Prof: Well,
what we'll do this morning is
to start right now.
 
And we'll be dealing today with
the beginnings of our first
major epidemic in the course.
 
We'll be talking about bubonic
plague.
This time we'll have an
overview of bubonic plague and
its passage through Western
society.
And then in the next two
classes we'll look at specific
features of bubonic plague;
next time, community responses
to the plague,
and the time after that,
the impact on society,
and in particular on European
culture.
 
So, that's where we're headed.
 
And this morning we'll have a
sort of overview.
Now, one of the reasons for
dealing first with the plague is
that it's very important as part
of testing the theme of our
course;
the theme being--one of the
themes--that epidemic diseases
aren't just interchangeable
causes of illness and death;
that each one has its own
particular history that is
determined by a number of
variables that we'll be looking
at,
such as virulence,
the nature of the symptoms of
the disease,
and a number of others.
And we'll be testing the theory
too that epidemic diseases are
major determinants of historical
change, and have major impacts
on society.
 
Well, plague,
in a sense, set the standard by
which all other epidemics are
judged.
The plague was,
we might call it,
the worst-case scenario,
and we'll see that in later
centuries,
when societies experienced some
new and unfamiliar disease,
they waited anxiously to see if
those diseases would be similar
in their impact.
And especially terrible
diseases like cholera,
in the nineteenth century,
and influenza,
just after the First World War,
were said to be "the
return of the plague."
 
Tuberculosis,
the great killer of the
nineteenth century,
was known also as "the
white plague."
 
What were some of the
distinctive features of bubonic
plague?
 
The first thing that stands out
is its extreme virulence.
That's one of the first words
that we may want to define as we
move on.
 
By that I mean its capacity to
cause harm and symptoms in the
human body.
 
It's a measurement of the
ability of a pathogen to cause
disease.
 
Plague in that sense was highly
virulent.
It also struck rapidly.
 
It caused excruciating and
degrading symptoms,
and it achieved a case fatality
rate--
another technical term,
which simply means the kill
rate that a disease achieved.
 
In the case of bubonic plague,
it normally killed fifty to
seventy percent of the patients
it infected;
a rate attained by few other
diseases.
Its course in the human body
was also terrifyingly swift.
Normally it killed within about
three days of the first
appearance of symptoms.
 
Another feature that was
characteristic of bubonic plague
was the profile of its victims.
 
I mean that both in terms of
their age and their social
class.
 
Familiar endemic childhood
diseases in a society tend to
strike primarily children and
the elderly.
That, if you like,
would be the normal experience
of society with infectious
diseases.
But the plague was different.
 
It struck men and women in the
prime of life.
And this fact,
among others,
made plague seem like an
unnatural, or might we say
supernatural,
event.
It also magnified the economic
and social dislocations it
caused.
 
In other words,
plague left in its wake vast
numbers of orphans,
widows and destitute families.
Furthermore,
the plague, unlike most
epidemic diseases,
did not show a predilection for
the poor.
 
It struck universally,
again magnifying a sense that
this was the final day of
reckoning, a divine visitation.
Another feature of plague we'll
be looking at is terror as a
response to it.
 
All of the things that we'll be
saying about plague magnified
the responses of the societies
that were afflicted.
Plague was associated with mass
hysteria;
with terror;
with violence;
with religious revivals,
as people sought to assuage the
divine wrath.
 
It was associated with
scapegoating and witch-hunts,
for the guilty people in
society responsible for the
disaster.
 
Perhaps those were the sinful,
for those who saw the disease
as divine retribution.
 
Or it could be a search for the
homicidal agents of some human
conspiracy, for the demonic
interpretation of disease.
Those might be foreigners,
witches, Jews or poisoners.
Then the plague was important
because it generated a major
societal response:
the development of the first
forms of public health.
 
In part because of its very
virulence,
the plague inspired the first
and most extreme form of public
health policy to protect
populations and contain the
spread of this horrendous and
terrible disease.
Plague public health--and we'll
see this more next
time--involved a military style
policy carried out by the army
and the navy.
 
It involved maritime and
land-based quarantines,
sanitary cordons,
which are military lines
isolating a population.
 
It gave rise to pest houses or
lazarettos.
And to new health
authorities--variously called,
over the centuries,
health magistrates or boards of
health--
equipped with extraordinary
powers to enforce the plague
measures.
In some places there were
erected stocks and scaffolds to
remind the population of the
powers of these authorities.
Early Italian states,
at the time of the Renaissance,
devoted a special
role--deserved a special role as
the inventors of these public
health measures.
This was thrust upon them by
their vulnerable position at the
geographic center of trade
routes in the Mediterranean.
So, we'll see the decisive role
in the development of these
measures was played by places
like Florence and the great port
cities like Genoa,
Naples, Venice.
Later centuries will see
another pattern,
when a new, mysterious and
frightful disease strikes--
say cholera,
yellow fever or AIDS--one of
the first responses of
authorities is to return to
plague measures of self-defense.
 
It's said of generals that they
always try to fight the last war
over again, often confronting
new enemies with inappropriate
strategies.
 
The same might be said of
public health authorities over
the centuries.
 
And this temptation is all the
greater for authorities because
the battery of anti-plague
defenses gives an impression of
taking forceful and decisive
action;
providing the population,
in other words,
with some sense of security.
 
A third feature of the plague
is its enormous impact on
society.
 
As we've said,
infectious diseases are not
narrow, specialized interests.
 
They're often part of the big
picture,
as essential for understanding
a society and its history as
studying war,
religion, economics,
high politics and culture.
 
I'm not trying to make a case
for disease determinism,
and I'm not what you might want
to call a microbial Marxist.
My argument instead is simply
that certain diseases do have a
transforming effect on society,
plague being one of them.
Certain others do not,
even great killers such as
polio or influenza.
 
We're going to examine why this
major difference--why some
diseases have a much more
lasting footprint than others.
Bubonic plague was a disease
that affected every aspect of
society.
 
It transformed the demography
of Europe.
Recurring cycles of plague,
with an epidemic every
generation,
constituted a major break on
population between the
fourteenth century and the
eighteenth.
 
It had devastating effect on
economic life and economic
growth.
 
It also had a major impact on
religion and popular culture.
It gave rise to a new piety,
to cults of plague saints,
to passion plays.
 
Plague led to an outpouring of
sermons and religious pamphlets,
with a central theme being what
we might call theodicy;
that is, how do you justify
God's ways towards men?
A just and loving God could be
angry and punish sinners who
turned from him and disobeyed.
 
But how were priests and
ministers to explain the
gruesome suffering and death of
innocents, and in particular of
children?
 
Thus also we see another
undertow.
We talked about piety.
 
I would argue that plague also
led sometimes to its opposite;
the terrifying conclusion that
how could there be a good God,
because a loving and
all-powerful being would not
take the lives of half the
population of a great city,
indiscriminately killing men,
women and children.
So, for some,
the result wasn't an act of
atheism but a mute despair that
was not articulated;
a psychological impact that
with historical hindsight we
might even call post-traumatic
stress.
So, plague had a major
psychological impact on the
relationship of human beings to
their mortality,
and to their god.
 
Plague had a major impact on
the arts and culture.
In literature we'll be
seeing--and in fact you're
starting to see,
I hope already,
by reading Defoe--that there's
a whole genre of plague
literature,
including not only Defoe but
names like Boccaccio,
Camus, Manzoni;
of whom more later.
 
It affected European painting
profoundly, and we'll be looking
at that.
 
It affected architecture,
with large numbers of churches
dedicated to the redeemer and
the plague saints.
It led to sculpture,
and plague columns appeared
throughout Vienna and the
Austrian cities.
We have, even in modern times,
the film that I hope you'll be
seeing, The Seventh Seal
by Bergman.
Plague also had a major impact
intellectually on the medical
paradigm of disease.
 
Plague profoundly tested the
humoral framework of disease.
And we can see this in a man I
mentioned in the last lecture,
Girolamo Fracastoro,
who developed a theory of
contagionism.
 
Now, the humoral idea,
and Hippocrates,
had recognized the difficulty
that epidemics pose for humoral
theory.
 
How is it possible to account
for vast numbers of people
experiencing the same humoral
imbalance at precisely the same
time?
 
Well, Fracastoro took that idea
and he eliminated the mediation
of the humors,
suggesting instead that the
disease was caused by a
poisonous chemical,
transmitted in a way he didn't
understand,
from one person to another.
 
But let's not think of
Fracastoro as a modern medical
scientist.
 
He thought that plague was
caused, not by a living entity,
but by a chemical.
 
That's the background, then.
 
Let's remember the history of
three pandemics of bubonic
plague that afflicted the West.
 
Now, first maybe we should
define what we mean.
An outbreak--let's talk about
three terms--an outbreak,
an epidemic and a pandemic.
 
An outbreak is a small surge in
morbidity and mortality in a
locality.
 
So, we might talk of an
outbreak of influenza in New
Haven.
 
An epidemic is a much bigger
surge, over a larger area.
And a pandemic is when an
epidemic goes transnational;
becomes an international
phenomenon, affecting whole
continents, or occasionally
going global.
The plague struck the West in
three pandemic waves.
We'll be talking about the
history, then,
of three pandemics of bubonic
plague.
And each pandemic as a subset,
if we like, had a series of
recurring visitations that might
even last for centuries.
And in addition to being
cyclical in that sense,
plague had a pronounced
seasonality.
An epidemic of bubonic plague
usually began in the spring or
summer months,
and faded away with the coming
of winter.
 
Especially favorable were
months that were both hot and
wet.
 
The explanation for that,
as we'll see,
wasn't a humoral one.
 
But that provides an ideal
environment for fleas,
which are decisive in plague,
and their need for warmth and
humidity, for their eggs to
hatch;
and they become inactive in
cold or very dry climate.
The first pandemic,
when was that?
That lasted for two centuries
after 541 A.D.,
and is called the Plague of
Justinian.
It was the first appearance of
bubonic plague as a major player
in world history,
and there are estimates that it
afflicted Africa,
Asia and Europe with--people
are guessing,
but there are figures bandied
about of perhaps a hundred
million victims.
There are few accounts,
or records that have survived,
and there's some debate about
whether this so-called Plague of
Justinian was even bubonic
plague at all,
or whether it was some other
disease.
But as we speak,
paleopathologists are at work
exhuming bodies from ancient
cemeteries in order to find
conclusive DNA evidence to
support a firm diagnosis,
and the latest news is that
they're pretty certain that it
was bubonic plague.
 
The second pandemic occurred
from the 1330s,
in the Middle East,
until the 1830s.
So, we have--what's that?--five
centuries of bubonic plague in
the second pandemic.
 
It began with what was called
the Black Death.
This erupted in Central Asia in
the 1330s, and first invaded
Europe in 1347.
 
And the early years,
from 1347 into the 1350s,
were usually called the Black
Death, which referred to the
first wave of the second
pandemic;
after which it's usually
referred to simply as bubonic
plague, plague,
or pestilence.
It may well--and this is the
common theory--have arrived
aboard a Genoese merchant ship
that had sailed from the Black
Sea in the summer of 1347.
 
In any case,
Italy was the first land to be
invaded by the disease;
again, as I say,
not by chance,
because Italy was at the center
of the trade routes of the
Mediterranean,
and therefore was always,
at this time,
permanently at risk.
 
About a third of the population
of Europe is estimated to have
perished.
 
And after the 1350s,
after the Black Death,
the plague returned more or
less once in a generation,
for a number of centuries,
with some famous local
epidemics.
 
Let me just remember some of
the worst cases.
Florence in 1348,
when the disease killed half
the population--and that's
portrayed vividly in Boccaccio's
Decameron;
1576 to 1577, Milan;
1630, again Milan--and there
are two major plague works of
literature: Manzoni's novel
The Betrothed,
and his work The Column of
Infamy--
1656 in Naples;
and 1665 and 1666 in London,
which you're reading about in
Dafoe's Journal of the Plague
Year.
 
Then for reasons we're going to
return to,
the plague was vanquished in
Western Europe between the end
of the seventeenth century and
the middle of the eighteenth.
The last outbreaks in Western
Europe, of the second pandemic,
were 1720 to 1722,
at Marseilles in France,
the last on the Western
European mainland;
and in 1743 at Messina and
Sicily.
Interestingly,
Messina is a convenient
bookend;
the very first place in Western
Europe to be afflicted by the
plague, and also the last,
during the second pandemic.
 
Now, don't make the mistake of
assuming that the virulence of
the plague declines over these
centuries.
In many cases the last
epidemics of the seventeenth or
eighteenth century were the most
devastating of all,
including the experience of
London that you're reading
about.
 
Then we come to the third
pandemic, which lasted from
about 1855 until 1959,
more or less,
when it fades away.
 
It began in earnest,
and attracted world attention
in China, when it attacked Hong
Kong and Canton in 1894.
And, as I said,
it lasted until the middle of
the twentieth century.
 
Now, this pandemic ravaged
India and affected five
countries,
but mostly not the industrial
West,
apart from a brief flare-up in
Naples in 1899,
and an also limited outbreak in
San Francisco in the early years
of the twentieth century.
That's the topic of Marilyn
Chase's work that you'll be
reading, The Barbary
Plague.
It was the steamship that
enabled plague to reach the New
World for the first time in the
twentieth century.
It had limited impact on
humans, but it did establish a
stable reservoir of infection
among wild rodents in the
southwest of the United States,
where it persists to this very
day and causes an ongoing
trickle of cases of bubonic
plague in this country.
 
The great disaster was India
from 1898 to 1908,
which experienced some 13
million deaths from the bubonic
plague.
 
Present day plague--and I think
a number of you may have the
idea that plague is something
medieval that doesn't have
anything to do with the modern
world,
and I want to make it clear
that plague is not extinct.
Indeed, I have a friend myself
who is a survivor of bubonic
plague, which she contracted in
Arizona in the southwest.
As I said, it continues to
cause a trickle of cases every
year in the United States,
because it persists in the wild
animal population,
and there are occasional
flare-ups.
 
We also need to remember
there's a somber background
threat,
then, of bubonic plague even
today,
which is made more vivid by the
threat possibly of bubonic
plague as an instrument of
bio-terror.
 
And just to show the sort of
modern--here's a modern image of
the grim reaper as still with
us.
Now, our focus here in our
class will be instead firmly on
the second pandemic,
and especially its last
terrible century in Europe,
the seventeenth.
Let's talk about some of the
features of bubonic plague,
and we'll begin with its
etiology.
Again a bit of jargon,
and by that I simply mean the
causes or origins of the
disease.
And the plague is a disease
with a complex history of four
protagonists.
 
First there's the
bacterium--and there it
is--Yersinia pestis,
sometimes called,
in a more old-fashioned way,
Pasteurella pestis.
It was discovered in Hong Kong
by Alexander Yersin,
a Swiss student of Louis
Pasteur, and at the same time by
his rival the Japanese
physician,
Shibasaburo Kitasato,
a prot�g� instead of Robert
Koch.
 
So, the first protagonist is
this bacterium,
Yersinia pestis.
 
And then there are two vectors.
 
The vector is normally another
bit of jargon:
An animal or insect responsible
for conveying a disease to human
beings.
 
And in this case there are two
vectors or carriers that convey
the disease to human beings:
fleas and rodents,
especially rats.
 
And then there's the fourth
protagonist, you and me.
By between 1894 and 1898,
Yersin and his colleague,
Paul-Louis Simond,
unraveled the complex
relationship among rats,
fleas and humans,
and the bacterium,
that governs the epidemiology
of bubonic plague.
 
Normally the plague began as an
infection,
an epidemic among animals and
especially wild rodents:
hamsters,
gerbils, prairie dogs,
chipmunks, squirrels in their
burrows,
where underground catastrophes,
unknown to humans,
took place.
 
A particularly important moment
was when it inflicted this
particular creature and friend,
that lives not so distant from
us, Rattus rattus,
the black rat or ship rat;
and as you see,
extremely cute it is.
Unlike his cousin,
the brown rat,
that took over its ecological
niche later on,
and is more familiar in modern
times,
the black rat was definitely
not shy,
but lived in close proximity to
people,
with whom they shared the same
dietary preferences.
So, the rat was extremely
important.
The bacterium was spread in a
third major character,
the flea, a highly efficient
vector for bubonic plague.
The flea is naturally parasitic
on warm-blooded animals.
In a single feed it sucks up an
amount of blood equal to its own
weight.
 
I'm talking about something
like a billion bacteria at a
time.
 
And here we're looking at the
slide of a flea engorged with
blood after a meal.
 
Now, once infected--and here
you'll feel sorry for the poor
flea--the flea does not survive
the plague either.
The bacterium blocks the gut of
the flea, causing it to starve
to death.
 
Poor thing.
 
But before dying,
in a frenzied bid to survive,
the flea feeds repeatedly,
and in each bite inoculates
perhaps a hundred thousand
bacteria into the bloodstream of
its warm-blooded victim.
 
So, when a rodent host of fleas
sickens and dies,
the fleas leap to the warm body
of another mammal that passes
within leaping radius.
 
And the flea also is capable of
hibernating for as much as a
couple of months,
lying in wait.
Now, how did human beings come
to be involved in this
catastrophe?
 
Well, it might be sometimes
that the remote steppes where
wild rodents lived had their
ecological systems disrupted,
perhaps by floods or droughts,
that sent animals scurrying
over long distances,
and then they encountered other
rodents who lived in close
proximity to man,
and especially our friend the
black rat.
Alternatively,
human beings invaded rodents'
habitats, exposing themselves to
infection;
soldiers perhaps,
or refugees in times of war,
or hunters and shepherds.
 
So, the first foci--that is,
the first locuses where
infections sprang up amongst
human beings--
were the first infected men and
women which shared their fleas
and infection with other members
of their household.
The plague would then begin,
not as a disease so much of
isolated individuals,
but of households.
Housing conditions were
important.
Overcrowding,
with whole families sleeping in
a single bed,
facilitated the exchange of
fleas.
 
And there were particular
moments that were especially
dangerous, such as the laying
out and final attentions to the
dead.
 
As the body cooled,
the fleas infesting it became
desperate to escape to the next
warm body that approached;
quite possibly you and me.
 
Then there was the wider spread;
and this was dependent on
networks of trade and commerce.
 
It was not an accident that
plague emerged when it did in
European history.
 
It spread overland and along
river valleys,
by river traffic.
 
Now, fleas obviously are
severely restricted in their
range, but rats are really
wonderful travelers.
They hide in the shipments of
wheat and are transported
overland.
 
They travel by barge down
waterways.
But the garments of victims
were also important,
because they were recycled.
 
Remember how precious an item
of clothing was in the early
modern world.
 
And, so, the clothing of dead
men and women was packed in
crates, and sold in markets and
fairs, often with fleas intact
among their folds.
 
Certain professions were also
highly at risk:
street vendors,
market-stall-holders,
washerwomen,
gravediggers,
physicians, priests,
and also millers and bakers,
because of the dietary
preferences of your friend the
black rat.
 
But the disease also went
further afield,
and it did so by sea.
 
And shipping was essential to
the spread of the plague over
long distance,
and helps to explain its
epidemiology;
its tendency,
that is, to arrive in a country
first by striking port cities,
and only then moving inland by
road and river traffic.
Infected rats would clamor
aboard ships,
by ropes and gangplanks,
or they could be lifted aboard
in crates of grain or shipments
of clothes.
Istanbul was a great hub of
trade in the Middle East,
and it linked the rest of the
Mediterranean world by trade
overland across the Balkans,
and by ship to Venice,
Naples, Genoa,
Marseilles, Valencia.
Sometimes there was havoc at
sea when a whole crew and its
passengers would be killed by
the plague before they arrived
at port,
and there were ghost ships that
floated on the Mediterranean.
 
Once reaching a port,
however, the ship would dock
and rats would disembark,
in crates, or by rope,
or by the gangplank again,
and at the same time infected
passengers and crew could go
ashore,
together with their fleas.
 
Normally the first indication
of plague--
one that's dramatically
apparent in Camus' novel The
Plague,
but we'll also see in some of
the paintings that we'll look at
time after next--
an important indication was a
sudden and massive die-off of
rats.
 
And there would be pictures
like this of rats killed by an
epidemic of bubonic plague;
in this case Sydney, Australia.
So, ports are crucial in
epidemics, and in the
development of public health
measures to counter them.
Almost invariably in Western
Europe the plague arrived in
port cities and then spread
inland, following roads and
rivers.
 
In the large cities,
the disease typically would
arrive in the spring,
reach a peak of ferocity after
a few weeks,
then continue as a violent
outbreak for two to four months,
and then decline with the
coming of colder,
dry weather,
either to disappear entirely,
or to be rekindled when
favorable climatic conditions
returned.
Well, that's the etiology,
in a nutshell,
of the plague.
 
I'd like to turn now to its
symptomatology and pathology;
that is, how does it affect the
individual human body?
And the study of the symptoms
of the epidemics we study isn't
just a matter of ghoulish
curiosity.
I'm going to argue that the
history of each epidemic disease
is distinct.
 
That's one of the reasons that
I will be showing slides,
to fix the image of a
particular disease in your mind.
Because it's important not to
confuse them,
because each has its own
history.
And a crucial variable is the
differing way in which each of
these diseases affected its
victims.
A feature of the plague,
I would argue,
is that it seemed almost
purposefully designed to
maximize terror.
 
I will be showing you some
vivid material,
and I'm sorry that it's just
before lunch.
And indeed a couple of years
ago in this class someone in the
front row fainted with some of
the pictures.
So, if you don't wish to look
at them, I can tell you in
advance it's not compulsory.
 
You can simply close your eyes.
 
In any case,
Yersinia pestis is
exceptionally virulent because
of its ability to overwhelm the
immune system of the body.
 
After an infective bite,
there's an incubation period,
usually of one to six days,
and then the classic symptoms
appear--
the first beginning--launching
the first stage of bubonic
plague.
That is, at the site of the
flea bite, there's what's called
a carbuncle or gangrenous black
blister, surrounded by red pot
marks.
 
And this will be familiar to
you because it's been
immortalized in the nursery
rhyme, "The Ring a Ring o'
Roses."
 
But also, along with it,
there's high temperature and
shivering, violent headache,
nausea and vomiting,
and general flu-like symptoms;
after which the patient passes
on to the second stage of
bubonic plague,
when it invades--the bacteria
invade the lymph system and
drain into the lymph nodes.
 
A couple of days later a
so-called bubo--which gives the
symptom that gives the disease
its name, bubonic plague--the
plague of buboes appears.
 
This is an infected swelling of
the lymph nodes,
a hard mass the size of an
orange beneath the skin.
The site of the bubo varies,
according to the location of
the infective bite.
 
If a flea bites the legs,
the bubo is usually in the
groin, and would look like that.
 
If the fleas instead were to
bite the arms,
the bubo would appear in the
armpit or on the neck,
and there would be
symptoms--would look like this,
or like that.
 
In any case,
Daniel Defoe imagined,
and he writes in our book,
that the agony was so violent
from the bubo that victims
hurled themselves from roofs,
or into the Thames to escape it.
 
And there was a general
consensus that the body and all
of its excretions--urine,
sweat, the breath--had an
overpowering stench.
 
This led--I want us to remember
how dehumanizing the symptoms of
plague were,
and that's tremendously
important to the way that
societies experienced its
outbreak.
 
In the third stage,
the bacteria releases a
powerful toxin,
and this circulates throughout
the bloodstream,
and it's the toxin that kills.
It attacks tissues,
causing blood vessels to
hemorrhage, and giving rise to
purpurous, subcutaneous spots,
the so-called tokens of plague.
 
Another bit of jargon to
remember.
The plague is associated with
tokens and these--let's have a
look at--which look like this.
 
They gain their name because
they were thought by many to be
the signs,
that is the tokens,
of God's anger,
the anger that led him to smite
his people with the plague.
 
The toxin initiates the septic
phase of this disease,
causing rapid degeneration of
the muscles of the heart,
of the kidneys,
of the nerves and the central
nervous system,
and this leads to such symptoms
as bloodshot eyes,
general prostration,
fever, nausea,
severe headache,
and progressive neurological
damage that's manifested by
slurred speech,
a staggering gait,
psychic disturbances and
derangement.
We again see how this disease
is terrifyingly dehumanizing and
agonizing.
 
And it leads then to delirium
and coma.
Sometimes it also causes
gangrene of the extremities--
and I will also have a picture
of that--
and this may,
in fact, be the origin of the
term Black Death.
 
Now, in terms of the
symptomatology--let me pass on
from that to this.
 
This is a Franciscan friar,
Michael of Piazza,
a chronicler--you'll remember I
said Messina was the first place
to be afflicted by bubonic
plague in 1347.
He wrote this terrifying
description of how it afflicted
a sufferer.
 
He wrote: "Not only did
the burned blisters appear,
but there developed in
different parts of the body
gland boils;
in some on the sexual organs.
In others"--whoops,
sorry, there we go--"In
others on the arms or the neck.
 
At first these were the size of
a hazelnut and developed
accompanied by violent shivering
fits that soon rendered those
attacked so weak they could no
longer stand upright,
but were forced to lie in their
beds,
consumed by violent fever and
overcome by great tribulation.
Soon the boils grew to the size
of a walnut,
then a hen's egg,
and they were exceedingly
painful and irritated the body,
causing it to vomit blood by
vitiating the juices.
 
The blood rose from the
affected lungs to the throat,
producing on the whole body a
putrefying and decomposing
effect.
 
The sickness lasted three days,
and on the fourth,
at the latest,
the patient succumbed."
So, as soon as anyone was
seized with headache and
shivering,
he knew that he was bound to
pass away within the specified
time,
and first confessed his sins to
the priest,
and then made his will.
 
Death occurred in about half of
cases within a few days,
though some of the afflicted
lingered in agony for as long as
three to four weeks,
and then a minority slowly
recovered.
 
The symptoms of bubonic plague
are agonizing.
They're terrifying,
dehumanizing,
as suffers succumb to
hallucinations and delirium.
Now, there are three forms of
bubonic plague,
and I want to mention what
those are immediately.
These are not three separate
diseases.
They're one disease in three
separate manifestations.
The first is what we've been
describing as classic bubonic
plague, the most common and
historically most important
form.
 
Then there's septicemic plague,
which is an overwhelming
infection in which the patient
frequently dies,
even before developing a bubo.
 
But this, as I said,
is not a separate disease;
simply a fulminant form of
plague;
and it's most common among the
elderly.
Then there's pneumonic plague,
which again is the same
disease, but clinically and
epidemiologically distinct.
It begins with an ordinary case
of plague, complicated by
pneumonia, and can then give
rise to a secondary catastrophe,
within the general disaster;
that is, the disease is then
spread by bacteria coughed out
in the sputum of the victim and
spread person to person when
inhaled by those near him or
her.
 
This form of plague is not
dependent on fleas.
It's highly infectious,
and as far as is known is one
hundred percent fatal.
 
And even today,
in the antibiotic era,
there's no cure for pneumonic
plague.
And pneumonic plague is also
recorded in your favorite
nursery rhyme.
 
This is the,
"ah-choo,
ah-choo, we all fall
down."
Now, what did doctors do?
 
What were treatments
historically?
There was a continuity of
strategy from the Black Death,
through the eighteenth century,
based on Galenic principles of
dealing with the a
disequilibrium of the humors.
So, the main indication of
treatment was to assist the body
in expelling what was called the
peccant humor responsible,
or the morbific poison.
 
The physician regarded his task
as one of assisting Nature,
as the body was already clearly
attempting to expel the poison.
After all, it was vomiting,
there was diarrhea and
sweating.
 
So, physicians attempted to
assist the body in its fight;
perhaps directly by bleeding,
a very popular therapy,
although there were intense
debates about timing,
about the best veins to be
opened, and the amount of blood
to be drawn.
 
Other key practices were
administering powerful
purgatives or emetics,
so the poison could pour forth
more copiously;
or to cause the patient to
sweat, piling him or her high
with clothes,
even mattresses,
so the poison would pass out
through the pores;
and forbidding the sufferer to
drink;
and of course lancing or
cauterizing the bubo itself,
so that it too could discharge
its load of poison directly.
 
Some doctors applied hot
compresses.
There were also internal
medicines that were
administered,
as they were thought to raise
the buboes,
or to hasten recovery by
fortifying what was called the
flagging animal energy of the
victim;
things like brandy or opium.
But in practice,
treatment was pitifully rare
for plague sufferers.
 
Physicians, priests and
attendants recognized that they
were powerless;
that they were too few in
number to cope with the
catastrophe that engulfed them.
And they perished too in great
numbers during the outbreaks.
And many, overcome with terror
like everyone else,
simply fled.
 
So, one of the terrors of the
plague was that it broke the
common bonds of humanity,
and the common plight of plague
victims was often to be
abandoned,
to face agony and death alone.
 
Let's listen to the famous and
awful testimony of Boccaccio in
The Decameron,
describing Florence.
Sorry for a momentary
technological glitch,
but we'll get there.
 
There we are.
 
This is Boccaccio describing
Florence in 1348.
"Let us omit that one
Citizen fled after another,
and one neighbor had not any
care of another,
Parents nor kindred ever
visiting them,
but utterly they were forsaken
on all sides:
this tribulation pierced into
the hearts of men,
and with such a dreadful
terror, that one brother forsook
another,
the Uncle, the Nephew,
the Sister, the Brother,
and the Wife the Husband:
nay a matter much greater,
and almost incredible;
Fathers and Mothers fled from
their own Children,
even as if they no way
appertained to them.
In regard whereof,
it could not be otherwise,
but that a countless multitude
of men and women fell sick;
finding no charity among their
friends, except a very few,
and were subject to the avarice
of servants."
So, this is our first overview
of plague in its three
pandemics.
 
Next time what I'd like to do
is to talk about the response of
communities to this catastrophe,
and to look in particular at
public health measures designed
to protect communities.
That's where we're heading next.
 
 
 
