Learning from the past in the COVID-19 era: rediscovery of quarantine, previous pandemics, origin of hospitals and national healthcare systems, and ethics in medicine.

After the dramatic coronavirus outbreak at the end of 2019 in Wuhan, Hubei province, China, on 11 March 2020, a pandemic was declared by the WHO. Most countries worldwide imposed a quarantine or lockdown to their citizens, in an attempt to prevent uncontrolled infection from spreading. Historically, quarantine is the 40-day period of forced isolation to prevent the spread of an infectious disease. In this educational paper, a historical overview from the sacred temples of ancient Greece-the cradle of medicine-to modern hospitals, along with the conceive of healthcare systems, is provided. A few foods for thought as to the conflict between ethics in medicine and shortage of personnel and financial resources in the coronavirus disease 2019 era are offered as well.

[Philo of Alexandria and his views on health and sickness]. / Gesundheit und Krankheit bei Philo von Alexandrien.

Philo of Alexandria, Torah scholar and philosopher of religion, (c. 20 BC to 50 BCE) is the first Middle Platonic philosopher whom we know through his own works. His thinking was determined by the two antitheses of God and world, and virtue and vice. The Logos (divine reason) mediates between the transcendent God and the earthly world. His thoughts on health and illness and on the possibilities and limitations of medicine are testimony to his comprehensive philosophical education as well as to his belief in God as ruler of the world and of human life. He saw human health as the reward for self-control for which one was best prepared by the classical education programme. Self-control and physical exercise were therefore, in his view, possible guarantors of health, and a coach potentially more important than a physician. Illnesses, if they result from the loss of self-control, may point to the necessity for penitence. Philo therefore saw virtuousness as the safest precondition for a healthy and cheerful life. That the life forces increase during youth and diminish in old age is part of destiny. Similarly, illness can be brought about by strokes of fate. If illness occurred in this or any other way, medicine was there to help and its success or failure depended on divine providence. Like Jesus Sirach, the Jewish scholar who taught around a hundred years earlier, Philo did not think it sinful to use medical help if one was ill, seeing that God himself had made natural remedies available. He compared the importance of physicians for their patients to that other professionals have in people's lives. Philo did not provide a compendium on the work of the physician, but he gave indications, on nutrition for instance, or on the use of laxatives and fragrances, or that complaints can be necessary stages of recovery. Philo also asked himself whether physicians were always obliged to tell patients the truth. The only case of illness he described in sufficient detail was one of leprosy, which he diagnosed in accordance with Leviticus 13:2. Philo saw physicians as helpers of God, who was the Lord of life and who would therefore decide on the fate of the healthy and sick. Faith in God, Philo thought, was vital if one was to cope with life's ups and downs. Only the wicked had to fear death, however, while the souls of the righteous returned to heaven after death.

The ophthalmic trials of G. H. A. Hansen.

G. H. A. Hansen (1841-1912) is widely known as the discoverer of the infectious cause of leprosy. It is less well known that his career was threatened by an episode involving experimentation on the eye. As a staff physician at the leprosy hospitals of Bergen, Norway, early in his career, Hansen learned about ocular involvement in leprosy and co-authored Leprous Diseases and the Eye. In 1873 he observed bacilli in leprous nodules, but proof of an infectious origin was difficult to obtain because the agent could not be cultured and no one had demonstrated direct transmission. Hansen tried several unsuccessful experiments, and in 1879 he passed a cataract knife that had incised an active leprous nodule into a woman's conjunctiva. No nodule developed, but the woman complained of pain and said she was never asked for permission. Hansen was brought to trial where eminent physicians testified on his behalf-but Hansen himself readily admitted that no permission had been sought for fear the woman would say no. He was convicted, and relieved of his post as staff physician, but he was allowed to retain an appointment as Chief Medical Officer of Health for Leprosy, in which capacity he worked for the rest of his life.

[Human experimentation in dermatology 100 years ago and today]. / Versuche am Menschen in der Dermatologie vor 100 Jahren und heute.

The problem of ethics in dermatology is explored using selected examples from the literature. The classic case of Neisser as well as Eduard Arning's experiments on a Hawaiian with leprosy convicted to death are discussed. In addition, inoculation studies with syphilis 100 years ago and the author's own experiences are cited. The differences in the approaches to medical ethics 100 years ago and today lead to the conclusion that ethics change to fit the needs of the society and do not have a permanent fixed status.

Research ethics--a brief historical review to 1965.

Most discussions on modern research ethics--particularly the formation of research ethics committees (institutional review boards)--focus on the revelations of the dreadful practices in the Nazi concentration camps at the Nuremberg trial after the second world war, with the subsequent production of the Nuremberg and Helsinki Codes. In fact, however, these trials were not pivotal: there was a long history of such concerns, going back at least to the 1830s, when William Beaumont introduced a contract with his patient Alexis St Martin, as well as the later part of the century when the celebrated leprosy worker Hansen was prosecuted in Bergen for having experimented on a patient without her consent, losing his post as a result. Probably, had it not been for the entry of the USA into the First World War, public indignation at the growing number of reports of unethical experimentation in public hospitals would have resulted in regulations, while official codes were introduced in Prussia at the turn of the century and in Berlin again in 1931. Nevertheless, the impetus for modern developments came principally from the furore aroused by the proselytising of two physicians: Henry Beecher, an anesthesiologist at Harvard, and Maurice Pappworth in London, whose respective books Experimentation in Man and Human Guinea Pigs, documented case histories of egregiously less than ethical research practices that went largely unquestioned by other clinical research workers. Here I shall discuss the reactions to and influence of some of these episodes, as well as more recent developments.

On the obligation of physicians to treat AIDS: is there a historical basis?

This study examines the historical bases of what physicians ought to do as well as what they actually have done with regard to the treatment of diseases such as AIDS, which put them at risk for their lives. The earliest explicit statement of what ought to be done goes back only to 1847, when the American Medical Association was founded. However, this statement conflicts with a 75-year-old assertion that physicians have a right to choose whom they will serve. The conflict is compounded by the suspicion that both stated principles were based, at least in part, on socioeconomic considerations rather than moral imperatives. Of what physicians have actually done over the last 2,400 years, little more can definitely be said than that many have not tried to escape mortal risk while others have done so. Thus it is difficult to employ history as a basis for claiming that physicians have an obligation to treat AIDS.