the ninja turtles – transformed their field with their genius. But it
also ushered in great leaps forward in our scientific understanding.

This was when the physicist Nicholas Copernicus discovered that the
Earth revolves around the Sun, rather than the other way around, and da
Vinci drew up plans for making parachutes, helicopters, armoured
vehicles, and an early robot. Then around 1500, leading thinkers built
on the idea that diseases were caused by "bad air", to incorporate the
possibility that people could become sick from [43]touching objects
that had been contaminated by this miasma.

One of the things that they thought was the most risky was textiles – Alex
Bamji

"I see a connection between the development of the Renaissance and the
ability of people in the 16th Century to understand more about how
disease was spread," says Benedictow. "Angelerio understood that it was
spread by contact and connection." One example is his stipulation that
the owners of houses must disinfect, whitewash, ventilate and "water"
them. He explained that any objects that aren't particularly valuable
should be burned, while expensive furniture can be washed, exposed to
the wind, or disinfected in an oven instead.

At the time, it was also common to disinfect goods as they arrived –
especially those from ships. "One of the things that they thought was
the most risky were textiles," says Alex Bamji, a social and
cultural historian of early modern Europe from the University of Leeds.
"But all sorts of things get disinfected, including letters," she says.
Sometimes this leaves behind traces that can still be seen today. "If
smoke and fire were used to disinfect them, you can still find the odd
scorch mark here and there."

Health passports

One popular way to prevent the plague from turning up was to carefully
check the health status of anyone who wanted to enter a city. Though
the system failed at Alghero, where the 1582 outbreak's patient zero
slipped past the guards stationed at the port, it was common elsewhere
in Europe at the time.

In some cases, the authorities issued [44]physical documents which
enabled the bearer to pass through the gates despite any restrictions,
either because they had been certified as plague-free or happened to
know the right people.

"So, if you're a traveller, and you're going on business from one city
to another – either your city has the plague or you're travelling to a
city with the plague – you will need a health passport," says Philip
Slavin, an associate professor of history at the University of
Stirling.
Archaeologists found traces of 660-year-old bacteria in the skeletons
of plague victims unearthed by the Crossrail project in London (Credit:
Amer Ghazzal/Alamy)

Archaeologists found traces of 660-year-old bacteria in the skeletons
of plague victims unearthed by the Crossrail project in London (Credit:
Amer Ghazzal/Alamy)

When the Covid-19 pandemic began, the concept of "health passports" was
resurrected. Recently several international airports – including
London, New York, Hong Kong and Singapore – have been trialling
"[45]CommonPass", a digital document that can display a user's test
results and vaccination records. The idea is to easily confirm their
infection status to make international travel safer and more
efficient.

Intriguingly, though the Alghero epidemic occurred centuries before the
scientific concept of immunity emerged, Angelerio also assigned certain
tasks to those who had already acquired and survived the plague. He
decreed that grave-diggers should be hired from among this group – a
high-risk job because they were expected to transport confessional
booths to the bedsides of dying patients, and, of course, deal with the
bodies of the deceased.

Quarantine

Italy was an early pioneer of isolating people suspected of having the
plague – and on a truly massive scale. The first plague hospital, or
lazaretto, was set up in Venice in 1423 – and soon they had separate
facilities for active patients versus those who were recovering or who
had come into contact with someone who was infected. By 1576, the city
had [46]up to 8,000 people staying at the former, plus around 10,000 at
the latter.

In Angelerio's account of the lazarettos in Alghero, they are remarkably
well-ordered

Eventually lazarettos became part of the standard model for dealing
with the disease, and examples sprung up all over Italy, including
Sardinia. They were part-hospital, part-prison – the quarantine
facilities were usually mandatory, and in some circumstances patients
were taken directly there by a city's plague guardians.

"They're not viewed positively – people at the time often described
them as being 'like hell'," says Bamji, though she cautions that this
may be more of a reflection of the stigma that surrounded them, than
what they were really like.

"Huge amounts of money was spent on them – that's one thing to say,"
says Bamji. "And there's evidence that the food was pretty good." She
explains that around half the people who stayed at lazarettos died, but
of course the other half went home – and this is a comparable fatality
rate to that seen in the rest of the population.

In Angelerio's account of the lazarettos in Alghero, they are
remarkably well-ordered. The plague guardians were expected to keep
track of everything brought into and out of the institutions, such as
beds, furniture, and food. The poorest members of society were not
expected to pay for their treatment. Sick patients were sometimes
carried there from their homes, while orphaned babies who didn't have a
wet nurse were bottle-fed with the milk of "well-fed goats", which were
allowed to roam freely within its walls.

Dead cats

For all the similarities between the measures taken against outbreaks
in the 16th Century and the kind we're familiar with today, there are
some crucial differences.

In Renaissance Sardinia, superstition and religion were still key
elements of Angelerio's epidemiological plans – he told the public that
the plague was a divine punishment, and warned them to be on their best
moral behaviour – and some of his instructions weren't just
ineffective, they were baffling.
The Lazzaretto Nuovo was built on an island next to Venice in 1468, as
a place to quarantine incoming ships and cargo (Credit: Alamy) (Credit:
AlFA Visuals/Alamy)

The Lazzaretto Nuovo was built on an island next to Venice in 1468, as
a place to quarantine incoming ships and cargo (Credit: Alamy) (Credit:
AlFA Visuals/Alamy)

One example is the instruction that "turkeys and cats must be killed
and thrown in the sea". This was a surprisingly common reaction to an
epidemic – the author Daniel Defoe reported that, during the 1665
plague in London, the mayor ordered the slaughter of [47]40,000 dogs
and 200,000 cats – and special dog-killers were appointed for the task.

However, this mass-execution of the city's predators may have had the
opposite effect to the one intended – since rats are known carriers of
the plague. (Rats were also persecuted directly in some cities, but not
mentioned in Angelerio's account.)

Fast-forward to 2020 and, though there is hard evidence that [48]cats
and dogs can become infected with Covid-19, they remain as beloved as
ever – many pet charities have reported record numbers of adoptions in
recent months, with a branch of the RSPCA in Australia [49]reporting
20,000 applications since the start of the pandemic.

The outbreak lasted for eight months, and then the city didn't see another
plague epidemic for 60 years

In Benedictow's view, comparisons between the plague and Covid-19
should be viewed with some scepticism. "Plague epidemics were much
worse and had an almost inconceivable mortality rate," he says. "It was
usual that 60% and even 70% of a town or district population lost their
lives."

So what happened to the residents of Anghero? The outbreak lasted for
eight months, and then the city didn't see another plague epidemic for
60 years – but when it did, the first thing they did was turn to
Angelerio's manual. The Protomedicus during the 1652 outbreak followed
his instructions to the letter, introducing quarantine, isolation, the
disinfection of goods and houses, and establishing sanitary cordons
around the city.

The ill-fated sailor who arrived at Alghero nearly four-and-a-half
centuries ago may have ignited an epidemic, but he also led to
something else: a comprehensive guide to hygiene and social distancing,
way ahead of its time.

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