Plagues in World History (5 page)

The initial symptoms of all forms of plague are not all that different from other diseases: These include high fever, violent headaches, and body stiffness, chills, or pains. They may also be accompanied by nausea and vomiting, constipation, sensitivity to light, bloodshot eyes and a coated tongue, restlessness and an inability to sleep, delirium or stupor and loss of motor control, and, in general, a vague but unmistakable feeling of anxiety, dread, and fear.7 But, of course, the Plague y 21

distinguishing symptom of plague, at least in its bubonic form, is the bubo, a lymphatic swelling caused by bacterial accumulation at the nodular point closest to where the flea has bitten the victim. This will then usually occur on the groin, armpits, or neck area, where the lymph nodes are located. (Medieval doctors referred to these as the “emunctories” and thought they drained poisonous materials or humors from, respectively, the liver, heart, and brain.) Observers of the Third Pandemic of plague at the turn of the twentieth century noted that inguinal buboes were the most frequent, which makes sense if fleas mostly have access to their human victims on the ground and jump onto them as they walk around the house during the day. Next in frequency were axillary buboes followed lastly by cervical ones, which presumably occurred as a result of patients being bitten on the torso or above by fleas in their bedding as they lay asleep. However, it should be remembered that cervical buboes can also occur in “tonsillar” plague, a sort of intermediary form of the disease that is caused by interhuman transmission, when airborne droplets are breathed in and collect in the throat but do not travel all the way down to the lungs, which results in bubonic symptoms and not pneumonic ones.

This may help explain why some medieval observers of the Second Pandemic, the Black Death, seem to attest to a greater frequency of cervical buboes than during the Third Pandemic.8 It is also not unknown for buboes to form on other places aside from the lymph nodes, such as on the inside of the elbow or on the back of the knee, and medical chroniclers of the Third Pandemic likewise noted other skin manifestations of bubonic plague, such as pustules or carbuncles, that could appear almost anywhere on the body.9

The bubo is considered by most medical experts—whether medieval or modern—to be the defining symptom for a conclusive diagnosis of bubonic plague, even when the case is so mild that it can barely be distinguished from other diseases.10 It is also the symptom that has allowed historians to make a positive identification of the first plague pandemic in history, owing to the description by Procopius of Caesarea and John of Ephesus of the swelling that occurred in the “boubon,” the Greek word for groin, that accompanied the disease’s appearance in Constantinople in 542 C.E.11 In both modern and medieval cases, it has been noted that the bubo getting larger in size (approaching the dimensions of a walnut) is actually a good sign for a prognosis of recovery, even as it remains tender or painful to the touch.12 After about a week of living with these symptoms, recovery is marked by spontaneous suppuration, or bursting open, of the bubo, releasing its pus;13 in the Middle Ages, the maturing or “ripening” of the boil was typically aided by a poultice or specially prepared plaster, cutting or scarification, cupping (applying a heated glass vessel to the area to create a vacuum suction), or cautery, either using inflammatory compounds or the more direct heat from a red-hot branding iron. Without the timely interven-22 y Chapter 1

tion of modern-day antibiotics, death occurs in 60 to 90 percent of bubonic plague cases, usually three to six days after the onset of symptoms.

In the case of pneumonic plague, the characteristic symptom is the coughing up of bloody sputum, accompanied by rapid and painful breathing, although this can also occur in pneumonia, tuberculosis, and influenza. What seems to ultimately confirm the presence of plague is that in the pneumonic form it is 100

percent fatal and death ensues quite quickly, usually within two days. Unless they die suddenly from heart failure, pneumonic plague patients can be cursed with a horrible death, gasping for hours from “air hunger.”14

By contrast, septicemic plague has almost no distinguishing symptoms beyond those characterizing the general onset of the disease, since it usually kills the patient too quickly—sometimes in twenty-four hours or less—to allow more marked outward signs such as the bubo to manifest themselves. However, for those who do live a little longer, before they invariably die, some very odd symptoms can emerge, such as spontaneous bleeding from the nose and eyes, blood present in the urine and stool, and subcutaneous bleeding all over the body resulting in dark, purplish spots, called in medical parlance “petechiae” or “disseminated intravascular coagulation” (DIC).15 Tull still bears the purpuric spots on his skin from his bout with septicemic plague to this day. Interestingly enough, these same symptoms of petechiae or DIC also seem to have been noted by medieval observers of the plague.

As noted earlier, some disease epidemics that are called plagues were not true plague, as is the case of the “Plague of Athens” of 430–426 B.C.E., or the “Antonine Plague” that struck the Roman Empire in 164–180 C.E.; both these ills were probably smallpox (to be discussed in chapter 2). Yet, plague was probably present in endemic form in the Mediterranean and the Near East in ancient times, even if it never seems to have broken out beyond localized epidemics. Its symptoms, especially the occurrence of
bubones
or bubonic swellings, are discussed extensively in the
Epidemics
attributed to the Hippocratic corpus at the end of the fifth and first half of the fourth centuries B.C.E. and by the Greek physician Rufus of Ephesus who practiced during the reign of the Roman emperor Trajan (98–117 C.E.) but who was quoting earlier works dating back to the third and first century B.C.E.16 Possibly because plague was a newly evolved disease and because populations in the ancient world did not have the requisite densities, it was not until the sixth century C.E. that the first worldwide outbreak, or pandemic, of plague occurred.17

In terms of the historical occurrence of the disease, plague is therefore reserved for one of three pandemics: the First Pandemic, sometimes also known as the “Plague of Justinian,” that struck the Mediterranean world between 541 and 750 C.E.; the Second Pandemic, more commonly referred to as the “Black Plague y 23

Death,” that struck Europe and the Middle East beginning in 1347–1348 and persisted periodically right down to the eighteenth and nineteenth centuries; and the Third Pandemic, which struck Asia at the turn of the twentieth century, beginning with Hong Kong in 1894 and Bombay, India, in 1896, and that lasted down to the 1940s in India and Senegal, the 1950s in Thailand, and the 1960s in Vietnam. Indeed, the presence of plague to this day in the western United States stems from this last pandemic of the disease, when it first arrived in San Francisco in 1900. Each of these pandemics will now be discussed in turn.

A theme running through al three pandemics is that plague inspired some dramatic responses among the populations affected that had enduring consequences for cultural identity and survival. Not al of these responses, perhaps, are unique to plague, but they are usually associated with the disease because of both its unique nature and how it was perceived. As we have already noted, plague is a particularly deadly disease, kil ing in al of its forms an average of 70

to 80 percent of its victims, as well as striking with a very high morbidity, or incidence among the population at large, even if not al of them succumb to its mortality. (During the Second Pandemic in Europe, the high average mortality rate of 50 percent means that morbidity had to be well above that number.) But plague was also seen, and quite rightly, as an especial y horrible disease to die from: either patients suffered a prolonged il ness accompanied by distinctively nauseating symptoms, as in the case of bubonic plague, or they could die quite suddenly and unexpectedly, with little warning or opportunity to prepare for death, as in the case of pneumonic or septicemic plague. Plague thus made a great impression on all concerned, whether they came down with the disease or not, and they reacted accordingly.

The First Pandemic of plague is important above all for setting the pattern of various societal responses to the disease, which were to recur during the Second and even Third Pandemics centuries later. Otherwise, its historical impact, both relative to the other pandemics and in the contemporary context of the early Middle Ages when it occurred, is still very much open to debate. Perhaps the most neglected of the three pandemics, the First Pandemic is only now starting to get some of the scholarly attention that it deserves.18

The First Pandemic seems to have originated in Upper Egypt, arrived at the eastern end of the Nile delta during the summer of 541, and spread eastward from there into the hinterland of southern Palestine.19 Alexandria was struck in the autumn of that year, followed by Jerusalem at the beginning of 542. By the following spring, the plague had come to Constantinople, the capital of the Byzantine Empire, from where it probably spread to Asia Minor, northern Palestine, Syria, and Persia. The plague persisted in the capital until August and then by the end of the year had reached North Africa and possibly Sicily and 24 y Chapter 1

Spain. In 543 the disease spread to Italy, the Balkans, Spain, and France, and it reached Ireland in 544 but does not seem to have been known in England until a century later. There is further speculation that it may have struck Scandinavia and Poland at some point, but this is based entirely on interpreting the evidence of mass grave sites. After this first outbreak, plague seems to have returned to various parts of primarily the Mediterranean region in recurring waves, striking, with few exceptions, almost once a decade throughout the second half of the sixth, the whole of the seventh, and the first half of the eighth centuries. The last outbreak apparently encompassed Syria, Mesopotamia, Sicily, Rome, and Constantinople between 744 and 750.20

Obviously, it was the first outbreak of 541–544 that became the most famous disease incident of this pandemic and has had the most historical impact. This is partly due to the attention it received from the Byzantine court historian, Procopius of Caesarea. But it is often overlooked that other sixth-century writers also recorded the pandemic, the most important of which was John of Ephesus, a churchman who witnessed the plague firsthand in his travels to Alexandria, Palestine, Mesopotamia, and Syria. Procopius, for his part, gives us an invaluable perspective from the capital, Constantinople, where he remained throughout the course of the epidemic. Based on the descriptions of these authors and others, there is little disputing that the disease that struck in 541–542 featured bubonic plague: both Procopius and John of Ephesus mention the
bubones
, or swellings in the groin, that became a signature symptom of the pandemic.21 A third eyewitness, Evagrius Scholasticus, adds the authority of his own personal experience to this identification, for he says that he himself came down with buboes during this first outbreak when he was a boy and later watched his wife, children, and several other members of his family and servants succumb to the same symptoms in later recurrences of the disease.22 For sources in Syriac and Arabic, special terms evolved that denoted the bubonic swellings and that were used to specifically distinguish plague from more general references to “mortality” or “pestilence.”23 Elsewhere, the occurrence of this symptom in the historical record is practically our only sure record of the disease: For example, Bede’s mention that St. Cuthbert received a “tumor” on his thigh is our first evidence that plague struck England in 664.24

How did Byzantine society and culture react to the First Pandemic? As would be expected, attributions of the plague to the marvelous and the divine figure large in contemporary accounts. Procopius reports visions “of supernatural beings in human guise” and dream portents accompanying the advent of the plague in Constantinople.25 This is very reminiscent of the cult of Asclepius from ancient Greece, and it should be no surprise that similar responses make their reappearance in a society imbued with Greek culture. “Terrifying phantoms” or Plague y 25

specters were likewise cited by John of Ephesus as heralding the arrival of plague in southern Palestine, in the form of “headless black people” appearing on the sea off the coast in shining copper boats, a testament, perhaps, to the importance of maritime trade in spreading the disease. Otherwise, John of Ephesus employs a common rhetorical trope toward the beginning of his account in an attempt to convey the stupefying scale of the catastrophe: even if words could be found to describe it, a task that the author claims to find almost excessively daunting, who would be left alive to read them when the world is about to end, a sentiment summed up by the memorable phrase “for whom does the writer write?” These are the kinds of literary flourishes we encounter again during the Second Pandemic, or Black Death. John’s only answer to his own question is that perhaps future generations will learn from his contemporaries’ punishment for their transgressions and so avoid their fate, a supremely ironic observation in light of the even more catastrophic Black Death some six centuries later.26

John’s theme of the plague being a punishment for people’s sins is, of course, greatly amplified by his ample quotations from the Old Testament, which provides numerous examples of how disasters such as the plague were just instru-ments of God’s wrath.27 But one must remember that, at this same time, the concept of original sin was being promulgated and developed by the Christian Church, largely through its leading thinkers such as St. Augustine (354–430

C.E.). Deriving its theology ultimately from the New Testament rather than the Old, original sin imposed an individual need for repentance upon the believer as the descendant of Adam, as opposed to the collective sense of guilt of an entire people when punished by Yahweh. It is striking, for example, how the plague apparently persuaded people to amend their lives, especially when they feared an immediate death, even though they would backslide once again as soon as the threat had passed. Here, Procopius is reporting a response that is almost the exact opposite of what had been chronicled by Thucydides.28 Both authors concur, however, that many people who could have been saved from the disease instead died from sheer neglect, although Procopius excuses this un-Christian response with the exhausting effort that was required to attend plague patients.29 John of Ephesus, on the other hand, tells a couple of stories of how people who sought to profit from the plague by seizing valuables of the dead were then immediately struck down as punishment for their greed.30