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Decision Making in Health
and Medicine
Integrating Evidence and Values

Second Edition
Decision Making in Health
and Medicine
Integrating Evidence and Values

Second Edition

M.G. Myriam Hunink

Milton C. Weinstein

Eve Wittenberg
Michael F. Drummond
Joseph S. Pliskin
John B. Wong
Paul P. Glasziou
University Printing House, Cambridge CB2 8BS, United Kingdom

Cambridge University Press is part of the University of Cambridge.

It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781107690479
Second Edition © M. G. Myriam Hunink, Milton C. Weinstein, et al. (the authors) 2014
First Edition © M. G. Myriam Hunink, Paul P. Glasziou, et al. (the authors) 2001
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
Second Edition first published 2014
First Edition first published 2001
Printed in Spain by Grafos SA, Arte sobre papel
A catalog record for this publication is available from the British Library
Library of Congress Cataloging in Publication data
Hunink, M. G. Myriam, author.
Decision making in health and medicine : integrating evidence and values / M.G. Myriam Hunink,
Milton C. Weinstein, Eve Wittenberg, Michael F. Drummond, Joseph S. Pliskin, John B. Wong,
Paul P. Glasziou. – Second edition.
p. ; cm.
Preceded by Decision making in health and medicine : integrating evidence and values / M.G. Myriam
Hunink . . . [et al.]. 2001.
Includes bibliographical references and index.
ISBN 978-1-107-69047-9 (Paperback)
I. Title.
[DNLM: 1. Decision Making. 2. Delivery of Health Care. 3. Decision Support
Techniques. 4. Evidence-Based Medicine. 5. Uncertainty. W 84.1]
R723.5
610–dc23 2014000260
ISBN 978-1-107-69047-9 Paperback
Additional resources for this publication are available at www.cambridge.org/9781107690479
Cambridge University Press has no responsibility for the persistence or accuracy
of URLs for external or third-party internet websites referred to in this publication,
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.
........................................................................................................................................

Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and practice
at the time of publication. Although case histories are drawn from actual cases,
every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors, and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers
are strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.
In memoriam
Howard S. Frazier
Jane C. Weeks
Contents

Foreword page viii

Foreword to the first edition x
Preface xiii
Acknowledgments xv
List of abbreviations xvi
About the authors xviii

1 Elements of decision making in health care 1

2 Managing uncertainty 29
3 Choosing the best treatment 53
4 Valuing outcomes 78
5 Interpreting diagnostic information 118
6 Deciding when to test 145
7 Multiple test results 165
8 Finding and summarizing the evidence 209
9 Constrained resources 237
10 Recurring events 300
11 Estimation, calibration, and validation 334
12 Heterogeneity and uncertainty 356
13 Psychology of judgment and choice 392

Index 414
Additional resources can be found at www.cambridge.org/9781107690479

vii
 Foreword

Suppose we are sitting in a room, and I tell you that if you walk out a certain
door, you will die instantly. However, if you remain in your chair for another
five minutes, you can leave when you like with no ill effects. If you believe me,
and you value your life, you will stay put, at least for five minutes.
This situation poses an easy choice. It requires little thought and no
analysis, and the best option is transparently clear. A number of attributes
make this an easy case: First, the choice is stark, with only two extreme
outcomes, live or die. Second, the consequences are certain-live if you stay,
die if you leave. Third, the outcomes are immediate, with no time delay.
Fourth, there are no financial costs involved, and if anything the preferred
choice (staying in your chair) is easier than getting up and leaving. And
finally, you are making this choice for yourself; you are the one who decides
and who will experience the outcomes.
Unfortunately, real-life situations related to medicine and health are murk-
ier and more complicated. The choices are much more varied than “stay or
go” and may involve a range of possible tests and treatments, as well as
watchful waiting. The attainable outcomes include many possible states of
ill-health, ranging from minor inconvenience to severe pain and disability, as
well as death. The intermediate and ultimate results are rife with uncertainty,
and the various states of illness may play out over a long time period.
Typically, both a doctor and a patient are involved in decision-making, and,
in some cases, perhaps family members and others as well. The doctor
generally knows more about what may happen, and the patient understands
more about their own preferences, and both information and values bear on
the best decision. Layer on top of all this the emotionality and urgency that
occasionally attends to health and medical care. And then try to contemplate
questions of cost and choices that can affect the health of an entire population.

viii
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ix Foreword

This book presents a systematic approach to identifying, organizing, and

considering these many complexities in health and medical care. In a sense, all
of the tools described in these pages are designed to convert the complex and
uncertain realities of health and medicine into the decision-equivalent of the
simple “stay or go” question posed above. For example, probability analysis
converts the array of uncertain, intermediate, and ultimate states into an
overall expectation of what will or will not happen (as if they were simply
certain to live or certain to die). Utility assessment allows a decision maker to
rank the value of all possible outcomes on a scale (between life and death) that
is quantitatively meaningful for decisions. Discounting allows one to set
equivalents for outcomes that play out at different times (as if the outcomes
were all to occur now). Modeling enables one to take account of complex
interactions and the iterative quality of many disease processes over time (as if
they were clear-cut and instantaneous). Tools such as balance sheets and
decision diagrams enable one to take account of the problem as a whole
and to focus at different times on specific parts without losing sight of the
whole, something the unaided human mind cannot possibly accomplish. And
cost-effectiveness analysis enables one to consider systematically the most
efficient means of achieving one’s aims, when costs matter. And today, costs
frequently matter.
The Institute of Medicine (IOM) has long been a champion of patient-
centered care. It is one of the six core attributes of quality defined by the IOM
and arguably the most fundamental aim. If we are truly centered on the needs
of patients, and on the health needs of people more generally, the goals of safe,
effective, timely, efficient, and equitable care naturally follow as part of
attaining higher-quality care. The tools and techniques outlined in this text
will not make an uncaring physician more compassionate, nor an indifferent
caregiver more centered on the needs of the patient. However, for doctors
who are compassionate and caring, these tools will strengthen their ability to
reach decisions with patients that truly serve the patient’s interests in health
and medicine.

President, Institute of Medicine Harvey V. Fineberg, M.D., Ph.D.

June 2014
 Foreword to the first edition (2001)

. . . high Arbiter Chance governs all.

John Milton, Paradise Lost, book II, lines 909–10

When the predecessor to this book was being prepared in the late 1970s
(Weinstein et al., 1980), medical decision making seemed to have become
more complicated than ever before. The number of diagnostic and therapeutic
options dwarfed those of an earlier generation, and the costs of care were
growing relentlessly. Increasing numbers of patients expected to play an active
role in decisions that affected their lives, and many physicians were acclimat-
ing themselves to a less authoritarian doctor–patient relationship. The tools of
decision analysis permitted the clinician and patient to break down the
complexity of a medical situation into its constituent parts, to identify and
assess the pertinent uncertainties and values, and to reassemble the pieces into
a logical guide to action.
Today, a generation later, the dilemma of medical decision making seems
even more problematic. This is not merely the result of scientific and tech-
nologic advances – ingenious new devices, pharmaceuticals, surgical possibil-
ities, and other interventions. The environment of decision making has itself
become confounded by government agencies and service delivery systems
playing a more direct (and directive) role in decision making. Today, not
only are the costs of care a prime concern, so, too, is the quality of care.
Patients no longer need rely mainly on their physicians to gain access to
medical information – the internet has given millions a direct line to abun-
dant information, though of variable accuracy and pertinence. In light of
progress in mapping the human genome, clinicians may soon face profound
ethical questions that only a generation ago were the stuff of science fiction.
These dynamic changes in medicine, in science, and in the health-care
environment make this new book more valuable than ever. This volume

x
xi Foreword to the first edition (2001)

conveys both fundamental and sophisticated methods that can render com-
plex health-care situations more comprehensible. It would be a mistake,
however, to think that the methods described in this volume apply only to
the exceptional case, to the rare clinical encounter. The task of integrating
scientific knowledge, clinical evidence, and value judgments into coherent
decisions remains the daily task of medical care.
Much of what counts for differences in outcome related to medicine comes
not from failure to access experimental and expensive technology. It comes
rather from the failure to deploy relatively inexpensive and proven technology
to all those who need it: vaccine against pneumonia for those at risk, beta-
blockers in the period following myocardial infarction, appropriate screening
for cancer, and much more. The challenge for quality improvement is not the
extraordinary case and exceptional decision so much as the challenge to
implement systematically the preventive, diagnostic, and therapeutic meas-
ures for all who would benefit at reasonable cost. The lessons in this book can
reinforce the case for sounder everyday decisions in medicine and health care.
Regardless of how far science and health care advance, the element of
chance will remain a fixture in medical encounters. A refined understanding
of causation and prognosis will alter how much we know about the likelihood
of certain consequences, but uncertainty will persist. Much of medical learn-
ing can be interpreted as an effort to reduce the range of uncertainty in
medical care. The ideas and methods provided in this volume teach how to
make informed decisions in the face of the uncertainty which inevitably
remains.
The methods in this book to aid decision makers are simply tools. They are
tools for the willing clinician. They are tools for the worried patient. They are
tools for the concerned policy maker and payer. They will not make a
hazardous situation safe, nor will they make a lazy or incompetent clinician
into a superior caregiver. If the methods do not eliminate controversy, they
can clarify the reasons for differences of opinion. In dealing with the realities
and uncertainties of life and illness, they will enable the thoughtful clinician,
the honest patient, and the open-minded policy maker to reach more
reasoned conclusions.

Provost, Harvard University Harvey V. Fineberg

REFERENCE

Weinstein MC, Fineberg HV, Elstein AS, et al. Clinical Decision Analysis.
Philadelphia, USA: WB Saunders; 1980. ISBN 0-7216-9166-8.
Preface

How often do you find yourself struggling with a decision, be it a medical

decision, a policy decision, or a personal one? In clinical medicine and health-
care policy, making decisions has become a very complicated process: we have
to make trade-offs between risks, benefits, costs, and preferences. We have to
take into account the rapidly increasing evidence – some good, some poor –
presented in scientific publications, on the worldwide web, and by the media.
We have to integrate the best available evidence with the values relevant to
patient and society; and we have to reconcile our intuitive notions with
rational analysis.
In this book we explain and illustrate tools for integrating quantitative
evidence-based data and subjective outcome values in making clinical and
health-policy decisions. The book is intended for all those involved in clinical
medicine or health-care policy who would like to apply the concepts from
decision analysis to improve their decision making process. The audience we
have in mind includes (post-)graduate students and health-care professionals
interested in medical decision making, clinical decision analysis, clinical
epidemiology, evidence-based medicine, technology assessment in health care,
and health-care policy. The main part of the book is written with graduate
students as audience in mind. Some chapters cover advanced material and as
such we would recommend reserving this material for advanced courses in
decision modeling (the second half of Chapters 4 and 7, and the entire
Chapters 10, 11, and 12).
The authors’ backgrounds ensure that this is a multidisciplinary text.
Together we represent general practice, internal medicine, radiology, math-
ematics, decision sciences, psychology of decision making, health economics,
health-care policy and management. The examples in the book are taken from
both clinical practice and from health policy.

xiii
xiv Preface

There is a previous version of this book (Weinstein et al., 1980), but the
name of the book has changed, the content is 80% different, the publisher has
changed, and the list of authors has changed. The main message is, however,
the same! And the main message is the same: decisions in clinical medicine
and health care in general can benefit from a proactive approach to decision
making in which evidence and values are integrated into one framework. In
addition, substantial changes have been made compared with the first edition
of this book (Hunink et al., 2001): Chapters 11 and 13 are totally new, all
existing chapters have been thoroughly revised to present current insights,
examples throughout the book have been updated to be clinically relevant in
today’s practice, figures have been improved (especially in Chapter 6) and
more figures have been added, and the supplementary material has been
expanded and revised.
The book comes with a website. The book itself can, however, be read
without immediate access to the website, that is, in a comfortable chair or on a
couch! The website supplies additional materials: assignments and their
solutions, examples of the decision models in the book programmed using
decision analytical software, supplementary materials for the chapters includ-
ing some useful spreadsheets and model templates, and the references. Access
to the teachers’ website, which contains additional useful material, is available
on request.
We hope you enjoy reading. Good (but calculated) luck with your decision
making!

M.G. Myriam Hunink

on behalf of all the authors

REFERENCE

Hunink MGM, Glasziou PP, Siegel JE, Weeks JC, Pliskin JS, Elstein AS,
Weinstein MC. Decision Making in Health and Medicine: Integrating
Evidence and Values. Cambridge: Cambridge University Press,
Cambridge; 2001. ISBN 978-0521770293.
Weinstein MC, Fineberg HV, Elstein AS, et al. Clinical Decision Analysis.
Philadelphia, USA: WB Saunders; 1980. ISBN 0-7216-9166-8.
Acknowledgments

A book never gets prepared by the authors only. Numerous people helped to
make this book come into being. We would like to thank those who reviewed
the manuscript, edited, revised, and helped prepare the exercises, solutions,
references, and supplementary material. For the second edition this included:
Marieke Langhout, Ursula Rochau, Isha Argawal, Bart Ferket, Bob van Kem-
pen, Steffen Petersen, Jane Weeks, Ewout Steyerberg, and Bas Groot
Koerkamp.
We would especially like to acknowledge the contributions of the authors
of the previous version and the authors of the first edition of the book who
were not directly involved this time: Harvey V. Fineberg, Howard S. Frazier,
Duncan Neuhauser, Raymond R. Neutra, Barbara J. McNeil, Joanna E. Siegel,
Jane C. Weeks, and Arthur S. Elstein. Also, we would like to thank the
reviewers of the first edition.
Writing a book consists not only of putting text on paper, making illustra-
tions, and having the chapters proofread, but also the thoughts, ideas, and
intellectual input from many, too numerous to list and often difficult to
identify, have played a role in getting this book together. We are grateful
for the intellectual input from our colleagues, students, and postgraduates at
the University of Queensland, Bond University, Ben Gurion University,
University of York, Erasmus University Medical Center Rotterdam, Nether-
lands Institute of Health Sciences, Tufts University Medical School, Harvard
School of Public Health, and members of the Society for Medical Decision
Making.
Last, but certainly not least, we would like to thank our families for being
supportive and giving us the opportunity to spend time working on the book
during many evenings and weekends.

xv
 Abbreviations

ACP American College of Physicians

ASR age–sex–race
CABG coronary artery bypass grafting
CAD coronary artery disease
CDC Centers for Disease Control and Prevention
CEA carotid endarterectomy
CEA cost-effectiveness analysis
CE25 certainty equivalent 25
CE50 certainty equivalent 50
CE ratio cost-effectiveness ratio
CI confidence interval
CPI Consumer Price Index
CRC colorectal cancer
CT computed tomography
CTA computed tomography angiography
CVD cardiovascular disease
DALY disability-adjusted life year
DRG diagnostic-related group
DVT deep venous thrombosis
EBCT electron beam computed tomography
EKG electrocardiogram
EQ-5D EuroQol with five dimensions
EU expected utility
EVCI expected value of clinical information
EVPI expected value of perfect information
EVPPI expected value of partial perfect information
EVSI expected value of sample information
FNR false-negative ratio
FOBT fecal occult blood test
xvi
xvii List of abbreviations

FPR false-positive ratio

HBV hepatitis B virus
HDL high-density lipoprotein
HIV human immunodeficiency virus
HMO health maintenance organization
HRR hazard rate ratio
HUI Health Utilities Index
IV intravenous
LE life expectancy
LR likelihood ratio
MeSH Medical Subject Headings
MI myocardial infarction (‘heart attack’)
MISCAN Microsimulation of Screening for Cancer
MRI magnetic resonance imaging
MRA magnetic resonance angiography
NHB net health benefit
NMB net monetary benefit
OME otitis media with effusions (‘glue ear’)
OR odds ratio
ORS oral rehydration solution
PAD peripheral artery disease
PAT paroxysmal atrial tachycardia
PE pulmonary embolism
PTA percutaneous transluminal angiography
PV present value
QALE quality-adjusted life expectancy
QALY quality-adjusted life year
QWB Quality of Well-Being scale
RCT randomized controlled trial
ROC receiver operating characteristic
RR relative risk
RRR relative risk reduction
RRTO risk–risk trade-off
RS rating scale
SF-36 36-Item Short Form
SG standard gamble
SIP Sickness Impact Profile
TNR true-negative ratio
TPR true-positive ratio
VAS visual analog scale
V/Q scan ventilation–perfusion scan
WTP willingness to pay
 About the authors

M.G. Myriam Hunink, B.Sc., M.D., Ph.D. trained and practiced as an

interventional and cardiovascular radiologist. Currently she directs the
Assessment of Radiological Technology (ART) program and the division of
Clinical Epidemiology at the Erasmus MC and dedicates herself to research
and teaching. She is Professor of Clinical Epidemiology and Radiology at the
Erasmus University Medical Center, Rotterdam, the Netherlands and Adjunct
Professor of Health Decision Sciences at Harvard School of Public Health,
Harvard University, Boston. She is a past president of the Society for Medical
Decision Making and a recipient of their Distinguished Service award. Her
main research interests are comparative effectiveness research and health
technology assessment studies of diagnostic and prognostic imaging tests
(biomarkers) and image-guided therapies, in particular for cardiovascular
disease. Other research interests include integrated diagnostics, computerized
decision support for evidence-based use of imaging tests, and (imaging to
measure) the effectiveness of lifestyle interventions. Her vision is to optimize
medical decisions by combining the best available quantitative evidence on
risks and benefits from diverse sources and integrating patient values, prefer-
ences, quality of life, and costs.

Milton C. Weinstein, A.B./A.M., M.P.P., Ph.D. is the Henry J. Kaiser Pro-

fessor of Health Policy and Management at the Harvard School of Public
Health and Professor of Medicine at the Harvard Medical School. At the
Harvard School of Public Health he is Academic Director of the Center for
Health Decision Science, and Director of the Program on Economic Evalu-
ation of Medical Technology. He is best known for his research on cost-
effectiveness of medical practices and for developing methods of economic
evaluation and decision analysis in health care. He is a co-developer of the
CEPAC (Cost-Effectiveness of Preventing AIDS Complications) computer

xviii
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xix About the authors

simulation model, and has conducted studies on prevention and treatment of

HIV infections. He was the co-developer of the Coronary Heart Disease Policy
Model, which has been used to evaluate the cost-effectiveness of cardiovascu-
lar prevention and treatment. He consults with industry and government and
is a Principal Consultant with Optuminsight. He is an elected member of the
Institute of Medicine of the National Academy of Sciences, a past president
and recipient of the Career Achievement Award of the Society for Medical
Decision Making, and the Avedis Donabedian Lifetime Achievement Award
from the International Society for Pharmacoeconomics and Outcomes
Research.

Eve Wittenberg, M.P.P., Ph.D. is a Senior Research Scientist at the Center for
Health Decision Science at the Harvard School of Public Health. Her interests
include the conceptualization and measurement of well-being and values
across individuals and health conditions, and the application of this infor-
mation to clinical decision making and policy. She has estimated economic
utilities for conditions ranging from cancer to intimate partner violence, and
has a special focus on health issues for vulnerable and under-studied popula-
tions. Her recent work includes studies of choice-based methods to inform
preference research and design of interventions, as well as measurement
approaches to capture family spillover effects of illness. She teaches in the
decision science curriculum at the Harvard School of Public Health and
advises students in health policy.

Michael F. Drummond, B.Sc., M.Com., D.Phil. is Professor of Health Eco-

nomics and former Director of the Centre for Health Economics at the
University of York, UK. His particular field of interest is in the economic
evaluation of health care treatments and programmes. He has undertaken
evaluations in a wide range of medical fields including care of the elderly,
neonatal intensive care, immunization programs, services for people with
AIDS, eye health care and pharmaceuticals. He has acted as a consultant to
the World Health Organization and was Project Leader of a European Union
Project on the Methodology of Economic Appraisal of Health Technology. He
has been President of the International Society of Technology Assessment in
Health Care, and the International Society for Pharmacoeconomics and Out-
comes Research. He was previously a member of the Guidelines Review Panels
of the National Institute for Health and Clinical Excellence (NICE) in the UK,
is a Principal Consultant for Optuminsight, and editor-in-chief of Value in
Health. He has been awarded two honorary degrees, from City University,
London (2008) and Erasmus University, Rotterdam (2012). In 2010 he was
made a member of the Institute of Medicine of the National Academies in the
USA and in 2012 he was the recipient of The John Eisenberg Award, in
xx About the authors

recognition of exemplary leadership in the practical application of medical

decision-making research, by the Society for Medical Decision Making.

Joseph S. Pliskin, B.Sc., S.M., Ph.D. is the Sidney Liswood Professor of

Health Care Management at Ben Gurion University of the Negev, Beer-
Sheva, Israel. He was chairman of the Department of Health Systems Man-
agement and is a member of the Department of Industrial Engineering and
Management. He is also an Adjunct Professor in the Department of Health
Policy and Management at the Harvard School of Public Health, Boston, USA.
His research interests focus on clinical decision making, operations manage-
ment in health care organizations, cost–benefit and cost-effectiveness analysis
in health and medicine, technology assessment, utility theory, and decision
analysis. He has published extensively on issues relating to end-stage renal
disease, heart disease, Down syndrome, technology assessment, and methodo-
logical issues in decision analysis. In 2004 he received the Career Achievement
Award of the Society for Medical Decision Making and in 2012 he was the
recipient of a Harvard School of Public Health teaching award.

John B. Wong, B.S., M.D. is a general internist, Chief of the Division of

Clinical Decision Making at Tufts Medical Center, Director of Comparative
Effectiveness Research at Tufts Clinical Translational Science Institute, and
Professor of Medicine at the Tufts University School of Medicine. He is a past
president of the Society for Medical Decision Making and a recipient of their
Distinguished Service award. He has been an invited member of the ISPOR-
SMDM Modeling Good Research Practices Task Force and of guideline
committees for the American Association for the Study of Liver Disease,
European League Against Rheumatism, the AMA Physician Consortium for
Performance Improvement Work Groups on Coronary Artery Disease,
Hypertension, Heart Failure, Cardiac Imaging, and Hepatitis C, and the
Technical Panel for the ACCF Appropriate Use Criteria for Diagnostic
Catheterization and Multi-modality Imaging. His research focuses on the
application of decision analysis to help patients, physicians, and policymakers
choose among alternative tests, treatments, or policies, thereby promoting
rational evidence-based efficient and effective patient-centered care. As a
content editor at the Informed Medical Decisions Foundation, he has helped
develop award winning decision aid programs for testing, treatment, and
management of heart disease to facilitate shared decision making.

Paul P. Glasziou, F.R.A.C.G.P., Ph.D. is Professor of Evidence-based Medi-

cine and Director, Centre for Research in Evidence-based Practice, Bond
University, Australia. He was a general practitioner at the Inala Community
Health Centre, and at Beaumont St, Oxford. He teaches evidence-based
xxi About the authors

practice to medical students and other health care workers. He holds honor-
ary positions as Professor at the University of Oxford, and Professor at the
University of Sydney. Dr Glasziou was the co-editor of the BMJ’s Journal of
Evidence-Based Medicine, and Director of the Centre for Evidence-based
Medicine, University of Oxford. His research interests focus on identifying
and removing the barriers to using high-quality research in everyday clinical
practice.
 1

Elements of decision making

in health care

And take the case of a man who is ill. I call two physicians: they differ in opinion. I am not
to lie down and die between them: I must do something.
Samuel Johnson

1.1 Introduction
How are decisions made in practice, and can we improve the process? Decisions
in health care can be particularly awkward, involving a complex web of diag-
nostic and therapeutic uncertainties, patient preferences and values, and costs. It
is not surprising that there is often considerable disagreement about the best
course of action. One of the authors of this book tells the following story (1):

Being a cardiovascular radiologist, I regularly attend the vascular rounds at the

University Hospital. It’s an interesting conference: the Professor of Vascular
Surgery really loves academic discussions and each case gets a lot of attention. The
conference goes on for hours. The clinical fellows complain, of course, and it sure
keeps me from my regular work. But it’s one of the few conferences that I attend
where there is a real discussion of the risks, benefits, and costs of the management
options. Even patient preferences are sometimes (albeit rarely) considered.

And yet, I find there is something disturbing about the conference. The discussions
always seem to go along the same lines. Doctor R. advocates treatment X because he
recently read a paper that reported wonderful results; Doctor S. counters that
treatment X has a substantial risk associated with it, as was shown in another paper
published last year in the world’s highest-ranking journal in the field; and Doctor
T. says that given the current limited health-care budget maybe we should consider
a less expensive alternative or no treatment at all. They talk around in circles for ten
to 15 minutes, each doctor reiterating his or her opinion. The professor, realizing
that his fellows are getting irritated, finally stops the discussion. Practical chores are
waiting; there are patients to be cared for. And so the professor concludes: ‘All right.
We will offer the patient treatment X.’ About 30% of those involved in the decision-
making process nod their heads in agreement; another 30% start bringing up
objections which get stifled quickly by the fellows who really do not want an encore,
and the remaining 40% are either too tired or too flabbergasted to respond, or are
more concerned about another objective, namely their job security.

1
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persons in Milan in the year 1630.’ Fletcher appends this further
description: ‘This is followed by the names of the Magnificos, who
sat in judgement, and the particulars of the punishment decreed.
Each scene in the picture has its letter, which is referred to in an
explanatory legend below. The entire disregard of the unities of time
and place, which characterized such productions, is well displayed in
this curious engraving. On the right is the shop of the barber Mora,
and in front of it the “Column of Infamy” is already erected. A large
platform car, drawn by two oxen, exhibits the victims, executioners,
and priests. A brazier of live charcoal contains the pincers with which
the flesh was to be torn. The barber’s right hand is on the block, and
a chopper held over the wrist is about to be struck down by a mallet
held aloft by the executioner. Further on is seen a large platform, on
which the two victims are having their limbs broken by an iron bar,
preparatory to their exposure on the wheel for six hours. The wheels
are also displayed, one of them already on a pole, with the men
bound upon them. Still further on are the fires consuming the
bodies, and, last scene of all, on the extreme left is a fussy little
stream, foaming under bridges, which is supposed to be a river, and
into it a man is throwing the ashes of the two malefactors.’
One dark night in 1788 Nature for very shame let loose a storm
that wrecked the Column: her minion Man then tardily demolished
the monument of his own infamy. The balcony of Catarina Rosa’s
house was also taken down, so that no structure stands to call to
mind the hideous tragedy. The corner-house of the Vedra de’
Cittadini, on the left hand as one comes from the Corso di Porta
Ticinese, occupies the site of poor Mora’s house. A dwelling has
rested on the accursed site since 1803.
It is surprising to find that not only does not Ripamonti deny the
guilt of the victims, but now and again he seems to hint at its reality.
It has to be borne in mind that in his position as official
historiographer of Milan it was hardly permissible for him to express
sentiments opposed to popular conviction and the decisions of the
courts of justice. As late as 1832, during an epidemic of cholera in
St. Petersburg, the most circumstantial statements of miscreants
putting poison in the food and drink of the people were in every
mouth.
Manzoni’s Colonna Infame is a simple unadorned narrative of the
trial and execution of the two Anointers, quite different in literary
form from his Promessi Sposi. It is written with a definite purpose in
view. Verri had introduced the story into his Observations on Torture,
merely as an illustration of the way in which the confession of a
crime, both physically and morally impossible, may be extracted by
torture. Manzoni retells the tale, in the interest of humanity at large,
to show that no matter how deep may have been the belief in the
efficacy of ointments, and despite the existence of a legislature that
countenanced and approved torture, it was competent to the judges
to convict them, only by recourse to artifices and expedients, of the
injustice of which they were perfectly well aware.
Manzoni’s Promessi Sposi is a happy blend of antiquarian
research and imaginative description, and the incidents of the plague
are dexterously woven into the fabric of his story. Manzoni wrote at
a time when literature, freed from the trammels of convention, was
being slowly brought into harmony with the outlook of modern
thought. Though an aristocrat by birth, his upbringing had taught
him to regard life with the eyes of the peasant, and not with those
of his overlord. In his genius for romance and in his reverence for
the past Manzoni has much in common with Scott, but with this
difference, that Scott sees the social fabric from above, Manzoni
from below. To Scott life was a pageant in which knights of chivalry
and courtly dames shared all the leading parts: Manzoni’s stage is
filled with men struggling to be rid of the yoke of feudal oppression.
The plague of Milan, falling alike on rich and poor, afforded him the
text from which to preach the essential equality of all men. His
whole narrative is so moulded as to throw into striking contrast the
vices of the rich with the virtues of the poor. The plague scenes, too,
give him scope for his remarkable insight into the psychology of
crowds, and for his skill in marshalling men in masses, a gift in
which he rivals Tintoretto. It is the genius of Manzoni that he
persuades without preaching.
 The total mortality of this pestilence in Milan has been estimated
roughly at 150,000 persons. The Sanità, or Board of Health, profiting
by the lessons of the previous plague, seem to have acted with
sense and energy, though hampered by the ignorant obstinacy of
the Senate, the Council of Decurions, and the Magistrates, who were
afraid of driving away trade, if the presence of plague were
admitted. One strange remedial measure was the organization of an
immense procession through the streets in honour of San Carlo.
During the procession all the sequestered houses were fastened up
with nails to prevent the infected inmates from joining in it. Deaths
were so numerous at the height of the plague that the burial-pits
were filled, and bodies lay putrefying in the houses and streets. The
Sanità sought the help of two priests, who undertook to dispose of
all the corpses in four days. With the assistance of peasants, whom
they summoned from the country in the name of religion, three
immense pits were dug. The Sanità employed monatti to bring out
the dead and cart them to the pits, and the priests accomplished
their task within the appointed time. Besides the monatti they
appointed apparitores, or summoners, who went in advance of the
monatti ringing a bell to warn the people to bring out their dead.
Commissari supervised both apparitores and monatti. Piazza was
one of these overseers.

The plagues of the seventeenth century have left behind them

very many memorials both in literature and in art: among them the
great plague of Milan is only one of many.
Southern France was attacked again and again, and in 1643
plague raged fiercely at Lyons. Over the portico of the church of
Notre-Dame de Fourvière, which stands high up on the precipitous
hill that overhangs the town, is a frieze commemorating this plague.
In Italy, city after city succumbed. Guido’s picture, ‘Il Pallione del
Voto,’ reminds us that Bologna suffered along with Milan. Venice
suffered too, and out of her ruin rose the church of S. Maria della
Salute.
Florence retains in the Bargello a hideous reminiscence of her
visitation in a wax representation of ‘Pestilenza’ by Zumbo Gaetano
Giulio (1656-1701). Corpses are lying about in various stages of
decomposition: among them lies a dead mother beside her infant
child. A man, whose nostrils are covered with a bandage, attempts
to carry away a corpse. In the background great bonfires are
burning. The modelling of the carcases is anatomically exact, but the
production as a whole is utterly repulsive.
In 1656 Naples assumes the leading rôle in this hideous Dance of
Death. Soldiers brought the plague on a transport from Sardinia. At
first the viceroy attempted to disguise the true character of the
disease. The first doctor who dared to pronounce the sickness
plague was promptly put in prison. Malcontents spread the report
that the Spaniards had designedly introduced the plague, and were
employing people to go through the city in disguise, sowing
broadcast poisoned dust. The infuriated populace turned on the
Spanish soldiery, who sought safety by transferring the accusation to
the French. Nothing but blood would satisfy the mob, and Angelucci
di Tivoli, reputed author of the plague powder, was broken on the
wheel as a peace-offering to their bloodt-hirsty fury. The Spaniards
were accused also of poisoning the holy water in the churches by
means of the deadly powder. Superstition was rampant in every
form. One said that he had been miraculously cured by drinking holy
water before an image of the Virgin. Another saw a marble statue of
the Madonna and Child in the church of S. Severo covered with
sweat, and the faces of both livid and marked by the plague. A
doctor, Francesco Mosca, who printed a formula for curing the
plague, was honourably entitled Protomedico. A nun prophesied that
the building of a convent on the hill of St. Martin for her sisterhood
would bring to an end the pestilence. The building was taken in
hand in eager haste, rich and poor vying in bodily labour, but in spite
of all their efforts the mortality grew apace. By a strange perversity
of reasoning penitential processions paraded both day and night the
very streets in which priests, in terror of the contagion, were
administering the Sacrament on the end of a stick. The death-roll of
six months was 400,000 lives. Various writers have described this
plague, among them Muratori, Giannone, and de Renzi in his Naples
in the year 1656, published in 1667. The Papal Nuncio in Naples at
the time thought fit to write a pamphlet on it, and of modern writers
Shorthouse has made poor use of it in his John Inglesant.
Micco Spadara (1612-79), who actually witnessed this plague,
has left a picture of it, which is now in the National Museum at
Naples. It represents the Piazza Mercatello, a veritable
pandemonium of dead and dying. Monatti, drawn from the galley-
slaves, are dragging the corpses with hooks to carts in which to
carry them to the burial-pits. Here and there sedan chairs are seen.
These were used to carry the sick to the lazarettos. At first chair-
bearers were selected from the citizens who volunteered for the
task, but when all these were dead, galley-slaves and convicts took
their place. In the plague of Marseilles in 1720 sedans were put at
the disposal of the doctors, ‘for their more easy conveyance
everywhere’, by order of the Town Council.
There was plague in Rome as well as Naples in 1656. Nicolas
Poussin (1594-1665) was resident in Rome, and has left the
testimony of an eye-witness in his picture, ‘The Plague of Rome,’
now in the Czernin Collection at Vienna. It is a landscape with
architectural features, of which Denio[179] gives this brief notice:
‘Two men are seen dragging a corpse to the mouth of a vault, whose
opening is already barred by dead bodies. A man, enveloped in a
white mantle, directs the bearers where to go: by his side is a
jackal-like dog. On the high platform of the receptacle we notice a
group of six men. Broken columns take the place of the half-seen
trees in other works, while sarcophagi and tombs indicate a
cemetery. Beyond the arch stretches the Campagna.’ Poussin has
introduced into the picture the Castle of S. Angelo, mindful, no
doubt, of the legend of Gregory’s vision.
 PLATE XXVI PLAGUE OF NAPLES, 1656.
BY MICCO SPADARA
Photograph by Brogi, Florence (Face Page 184)

The church of Santa Maria in Campitelli at Rome was rebuilt, in

its present form, in 1659, by Carlo Rainaldi, to accommodate a
miraculous image of the Virgin, to which the cessation of the plague
of 1656 was ascribed. The church is sometimes called S. Maria in
Portico, because of the neighbouring Portico of Octavia. The
miraculous Madonna is placed now beneath the canopy over the
high altar. It is still believed to protect Rome from the contagion of
pestilence. Here, too, came constantly the Elder Pretender and his
son Henry, who took his Cardinal’s title from this church, to offer
prayers to this self-same image of the Madonna, for the liberation of
England from the plague of Protestant apostasy. To this end James
instituted in perpetuity an office of prayer, and ordained that every
Saturday Mass should be said at 11 of the morning before the
picture, with the Sacrament exposed, and that after recital of the
prayers a blessing should be given along with the Sacrament. This
ceremony has ever since been regularly performed.
In the sacristy is a framed engraving of the miraculous Madonna,
dated 1747. It is surrounded by a series of small pictures, one of
which shows the appearance of the image to S. Galla in the
pontificate of John I (523-6), as she ministered to the wants of
twelve poor men in her house. Another shows Pope John dedicating
the miraculous picture in the oratory of S. Galla, which was
transformed later into the church of S. Maria in Campitelli. The
remaining pictures represent scenes in successive pontificates, in
which this miraculous Madonna brought about a cessation of plague.
A brief explanation in Latin is attached to each.
The plague of 1656 occurred in the pontificate of Alexander VII.
This Pope did much to atone for the craven spirit of his papal
predecessors by his courage and devotion to his people throughout
the epidemic. It is surprising that no memorial has been erected to
commemorate his services.
Two rare contemporary prints represent scenes in the course of
this visitation. One is figured by Lanciani in his Golden Days of the
Renaissance:[180] the other is reproduced here.[181] Both were to be
seen in the Medical Exhibition in the Castel S. Angelo in the spring of
1912. Lanciani’s print shows the following scenes:
1. Inspection of the city gates by Prince Chigi.
2. Barge-loads of corpses from the lazaretto on the
island of S. Bartolommeo.
3-5. Various methods of fighting the plague in
infected districts.
6. The ‘Field of Death’ near St. Paul-outside-the-
Walls.
 The second print is of even greater interest than this: the first
two rows of plates give some idea of the character of the lazarettos,
and show how they were guarded by palisades and sentries: they
also show the carts for transport of the sick attended by armed
soldiers. The disinfection of the books and personal ornaments of
the sick, a dead dog being dragged away to be thrown into the river,
and a sick-cart marked with a cross, are other details of interest. The
third row indicates the removal of infected goods to places outside
the city, where they were either washed or cleansed; places where
other things were deposited; a country residence of the Popes
converted into a convalescent home; and the ruined palace of the
Antonines, where woollen goods were taken for disinfection. The
fourth row represents chiefly wash-houses and washing-places, to
which clothes and bedding were removed for cleansing. The fifth
row, the execution of those who transgressed the sanitary
regulations, the shooting of sick criminals, and the various measures
taken to restrict the river traffic. A cable is thrown across the river,
and palisades are erected on the shores, so as to break all contact
between the city and boats bringing in provisions. The huts are
shown, in which soldiers and officials were lodged, whose duty it
was to compel obedience to the prescribed regulations.
PLATE XXVII PLAGUE SCENES IN ROME, 1656
From an old engraving (Face Page 186)
 CHAPTER XII
The Great Plague of London, which reached its height in 1665,
has left an abundant aftermath both in literature and art. The main
story of its ravages is too well known to call for repetition.
There were still some ready to see in the plague, as they were in
the case of the fire, evidence of the handiwork of malevolent Jews.
Since their expulsion from England by Edward I, the Jews had never
yet obtained the legal right of re-entry, their open petition to
Cromwell having failed. With the restoration of Charles II to the
throne, they seem to have taken the matter into their own hands
and found their way quietly back, so that at the time of the plague
there were many resident in London, to the great advantage of trade
and to the relief of an ever-needy Government. But three centuries
of plague, punctuated by fierce outbreaks at regularly recurring
intervals, had served to unravel much of the mystery of pestilence,
and the people had learnt that it was not to be exorcised by a
holocaust of Jews, or by the brutal murder of imaginary poisoners.
Celestial portents were not lacking to presage the plague. A
blazing comet appeared for several months before the plague. Men
affected to see, in its dull colour and slow solemn movement, a
prediction of the heavy punishment of pestilence; whereas that
which preceded the fire was swift and flaming and foretold a rapid
retribution.
Superstition raked up images afresh from the scrap-heap of
discarded fancies. Women saw flaming swords in the heavens, some
even saw angels brandishing them over their heads. Astrologers had
strange tales of malignant conjunctions of the planets. Medical
opinion was still divided along the same lines of cleavage, as it had
been for 2,000 years before. There were those who referred the
disease to some occult poison, and those who referred it to an
excess of some manifest quality, such as heat, or cold, or moisture,
in each case corrupting the body humours. Speculation was rife as
to the nature of the causal poison. Some, as Lucretius had done,
conceived it to be pestiferous corpuscles of atomic character, outside
the range of human vision, generated either in the heavens by a
malignant conjunction of planets, or in the soil, and so often
liberated by the agency of earthquakes. These poisons, however
generated, found their way into the human body through the
medium of the distempered atmosphere.
Some had noticed an unusual absence of birds before the
epidemic, as Thucydides and Livy had done in their times. Boyle
observed a great diminution of flies in 1665, Boghurst a
superabundance of flies and ants in 1664. Sir George Ent and others
attributed the disease to minute invisible insects, but Blackmore
conceived these to be rather a consequence than a cause.
Insects, so-called, had been vaguely associated with pestilence
from remote antiquity, more especially flies, lice, and locusts; but in
the medical literature of the sixteenth century and after they are
assigned a much more definite role. Mercurialis[182] states that huge
numbers of caterpillars paraded the streets of Venice during the
plague of 1576. Goclenus[183] mentions swarms of spiders during
the plague of Hesse in 1612, and Hildanus swarms of flies and
caterpillars this same year in plague-stricken Lausanne. Bacon
speaks of flies and locusts, as characteristic of pestilential years, and
Diemerbroeck[184] of flies, gnats, butterflies, beetles, grasshoppers,
and hornets in the same connexion. Gottwald[185] reported the
presence of multitudes of spiders during the plague of Dantzig in
1709. Arabian physicians considered the putrefaction of swarms of
dead locusts an important cause of pestilence. Hancock,[186] as late
as 1821, argued that locusts caused famine by destroying the crops,
and so prepared the way for human pestilence.
Talismans, amulets, reliquaries, and all the stock-in-trade of
magic were in brisk demand among the populace. Quack vendors of
antipestilential remedies innumerable effectively replaced physicians,
most of whom took refuge in flight. All honour to those who stood
fast at their posts and reclaimed for medicine what Galen had
renounced, the captaincy of its own soul. These are the men who
had no fear for ‘the pestilence that walketh in darkness or the arrow
that flieth by day’:
1. Dr. Francis Glisson Presidents of the Royal College
2. Sir Thomas Witherley of Physicians.
3. Dr. Nicholas Davys
4. Dr. Edward Deantry
5. Dr. Thomas Allen
6. Sir John Baber
7. Dr. Peter Barwick
8. Dr. Humphrey Brooks Fellows of the Royal College
9. Dr. Alexander Burnett of Physicians.
10. Dr. Elisha Coysh
11. Dr. John Glover
12. Dr. Nathaniel Hodges
13. Dr. Nathan Paget
14. Dr. Thomas Wharton
15. Dr. William Conyers Member of the Royal College
of Physicians.
16. Dr. O’Dowd
17. Dr. Samuel Peck
18. John Fife
19. Thomas Gray Members of Barber-Surgeons’
20. Edward Hannan Company.
21. Edward Higgs
And yet a few beside these, whose names are inscribed on no
human document, but whose deeds are imprinted in imperishable
type on the deathless record of righteous human endeavour.
 Nathaniel Hodges[187] shows us something of the daily life of a
physician in the course of this plague. He himself rose early, took his
antipestilential dose, attended to the affairs of his household, and
then repaired to his consulting room, where crowds awaited him.
Some, who were sick, he treated, others he reassured and sent
away. Breakfast followed, then visits to patients at their homes. On
entering a house he would vaporize some aromatic disinfectant on a
charcoal brazier: if he arrived out of breath, he would rest a while,
and then place a lozenge in his mouth, before proceeding to the
examination of his patients. After a round of several hours’ duration,
he would return home, drink a glass of sack, and then dine on roast
meat and pickles or some similar condiments, all of which were
reputed antidotal. More wine followed the preliminary curtain-raiser.
Afternoon and evening, till eight or nine o’clock, were devoted to a
second round of visits. His late hours he spent at home, a stranger
to noxious fumes of tobacco, quaffing sack, to ensure cheerfulness
and certainty of sleep. Twice the fatal infection seemed to have
slipped past his outposts, but Hodges had still his remedy: he merely
doubled the dose.
Of all the literature of pestilence none has been more widely read
than Defoe’s Journal of the Plague Year: all later records take their
colour from Defoe. Nevertheless, a careful study and comparison of
other contemporary accounts leaves little room for doubt that
Defoe’s picture does not accurately represent the general state of
London during the plague. His picture is far more true of Marseilles
in 1720 than of London in 1665, and in this connexion one should
remember that he had sedulously collected materials for a diary of
the plague of Marseilles, which have been printed in some editions
of his works. These can hardly have failed to colour his Journal,
which was not submitted to the public till 1722, two years after the
plague of Marseilles.
Defoe himself was but six years old at the time of the plague, so
that his own childish memories can have aided him but little in his
task. He will have had, at most, a dim recollection of some hideous
catastrophe, round which ranged tales of parents and friends in his
boyhood. To these he will have added facts and incidents borrowed
from the chief records available in print. Intrinsic evidence goes to
show that these were three: London’s Dreadful Visitation, Hodges’s
Loimologia, and Vincent’s God’s Terrible Voice in the City. The first of
these will have given him the Bills of Mortality and other general
information: the second, the aspect of the plague from a physician’s
point of view: the third, a vision of the plague as it appealed to
popular imagination.
That Defoe intended to write history and not fiction, there is no
reason to doubt. Judged only by the accuracy of his facts it is
history, but it is in the facts that he omits, just because he had never
heard of them, that he unconsciously lapses into fiction. Comparison
of details and incidents with the unimpeachable record of Pepys
confirms his accuracy, but it shows also that, by separating incidents
from their surroundings and by compressing his description to the
exclusion of all but selected incidents, the picture, as a whole, does
not accurately represent the aspect of the city, as it was. Pepys, who
was an actual eye-witness, has noted not only the most striking
events but those of everyday commonplace interest, so that his
narrative is far more true to life. Defoe, on the other hand, has
removed his picture from its setting. Pepys shows us that, though
the spectre of plague was everywhere, everyday life went on,
though in subdued fashion. Defoe would have us believe that all
activity was paralysed.
For all this, however, as one reads the Journal the narrative has
such an air of verisimilitude, that one instinctively pictures the writer
as describing what he has seen with his own eyes, so perfect is the
illusion. Mead, indeed, himself an authority on the plague and so
soon after the event, believed that the Journal was the authentic
record of an eye-witness. Defoe’s faculty of visualizing what he has
not seen is inferior only to the vividness with which he describes
what he has visualized.
 What is the secret of this vividness? More than all else, extreme
simplicity of language. The simple style was Defoe’s natural style,
and for that reason his use of it is fluent and easy, and knowing this
he fitly puts his story into the mouth of a simple saddler. Defoe
wrote for a growing class of readers of a lowly social order. He is the
apostle of the common people: that is why he imitates their way of
speaking. Not only is his narrative colloquial, but it deliberately
affects the language a saddler would use in reciting to his intimates
the memories of what he had lived through. There is no striving for
dramatic effect, no drawing of lurid pictures, no literary artifice, but
always the same sustained simplicity of diction, even in describing
the most appalling occurrences. There must be no chance of missing
the smallest point, so he even does such thinking as is necessary by
running comments on his own story.
The educated reader, particularly in these days, when even
literature is administered in tabloid form, must needs be wearied by
the prolixity, and irritated by the redundancy of the narrative. But
again it must be pleaded in extenuation that these very defects are
deliberate. Constant repetition, as every teacher knows, sooner or
later penetrates the densest brain.
But the Journal is something more than a mere chronicle, vivid
enough at that, of what happened, and how men behaved, during
the plague. Defoe regards the plague as the judgement of God, and
this attitude imparts a strong moral purpose to the work. This is why
he dwells so much on the mental and moral effects of the
catastrophe, inculcating his lesson without the appearance of undue
insistence. Pepys, as we know, could find heart to make merry
during the plague, just as Boccaccio depicted his company of
Florentines: to Defoe the mere idea of merriment is revolting. Pepys,
on New Year’s Eve, as he looked back over the abomination of
desolation, could make this entry in his Diary:
‘December 31, 1665. I have never lived so merrily
(besides that I never got so much) as I have done this
plague time ... and great store of dancings we have
 had at my cost (which I am willing to indulge myself
and wife) at my lodgings. The great evil of this year,
and the only one indeed, is the fall of my Lord of
Sandwich, whose mistake about the prizes hath
undone him.’
Pepys was a stranger to imagination: his pleasures and his griefs
were things of the surface and matters of the moment. His creed is
egoistic hedonism in all its naked brutishness. He is far more
concerned over the fire, where there is a chance of losing his
property, than over the plague where the chance is of losing his life.
His New Year’s Eve retrospect is not the only glimpse he gives us of
callous indifference to the horrors of the plague. Look at September
30, 1665, when the fiercest spell was only just past:
‘So to sleep with a good deal of content, and saving
only this night and a day or two about the same
business a month or six weeks ago, I do end this
month with the greatest content, and may say that
these three months, for joy, health, and profit, have
been much the greatest that ever I received in all my
life, having nothing upon me but the consideration of
the sicklinesse of the season during this great plague
to mortify mee. For all which the Lord God be praised!’
It was not that Pepys was unconscious of the terrible scenes of
suffering around him, only that he was unmoved by them. Into one
short letter to Lady Cartaret, at the height of the plague, he
compresses all the grim details that fill a volume for Defoe.
Historians frequently lay it down that the fire of London swept
away the plague. As a fact it probably had little to do with its
departure. Several English towns were as hard hit as London, and
yet in the absence of any conflagration subsidence and
disappearance of plague followed the same course as in London. At
Salonica,[188] about a.d. 1500, a fire which destroyed 8,000 houses
was actually followed by an outbreak of plague. It was a common
contemporary belief that the departure of plague from London was
hastened by the coming of pit-coal into general use, so that the
atmosphere was constantly permeated by sulphurous fumes.
Records in art of the Great Plague of London, though numerous,
are mostly unimportant. Generally artists have been content to
illustrate its copious literature. In 1863 Frederic Shields commenced
an intended series of illustrations of the Journal of Defoe. Ruskin
lavished great praise on the woodcuts, for their imaginative power
and for the superlative excellence of the design. Proofs of six of
these woodcuts were to be seen at the Memorial Exhibition of the
works of Shields (Alpine Club, September-October 1911). The set of
six comprised the following scenes:
1. The Decision of Faith
A man is seated at a table, on which lies a Bill of
Mortality, with his Bible open before him. He says to
himself, ‘Well I know not what to do, Lord direct me.’
His finger points to the answer in the open Bible:
‘Because thou hast made the Lord, which is my refuge,
even the most High, thy habitation: there shall no evil
befall thee, neither shall any plague come nigh thy
dwelling.’
2. The Death of the First-born
A youth lies in convulsions on a bed, while a
woman kneels beside it. In the background are bearers
carrying away a corpse: both are smoking pipes. On
the ground lies an hour-glass.
3. Solomon Eagle warning the Impenitent
Solomon Eagle stands with a brazier of live coals on
his head in a fierce preaching attitude before a group
of lewd young women at an open window.
4. The End of a Refugee
A man with a long hooked pole is dragging a
corpse along. Beside him stands a grave-digger with
 spade, dog, and dinner-basket.
5. The Plague-Pit
Bodies are being shot from a cart into a pit by the
light of a torch, which a man is holding.
6. Escape of an Imprisoned Family
The door of a house has been hacked down, and is
lying on a dead body.
George Cruickshank contributed four plates to Brayley’s edition of
the Journal of the Plague Year. Three of them, the ‘Dead Cart’, the
‘Great Pit in Aldgate’, and ‘Solomon Eagle’ are vivid and powerful;
the fourth, ‘The Water-man’s Wife’, feeble and commonplace.
The preaching of Solomon Eagle is the subject of a picture by P.
F. Poole, R.A., in the Mappin Gallery at Sheffield. The scene depicted
is taken from Harrison Ainsworth’s novel Old Saint Paul’s. It shows
Solomon Eagle, with the brazier of live coals on his head, nude but
for a loin-cloth; and discoursing to the terrified citizens outside old St
Paul’s Cathedral, during the plague. All around are strewn bodies of
dead and dying: a house displays the damning red cross and the
words ‘Lord have mercy upon us’. In the background bearers are
carrying away a corpse to burial.
An incident, that Pepys describes in his Diary under September 3,
1665, as follows, is represented in a modern picture by Miss
Florence Reason.
‘Among other stories, one was very passionate,
methought, of a complaint brought against a man in
the towne for taking a child from London from an
infected house. Alderman Hooker told us it was the
child of a very able citizen in Gracious Street, a saddler,
who had buried all the rest of his children of the
plague, and himself and his wife now being shut up
and in despair of escaping, did desire only to save the
life of this little child: and so prevailed to have it
 received stark-naked into the arms of a friend, who
brought it (having put it into new fresh clothes) to
Greenwich; where, upon hearing the story, we did
agree it should be permitted to be received and kept in
the towne.’
In 1679 a terrible epidemic of plague broke out in Vienna, then
an opulent city, with a population of some 210,000, and the seat of
Leopold, the Holy Roman Emperor. Our chief knowledge of the
visitation is derived from Sorbait (Consilium medicum oder
freundliches Gespräch), Abraham a St. Clara (Merk’s Wien), and
Fuhrmann (Alt- und Neu-Wien). The disease was preceded by an
epidemic of the ‘Hot Sickness’, (Hitzige Krankheit), which was very
fatal. Bubonic plague followed in its wake and Vienna presented the
spectacle of one huge lazaretto for the sick, one gigantic plague-pit
for the dead. Convicts, as at Naples, were employed both to nurse
the sick and bury the dead. Clothing, furniture, and bedding lay
littered in the streets mixed with the dead and dying. When carts
failed, the bodies were thrown into the Danube. A Plague Committee
strove in vain to shut up all infected houses and segregate the
inmates in lazarettos and stations of quarantine. Death by public
hanging was the penalty of disobedience. Some of the royal princes,
and foremost among them Prince Ferdinand of Schwartzenburg,
together with many of the nobility, devoted themselves courageously
to fighting the plague, undertaking even the most menial duties. But
many of the citizens and the Emperor himself fled. Leopold
conceived his obligations to his people discharged by a pilgrimage to
Maria-Zell to pray for cessation of the plague. Then he moved his
court to Prague, whence plague drove him to Linz.
During the plague the Viennese set up a wooden column, to
which frequent processions were made, observing the ancient ritual
of the Flagellants. At the end of the plague Leopold made a vow at
St. Stephan’s to replace it by a marble column, which was duly
erected in the Graben between 1687-93.
 An incident of this plague, the story of the street-singer Augustin,
who was thrown alive, but drunk, into the plague-pit, but escaped
none the worse for his experience, recalls the like occurrence in
Defoe. The man is said to have composed the familiar ‘O du lieber
Augustin’ in a beer-house on the very night he was thrown into the
plague-pit.
Amulets of various kinds were extensively employed in the
seventeenth century. In South Germany a common form was the so-
called Pest Penny. These had on one face, as a rule, the figure of St.
Benedict or St. Zacharias, and on the reverse some formula of
exorcism.
Vienna[189] fell a victim to outbreak after outbreak of plague, but
the experience gained in the visitation of 1679 enabled the
authorities to stamp out the infection in 1691 and 1709, before it
had grown out of hand. But in 1713 all preventive measures failed to
check its spread. Then, in the month of May, processions and litanies
were organized to the plague column. The Emperor Charles VI
remained in Vienna, and pronounced a solemn vow in St. Stephan’s,
that if the plague ceased he would erect a church as a thank-
offering. Such was the origin of the Karlskirche. This church is a rich
square edifice with a huge dome. It is the chef-d’œuvre of J. B.
Fischer von Erlach, commenced in 1715. The ravages of the plague
are portrayed in relief, by Stanetti, in the tympanum. Flanking the
portico are two domed belfries, resembling Trajan’s column, 108 feet
high, with reliefs from the life of S. Carlo Borromeo by Mader and
Schletter. In March 1714, when the plague died out after a total
mortality of 120,000, a thanksgiving Te Deum was sung in St.
Stephan’s, at which the emperor was present. Two series of
memorial coins were struck, the one showing the votive column, the
other the church dedicated to S. Carlo Borromeo.
The Plague Regulations, published in separate form at Vienna at
the time of this epidemic, give a good idea of current popular
opinion as to the nature of plague. There was no lack of adherents
for each belief of every preceding period. There were those who
regarded it as a signal evidence of God’s displeasure. There were
those who attributed it to poison in the air or food, generated in the
stars and spread by the malice of grave-diggers for their own
purposes. Even the Jews were incriminated. There were those who
read its origin in the conjunction of certain stars. Others ascribed it
to famines, to poisonous fumes set free by earthquakes, to comets,
and even to dry seasons through the multiplication of insects. Come
how it might, clouds taking the form of biers and funeral
processions, noises in churchyards, and dreary sounds in the air
foretold its coming. On infected bodies the virus was often visible as
blue sulphurous fumes. There were clearly also some who conceived
a natural origin. A doctor, named Gregorovius, dissected three dead
bodies in search of the cause, but failed to find it. His intrepid zeal
was duly rewarded by the Emperor and by the Faculty of Medicine in
Vienna.
Conformably with the varying conceptions of cause, remedies
were varied and multifarious. Some pinned their faith to a devout
life, aided by processions and penitential sermons. Some lit fires to
cleanse the air, at times adding sulphur. A host of herbs, chief
among them Angelica, enjoyed repute as antipestilential remedies.
The simple life appealed to some, purgatives and blood-letting to
others.
But side by side with this ill-assorted medley of measures, a code
of sanitary precautions had slowly grown up. Early notification by the
doctors, quarantine of suspects and segregation of the sick,
cleanliness and disinfection were all recommended and sedulously
executed, and supplied in embryo the essential principles of modern
sanitary science. Doctors were enjoined to keep sober, to fumigate
themselves, and to wear silk or taffetas, to which the virus would
not cling. We have arrived indeed at the parting of the ways, and
henceforth the stream of medical science, polluted less and less by
the surface waters of superstition, flows on clear and full in its
appointed channel. The sun of science emerges at length from its
protracted winter solstice.
 CHAPTER XIII
In the year 1720 plague found its way to Marseilles. It was
believed to have been brought by a ship, the Grand-Saint-Antoine,
which arrived on May 25 from the Levant. As usual, the attempt was
made to hush it up for the sake of trade. At the beginning of August
something had to be done, so on the advice of two physicians,
Sicard, father and son, it was decided to light bonfires throughout
the city. For lack of firewood this was not done, but also for lack of
faith, for it was found that despite their vaunted specific, the Sicards
had fled the city. So sulphur was served out to the poor instead,
wherewith to ‘perfume’ their houses.
As early as August 2 the Town Council found it necessary to
adopt special measures to keep physicians and surgeons to their
task. Accordingly, they decided that the city should pay them a fixed
salary in place of fees from the sick, and allow them smocks of oiled
cloth, and sedan chairs to carry them on their rounds. There are
several illustrations extant of the dress adopted by doctors in the
plague of Marseilles. The same dress, with trifling variations, was
worn elsewhere in France, in Switzerland, and in Germany, and had
originated in Italy. It is shown in an old Venetian woodcut of a.d.
1493, from the works of Joannes de Ketham (Fasciculus Medicinae,
1493). This woodcut shows a physician in a long overall, but wearing
only a skull-cap on his head, visiting a plague patient in bed. He is
accompanied by attendants who carry lighted torches, while he
himself holds a medicated sponge before his mouth and nose, as he
feels the pulse. Grillot figured the dress as the frontispiece of his
Lyon affligé de la peste 1629, and Manget[190] has borrowed it from
him. From his description it would seem that the mantle, breeches,
shirt, boots, gloves, and hat were all of morocco leather. The beak
attached to the mask was filled with aromatics, over which the air
passed in respiration, and had an aperture for each eye, fitted with a
disk of crystal.
 PLATE XXVIII,
1. DRESS OF A MARSEILLES DOCTOR,
1720
 PLATE XXVIII,
2. GERMAN CARICATURE
OF THE SAME

(Face Page 200)

M. Reber[191] describes an engraving by John Melchior Fuesslin,
representing a doctor in the plague of Marseilles. The legend
beneath it, in German, is (translated) ‘Sketch of a Cordovan-leather-
clad doctor of Marseilles, having also a nose-case filled with smoking
material to keep off the plague. With the wand he is to feel the
pulse.’ Reber’s and Manget’s plates are both reproduced in the Bristol
Medico-Chirurgical Journal, March 1898, from the Janus blocks.
Gaffarel[192] gives the costumes both of a doctor and of a hospital
attendant: they closely resemble the dress of the Italian charitable
guilds of the fifteenth and sixteenth centuries.
By August 9 some of the physicians and almost all the master-
surgeons had fled, and an ordinance was issued demanding their
return, or in default their expulsion from their respective
corporations, and other special penalties as well. Two physicians
named Gayon volunteered their services for the Hôpital des
Convalescents, but forthwith paid the penalty with their lives. In the
absence of sufficient physicians in Marseilles, others were
summoned from Montpellier, Paris, and elsewhere. These exhausted
their energies in a dispute over the contagious character of plague.
Chicoyneau and Chirac maintained that it was not contagious.
Deidier proved, by successfully inoculating dogs with bile taken from
plague subjects, that at any rate it was communicable. Each
subsequently expounded his views in a formal discourse before the
School of Montpellier.
Existing hospital accommodation was quite unequal to the needs.
Emergency tents were erected outside the town, with mattresses for
the sick. Chevalier Rose equipped and maintained a hospital in the
district entrusted to him, at his own expense. A large temporary
hospital of timber covered with sail-cloth was hurriedly erected, but
when almost finished towards the end of September it was blown
down by a gale, and was not rebuilt till October 4. This hospital,
together with the Hôpital Général de la Charité of 800 beds,
provided ultimately sufficient accommodation, so that none need
remain in the streets.
From the first the mortality was such that it was wellnigh
impossible to bury the dead. On August 8 the Assembly resolved
that carts should be used to carry the dead to burial, and that pits
should be dug in which the bodies could be buried in lime. So two
huge pits were dug outside the walls, between the gate of Aix and
that of Joliette, M. Moustier overseeing the diggers and compelling
them to work. Chevalier Rose also had pits dug and organized a
corps of buriers in his own district. The duties of burial were at first
entrusted to sturdy beggars, but in a brief space of time the supply
of these failed, so that bodies began to accumulate in the houses
and streets. Then convicts were requisitioned in relays from time to
time.
These convicts were promised their liberty, to excite them to
work—a promise that was never fulfilled in the case of the few who
survived the task. Their ignorance of the management of carts and
horses, their idleness and lust of robbery rendered them so unfit for
the task, that Moustier and the other sheriffs and Chevalier Rose
were compelled to be always present on horseback, to superintend
the work. By August 21 corpses had already begun to accumulate in
old parts of the city, where the streets were too narrow and steep
for the carts to go. Accordingly, an order was issued that the vaults
of the churches in the upper town should be used for burials in
quicklime, and that, when full, they should be sealed up with
cement. By the end of August the streets were literally strewn with
dead bodies, some in an advanced stage of putrefaction, mingled
with cats and dogs that had been killed, and bedding thrown out
from the houses. The square in front of the building called the Loge,
as also the Palissadoes of the port, were filled with bodies brought
ashore from ships in the roadstead, to which whole families had fled
in the belief that plague would not reach them on the water.
By September 6 more than 2,000 dead bodies were lying in the
streets, exclusive of those in the houses. On the esplanade called La
Tourette, lying towards the sea between the houses and the
rampart, 1,000 corpses had lain rotting for weeks in the sun and
emitting a frightful stench. They were too rotten even to be lifted
into carts, and too foul to be carried to distant pits. Chevalier Rose,
mindful maybe of Procopius, conceived the idea of throwing them
into two huge vaults in the old bastions close to the esplanade, after
breaking in their roofs. The task was carried out in fierce haste by
100 galley-slaves, who tied handkerchiefs dipped in vinegar over
their mouths and noses. At the same time fishermen netted 10,000
dead dogs floating in the port and towed them out to sea.
 In the parish of St. Ferriol, the finest quarter of the city, Michel
Serre the painter undertook to see to the burial of the dead, with
carts and galley-slaves placed at his disposal, himself providing food
and lodging for the workers. A grateful city has repaid him by
hanging his two large pictures of Marseilles during the plague close
beneath the ceiling of an underground cellar, where it is impossible
to decipher their details.
When all the bodies were disposed of, the sheriffs employed the
galley-slaves to clear the filth from the streets and throw it into
barges, which carried it out to sea.
In the early days of the epidemic, the sheriffs had forbidden the
annual procession on August 16, in honour of St. Roch, at which the
saint’s bust and relics were carried through the streets; but the
people raised such an outcry that the procession was celebrated, the
sheriffs attending with their halberdiers to prevent a crowd following.
By September 7 even the civil authorities had come to regard the
plague as an instrument of God’s wrath, and the magistrates, to
appease it, vowed that every year the city should give 2,000 livres to
a House of Charity, to be established under the protection of our
Lady of Good Help, for orphans of the province.
At the height of the plague many parish priests and some of the
monks fled: the services of the Church were mostly suspended. But
many secular clergy and monks remained and devoted themselves
unflinchingly to the sick. The bishop, Belsunce, nobly played his part.
Wherever the poorest lay, there he went confessing, consoling, and
exhorting them to patience. To the dying he carried the Sacrament,
to the destitute the whole of his money in alms. Though plague
invaded his palace and carried off those about him, it spared him. It
is of him that Pope[193] asks,

Why drew Marseilles’ good Bishop purer breath

When nature sickened, and each gale was death?
 On All Saints’ Day, Belsunce headed a procession through the
streets from his palace, walking barefoot, as Borromeo of old, with a
halter about his neck, and carrying the cross in his arms. He wished
to appear among his people as a scapegoat laden with their sins,
and as a victim destined to expiate them. Accompanied by the
priests and canons of the Church he led the way to a place where an
altar had been erected. There, after exhorting the people to
repentance, he celebrated Mass before them all. Then he solemnly
consecrated the city to the Sacred Heart of Jesus, in honour of which
he had instituted a yearly festival. The tears coursing down his face
as he spoke moved all to cry aloud to the Lord for mercy. On
November 16 Belsunce was emboldened to exorcise the waning
plague. Calling together all that remained of the clergy to the church
of Acoulles, he read all the prayers that the Pope had prescribed for
deliverance from plague. Then after an eloquent and moving
exhortation he carried up the Holy Sacrament to the cathedral’s roof,
and there, under the open sky, with all the city lying before him,
uttered a solemn benediction, and performed the full ritual of
exorcism according to the forms of the Roman Catholic Church.
Belsunce was not the first human scapegoat to tread the streets
of Marseilles in voluntary expiation for its people. In times of
pestilence, in the old Greek colony of Massilia, one of the lower
orders offered himself on behalf of his fellow citizens. Dressed in
sacred garments and decked with sacred boughs he was led through
the streets, amid the prayers of the people that their ills might fall
on him, and then cast out of the city.
There stands this day on a lofty crest of land in the open square,
right in front of the episcopal palace of Marseilles, a statue of
Belsunce in bronze, by Ramus. The stone pedestal bears a
commemorative inscription and two reliefs in bronze. In one,
Marseilles in woman’s form is lying among her stricken children,
while Belsunce and his attendant priests implore the Sacred Heart to
stay the plague. In the other, Belsunce bears the Sacrament to sick
and dying.
 The statue of Belsunce, clad in full episcopal robes, stands with
face raised and arms outstretched to heaven, in attitude of earnest
supplication. Before him Nature has set a landscape of surpassing
beauty: sea, earth, and sky give freely of their best. Far down below
a polyglot people move hither and thither around the harbour quays,
like ants, at their appointed tasks. Beyond it spreads a matchless
expanse of Mediterranean sea, now smooth and silvery as a mirror,
now fretful with the rising tide. Away over the sea and over the low
land that bounds the bay, the evening sun lights up the face of
Belsunce with a last lingering radiance, as it goes down to its setting
in a glory of golden hues. If man’s graven image may enjoy the
perfect happiness denied to man, then surely Belsunce has his
reward.
Marseilles is rich in reminiscence of her bishop. In the Bureau
d’Intendance Sanitaire hangs a pleasing portrait of Belsunce by
Gobert; while in the Musée may be seen a poor picture, by Mansian,
of him giving the Sacrament to the victims of the plague. François
Gérard (1770-1837) presented his ‘Peste de Marseille’ to the Bureau
d’Intendance Sanitaire, where now it hangs. The wan dismal
colouring of the picture accords ill with the striking vigour of the
composition. In the foreground is set forth the whole tragedy of a
family stricken with plague. On the ground lies the father writhing
with agony: his hands are clenched, his eyes are starting from their
sockets: the dressing in the right armpit indicates one site of the
disease. The mother, seated on a chest, clasps to her body her elder
boy, wrapped in a blanket, too weak to stand: the younger child
leans against his mother, his eyes fixed in terror on his dying father.
Anguish is depicted in the death-like pallor of the mother’s face. In
the background Belsunce in full robes distributes to the sick and
starving poor the bread which an attendant is carrying. To the left of
the foreground bodies of the dead are lying huddled up beneath an
awning, while to the right convicts are dragging corpses away for
burial. The sublime serenity of the good bishop seems to bring to his
stricken people in their anguish some promise of that peace which
passeth all understanding.