Book Review

Miasmas and Disease: Public Health and the Environment in the Pre-Industrial Age

N Engl J Med 1993; 328:668-669March 4, 1993

Article

Miasmas and Disease: Public Health and the Environment in the Pre-Industrial Age
By Carlo M. Cipolla; Translated by Elizabeth Potter. 101 pp. New Haven, Conn., Yale University Press, 1992. $20. ISBN: 0-300-04806-8

In Miasmas and Disease, Carlo Cipolla provides a fascinating glimpse of illness, health care, and prevention in early-17th-century Italy. The first and concluding chapters set up the author's premise and draw his conclusions about the inability of the physicians of the time to break out of the ancient paradigm of the humoral nature of disease. “`Facts,”' he tells us, “are like the tiles of a mosaic; on their own they mean nothing.” But by presenting these facts as plainly as possible, Cipolla allows us the joy of discovery. The intervening chapters present information so deftly that the reader is almost unaware of the author's presence. Instead, thanks in great part to Elizabeth Potter's fine translation, physicians long dead grab us by the lapels and press their urgent claims.

The great motivating factor at the time was the plague. Anxious officials responded to every rumor of increased mortality in town and countryside, quickly sending out experts to substantiate claims and advise. These physicians took pains to gather first-hand information, tracking down various local sources (priest, physician, surgeon, or apothecary) and visiting the ill themselves. The theory of the time blamed foul odors for disease and considered the plague one end of a spectrum rather than a separate entity. Thus, concern for sanitation and removal of human and animal waste took on added importance. When a master mason reports that “there are many houses in this place whose privies empty into certain horrible backyards and open courtyards which look and smell so disgusting that this alone would be enough to bring on the plague when it is very hot,” we are not inclined to argue the point with him. Instead, of course, we applaud the vigorous efforts to discourage the keeping of animals within towns and to promote the construction and maintenance of adequate sewage systems. The irritating refusal of the citizenry to obey public health edicts is also familiar, and it is hard not to empathize with the physician who pleads, “It is necessary for Your Lordships to make them an order with penalties and punish someone, otherwise these smells will not be got rid of.”

During the period the book covers, there was no episode of plague in this region; instead, the author describes the base-line prevalence of disease, including endemic and epidemic typhus, malaria, influenza, and gastrointestinal illness. The reports are devastating. Most exclude childhood deaths, and mortality rates of 20 percent serve to reassure the observers that the illness is not the plague. One fatal outbreak includes persons who “had pains in their ears and many of them had great quantities of horrible discharge from their ears,” driving home both our own good fortune in practicing in the antibiotic era and the gritty determination required of those who preceded us.

One physician's astute observation that “if many poor people had enough bread to feed themselves there would not be so many sick” unfortunately rings true today. The same physicians blame poverty for the lack of medical care availble and act vigorously to provide that care (the district authorities are prevailed on to issue charitable contributions of pharmaceuticals and requisition a physician). The availability of treatment was, of course, a dubious blessing, and the repeated attribution of death to the absence of medical care starts to irritate until one comes across this comment:

Dr. Magiotti . . . was decidedly skeptical of medicine, of the therapeutic capabilities of the medicines of his time . . ., when [asked] how in all honesty he could accept money from patients knowing he could not cure them he replied: “Most Serene Highness, I take the money not for my services as a doctor but as a guard, to prevent some young man who believes everything he reads in books from coming along and stuffing something down the patients which kills them.”

Having now safely crossed the divide to a time when the average patient-physician encounter has a greater than random chance of benefiting the former, we can nevertheless learn from predecessors who set up an early-warning system to investigate unusual clusters of deaths using primary sources of data, ignored experts who provided “an excess of erudition and . . . corresponding lack of down to earth information,” recognized the special hazards of a migrant work force, and attempted to combine public health and clinical medicine. Cipolla suggests we might learn from their failures, as well; he leaves us to provide our own examples. Environmental health investigations that rely on immunologic or toxicologic techniques may well miss the mark if the framework we set up examines only chemical exposure and misses the fear of death and disability, or the horror of witnessing the incineration of another human being.

Rosemary K. Sokas, M.D., M.O.H.
United Arab Emirates University, Al Ain, United Arab Emirates