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[W]hat was most terrible in the whole affliction was the despair when someone realized he was sick, for immediately forming the judgment that there was no hope, they tended much more to give themselves up instead of holding out.Thucydides, The Peloponnesian War1(p51)
[W]hat was most terrible in the whole affliction was the despair when someone realized he was sick, for immediately forming the judgment that there was no hope, they tended much more to give themselves up instead of holding out.
Thucydides, The Peloponnesian War1(p51)
The emergence of plague is as frightening a prospect now as it has been throughout recorded history. From its earliest description in Athens in the 5th century BC,1 an understanding of the psychological factors involved has been considered critical. How can hope be sustained during a pandemic? The cause of the pandemic and actions taken to prevent its spread, medical treatment, personal support, painting, literature, and religion may all play a role.
Cover: Nicolas Poussin (1594-1665), French. The Plague of Ashdod, 1630. Oil on canvas, 148 × 198 cm. Musée du Louvre, Paris, France, Giraudon/Bridgeman Art Library.
Alexandre Yersin2 identified the bacterial etiology of bubonic plague in Hong Kong in 1896 when Louis Pasteur (who had previously treated Yersin for rabies) sent him to search for its cause. Another of Pasteur's students, Paul-Lewis Simond,3 identified the rat flea (xenopsylla cheopis) as carrying the infecting agent. The causative bacterium, Yersinia pestis,4 is a clone that evolved from Yersinia pseudotuberculosis 1500 to 20 000 years ago before the first pandemics of human plague. Paleomicrobiologists have distinguished 3 biovars (Antiqua, Medievalis, and Orientalis) of the Y pestis clone that may have been linked successively to the plague pandemic in the 6th century (the Justinian plague), one in the early Middle Ages, and the current plague pandemic.5 It is proposed that in the future more refined groupings may be based on molecular signatures when investigating the history of the plague bacteria.4 Amplification of Y pestis–specific DNA from dental pulp in victims of the Justinian plague and in victims of the 16th to 18th centuries in southern Europe has documented the presence of Y pestis in suspected cases.6,7
Plague was not the only cause of epidemics but history records its deadly impact. The first recorded outbreak of an epidemic consistent with plague occurred in Athens at the outbreak of the Peloponnesian War in the summer of 430 BC. One in 3 people (300 000) died: among them was the great orator Pericles. Thucydides survived the epidemic and documented its symptoms in both humans and animals. Because cremation was practiced in Athens, no tissue is available to carry out DNA analysis, so the exact cause may never be known. The first pandemic (the Justinian, AD 541-750) began in Ethiopia and spread quickly to Egypt, the Middle East, and parts of Mediterranean Europe. Others followed in 8- to 12-year cycles, resulting in the deaths of 50% to 60% of the population during this 200-year interval.8 For 600 years, plague was absent from Europe. The second pandemic, which began between AD 1330 and 1346, has been linked to global trade, war, crowding, poor nutrition, and poor sanitation. New and expanded trade routes to China, north of the traditional Silk Road, passed near southern Mongolia and northwest China where infected marmots were the source. It is said that in a battle at Caffa (present day Feodosia) in Crimea, the Mongols catapulted the bodies of dying plague victims into the city, an early form of biological terrorism.8
In the early Middle Ages, plague was spread by Genoese ships along trade routes that entered Europe through Messina, Genoa, and Marseilles in November 1347 and spread throughout the known world, resulting in the death of 30% to 40% of the population. The medieval physician Guy de Chauliac, dean of the oldest medical university in Montpellier, survived the plague and was asked by Pope Clement VI to track the epidemic that year.8 He found both bubonic and pulmonary forms with a mortality rate of 42%. The Renaissance masterpiece Decameron,9 by Giovanni Boccaccio (1313-1375), describes the plague in Florence, Italy, in 1348. He attributes it to the influence of heavenly bodies or divine righteous anger for “our iniquitous way of life.”9(p5) He emphasized the importance of interpersonal comradeship, displacing sorrow with joy, to combat fear and melancholy. In the Decameron, 7 ladies and 3 young men who have fled Florence entertain one another with story telling. Boccaccio provides a contemporary description of the plague:
[I]ts earliest symptom, in men and in women, was the appearance of certain swellings [buboes] in the groin or the armpit, some were egg-shaped whilst others were roughly the size of the common apple. . . . Later on, many people began to find dark blotches on their arms, thighs, and other parts of the body.9(p5)
These blotches were said to be an infallible sign of impending death and most died within 3 days. Medical treatment was “profitless and unavailing.”9(p5) They believed that plague spread from person to person like a racing fire via contact with an infected person or by handling the clothing or objects owned by an ill person. There was breakdown in civil life: some lived in isolation, others threw caution to the wind; husbands abandoned wives, and mothers their children. Such was the multitude of corpses that “there were no tears or candles or mourners to honour the dead.”9(p11) Plague recurred in 2- to 5-year cycles until the beginning of the 18th century. In Italy, there were epidemics in 1575, 1630, and 1656.
In the midst of the 1630 epidemic (which was most severe in Milan), Nicolas Poussin (1594-1665), in Rome (where public health measures prevented spread into that city), began a painting now known as The Plague of Ashdod, completing it in 1631. His intention in choosing this subject is not clearly known. Boeckl10 relies on Poussin's testimony in a court case when he referred to the painting as The Miracle of the Ark of the Covenant in the Temple of Dagon11(p275) at the 1631 trial of the Sicilian connoisseur, D Fabritio Valguarnera, who had fraudulently purchased the painting from him using the profits from stolen diamonds. Her interpretation is based on the biblical story from the book of Samuel. His preliminary drawing emphasized the Ark scene and did not include the central image of the mother and child, a then current plague image made popular by Raphael in his drawing The Plague of Phrygia.
Poussin was a French painter born in Normandy who worked mainly in Italy; he is best known for his highly imaginative paintings of biblical and mythological subjects that evoke the spirit of classical literature. In both the Old and New Testaments of the Bible, plagues are described as a divine means of justice and punishments. The best known of these are the 10 plagues of Egypt described in the book of Exodus. Among these pestilence is one of the most serious. Pestilence was used in retaliation against the Philistines, who captured the Ark of the Covenant (1 Samuel 5:1-6) from the Jews. The Ark of the Covenant was a large sacred chest containing the tablets of the Mosaic Law (the 10 Commandments) and signifying to the people of Israel that God was with them. It was kept in the most sacred portion of the Temple in Jerusalem. Yahweh stated that he would dwell in a cloud between the wings of the cherubim above the Mercy Seat (Leviticus 16:2) and His voice would be heard from between their wings (Numbers 7:89; Exodus 25:22).
The Philistines defeated the Israelites, killed 30 000, and captured the Ark and set it in the temple of Dagon (a major Philistine deity) in front of his statue, in the city of Ashdod. The following morning, the Philistines found Dagon face down before the Ark. Setting the idol up, the priests left, only to return and find Dagon fallen again with his head and hands cut off. A plague of tumors appeared in that city and in other Philistine cities where the Ark was taken until it was returned 7 months later. Poussin seems to have taken the plague of tumors to be the bubonic plague, although they were not interpreted this way previously. He also places rats in Dagon's temple, apparently based on a reading of the Latin Vulgate bible (used in the Middle Ages) where rodents are associated with plagues but not seen as etiologic agents.
Poussin's painting depicts both the destruction of Dagon and the horror of the plague. Boeckl10 emphasizes the biblical story whereas Barker12 focuses on the painting as illustrating Aristotle's tragic plot, the plague, and the plight of the Philistines. The cityscape setting depicted is taken almost exactly from the design by Sebastiano Serlio for the Tragic Stage.13 Dramatically, the Philistines experienced the 3 elements of the tragic plot: reversal of fortune (from happiness to misery), state of recognition (from ignorance to knowledge), and suffering (dying and death). The viewer is drawn through pity and terror to master these emotions in themselves. Poussin’s contemporary Robert Burton wrote in his Anatomy of Melancholy that when other remedies for melancholy fail, “it will not be amiss . . . to drive out one passion with another, or by some contrary passion . . . to dispel one fear with another, one grief with another. . . .”14(p146) Thus, through empathy with the afflicted, the emotions are purified through catharsis.
At the left of the painting, a crowd stands before the temple of Dagon, witnessing that, through the power of the Ark, Dagon's head and hands are broken off. The Ark with its cherubim seems suspended above him. Rats are seen in front of Dagon's temple. In the foreground, a man holds his nose and reaches out to a child, who looks up from the breast of his dead mother; another child lies dead beside her. A column has fallen in front of the temple. The stench of the plague is in the air and figures cover their noses. In the background, bodies are being carried away. Spectators look on in horror from an upper balcony, and others retreat from the city in the distance. The figure on the stairs may be reporting the events to the Philistine priest Eli. The infant in the center may be Ichabod, Eli's heir. The composition draws our attention to how the Philistines touch one another. The man in the blue toga is barely touched on his left arm by the man behind him. The man with a turban in the center in the foreground lightly touches the head of the dead mother's infant. The man in the yellow tunic entering from the right reaches behind him to gently touch the boy's shoulder. Is Poussin depicting fear of contagion by touch or tenderness in reaching out to touch others?
If divine judgment for malfeasance caused the plague, what was the Church's remedy? It was in ministering to the sick, encouraging penitence (confession) and charitable donations to the sick, administering the sacraments, and providing forgiveness for sins to reinstill hope. San Carlo Borromeo (1538-1584), Archbishop of Milan, embodied the religious approach to the plague in Milan in 1576 and 1577, “combining private and public penance with selfless, personal ministry to the afflicted.”15 In Pierre Mignard's (1612-1695) Saint Charles Borromeo (1538-84) Administering the Sacrament to Plague Victims in Milan (Figure), he is shown ministering to the sick and dying of the lazaretto (quarantine hospital) and camps of huts outside the city walls. In the painting, cherubs spread incense, attempting to cleanse the miasmatic air. Borromeo offers the host to a plague-stricken woman, her son clinging to her, an image of hope and caring in contrast to the desperation of the mother and child scene at the center of Poussin's painting. With little hope for their survival, Borromeo offers solace to the dying.
Pierre Mignard, Saint Charles Borromeo (1538-84) Administering the Sacrament to Plague Victims in Milan, ca 1647. Oil on canvas, 122 × 90 cm. Musée des Beaux-Arts deCaen, France, Giraudon/Bridgeman Art Library.
Harris JC. The Plague of Ashdod. Arch Gen Psychiatry. 2006;63(3):244–245. doi:10.1001/archpsyc.63.3.244
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