Historical

Plague outbreaks occurred prior to the current era (i.e., 2000 years ago), but the numbers affected and the societal impact of the events remain unrecorded. During the current era, however, there have been three well-documented plague pandemics. The first, the plague of Justinian, arrived in 542 and raged intermittently until 750. It came to the Mediterranean region from an original focus in northeastern India or central Africa and was spread by infected rats hitchhiking on ships. It is estimated that a million people died. In Constantinople, the capital of the Roman Empire in the east, plague contributed to Justinian's failure to restore imperial unity because of a diminution in resources, which in turn prevented Roman and Persian forces from offering more than token resistance to the Muslim armies that swarmed out of Arabia in 634.

In the year 1346, the second pandemic began, and by the time it disappeared in 1352 the population of Europe and the Middle East had been reduced from 100 million to 80 million people. It is estimated that in cities such as Siena, Marseilles, and London, at the height of the pandemic, approximately 1500 people died each day from the plague. This devastating phenomenon, known as the Black Death, the Great Dying, or the Great Pestilence, put an end to the rise in the human population that had begun in 5000 B.C., and it took more than 150 years before the population returned to its former size.

Providing the source of the second pandemic were bacteria from the first pandemic that had moved eastward and remained endemic for seven centuries in the highly susceptible black rats (Rattus rattus) of the Gobi Desert. Plague-infected rats and their fleas moved westward along the Silk Road, the caravan routes between Asia and the Mediterranean; plague traveled from central Asia around the Caspian Sea to the Crimea. There the rats and their fleas boarded ships and moved from port to port and country to country, spreading plague to the human populations living in filthy rat-infested cities. Indeed, the story of the Pied Piper of Hamlin may have had its roots in the plague-ridden cities of Germany.

By 1347, there were plague outbreaks in Kaffa, Constantinople, and Genoa. By 1348 it had spread via North Africa to Spain, and it was also present in France, Germany, Switzerland, and Great Britain. In 1349 a ship from London carrying its crew, wool cargo, and infected rats landed in Bergen, Norway. In this way plague came to Scandinavia. In 1351, it was in Poland and when, in 1352, it reached Russia, the plague had completed its circuit.

Because no one in medieval times knew that microbes cause infectious diseases, any public heath measures were crude and generally ineffectual: ships were restricted in their entry into ports and sailors had to remain on board for 40 days while their vessels were tied up at the dock, a practice that gave rise to the term quarantine (from quarant, meaning 40 in French). But the disease continued unabated because flea-bearing rats left the ships by means of docking lines. Cordon sanitaires (i.e., quarantine zones) may have had some effect, but oftentimes infected individuals were shut up in their homes with the uninfected members of the family and the flea-infested rats, conditions that actually led to higher mortality. More effective measures included the burning of clothing and bedding, and the burying of the dead as quickly as possible.

The public, unable to identify the real source of the plague, used Jews, prostitutes, the poor, and foreigners as scapegoats. The Black Death led to societal and religious changes: feudal institutions began to break down; the laboring class became more mobile; merchants and craftsmen became more powerful; and guild structures were strengthened. There was also a decline in papal authority, and people lost faith in a Catholic Church that was powerless to stem the tide of death. The horrors of the plague during this time are depicted in Pieter Brueghel's 1562 painting Triumph of Death and graphically described in the introduction to Giovanni Boccaccio's classic collection of short stories, the Decameron. "Plague doctors" who ministered to the dying wore special costumes depicted in drawings and engravings (Fig. 1), as seen in popular movies such as The Seventh Seal, directed by Ingmar Bergman.

Though the Black Death was undoubtedly the most dramatic outbreak of plague ever visited upon Europe, it did not disappear altogether after 1352. Between 1347 and

FIGURE 1 During the plague physicians wore protective clothing in an attempt to avoid acquiring the disease from their patients. The beaklike mask was supplied with aromatic substances and perfumes to ward off the stench of death, the stick was used to touch the afflicted. To prevent the disease vapors from entering the body of the "plague doctors," a hat was worn, as well as a coat impregnated with a waxy material. (Illustration from Der Pestarzt Dr. François Chicoyneau. © Germanisches National Museum, Munich. Reproduced with permission.)

FIGURE 1 During the plague physicians wore protective clothing in an attempt to avoid acquiring the disease from their patients. The beaklike mask was supplied with aromatic substances and perfumes to ward off the stench of death, the stick was used to touch the afflicted. To prevent the disease vapors from entering the body of the "plague doctors," a hat was worn, as well as a coat impregnated with a waxy material. (Illustration from Der Pestarzt Dr. François Chicoyneau. © Germanisches National Museum, Munich. Reproduced with permission.)

1722, plague epidemics struck Europe at infrequent intervals and occurred without the introduction from caravans from Asia. In England, the epidemics occurred at 2- to 5-year intervals between 1361 and 1480. In 1656-1657, 60% of the population of Genoa died, half of Milan in 1630, and 30% in Marseilles in 1720. In the Great Plague of 1665, which was described in the diary of Samuel Pepys (and fictionalized in Daniel Defoe's Journal of the Plague Year), at least 68,000 Londoners died.

The third and current pandemic began in the 1860s in the war-torn Yunnan region of China. Troop movements from the war in that area allowed the disease to spread to the southern coast of China. Plague-infected rodents, now assisted in their travels by modern steamships and railways, quickly spread the disease to the rest of the world. By 1894, plague had arrived in Hong Kong, and there Alexander Yersin (1863-1943) and Shibasaburo Kitasato (1852-1931), by taking material from buboes, independently discovered the occurrence of the bacillus in humans. Yersin also isolated the same bacterium from dead rats, thus demonstrating the importance of these rodents in transmission. Four years later, during the phase of the epidemic that swept over India, Paul-

Louis Simond and Masanori Ogata independently determined that the flea was the vector of plague.

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