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Contemporary accounts of the plague are often varied or imprecise. The most commonly noted symptom was the appearance of buboes (or gavocciolos) in the groin, the neck and armpits, which oozed pus and bled when opened.[20] Boccaccio's description is graphic: In men and women alike it first betrayed itself by the emergence of certain tumours in the groin or armpits, some of which grew as large as a common apple, others as an egg...From the two said parts of the body this deadly gavocciolo soon began to propagate and spread itself in all directions indifferently; after which the form of the malady began to change, black spots or livid making their appearance in many cases on the arm or the thigh or elsewhere, now few and large, now minute and numerous. As the gavocciolo had been and still was an infallible token of approaching death, such also were these spots on whomsoever they showed themselves.[21] Ziegler comments that the only medical detail that is questionable is the infallibility of approaching death, as if the bubo discharges, recovery is possible.[22] This was followed by acute fever and vomiting of blood. Most victims died two to seven days after initial infection. David Herlihy identifies another potential sign of the plague: freckle-like spots and rashes[23] which could be caused by flea-bites. Some accounts, like that of Louis Heyligen, a musician in Avignon who died of the plague in 1348, noted a distinct form of the disease which infected the lungs and led to respiratory problems[20] and which is identified with pneumonic plague. It is said that the plague takes three forms. In the first people suffer an infection of the lungs, which leads to breathing difficulties. Whoever has this corruption or contamination to any extent cannot escape but will die within two days. Another form...in which boils erupt under the armpits,...a third form in which people of both sexes are attacked in the groin.[24] Naming Medieval people called the catastrophe of the 14th century either the "Great Pestilence"' or the "Great Plague".[25][26] Writers contemporary to the plague referred to the event as the "Great Mortality". Swedish and Danish chronicles of the 17th century described the events as "black" for the first time, not to describe the late-stage sign of the disease, in which the sufferer's skin would blacken due to subepidermal hemorrhages and the extremities would darken with a form of gangrene, acral necrosis, but more likely to refer to black in the sense of glum or dreadful and to denote the terror and gloom of the events. Gasquet (1908) claimed that the Latin name "atra mors" (Black Death) for an epidemic first appeared in modern times in 1631 in a book on Danish history by J.I. Pontanus, where Pontanus wrote about a disease that occurred in 1348: "Vulgo & ab effectu atram mortem vocatibant." (Commonly and from [its] effects, they called [it] the black death.).[27][28][29] However, Gasquet doubted that Pontanus was referring to bubonic plague. Nevertheless, the name spread through Scandinavia and then Germany.[30] In England, it was not until 1823 that the medieval epidemic was first called the Black Death.[31] Causes Yersinia pestis (200x magnification). The bacterium which causes bubonic plague.[32] The Oriental rat flea (Xenopsylla cheopis) engorged with blood after a blood meal. This species of flea is the primary vector for the transmission of Yersinia pestis the organism responsible for bubonic plague in most plague epidemics. Both male and female fleas feed on blood and can transmit the infection. Oriental rat flea (Xenopsylla cheopis) infected with the Yersinia pestis bacterium which appears as a dark mass in the gut. The foregut (proventriculus),of this flea is blocked by a Y. pestis biofilm; when the flea attempts to feed on an uninfected host Y. pestis is regurgitated into the wound, causing infection. Medical knowledge had stagnated during the Middle Ages. The most authoritative account at the time came from the medical faculty in Paris in a report to the king of France that blamed the heavens, in the form of a conjunction of three planets in 1345 that caused a "great pestilence in the air".[33] This report became the first and most widely circulated of a series of "plague tracts" that sought to give advice to sufferers. That the plague was caused by bad air became the most widely accepted theory. The word plague had no special significance at this time, and only the recurrence of outbreaks during the Middle Ages gave it the name that has become the medical term. The importance of hygiene was recognised only in the nineteenth century; until then it was common that the streets were filthy, with live animals of all sorts around and human parasites abounding. A transmissible disease will spread easily in such conditions. One development as a result of the Black Death was the establishment of the idea of quarantine in Dubrovnik in 1377 after continuing outbreaks.[34] The dominant explanation for the Black Death is the plague theory, which attributes the outbreak to Yersinia pestis, also responsible for an epidemic that began in southern China in 1865, eventually spreading to India. The investigation of the pathogen that caused the 19th-century plague was begun by teams of scientists who visited Hong Kong in 1894, among whom was the French-Swiss bacteriologist Alexandre Yersin, after whom the pathogen was named Yersinia pestis.[35] The mechanism by which Y. pestis was usually transmitted was established in 1898 by Paul-Louis Simond and was found to involve the bites of fleas whose midguts had become obstructed by replicating Y. pestis several days after feeding on an infected host. This blockage results in starvation and aggressive feeding behaviour by the fleas, which repeatedly attempt to clear their blockage by regurgitation, resulting in thousands of plague bacteria being flushed into the feeding site, infecting the host. The bubonic plague mechanism was also dependent on two populations of rodents: one resistant to the disease, which act as hosts, keeping the disease endemic; and a second that lack resistance. When the second population dies, the fleas move on to other hosts, including people, thus creating a human epidemic.[35] The historian Francis Aidan Gasquet, who had written about the 'Great Pestilence' in 1893[36] and suggested that "it would appear to be some form of the ordinary Eastern or bubonic plague" was able to adopt the epidemiology of the bubonic plague for the Black Death for the second edition in 1908, implicating rats and fleas in the process, and his interpretation was widely accepted for other ancient and medieval epidemics, such as the Justinian plague that was prevalent in the Eastern Roman Empire from 541 to 700 CE.[35] More recently other forms of plague have been implicated. The modern bubonic plague has a mortality rate of 30–75% and symptoms including fever of 38–41 °C (100–106 °F), headaches, painful aching joints, nausea and vomiting, and a general feeling of malaise. Left untreated, of those that contract the bubonic plague, 80 percent die within eight days.[37] Pneumonic plague has a mortality rate of 90 to 95 percent. Symptoms include fever, cough, and blood-tinged sputum. As the disease progresses, sputum becomes free flowing and bright red. Septicemic plague is the least common of the three forms, with a mortality rate near 100%. Symptoms are high fevers and purple skin patches (purpura due to disseminated intravascular coagulation). In cases of pneumonic and particularly septicemic plague the progress of the disease is so rapid that there would often be no time for the development of the enlarged lymph nodes that were noted as buboes.[38] "Many modern scholars accept that the lethality of the Black Death stemmed from the combination of bubonic and pneumonic plague with other diseases and warn that every historical mention of 'pest' was not necessarily bubonic plague...In her study of 15th-century outbreaks, Ann Carmichael states that worms, the pox, fevers and dysentery clearly accompanied bubonic plague."[39] DNA evidence Skeletons in a mass grave from 1720–1721 in Martigues, France, yielded molecular evidence of the orientalis strain of Yersinia pestis, the organism responsible for bubonic plague. The second pandemic of bubonic plague was active in Europe from AD 1347, the beginning of the Black Death, until 1750. In October 2010, the open-access scientific journal PLoS Pathogens published a paper by a multinational team who undertook a new investigation into the role of Yersinia pestis in the Black Death following the disputed identification by Drancourt and Raoult in 1998.[40] Their surveys tested for DNA and protein signatures specific for Y. pestis in human skeletons from widely distributed mass graves in northern, central and southern Europe that were associated archaeologically with the Black Death and subsequent resurgences. The authors concluded that this new research, together with prior analyses from the south of France and Germany ...ends the debate about the etiology of the Black Death, and unambiguously demonstrates that Y. pestis was the causative agent of the epidemic plague that devastated Europe during the Middle Ages.[41] The study also found that there were two previously unknown but related clades (genetic branches) of the Y. pestis genome associated with medieval mass graves. These clades (which are thought to be extinct) were found to be ancestral to modern isolates of the modern Y. pestis strains Y. p. orientalis and Y. p. medievalis, suggesting the plague may have entered Europe in two waves. Surveys of plague pit remains in France and England indicate the first variant entered Europe through the port of Marseille around November 1347 and spread through France over the next two years, eventually reaching England in the spring of 1349, where it spread through the country in three epidemics. Surveys of plague pit remains from the Dutch town of Bergen op Zoom showed the Y. pestis genotype responsible for the pandemic that spread through the Low Countries from 1350 differed from that found in Britain and France, implying Bergen op Zoom (and possibly other parts of the southern Netherlands) was not directly infected from England or France in 1349 and suggesting a second wave of plague, different from those in Britain and France, may have been carried to the Low Countries from Norway, the Hanseatic cities or another site.[41] The results of the Haensch study have since been confirmed and amended. Based on genetic evidence derived from Black Death victims in the East Smithfield burial site in England, Schuenemann et al. concluded in 2011 "that the Black Death in medieval Europe was caused by a variant of Y. pestis that may no longer exist."[42] A study published in Nature in October 2011 sequenced the genome of Y. pestis from plague victims and indicated that the strain that caused the Black Death is ancestral to most modern strains of the disease.[5] DNA taken from 25 skeletons in London that died in the 14th century, have shown the plague is a strain of Y. pestis that is almost identical to that which hit Madagascar in 2013.[43][44] Alternative explanations Main article: Theories of the Black Death Plague victims being blessed, shown with symptoms from a late 14th-century manuscript Omne Bonum by James le Palmer This interpretation was first significantly challenged by the work of British bacteriologist J. F. D. Shrewsbury in 1970, who noted that the reported rates of mortality in rural areas during the 14th-century pandemic were inconsistent with the modern bubonic plague, leading him to conclude that contemporary accounts were exaggerations.[35] In 1984 zoologist Graham Twigg produced the first major work to challenge the bubonic plague theory directly, and his doubts about the identity of the Black Death have been taken up by a number of authors, including Samuel K. Cohn, Jr. (2002), David Herlihy (1997), and Susan Scott and Christopher Duncan (2001).[35] It is recognised that an epidemiological account of the plague is as important as an identification of symptoms, but researchers are hampered by the lack of reliable statistics from this period. Most work has been done on the spread of the plague in England, and even estimates of overall population at the start vary by over 100% as no census was undertaken between the time of publication of the Domesday Book and the year 1377.[45] Estimates of plague victims are usually extrapolated from figures from the clergy. In addition to arguing that the rat population was insufficient to account for a bubonic plague pandemic, sceptics of the bubonic plague theory point out that the symptoms of the Black Death are not unique (and arguably in some accounts may differ from bubonic plague); that transference via fleas in goods was likely to be of marginal significance and that the DNA results may be flawed and might not have been repeated elsewhere, despite extensive samples from other mass graves.[35] Other arguments include the lack of accounts of the death of rats before outbreaks of plague between the 14th and 17th centuries; temperatures that are too cold in northern Europe for the survival of fleas; that, despite primitive transport systems, the spread of the Black Death was much faster than that of modern bubonic plague; that mortality rates of the Black Death appear to be very high; that, while modern bubonic plague is largely endemic as a rural disease, the Black Death indiscriminately struck urban and rural areas; and that the pattern of the Black Death, with major outbreaks in the same areas separated by 5 to 15 years, differs from modern bubonic plague—which often becomes endemic for decades with annual flare-ups.[35] Walløe complains that all of these authors "take it for granted that Simond's infection model, black rat → rat flea → human, which was developed to explain the spread of plague in India, is the only way an epidemic of Yersinia pestis infection could spread", whilst pointing to several other possibilities.[46] Anthrax skin lesion A variety of alternatives to the Y. pestis have been put forward. Twigg suggested that the cause was a form of anthrax and N. F. Cantor (2001) thought it may have been a combination of anthrax and other pandemics. Scott and Duncan have argued that the pandemic was a form of infectious disease that characterise as hemorrhagic plague similar to Ebola. Archaeologist Barney Sloane has argued that there is insufficient evidence of the extinction of large number of rats in the archaeological record of the medieval waterfront in London and that the plague spread too quickly to support the thesis that the Y. pestis was spread from fleas on rats and argues that transmission must have been person to person.[47][48] However, no single alternative solution has achieved widespread acceptance.[35] Many scholars arguing for the Y. pestis as the major agent of the pandemic suggest that its extent and symptoms can be explained by a combination of bubonic plague with other diseases, including typhus, smallpox and respiratory infections. In addition to the bubonic infection, others point to additional septicemic (a type of "blood poisoning") and pneumonic (an airborne plague that attacks the lungs before the rest of the body) forms of the plague, which lengthen the duration of outbreaks throughout the seasons and help account for its high mortality rate and additional recorded symptoms.[20] In 2014, scientists with Public Health England announced the results of an examination of 25 bodies exhumed from the Clerkenwell area of London, as well as of wills registered in London during the period, which supported the pneumonic hypothesis.[43] Origins of the disease Main article: Black Death migration The plague disease, caused by Yersinia pestis, is enzootic (commonly present) in populations of fleas carried by ground rodents, including marmots, in various areas including Central Asia, Kurdistan, Western Asia, Northern India and Uganda.[8] Nestorian graves dating to 1338–9 near Lake Issyk Kul in Kyrgizstan have inscriptions referring to plague and are thought by many epidemiologists to mark the outbreak of the epidemic, from which it could easily have spread to China and India.[9] In October 2010, medical geneticists suggested that all three of the great waves of the plague originated in China.[10] In China, the 13th century Mongol conquest caused a decline in farming and trading. However, economic recovery had been observed at the beginning of the 14th century. In the 1330s a large number of natural disasters and plagues led to widespread famine, starting in 1331, with a deadly plague arriving soon after.[11] The 14th-century plague killed an estimated 25 million Chinese and other Asians during the 15 years before it reached Constantinople in 1347.[12] However, according to George Sussman, the first obvious medical description of plague in China dates to 1644.[13] The disease may have travelled along the Silk Road with Mongol armies and traders or it could have come via ship.[14] By the end of 1346, reports of plague had reached the seaports of Europe: "India was depopulated, Tartary, Mesopotamia, Syria, Armenia were covered with dead bodies".[15] Plague was reportedly first introduced to Europe at the trading city of Caffa in the Crimea in 1347. After a protracted siege, during which the Mongol army under Jani Beg was suffering the disease, the army catapulted the infected corpses over the city walls to infect the inhabitants. The Genoese traders fled, taking the plague by ship into Sicily and the south of Europe, whence it spread north.[16] Whether or not this hypothesis is accurate, it is clear that several existing conditions such as war, famine, and weather contributed to the severity of the Black Death. European outbreak The seventh year after it began, it came to England and first began in the towns and ports joining on the seacoasts, in Dorsetshire, where, as in other counties, it made the country quite void of inhabitants so that there were almost none left alive. ... But at length it came to Gloucester, yea even to Oxford and to London, and finally it spread over all England and so wasted the people that scarce the tenth person of any sort was left alive. Geoffrey the Baker, Chronicon Angliae There appear to have been several introductions into Europe. The plague reached Sicily in October 1347, carried by twelve Genoese galleys,[17] and rapidly spread all over the island. Galleys from Caffa reached Genoa and Venice in January 1348, but it was the outbreak in Pisa a few weeks later that was the entry point to northern Italy. Towards the end of January, one of the galleys expelled from Italy arrived in Marseille.[18] Spread of the Black Death in Europe (1346–53) From Italy, the disease spread northwest across Europe, striking France, Spain, Portugal and England by June 1348, then turned and spread east through Germany and Scandinavia from 1348–50. It was introduced in Norway in 1349 when a ship landed at Askøy, then spread to Bjørgvin (modern Bergen) and Iceland.[19] Finally it spread to northwestern Russia in 1351. The plague spared some parts of Europe, including the Kingdom of Poland, the majority of the Basque Country and isolated parts of Belgium and the Netherlands.[citation needed] Middle Eastern outbreak The plague struck various countries in the Middle East during the pandemic, leading to serious depopulation and permanent change in both economic and social structures. As it spread to western Europe, the disease entered the region from southern Russia also. By autumn 1347, the plague reached Alexandria in Egypt, probably through the port's trade with Constantinople, and ports on the Black Sea. During 1347, the disease travelled eastward to Gaza, and north along the eastern coast to cities in Lebanon, Syria and Palestine, including Ashkelon, Acre, Jerusalem, Sidon, Damascus, Homs, and Aleppo. In 1348–49, the disease reached Antioch. The city's residents fled to the north, most of them dying during the journey, but the infection had been spread to the people of Asia Minor.[citation needed] Mecca became infected in 1349. During the same year, records show the city of Mawsil (Mosul) suffered a massive epidemic, and the city of Baghdad experienced a second round of the disease. In 1351 Yemen experienced an outbreak of the plague, coinciding with the return of King Mujahid of Yemen from imprisonment in Cairo. His party may have brought the disease with them from Egypt.[citation needed] The Black Death was one of the most devastating pandemics in human history, resulting in the deaths of an estimated 75 to 200 million people and peaking in Europe in the years 1346–53.[1][2][3] Although there were several competing theories as to the etiology of the Black Death, analysis of DNA from victims in northern and southern Europe published in 2010 and 2011 indicates that the pathogen responsible was the Yersinia pestis bacterium, probably causing several forms of plague.[4][5] The Black Death is thought to have originated in the arid plains of central Asia, where it then travelled along the Silk Road, reaching the Crimea by 1343.[6] From there, it was most likely carried by Oriental rat fleas living on the black rats that were regular passengers on merchant ships. Spreading throughout the Mediterranean and Europe, the Black Death is estimated to have killed 30–60% of Europe's total population.[7] All in all, the plague reduced the world population from an estimated 450 million down to 350–375 million in the 14th century. The aftermath of the plague created a series of religious, social, and economic upheavals, which had profound effects on the course of European history. It took 150 years for Europe's population to recover.[citation needed] The plague recurred occasionally in Europe until the 19th century. |
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