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The Arrival of the Plague a.k.a. the Pestilence or the Great Mortality

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The Arrival of the Plague a.k.a. the Pestilence or the Great Mortality

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"The plague arrived in Europe in October 1347, when 12 ships from the Black Sea docked at the Sicilian port of Messina. People gathered on the docks were met with a horrifying surprise: Most sailors aboard the ships were dead, and those still alive were gravely ill and covered in black boils that oozed blood and pus."

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How Did the Black Plague Start?

Even before the "death ships" pulled into port at Messina, many Europeans had heard rumors about a "Great Pestilence" that was carving a deadly path across the trade routes of the Near and Far East. Indeed, in the early 1340s, the disease had struck China, India, Persia, Syria and Egypt.

The plague is thought to have originated in Asia over 2,000 years ago and was likely spread by trading ships, though recent research has indicated the pathogen responsible for the Black Death may have existed in Europe as early as 3000 B.C.

Symptoms of the Black Plague

Europeans were scarcely equipped for the horrible reality of the Black Death. "In men and women alike," the Italian poet Giovanni Boccaccio wrote, "at the beginning of the malady, certain swellings, either on the groin or under the armpits...waxed to the bigness of a common apple, others to the size of an egg, some more and some less, and these the vulgar named plague-boils."

Blood and pus seeped out of these strange swellings, which were followed by a host of other unpleasant symptoms-fever, chills, vomiting, diarrhea, terrible aches and pains-and then, in short order, death.

The Bubonic Plague attacks the lymphatic system, causing swelling in the lymph nodes. If untreated, the infection can spread to the blood or lungs.

How Did the Black Death Spread?

The Black Death was terrifyingly, indiscriminately contagious: "the mere touching of the clothes," wrote Boccaccio, "appeared to itself to communicate the malady to the toucher." The disease was also terrifyingly efficient. People who were perfectly healthy when they went to bed at night could be dead by morning.

Did you know? Many scholars think that the nursery rhyme "Ring around the Rosy" was written about the symptoms of the Black Death.

Understanding the Black Death

Today, scientists understand that the Black Death, now known as the plague, is spread by a bacillus called Yersinia pestis. (The French biologist Alexandre Yersin discovered this germ at the end of the 19th century.)

They know that the bacillus travels from person to person through the air, as well as through the bite of infected fleas and rats. Both of these pests could be found almost everywhere in medieval Europe, but they were particularly at home aboard ships of all kinds-which is how the deadly plague made its way through one European port city after another.

Not long after it struck Messina, the Black Death spread to the port of Marseilles in France and the port of Tunis in North Africa. Then it reached Rome and Florence, two cities at the center of an elaborate web of trade routes. By the middle of 1348, the Black Death had struck Paris, Bordeaux, Lyon and London.

Today, this grim sequence of events is terrifying but comprehensible. In the middle of the 14th century, however, there seemed to be no rational explanation for it.

No one knew exactly how the Black Death was transmitted from one patient to another, and no one knew how to prevent or treat it. According to one doctor, for example, "instantaneous death occurs when the aerial spirit escaping from the eyes of the sick man strikes the healthy person standing near and looking at the sick."

How Do You Treat the Black Death?

Physicians relied on crude and unsophisticated techniques such as bloodletting and boil-lancing (practices that were dangerous as well as unsanitary) and superstitious practices such as burning aromatic herbs and bathing in rosewater or vinegar.

Meanwhile, in a panic, healthy people did all they could to avoid the sick. Doctors refused to see patients; priests refused to administer last rites; and shopkeepers closed their stores. Many people fled the cities for the countryside, but even there they could not escape the disease: It affected cows, sheep, goats, pigs and chickens as well as people.

In fact, so many sheep died that one of the consequences of the Black Death was a European wool shortage. And many people, desperate to save themselves, even abandoned their sick and dying loved ones. "Thus doing," Boccaccio wrote, "each thought to secure immunity for himself."

Black Plague: God's Punishment?

Because they did not understand the biology of the disease, many people believed that the Black Death was a kind of divine punishment-retribution for sins against God such as greed, blasphemy, heresy, fornication and worldliness.

By this logic, the only way to overcome the plague was to win God's forgiveness. Some people believed that the way to do this was to purge their communities of heretics and other troublemakers-so, for example, many thousands of Jews were massacred in 1348 and 1349. (Thousands more fled to the sparsely populated regions of Eastern Europe, where they could be relatively safe from the rampaging mobs in the cities.)

Some people coped with the terror and uncertainty of the Black Death epidemic by lashing out at their neighbors; others coped by turning inward and fretting about the condition of their own souls.

Flagellants

Some upper-class men joined processions of flagellants that traveled from town to town and engaged in public displays of penance and punishment: They would beat themselves and one another with heavy leather straps studded with sharp pieces of metal while the townspeople looked on. For 33 1/2 days, the flagellants repeated this ritual three times a day. Then they would move on to the next town and begin the process over again.

Though the flagellant movement did provide some comfort to people who felt powerless in the face of inexplicable tragedy, it soon began to worry the Pope, whose authority the flagellants had begun to usurp. In the face of this papal resistance, the movement disintegrated.

How Did the Black Death End?

The plague never really ended and it returned with a vengeance years later. But officials in the port city of Ragusa were able to slow its spread by keeping arriving sailors in isolation until it was clear they were not carrying the disease-creating social distancing that relied on isolation to slow the spread of the disease.

The sailors were initially held on their ships for 30 days (a trentino), a period that was later increased to 40 days, or a quarantine- the origin of the term "quarantine" and a practice still used today.

Does the Black Plague Still Exist?

The Black Death epidemic had run its course by the early 1350s, but the plague reappeared every few generations for centuries. Modern sanitation and public-health practices have greatly mitigated the impact of the disease but have not eliminated it. While antibiotics are available to treat the Black Death, according to The World Health Organization, there are still 1,000 to 3,000 cases of plague every year.
Gallery: Pandemics That Changed History

Fact Check

We strive for accuracy and fairness. But if you see something that doesn't look right, click here to contact us! HISTORY reviews and updates its content regularly to ensure it is complete and accurate.

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The Black Death was a devastating global epidemic of bubonic plague that struck Europe and Asia in the mid-1300s. Explore the facts of the plague, the symptoms it caused and how millions died from it.

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This map shows how the Black Death spread in Europe and Northern Africa between 1346 and 1353.

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NIH research on Y. pestis

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Abstract

Plague is a widespread zoonotic disease that is caused by Yersinia pestis and has had devastating effects on the human population throughout history. Disappearance of the disease is unlikely due to the wide range of mammalian hosts and their attendant fleas. The flea/rodent life cycle of Y. pestis, a gram-negative obligate pathogen, exposes it to very different environmental conditions and has resulted in some novel traits facilitating transmission and infection. Studies characterizing virulence determinants of Y. pestis have identified novel mechanisms for overcoming host defenses. Regulatory systems controlling the expression of some of these virulence factors have proven quite complex. These areas of research have provide new insights into the host-parasite relationship. This review will update our present understanding of the history, etiology, epidemiology, clinical aspects, and public health issues of plague.

Cherepanov PA, Mikhailova TG, Karimova GA, Zakharova NM, Ershov Iu V, Volkovoi KI. Klonirovanie i detal'noe kartirovanie fra-ymt-oblasti plazmidy pFra Yersinia pestis. Mol Gen Mikrobiol Virusol. 1991 Dec;(12):19-26. [[PubMed] Google Scholar]

Kutyrev VV, Filippov AA, Shavina N Iu, Protsenko OA. Geneticheskii analiz i modelirovanie virulentnosti Yersinia pestis. Mol Gen Mikrobiol Virusol. 1989 Aug;(8):42-47. [[PubMed] Google Scholar]

Kutyrev VV, Popov Iu A, Protsenko OA. Plazmidy patogennosti chumnogo mikroba. Mol Gen Mikrobiol Virusol. 1986 Jun;(6):3-11. [[PubMed] Google Scholar]

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Yersinia pestis--etiologic agent of plague.

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Plague is a widespread zoonotic disease that is caused by Yersinia pestis and has had devastating effects on the human population throughout history. Disappearance of the disease is unlikely due to the wide range of mammalian hosts and their attendant ...

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"About 2 to 6 days after the flea bite, a person with bubonic plague develops a high fever, chills, muscle aches, headache and extreme weakness and within another 24 hours, 1 or more buboes appear. With prompt treatment of appropriate antibiotics, over 90% of people will survive. Without proper treatment, the Y. pestis bacteria could spread through the bloodstream and a person could develop septicemic plague."

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What is the Plague (Yersinia Pestis)?

Plague is caused by Yersinia pestis bacteria. It can be a life-threatening infection if not treated promptly. Plague has caused several major epidemics in Europe and Asia over the last 2,000 years. Plague has most famously been called "the Black Death" because it can cause skin sores that form black scabs. A plague epidemic in the 14th century killed more than one-third of the population of Europe within a few years. In some cities, up to 75% of the population died within days, with fever and swollen skin sores.

Worldwide, up to 3,000 cases of plague are reported to the World Health Organization (WHO) each year, mostly in Africa, Asia and South America.

Plague is primarily an infection of animals including many species of rodents (including mice, rats, ground squirrels, prairie dogs, chipmunks and rabbits). In the United States, it is most commonly transmitted to humans by the bite of an infected rat flea (Xenopsylla species). People are most at risk of infection when they are in areas where these rodents and their fleas are plentiful. Less commonly, humans can become infected in other ways:

When Y. pestis bacteria enter the body through a break in the skin after direct contact with the meat or blood of an infected animal (could happen, for example, when a hunter skins a carcass)

By breathing in droplets of Y. pestis bacteria if a person is in close contact with a human or animal with plague infection of the lungs (pneumonic plague)

From scratches or bites by infected domestic cats

People who are most likely to be infected include hunters, veterinarians, and those who camp or hike in areas where animals are infected with plague. Domestic cats or dogs also can spread the disease to their owners by bringing infected fleas into the home.

Symptoms

Plague occurs in different forms: bubonic, septicemic and pneumonic are the most common.

Bubonic plague. This form of plague is the most common of all (more than 80% of all cases). It takes its name from the infected lymph nodes called "buboes." Buboes are very painful, red and swollen lymph nodes that develop very quickly near the area of the flea bite. If the bite was on the leg, a bubo would probably appear in the groin. If the flea bite was on the arm, buboes might appear in the underarm or in the neck. About 2 to 6 days after the flea bite, a person with bubonic plague develops a high fever, chills, muscle aches, headache and extreme weakness and within another 24 hours, 1 or more buboes appear. With prompt treatment of appropriate antibiotics, over 90% of people will survive. Without proper treatment, the Y. pestis bacteria could spread through the bloodstream and a person could develop septicemic plague.

Septicemic plague. This form of plague is the second most common. It can develop when Y. pestis bacteria spread through the bloodstream and cause a blood infection called septicemia. It can also happen if Y. pestis spreads from a bubo or from the lungs into the bloodstream. It can also happen if the Y. pestis bacteria get into the bloodstream after a person has direct contact with the meat or blood of an infected animal. The first symptoms of septicemic plague can include nausea, vomiting, diarrhea and abdominal pain. The person can also develop severe bleeding problems, including sudden bleeding under the skin, scattered bruises, blood in the urine and abnormal bleeding from the mouth, nose and rectum. The bleeding problems can be followed by signs of shock (severe drop in blood pressure, rapid pulse, unconsciousness), kidney failure, severe breathing difficulties and even death. With appropriate treatment, however, 75% to 80% of people survive.

Pneumonic plague. This form of plague is currently very rare. It happens when Y. pestis bacteria infect the lungs and cause pneumonia. It can develop when a person breathes in droplets of Y. pestis from an animal or person who has plague infection in the lungs. People who have bubonic or septicemic plague can also develop Y. pestis infection in the lungs. Symptoms include high fever, chills, headaches, chest pain, rapid breathing, severe shortness of breath and cough that might bring up blood. Without proper treatment, the disease can quickly lead to death.

Diagnosis

If your doctor suspects you might have plague, he or she will ask whether you:

Recently noticed a flea bite

Have been around wild rodents

Have recently traveled to an area of the world where plague is known to occur.

Have been in contact with a dead animal

Have been treating a pet that has been extremely ill.

To confirm the diagnosis, blood or other body fluids can be tested to look for evidence of Y. pestis bacteria infection.

Expected Duration

With proper antibiotic treatment, most symptoms of uncomplicated bubonic plague will subside within two to five days. However, swollen buboes can remain for several weeks. Recovery from more severe septicemic plague and pneumonic plague usually takes longer.

Prevention

If you live, work or vacation in regions where plague affects local rodent populations, here are things you can do to help prevent getting the infection and allowing plague to spread:

Avoid contact with sick or dead animals, especially rodents. Report any observations of sick or dead animals to the local health department or law enforcement officials.

Avoid contact with the nests and burrows of squirrels, chipmunks and other rodents.

Eliminate sources of food and nesting places for rodents around homes, work places and recreation areas. Remove brush; rock piles; junk; cluttered firewood; and potential-food supplies, such as pet and wild animal food. Ask local health authorities how to rodent-proof your house.

If you live in areas where rodent plague occurs, use veterinarian-approved flea collars and other flea repellents on cats and dogs. Treat pet dogs and cats for flea control regularly and not allow these animals to roam freely. Follow your veterinarian's guidelines when handling a severely ill cat or dog, and have the animal examined promptly by your veterinarian.

If you anticipate being exposed to rodent fleas, apply an insect repellent containing DEET (diethyl toluamide) to your skin and use other insect repellents on clothing to prevent flea bites.

Wear gloves when handling potentially infected animals or a dead animal.

If someone is exposed to a person or animal infected with plague, antibiotics can be prescribed by a doctor to prevent the person from getting the disease.

A plague vaccine is no longer available in the United States.

Treatment

A person who is ill and is suspected of having the plague needs to be hospitalized. Hospital staff will take special steps to prevent the spread of the plague bacteria to other people. For example, the infected person will be put in a private room and the hospital staff will wear gloves, masks and protective clothing when coming into the room.

Antibiotics will be given intravenously (into a vein). Patients with severe bleeding problems or difficulty breathing will be treated in an intensive care unit. In the United States, the U. S. Public Health Service requires health care professionals to report all cases of suspected plague immediately to local and state health departments. The Centers for Disease Control (CDC) will confirm the diagnosis and report it to the World Health Organization (WHO).

When To Call a Professional

Call your doctor whenever you or someone in your family develops a fever or becomes very sick (fever, severe weakness, severe headache) after:

A flea bite or any unidentified insect bite

Exposure to a sick or dead animal, even a pet cat

Travel or work in areas where rodent burrows and nests are common

Travel to the high-risk areas of the Southwestern United States or to countries where plague is most common Also call your doctor if you develop a painful, swollen lymph node, especially if you have recently been bitten by an insect.

Prognosis

Without quick antibiotic treatment, plague can be fatal. Even with the right antibiotics and good hospital care, as many as 10% of plague patients in the United States die.

External resources

Centers for Disease Control and Prevention (CDC)
Division of Vector-Borne Infectious Diseases
www.cdc.gov/ncezid/dvbd

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
Medical Disclaimer

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Plague (Yersinia Pestis) Guide: Causes, Symptoms and Treatment Options

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Plague is caused by Yersinia pestis bacteria. It can be a life-threatening infection if not treated promptly. Plague has caused several major epidemics in Europe and Asia over the last 2,000 years. Plague has most famously been called "the Black Death" because it can cause skin sores that form black scabs.

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How it All Began and What Made the Plague So Deadly 

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How it All Began and What Made the Plague So Deadly 

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Festering, oozing pustules + fever & pain followed by death. A horrifying way to die. This video explains the consequences of the rapid spread of the Black Death.

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What Made The Black Death (The Plague) so Deadly?

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The frequently asked questions about plague - answered by the CDC: how plague is transmitted, the types of plague out there, and who is at risk today.

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Centers for Disease Control and Prevention

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What is plague?

Plague is an infectious disease that affects rodents, certain other animals, and humans. It is caused by the Yersinia pestis bacteria. These bacteria are found in many areas of the world, including the United States.

How do people become infected with plague?

People most commonly acquire plague when they are bitten by a flea that is infected with the plague bacteria. People can also become infected from direct contact with infected tissues or fluids while handling an animal that is sick with or that has died from plague. Finally, people can become infected from inhaling respiratory droplets after close contact with cats and humans with pneumonic plague.

What are the different forms of plague?

There are three forms of plague:

Bubonic plague: Patients develop fever, headache, chills, and weakness and one or more swollen, painful lymph nodes (called buboes). This form is usually the result of an infected flea bite. The bacteria multiply in a lymph node near where the bacteria entered the human body. If the patient is not treated with appropriate antibiotics, the bacteria can spread to other parts of the body.

Septicemic plague: Patients develop fever, chills, extreme weakness, abdominal pain, shock, and possibly bleeding into the skin and other organs. Skin and other tissues may turn black and die, especially on fingers, toes, and the nose. Septicemic plague can occur as the first symptoms of plague or may develop from untreated bubonic plague. This form results from bites of infected fleas or from handling an infected animal.

Pneumonic plague: Patients develop fever, headache, weakness, and a rapidly developing pneumonia with shortness of breath, chest pain, cough, and sometimes bloody or watery mucous. Pneumonic plague may develop from inhaling infectious droplets or from untreated bubonic or septicemic plague that spreads to the lungs. The pneumonia may cause respiratory failure and shock. Pneumonic plague is the most serious form of the disease and is the only form of plague that can be spread from person to person (by infectious droplets).

What is the basic transmission cycle of plague?

Fleas become infected by feeding on rodents, such as chipmunks, prairie dogs, ground squirrels, mice, and other mammals that are infected with the bacterium Yersinia pestis. Fleas transmit the plague bacteria to humans and other mammals during a subsequent feeding. The plague bacteria survive briefly (a few days) in the blood of rodents and for longer periods in the fleas. An illustration of plague ecology in the United States is available.

Could one person get plague from another person?

Yes, when a person has plague pneumonia they may cough droplets containing the plague bacteria into air. If these bacteria-containing droplets are breathed in by another person they can cause pneumonic plague. Human-to-human transmission is rare and typically requires direct and close contact with the person with pneumonic plague.

What is the incubation period for plague?

A person usually becomes ill with bubonic plague 2 to 8 days after being infected. The incubation period of septicemic plague is poorly defined but likely occurs within days of exposure. A person exposed to Yersinia pestis through the air would usually become ill in just 1 to 3 days.

When bubonic plague is left untreated, plague bacteria can invade the bloodstream. When plague bacteria multiply in the bloodstream, they spread rapidly throughout the body and cause a severe and often fatal condition called septicemic plague. Untreated bubonic plague can also progress into an infection of the lungs, causing pneumonic plague. If plague patients are not given specific antibiotic therapy, all forms of plague can progress rapidly to death.

How is plague diagnosed?

The first step in plague diagnosis is evaluation by a health worker. If the health worker suspects plague, samples of the patient's blood, sputum, or lymph node aspirate are sent to a laboratory for testing. Once the laboratory receives the sample, preliminary results can be ready in less than two hours. Laboratory confirmation will take longer, usually 24 to 48 hours. Often, presumptive treatment with antibiotics will start as soon as samples are taken, if plague is suspected.

How many cases of plague occur in the United States? Globally?

Plague was first introduced into the United States in 1900. Between 1900 and 2012, 1006 confirmed or probable human plague cases occurred in the United States. Over 80% of United States plague cases have been the bubonic form. In recent decades, an average of 7 human plague cases are reported each year (range: 1-17 cases per year). Plague has occurred in people of all ages (infants up to age 96), though 50% of cases occur in people ages 12-45. Worldwide, between 1,000 and 2,000 cases each year are reported to the World Health Organizationexternal icon (WHO), though the true number is likely much higher.

What is the death rate of plague?

In the pre-antibiotic era (1900 through 1941), mortality among those infected with plague in the United States was 66%. Antibiotics greatly reduced mortality, and by 1990-2010 overall mortality had decreased to 11%. Plague can still be fatal despite effective antibiotics, though it is lower for bubonic plague cases than for septicemic or pneumonic plague cases. It is hard to assess the mortality rate of plague in developing countries, as relatively few cases are reliably diagnosed and reported to health authorities. WHO cites mortality rates of 8-10%, however some studies (WHO, 2004) suggest that mortality may be much higher in some plague endemic areas.

How is plague treated?

Plague can be successfully treated with antibiotics. Once a patient is diagnosed with suspected plague they should be hospitalized and, in the case of pneumonic plague, medically isolated. Laboratory tests should be done, including blood cultures for plague bacteria and microscopic examination of lymph node, blood, and sputum samples. Antibiotic treatment should begin as soon as possible after laboratory specimens are taken. To prevent a high risk of death in patients with pneumonic plague, antibiotics should be given as soon as possible, preferably within 24 hours of the first symptoms.

Is the disease seasonal in its occurrence?

Yes. Although cases can occur any time of the year, most cases in the United States are acquired from late spring to early fall.

Where is plague most common in the United States?

Plague occurs in rural and semi-rural areas of the western United States. Plague is most common in the southwestern states, particularly New Mexico, Arizona, and Colorado.

Who is at risk for getting plague in the United States?

Human plague occurs in areas where the bacteria are present in wild rodent populations. The risks are generally highest in rural and semi-rural areas, including homes that provide food and shelter for various ground squirrels, chipmunks and wood rats, or other areas where you may encounter rodents.

Is a vaccine available to prevent plague?

A plague vaccine is not available. New plague vaccines are in development but are not expected to be commercially available in the immediate future.

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centers for disease control and prevention

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Answers to frequently asked questions about plague.

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Today, plague is treatable with antibiotics, but it has to be diagnosed on time.
Antibiotics that treat plague:

Gentamicin

Doxycycline (Monodox, Vibramycin, others)

Ciprofloxacin (Cipro)

Levofloxacin

Moxifloxacin (Avelox)

Chloramphenicol

(Mayo Clinic)

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Diagnosis

If your doctor suspects plague, he or she may look for the Yersinia pestis bacteria in samples taken from your:

Buboes. If you have the swollen lymph nodes (buboes) typical of bubonic plague, your doctor may use a needle to take a fluid sample from them (aspiration).

Blood. You'll generally have Yersinia pestis bacteria present in your bloodstream only if you have septicemic plague.

Lungs. To check for pneumonic plague, your doctor will take mucus (sputum) or fluid from your airways using a thin, flexible tube inserted through your nose or mouth and down your throat (endoscopy).

Treatment

Medications

As soon as your doctor suspects that you have plague, you'll need to be admitted to a hospital. You'll receive powerful antibiotics, such as:

Gentamicin

Doxycycline (Monodox, Vibramycin, others)

Ciprofloxacin (Cipro)

Levofloxacin

Moxifloxacin (Avelox)

Chloramphenicol

Preparing for your appointment

If you suspect you have plague, you're likely to start by going to an emergency room. You may eventually need to see a doctor specializing in infectious disease.

What you can do

If you have respiratory symptoms, you may need to wear a surgical mask to your appointment to help prevent spreading the disease to others. You might also want to:

Tell your doctor about any relevant travel or possible plague exposures you've had.

Write down any symptoms you're experiencing, including when they started.

Write down key personal information, including whether you've recently traveled to an area where plague is common and whether you've handled wild animals.

Make a list of all medications, vitamins or supplements you're taking.

Bring a family member or friend along, if possible. Sometimes it can be difficult to retain all the information you get during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Write down questions to ask your doctor.

For plague, some basic questions to ask your doctor include:

What is likely causing my symptoms or condition?

Other than the most likely cause, what are other possible causes for my symptoms or condition?

What tests do I need?

What is the best course of action?

Will I need to be in isolation?

What are the alternatives to the primary approach you're suggesting?

I have other health conditions. How can I best manage them together?

Are there any restrictions I need to follow?

Don't hesitate to ask any other questions.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, including:

When did you begin experiencing symptoms?

Have you recently traveled to areas where plague is common?

Have you recently handled wild animals or cats?

Are you aware of having been bitten by fleas?

Have your symptoms been continuous or occasional?

How severe are your symptoms?

What, if anything, seems to improve your symptoms?

What, if anything, appears to worsen your symptoms?

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If your doctor suspects plague, he or she may look for the Yersinia pestis bacteria in samples taken from your: Buboes. If you have the swollen lymph nodes (buboes) typical of bubonic plague, your doctor may use a needle to take a fluid sample from them (aspiration). Blood.

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Infographic that puts the size of the outbreak in perspective.

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Rubbing onions, herbs or a chopped up snake (if available) on the boils or cutting up a pigeon and rubbing it over an infected body.

Drinking vinegar, eating crushed minerals, arsenic, mercury or even ten-year-old treacle!

Sitting close to a fire or in a sewer to drive out the fever, or fumigating the house with herbs to purify the air.

People who believed God was punishing you for your sin, 'flagellants', went on processions whipping themselves.

In the 1361 - 1364 outbreak, doctors learned how to help the patient recover by bursting the buboes.

Doctors often tested urine for colour and health. Some even tasted it to test. (BBC)

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In the 1347 - 1350 outbreak, doctors were completely unable to prevent or cure the plague. For those who believed in the Greek humours there were a range of cures available. 'Blood-letting' - deliberately bleeding a vein - was a way of reducing 'hot' blood, whilst blowing your nose or clearing your throat was a way of getting rid of too much 'cold' phlegm. Mustard, mint sauce, apple sauce and horseradish were used to balance wet, dry, hot and cold in your diet!

A source from 1380 presents a cynical view of their work:

"Doctors need three qualifications: to be able to lie and not get caught; to pretend to be honest; and to cause death without guilt." Jean Froissart's Chronicles

Some of the cures they tried included:

Rubbing onions, herbs or a chopped up snake (if available) on the boils or cutting up a pigeon and rubbing it over an infected body.

Drinking vinegar, eating crushed minerals, arsenic, mercury or even ten-year-old treacle!

Sitting close to a fire or in a sewer to drive out the fever, or fumigating the house with herbs to purify the air.

People who believed God was punishing you for your sin, 'flagellants', went on processions whipping themselves.

In the 1361 - 1364 outbreak, doctors learned how to help the patient recover by bursting the .

Doctors often tested urine for colour and health. Some even tasted it to test.

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Cures for the Black Death - The Black Death - KS3 History Revision - BBC Bitesize

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In the 1347 - 1350 outbreak, doctors were completely unable to prevent or cure the plague. For those who believed in the Greek humours there were a range of cures available. 'Blood-letting' - deliberately bleeding a vein - was a way of reducing 'hot' blood, whilst blowing your nose or clearing your throat was a way of getting rid of too much 'cold' phlegm.

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Plague is transmitted via flea bites.

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Centers for Disease Control and Prevention

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Ecology and transmission of plague | CDC

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How does plague occur, and how is plague transmitted to humans?

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Plague was such a prominent part of life that its terrors have been memorialized in art. Follow this link to see noteworthy paintings.

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As the coronavirus is spreading around the globe we want to show you how artists depicted plague in art in times when plagues were really deadly.

I know it's not comforting under current circumstances but actually, when you think about it, untreatable plagues were a regular part of human life for centuries. The medieval Black Death was one of the most devastating pandemics in human history. It resulted in the deaths of an estimated 75 to 200 million people in Eurasia, peaking in Europe from 1347 to 1351. 200 million!

The 1918 an influenza pandemic known as Spanish flu (present from January 1918 to December 1920) infected 500 million people around the world. This amounts to 27% of the world population at the time. The death toll is estimated to have been anywhere from 17 million to 50 million, and possibly as high as 100 million. 100 million! And it happened only one hundred years ago.

Or take HIV/AIDS, it is estimated that since the beginning of the epidemic in 1980s 75 million people have been infected with the HIV virus and about 32 million people have died of it. There is no cure or vaccine for it yet, however antiretroviral treatments can slow the course of the disease and lead to a near-normal life expectancy. Still, close to 13,000 people with AIDS in the United States are dying each year. The peak of this pandemic happened only thirty years ago.

We don't know yet what would be the final numbers of coronavirus (also known as COVID-19) pandemia. Since the outbreak began in December 2019, 108,000 cases have been identified and 3,666 deaths have been reported. Also, 61,000 people have fully recovered (as of March 8th). So, please clean your hands (according to WHO it is the best way to prevent the coronavirus) and get ready for a short ride through art history and masterpieces you should know about in the times of Coronavirus.

1. Tournai Citizens Burying the Dead During the Black Death, 14th century

In the time of the Black Death (1347 to 1351) themes such as skeletons, death, and the Dance of Death were very common in culture and especially art. There is no surprise here, it's estimated that more than 30% of the European population died in the epidemic. In some cities, such as Venice, up to 60% of the inhabitants died. Also half of Paris's population of 100,000 people died. Giovanni Bocaccio in his Decameron (1353) wrote:

"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."
Giovanni Bocaccio, Decameron, 1353.

Following this victims developed an acute fever and started vomiting blood. Most victims died two to seven days after initial infection.

Contemporary reports tell of mass burial pits dug in response to the large numbers of dead. Before 1350 there were about 170,000 settlements in Germany. By 1450 this number dropped by nearly 40,000 due to the Black Death. In this miniature we see how the citizens of Tournai, Belgium were burying the dead en masse. There are fifteen mourners and nine coffins all crammed into the small space. Interestingly the face of each mourner is given individual attention, each conveys genuine sorrow, and even more genuine fear.

2. Giacomo Borlone de Burchis, The Triumph of Death with The Dance of Death, 15th century

The horror of the Black Death had another unexpected effect, very dark humor. The plague was often seen through a macabre and grim lens. The theme of The Dance of Death ( Danse Macabre) is a great example of this. The earliest known appearances of it were in story-poems that told about encounters between the living and the dead. Most often the living characters were proud and powerful members of society, such as knights and bishops. The dead interrupted their procession: "As we are, so shall you be" was the underlying message, "and neither your strength nor your piety can provide escape".

Clusone's Dance of Death is a part of The Triumph of Death scene. It shows several characters from different social classes walking with skeletons to join the fatal dance of death. In The Triumph of Death Death itself is represented as a crowned skeleton queen swinging scrolls in both her hands. She has two fellow skeletons at her sides killing people with a bow and an ancient arquebus. Around her a group of powerful but desperate people are offering valuables and begging for mercy. Death is not interested in their mundane wealth however, she only wants their lives. Beneath her feet is a marble coffin where the corpses of an emperor and a pope lie surrounded by poisonous animals, symbols of a fast and merciless end.

3. Pieter Bruegel the Elder, Triumph of Death, c. 1562

Pieter Bruegel the Elder, Triumph of Death, c. 1562, Museo del Prado, Madrid.

We are not in the Middle Ages anymore but The Triumph of Death by Flemish Renaissance master Pieter Bruegel the Elder with a very deadly swing shows how the Black Death could look like in an average European town. OK, maybe I'm exaggerating a little, but an army of skeletons wreaking havoc across a blackened, desolate landscape makes a huge impression to this day. Fires are burning in the distance, the sea is full of shipwrecks. Everything is dead, even the trees and the fish in a pond. This painting depicts people of all social backgrounds, from peasants and soldiers to nobles as well as a king and a cardinal. Death takes them all indiscriminately.

4. Paulus Furst of Nuremberg, Doctor Schnabel von Rom, 1656

The Black Death was more than a medieval horror, it kept coming back. For more than the next 300 years the plague became a regular part of everyday life in Europe. Terrible outbreaks periodically devastated cities. Look at this this way, the whole story of Europe between 14th to the late 17th century was constantly marked by the plague. Some great artists, probably including Hans Holbein and Titian, died of it. Meanwhile others tried to fight it with art, like Tintoretto. He painted his greatest works in the Scuola Grande di San Rocco in Venice, a building dedicated to a plague-protective saint. Death from the plague was a regular part of human life at the time.

In this etching we see a protective costume used in France and Italy in the 17th century. It terrified people because it was a sign of imminent death. It consisted of an ankle-length overcoat, a bird-like beaked mask, along with gloves, boots, a wide-brimmed hat, and another over-clothing garment. The mask had glass openings in the eyes and a curved beak shaped face with straps that held the beak in front of the doctor's nose. The mask also had two small nose holes and was a type of early respirator which held sweet or strong smelling substances (usually lavender). The beak could also hold dried flowers, herbs, spices, camphor, or a vinegar sponge too. The purpose of the mask was to keep away bad smells, known as miasma, which were thought to be the primary cause of the disease. Germ theory later disproved this.

5. Arnold Böcklin, Plague, 1898

Plague exemplified Arnold Böcklin's obsession with nightmares of war, pestilence, and death. Böcklin was a Symbolist and here his personification of Death rides on a winged creature, flying through the street of a medieval town. According to art historians he took inspiration from news about the plague appearing in Bombay in 1898. Although there is no straightforward, visible evidence of Indian inspiration (Symbolists always used as ambiguous and universal symbols as possible) Böcklin created a scene that the creators of the Game of Thrones would not be ashamed of.

6. Egon Schiele, The Family, 1918

The 20th century brought two World Wars, the Holocaust, unimaginable atrocities, and the Spanish Flu. The horrific scale of this pandemic is hard to fathom. The virus infected 500 million people worldwide and killed an estimated 100 million victims. For perspective that's more than all of the soldiers and civilians killed during World War I combined.

It had symptoms of a normal flu: fever, nausea, aches and diarrhea. Many developed severe pneumonia as well. Also dark spots would appear on the cheeks and patients would turn blue, suffocating from a lack of oxygen as their lungs filled with a frothy, bloody substance. Unlike a typical flu where the highest mortality is in infants and the elderly, the 1918 flu also struck down young, healthy adults.

Egon Schiele was one of the great artists who died from it. The Family was unfinished at the time of Schiele's death and initially was titled Squatting Couple. It was one of his last paintings. In it we see Schiele himself with his wife Edith and their unborn child. In his last letter he described his concern for her writing "Dear Mother Schiele, Edith got the Spanish Flu eight days ago and has pneumonia. She is six months pregnant. The disease is very serious and life-threatening; I am preparing myself for the worst". Edith died of Spanish flu in the 6th month of her pregnancy. Three days after she died Egon did too.

7. Edvard Munch, Self-Portrait after Spanish Influenza, 1919

Among other famous artists who died of the Spanish flu were Gustav Klimt, Amadeo de Souza Cardoso, and Niko Pirosmani. Spoiler Alert: Edvard Munch caught it but he survived. Munch painted this work in 1919. He created a series of studies, sketches, and paintings, where in a very detailed way he depicted his closeness to death. As we see here, Munch's hair is thin, his complexion is jaundiced, and he is wrapped in a dressing gown and blanket.

By the summer of 1919, the flu pandemic had come to an end. Those that were infected had either died or had developed immunity.

8. Keith Haring, Ignorance = Fear 1989

In the 1980s and early 1990s the outbreak of HIV and AIDS swept across the United States and rest of the world. The disease originated decades earlier though. Today, over 70 million people have been infected with HIV and about 35 million have died from AIDS since the start of the epidemic. The virus is transmitted through bodily fluids such as blood, semen, vaginal fluids, anal fluids, and breast milk. In 1980s the public considered AIDS a "gay disease", it was even called the "gay plague" for many years. Historically HIV spread from person to person through unprotected sex, sharing of needles for drug use, and through birth.

Keith Haring designed and executed this poster in 1989 after he was diagnosed with AIDS the previous year. In 1989 one American was diagnosed with HIV every minute and four people died of AIDS every hour. By 1991 the epidemic had claimed the lives of 100,000 Americans. The poster depicts three figures gesturing "see nothing, hear nothing, say nothing". This implied the struggles faced by those living with AIDS and the challenges posed by individuals or groups that fail to properly acknowledge and respect the epidemic. The state of information about AIDS/HIV in United States 1980s was truly horrendous. At the time disinformation was common, the American government's response to what was happening was shamefully inadequate, and the medicines and medical care were extremely expensive. People infected with HIV were left by themselves.

Keith Haring died of AIDS in 1990 at the age of 31.

9. David Wojnarowicz, Untitled (Falling Buffalos), 1988-1989

David Wojnarowicz's Untitled (Falling Buffalos) is one of the artist's best-known works and perhaps one of the most haunting artistic responses to the AIDS crisis of the 1980s. In this photo-montage we see a herd of buffalo falling off a cliff to their deaths. The falling buffalos evoke feelings of doom and hopelessness, making the work extremely powerful and provocative. Made in the wake of the artist's HIV-positive diagnosis, Wojnarowicz's image draws a parallel between the AIDS crisis and the mass slaughter of buffalos in America in the nineteenth century. It reminds viewers of the neglect and marginalization that characterized the politics of HIV/AIDS at the time. You can read how he manifested his outrage in the times of HIV/AIDS pandemic here.

Wojnarowicz died of HIV/AIDS in 1992.
Here's a full list of our "Lockdown" home entertainment articles. Stay safe and #Stayhome! 7 Entertaining Art History Podcasts to Listen to 10 Best Movies Related to Art for Time Spent in Quarantine The Best Art Videos for the Age of Quarantine The Best of the Best Museums to Visit Virtually on Lockdown (Constantly Updated) Lockdown Artsy Entertainment Toolkit Virtual Art Repositories - Explore Endless Artworks from Quarantine Theatre Plays, Opera and Music Online to Keep you Entertained During Lockdown 15 Artsy Books To Read During Self-Quarantine What to Do with Your Time when in Quarantine? Tips from Art! Art-Guide to Quarantine by DailyArt Magazine Plague in Art: 10 Paintings You Should Know in the Times of Coronavirus

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Plague in Art: 10 Paintings You Should Know in the Times of Coronavirus

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As the coronavirus spreads around the globe we want to envision you how famous artists presented plague in art - check 10 paintings to know!

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Cat in Colorado Testing Positive for Plague

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Cat in Colorado Testing Positive for Plague

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Y. pestis is here today!

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By NewsDesk @infectiousdiseasenews

A cat living near North Foothills Highway and Plateau Road in Boulder County was examined by a veterinarian on June 2 and tested positive for plague. The cat's owner was concerned when the cat became ill 2-3 weeks after being found with a baby rabbit.

This is the first time plague activity has been confirmed in Boulder County this season and public health officials want to remind residents of how to protect themselves against plague.

Boulder County Parks and Open Space was notified of the positive plague in that area, and warning signs will be posted in this neighborhood with precautionary measures to avoid the plague.

"Because plague is most commonly transmitted by fleas, taking steps to avoid flea exposures will help prevent spread of the disease," said Carol McInnes, Boulder County Public Health Environmental Health Specialist.
Plague confirmed in Colorado Springs domestic pet
Public health officials recommend the following precautions to reduce the likelihood of being exposed to plague:

AVOID FLEAS! Protect pets with flea treatment recommended by your veterinarian and keep pets on a leash and out of wildlife habitats.

STAY OUT of areas that wild rodents and rabbits inhabit. If you enter areas with rodents or rabbits, wear insect repellent containing DEET and tuck pants cuffs into socks to prevent flea bites.

AVOID all contact with wildlife, including rabbits and squirrels; do not feed or handle them.

DO NOT TOUCH sick or dead animals.

PREVENT rodent infestations around your house: clear plants and materials away from outside walls, reduce access to food items, and set traps.

TREAT burrows on your property if you find dead rabbits or rodents with an insecticide approved by the EPA for use on fleas and follow the manufacturer's instructions on the label.

Household pets, such as dogs and especially cats, can either get plague or carry infected fleas home to their owners. In rare instances, plague can be transmitted to people from cats sick with plague.

"Keeping cats indoors is the best way to protect them from getting plague," said McInnes. "Pet owners should also discuss with their veterinarians the best way to protect pets from fleas."

Plague occurs naturally in Colorado, and is an infectious disease spread by fleas to wild rodents and other small mammals such as prairie dogs and rabbits. Bubonic plague is the most common form of plague and occurs after a bite from an infected flea. Plague can spread to humans when infected fleas from rabbits, prairie dogs, and other wild rodents bite a human.

Symptoms of plague include high fever, extreme fatigue, and painful swollen lymph nodes. If you observe these symptoms in a person or pet, it is important to contact your healthcare provider or veterinarian immediately. Plague can be treated with antibiotics, but this treatment is most successful when the disease can be diagnosed quickly.
Colorado: Adams county miniature horse tests positive for rabies Plague suspected in the death of squirrels in the Colorado Springs area Colorado: Botulism cases prompt health warning on food safety Colorado reports 2nd human plague case of 2020

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Colorado: Plague confirmed in Boulder County cat - Outbreak News Today

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By NewsDesk @infectiousdiseasenews A cat living near North Foothills Highway and Plateau Road in Boulder County was examined by a veterinarian on June 2 and tested positive for plague. The cat's owner was concerned when the cat became ill 2-3 weeks after being found with a baby rabbit.

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Very interesting documentary about how Black Death was attempted to be managed with limited knowledge about the disease and its transmission.

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Black Death and the Failure of Pandemic Lockdowns - Pandemic History 03

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The reason behind wearing beaked masks while dealing with plague patients.

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The plague was once the most feared disease in the world, capable of wiping out hundreds of millions of people in seemingly unstoppable global pandemics and afflicting its victims with painfully swollen lymph nodes, blackened skin, and other gruesome symptoms.

In 17th-century Europe, the physicians who tended to plague victims wore a costume that has since taken on sinister overtones: they covered themselves head to toe and wore a mask with a long bird-like beak. The reason behind the beaked plague masks was a misconception about the very nature of the dangerous disease.

During that period's outbreaks of the bubonic plague-a pandemic that recurred in Europe for centuries-towns gripped by the disease hired plague doctors who practiced what passed for medicine on rich and poor residents alike. These physicians prescribed what were believed to be protective concoctions and plague antidotes, witnessed wills, and performed autopsies-and some did so while wearing beaked masks.

The costume is usually credited to Charles de Lorme, a physician who catered to the medical needs of many European royals during the 17th century, including King Louis XIII and Gaston d'Orléans, son of Marie de Médici. He described an outfit that included a coat covered in scented wax, breeches connected to boots, a tucked-in shirt, and a hat and gloves made of goat leather. Plague doctors also carried a rod that allowed them to poke (or fend off) victims.

Their head gear was particularly unusual: Plague doctors wore spectacles, de Lorme continued, and a mask with a nose "half a foot long, shaped like a beak, filled with perfume with only two holes, one on each side near the nostrils, but that can suffice to breathe and carry along with the air one breathes the impression of the [herbs] enclosed further along in the beak."

Though plague doctors across Europe wore these outfits, the look was so iconic in Italy that the "plague doctor" became a staple of Italian commedia dell'arte and carnival celebrations-and is still a popular costume today. ( Memories of the plague resonate in Venice during the coronavirus pandemic.)

But the forbidding ensemble was not just a deathly fashion statement: It was intended to protect the doctor from miasma. In the times before the germ theory of disease, physicians believed that the plague spread through poisoned air that could create an imbalance in a person's humors, or bodily fluids. Sweet and pungent perfumes were thought to be able to fumigate plague-stricken areas and protect the smeller; nosegays, incense, and other perfumes were common in the era.

Plague doctors filled their masks with theriac, a compound of more than 55 herbs and other components like viper flesh powder, cinnamon, myrrh, and honey. De Lorme thought the beak shape of the mask would give the air sufficient time to be suffused by the protective herbs before it hit plague doctors' nostrils and lungs.

In fact, plague is caused by Yersinia pestis, bacteria that can be transmitted from animals to humans and through flea bites, contact with contaminated fluid or tissue, and inhalation of infectious droplets from sneezing or coughing people with pneumonic plague.

Three horrific plague pandemics swept across the globe before its cause was ultimately uncovered-the Plague of Justinian, which killed up to 10,000 people a day circa A.D. 561; the Black Death, which wiped out up to a third of Europeans between 1334 and 1372 and continued with intermittent outbreaks as late as 1879; and the Third Pandemic, which ravaged much of Asia between 1894 and 1959. ( What is a pandemic-and why does it matter?)

Ultimately, the plague doctors' outfits-and methods-didn't make much of a difference. "Unfortunately," writes historian Frank M. Snowden, "the therapeutic strategies of early modern plague doctors did little to prolong life, relieve suffering, or effect a cure."

Plague doctors may have been immediately recognizable, but until the rise of the germ theory of disease and modern antibiotics, their costumes didn't provide real protection against the disease.

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Why plague doctors wore those strange beaked masks

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In the 17th century, people believed these outfits could purify poisonous air. They were wrong.

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Historically Few Public Health Tools Available to Deal with Plague

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Historically Few Public Health Tools Available to Deal with Plague

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Quarantine was nearly the only public health tool available at the time. Although there were also attempts to bury the dead further away from the villages and towns to avoid further infections.

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In the autumn of 1348 a ship glided into the port of Southampton in England, carrying a disease from the east that had already ravaged the western world. It had killed men, women and children in their thousands quickly and mercilessly. This was the bubonic plague, identified by the blackening 'buboes' that formed within the joint area of an infected person - the groin or armpit were the most common places. These were accompanied by bodily aches, cold, lethargy and a high fever. When the infection got into the blood stream it effectively poisoned the blood, leading to probable death. Some survived the infection but most people died within days, sometimes hours. This wave of bubonic plague became known then as the Pestilence - or later, the Black Death.

By November 1348 the disease had reached London, and by New Year's Day 1349 around 200 bodies a day were being piled into mass graves outside the city. Henry Knighton, an Augustinian monk, witnessed the devastation of the Black Death in England: "there was a general mortality throughout the world... sheep and oxen strayed through the fields and among the crops and there was none to drive them off or collect them, but they perished in uncounted numbers... for lack of shepherds... After the Pestilence many buildings fell into total ruin for lack of inhabitants; similarly many small villages and hamlets became desolate and no homes were left in them, for all those who had dwelt anthem (sic) were dead."

The countryside went to ruin, with crops, livestock and produce dying for lack of people to tend to them. Towns were abandoned, left only with the dead to occupy them, and war with France - the first part of the later-named Hundred Years' War - was put on hold. England and the rest of Europe was forced to come to terms with an epidemic of an apocalyptic nature that drastically changed the landscape of society.

In a bid to take control of the epidemic, Edward III, king of England as the time, was forced to turn his attention to domestic matters. Before the outbreak in England, his daughter Princess Joan had contracted plague after her ship docked in Bordeaux. She was on her way to marry Peter of Castile as part of a diplomatic marriage alliance between the two kingdoms. She never reached Castile and, upon discovery that the plague had taken hold of Bordeaux, she took refuge in a small village called Loremo, where she died alongside a large part of her entourage.

The king was devastated by the news and acted quickly and decisively to try to curb the outbreak in England. The 1349 January parliament was postponed until Easter (however, when spring came parliament was still empty.) Officials fled to their homes in the country and sheriffs refused to conduct their business for fear of their lives. The country was in lockdown and the people looked to the king to support them in the crisis.

Edward's response was rational: he suspected that poor public hygiene was responsible for the epidemic. In a bid to tackle the spread of infection, he opposed the idea of digging a burial pit for the plague victims in East Smithfield - it being in close proximity to the Tower of London and surrounding residential areas. Pits were dug further away, the largest one in Smithfield. In 1349 Edward III wrote to the Mayor of London directing him to have the streets thoroughly cleaned, for they were "foul with human faeces, and the air of the city poisioned (sic) to the great danger of men passing, especially in this time of infectious disease".

Overseas, further precautions were taken. In Italy in 1347, almost a year before the plague reached England, ports began to turn away ships, fearful that they carried the deadly disease. By March 1348, these protective measures were formalised and Venice became the first city to close its ports to incoming vessels. Those they did admit were subjected to 30 days of isolation, later raised to 40, which eventually lead to the birth of the term 'quarantine', for ships were forced to wait in the middle of the Venetian lagoon before they were permitted to disembark. Remote cemeteries were dug and in a later outbreak, the Venetians even went as far as establishing a quarantine island on Lazzaretto Vecchio, a small island in the Venetian Lagoon. An excavation in 2007 revealed more than 1,500 skeletons, all supposedly victims of bubonic plague. Thousands more are believed to remain below ground on the island.

However, these measures were too little too late. Plague still took hold in Venice - as it did globally - killing an estimated 100,000 people, a catastrophic proportion of the Venetian population.

Which parts of England were affected by plague?

England shared the same fate. In 1300 the population had reached around five million, and by 1377 this was reduced to 2.5 million. Plague had claimed half of the population, wiping out entire families, villages and even towns such as Bristol. The measures that were taken to hinder the spread of the first Black Death epidemic were powerless, but there were contingency plans for future outbreaks later in history.

In 1563, when plague struck again (as the disease did most years, although some outbreaks were more severe than others), the lord mayor ordered that blue crosses should be attached to doors of houses that held anyone infected with plague over the past week. Inhabitants were to stay indoors for one month after the death or infection of anyone in the building. Only one uninfected person was allowed out of the house, in order to buy provisions for the sick or healing. To mark their health they were meant to carry a white rod, which if they forgot would incur a fine or even imprisonment. In 1539 plague struck London again and houses were to be incarcerated for 40 days - the typical quarantine period stipulated in 14th-century Venice. By 1580 shipping was heavily monitored, and crews and passengers were quarantined either on board their vessels or in the port where they had disembarked. Merchants were kept at the port of Rye and were prohibited from entering the city, and all goods were to be aired in order not to transport infection. Movement was also monitored within the country - travellers into London from outside counties were prohibited if there was known to be plague in their area.

Outbreaks of plague continued into the 17th century, the most savage and famous being the 1665-56 epidemic. In 1630, quarantine measures were taken in London, with the Privy Council ordering that again houses were shut up when those inside were infected. However, to enforce the order, guards were to be stationed outside the infected house. This was soon replaced with the order that the people inside were to be sent to the Pest House (an enclosed hospital for those suffering from the plague) while the house was closed up. More famously, the village of Eyam in Derbyshire bravely imposed a self-quarantine in order to prevent the spread of infection into other villages, losing 260 villagers in the process.

Over four centuries, plague devastated the lives of millions, and despite the best efforts of the authorities, there was little to be done in order to control the spread of such virulent infection. People blamed themselves, usually in the belief that they were being punished by God for their sins - some even believed that the epidemic was an apocalypse.

Although today plague has generally ceased to exist, there was an outbreak in the US in 1924, and in India as late as 1994, killing 52 people and causing mass panic as people fled out of fear of infection. However, we do not tend to experience the rate of mortality seen in the 14th, 15th, 16th and 17th centuries. With the advancement of modern medicine and practical contingency, we hope that bio-medical disaster remains as history.
is a historian, writer and producer

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Black Death quarantine: how did we try to contain the most deadly disease in history?

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People across the globe are self-isolating to help stop the spread of coronavirus. But, says historian Helen Carr, the practice of quarantine is nothing new. Here she explores how it was used alongside other measures in the 14th century to curb the disease that became known as the Black Death...

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"Quarantine is becoming a powerful component of the public health response to emerging and reemerging infectious diseases."

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Lessons from the History of Quarantine, from Plague to Influenza A

Eugenia Tognotti

Author affiliation: Author affiliation: University of Sassari, Sassari, Sardinia, Italy

Cite This Article

Abstract

In the new millennium, the centuries-old strategy of quarantine is becoming a powerful component of the public health response to emerging and reemerging infectious diseases. During the 2003 pandemic of severe acute respiratory syndrome, the use of quarantine, border controls, contact tracing, and surveillance proved effective in containing the global threat in just over 3 months. For centuries, these practices have been the cornerstone of organized responses to infectious disease outbreaks. However, the use of quarantine and other measures for controlling epidemic diseases has always been controversial because such strategies raise political, ethical, and socioeconomic issues and require a careful balance between public interest and individual rights. In a globalized world that is becoming ever more vulnerable to communicable diseases, a historical perspective can help clarify the use and implications of a still-valid public health strategy.

The risk for deadly infectious diseases with pandemic potential (e.g., severe acute respiratory syndrome [SARS]) is increasing worldwide, as is the risk for resurgence of long-standing infectious diseases (e.g., tuberculosis) and for acts of biological terrorism. To lessen the risk from these new and resurging threats to public health, authorities are again using quarantine as a strategy for limiting the spread of communicable diseases (1). The history of quarantine-not in its narrower sense, but in the larger sense of restraining the movement of persons or goods on land or sea because of a contagious disease-has not been given much attention by historians of public health. Yet, a historical perspective of quarantine can contribute to a better understanding of its applications and can help trace the long roots of stigma and prejudice from the time of the Black Death and early outbreaks of cholera to the 1918 influenza pandemic (2) and to the first influenza pandemic of the twenty-first century, the 2009 influenza A(H1N1)pdm09 outbreak (3).

Quarantine (from the Italian "quaranta," meaning 40) was adopted as an obligatory means of separating persons, animals, and goods that may have been exposed to a contagious disease. Since the fourteenth century, quarantine has been the cornerstone of a coordinated disease-control strategy, including isolation, sanitary cordons, bills of health issued to ships, fumigation, disinfection, and regulation of groups of persons who were believed to be responsible for spreading the infection (4,5).

Organized institutional responses to disease control began during the plague epidemic of 1347-1352 (6). The plague was initially spread by sailors, rats, and cargo arriving in Sicily from the eastern Mediterranean (6,7); it quickly spread throughout Italy, decimating the populations of powerful city-states like Florence, Venice, and Genoa (8). The pestilence then moved from ports in Italy to ports in France and Spain (9). From northeastern Italy, the plague crossed the Alps and affected populations in Austria and central Europe. Toward the end of the fourteenth century, the epidemic had abated but not disappeared; outbreaks of pneumonic and septicemic plague occurred in different cities during the next 350 years (8).

Medicine was impotent against plague (8); the only way to escape infection was to avoid contact with infected persons and contaminated objects. Thus, some city-states prevented strangers from entering their cities, particularly, merchants (10) and minority groups, such as Jews and persons with leprosy. A sanitary cordon-not to be broken on pain of death-was imposed by armed guards along transit routes and at access points to cities. Implementation of these measures required rapid, firm action by authorities, including prompt mobilization of repressive police forces. A rigid separation between healthy and infected persons was initially accomplished through the use of makeshift camps (10).

Quarantine was first introduced in 1377 in Dubrovnik on Croatia's Dalmatian Coast (11), and the first permanent plague hospital (lazaretto) was opened by the Republic of Venice in 1423 on the small island of Santa Maria di Nazareth. The lazaretto was commonly referred to as Nazarethum or Lazarethum because of the resemblance of the word lazaretto to the biblical name Lazarus (12). In 1467, Genoa adopted the Venetian system, and in 1476 in Marseille, France, a hospital for persons with leprosy was converted into a lazaretto. Lazarettos were located far enough away from centers of habitation to restrict the spread of disease but close enough to transport the sick. Where possible, lazarettos were located so that a natural barrier, such as the sea or a river, separated them from the city; when natural barriers were not available, separation was achieved by encircling the lazaretto with a moat or ditch. In ports, lazarettos consisted of buildings used to isolate ship passengers and crew who had or were suspected of having plague. Merchandise from ships was unloaded to designated buildings. Procedures for so-called "purgation" of the various products were prescribed minutely; wool, yarn, cloth, leather, wigs, and blankets were considered the products most likely to transmit disease. Treatment of the goods consisted of continuous ventilation; wax and sponge were immersed in running water for 48 hours.

It is not known why 40 days was chosen as the length of isolation time needed to avoid contamination, but it may have derived from Hippocrates theories regarding acute illnesses. Another theory is that the number of days was connected to the Pythagorean theory of numbers. The number 4 had particular significance. Forty days was the period of the biblical travail of Jesus in the desert. Forty days were believed to represent the time necessary for dissipating the pestilential miasma from bodies and goods through the system of isolation, fumigation, and disinfection. In the centuries that followed, the system of isolation was improved (13-15).

In connection with the Levantine trade, the next step taken to reduce the spread of disease was to establish bills of health that detailed the sanitary status of a ship's port of origin (14). After notification of a fresh outbreak of plague along the eastern Mediterranean Sea, port cities to the west were closed to ships arriving from plague-infected areas (15). The first city to perfect a system of maritime cordons was Venice, which because of its particular geographic configuration and its prominence as a commercial center, was dangerously exposed (12,15,16). The arrival of boats suspected of carrying plague was signaled with a flag that would be seen by lookouts on the church tower of San Marco. The captain was taken in a lifeboat to the health magistrate's office and was kept in an enclosure where he spoke through a window; thus, conversation took place at a safe distance. This precaution was based on a mistaken hypothesis (i.e., that "pestilential air" transmitted all communicable diseases), but the precaution did prevent direct person-to-person transmission through inhalation of contaminated aerosolized droplets. The captain had to show proof of the health of the sailors and passengers and provide information on the origin of merchandise on board. If there was suspicion of disease on the ship, the captain was ordered to proceed to the quarantine station, where passengers and crew were isolated and the vessel was thoroughly fumigated and retained for 40 days (13,17). This system, which was used by Italian cities, was later adopted by other European countries.

The first English quarantine regulations, drawn up in 1663, provided for the confinement (in the Thames estuary) of ships with suspected plague-infected passengers or crew. In 1683 in Marseille, new laws required that all persons suspected of having plague be quarantined and disinfected. In ports in North America, quarantine was introduced during the same decade that attempts were being made to control yellow fever, which first appeared in New York and Boston in 1688 and 1691, respectively (18). In some colonies, the fear of smallpox outbreaks, which coincided with the arrival of ships, induced health authorities to order mandatory home isolation of persons with smallpox (19), even though another controversial strategy, inoculation, was being used to protect against the disease. In the United States, quarantine legislation, which until 1796 was the responsibility of states, was implemented in port cities threatened by yellow fever from the West Indies (18). In 1720, quarantine measures were prescribed during an epidemic of plague that broke out in Marseille and ravaged the Mediterranean seaboard of France and caused great apprehension in England. In England, the Quarantine Act of 1710 was renewed in 1721 and 1733 and again in 1743 during the disastrous epidemic at Messina, Sicily (19). A system of active surveillance was established in the major Levantine cities. The network, formed by consuls of various countries, connected the great Mediterranean ports of western Europe (15).

By the eighteenth century, the appearance of yellow fever in Mediterranean ports of France, Spain, and Italy forced governments to introduce rules involving the use of quarantine (18). But in the nineteenth century, another, even more frightening scourge, cholera, was approaching (20). Cholera emerged during a period of increasing globalization caused by technological changes in transportation, a drastic decrease in travel time by steamships and railways, and a rise in trade. Cholera, the "Asiatic disease," reached Europe in 1830 and the United States in 1832, terrifying the populations (21-24). Despite progress regarding the cause and transmission of cholera, there was no effective medical response (25).

During the first wave of cholera outbreaks, the strategies adopted by health officials were essentially those that had been used against plague. New lazarettos were planned at western ports, and an extensive structure was established near Bordeaux, France (26). At European ports, ships were barred entry if they had "unclean licenses" (i.e., ships arriving from regions where cholera was present) (27). In cities, authorities adopted social interventions and the traditional health tools. For example, travelers who had contact with infected persons or who came from a place where cholera was present were quarantined, and sick persons were forced into lazarettos. In general, local authorities tried to keep marginalized members of the population away from the cities (27). In 1836 in Naples, health officials hindered the free movement of prostitutes and beggars, who were considered carriers of contagion and, thus, a danger to the healthy urban population (27,28). This response involved powers of intervention unknown during normal times, and the actions generated widespread fear and resentment.

In some countries, the suspension of personal liberty provided the opportunity-using special laws-to stop political opposition. However, the cultural and social context differed from that in previous centuries. For example, the increasing use of quarantine and isolation conflicted with the affirmation of citizens' rights and growing sentiments of personal freedom fostered by the French Revolution of 1789. In England, liberal reformers contested both quarantine and compulsory vaccination against smallpox. Social and political tensions created an explosive mixture, culminating in popular rebellions and uprisings, a phenomenon that affected numerous European countries (29). In the Italian states, in which revolutionary groups had taken the cause of unification and republicanism (27), cholera epidemics provided a justification (i.e., the enforcement of sanitary measures) for increasing police power.

By the middle of the nineteenth century, an increasing number of scientists and health administrators began to allege the impotence of sanitary cordons and maritime quarantine against cholera. These old measures depended on the idea that contagion was spread through the interpersonal transmission of germs or by contaminated clothing and objects (30). This theory justified the severity of measures used against cholera; after all, it had worked well against the plague. The length of quarantine (40 days) exceeded the incubation period for the plague bacillus, providing sufficient time for the death of the infected fleas needed to transmit the disease and of the biological agent, Yersinia pestis. However, quarantine was almost irrelevant as a primary method for preventing yellow fever or cholera. A rigid maritime cordon could only be effective in protecting small islands. During the terrifying cholera epidemic of 1835-1836, the island of Sardinia was the only Italian region to escape cholera, thanks to surveillance by armed men who had orders to prevent, by force, any ship that attempted to disembark persons or cargo on the coast (27).

Anticontagionists, who disbelieved the communicability of cholera, contested quarantine and alleged that the practice was a relic of the past, useless, and damaging to commerce. They complained that the free movement of travelers was hindered by sanitary cordons and by controls at border crossings, which included fumigation and disinfection of clothes ( Figures 1, 2, 3). In addition, quarantine inspired a false sense of security, which was dangerous to public health because it diverted persons from taking the correct precautions. International cooperation and coordination was stymied by the lack of agreement regarding the use of quarantine. The discussion among scientists, health administrators, diplomatic bureaucracies, and governments dragged on for decades, as demonstrated in the debates in the International Sanitary Conferences (31), particularly after the opening, in 1869, of the Suez Canal, which was perceived as a gate for the diseases of the Orient (32). Despite pervasive doubts regarding the effectiveness of quarantine, local authorities were reluctant to abandon the protection of the traditional strategies that provided an antidote to population panic, which, during a serious epidemic, could produce chaos and disrupt public order (33).

A turning point in the history of quarantine came after the pathogenic agents of the most feared epidemic diseases were identified between the nineteenth and twentieth centuries. International prophylaxis against cholera, plague, and yellow fever began to be considered separately. In light of the newer knowledge, a restructuring of the international regulations was approved in 1903 by the 11th Sanitary Conference, at which the famed convention of 184 articles was signed (31).

In 1911, the eleventh edition of Encyclopedia Britannica emphasized that "the old sanitary preventive system of detention of ships and men" was "a thing of the past" (34). At the time, the battle against infectious diseases seemed about to be won, and the old health practices would only be remembered as an archaic scientific fallacy. No one expected that within a few years, nations would again be forced to implement emergency measures in response to a tremendous health challenge, the 1918 influenza pandemic, which struck the world in 3 waves during 1918-1919 ( Technical Appendix). At the time, the etiology of the disease was unknown. Most scientists thought that the pathogenic agent was a bacterium, Haemophilus influenzae, identified in 1892 by German bacteriologist Richard Pfeiffer (35).

During 1918-1919, in a world divided by war, the multilateral health surveillance systems, which had been laboriously built during the previous decades in Europe and the United States, were not helpful in controlling the influenza pandemic. The ancestor of the World Health Organization, the Office International d'Hygiène Publique, located in Paris (31), could not play any role during the outbreak. At the beginning of the pandemic, the medical officers of the army isolated soldiers with signs or symptoms, but the disease, which was extremely contagious, quickly spread, infecting persons in nearly every country. Various responses to the pandemic were tried. Health authorities in major cities of the Western world implemented a range of disease-containment strategies, including the closure of schools, churches, and theaters and the suspension of public gatherings. In Paris, a sporting event, in which 10,000 youths were to participate, was postponed (36). Yale University canceled all on-campus public meetings, and some churches in Italy suspended confessions and funeral ceremonies. Physicians encouraged the use of measures like respiratory hygiene and social distancing. However, the measures were implemented too late and in an uncoordinated manner, especially in war-torn areas where interventions (e.g., travel restrictions, border controls) were impractical, during a time when the movement of troops was facilitating the spread of the virus.

In Italy, which along with Portugal had the highest mortality rate in Europe, schools were closed after the first case of the unusually severe hemorrhagic pneumonia; however, the decision to close schools was not simultaneously accepted by health and scholastic authorities (37). Decisions made by health authorities often seemed focused more on reassuring the public about efforts being made to stop transmission of the virus rather than on actually stopping transmission of the virus (35). Measures adopted in many countries disproportionately affected ethnic and marginalized groups. In colonial possessions (e.g., New Caledonia), restrictions on travel affected the local populations (3). The role that the media would play in influencing public opinion in the future began to take shape. Newspapers took conflicting positions on health measures and contributed to the spread of panic. The largest and most influential newspaper in Italy, Corriere della Sera, was forced by civil authorities to stop reporting the number of deaths (150-180 deaths/day) in Milan because the reports caused great anxiety among the citizenry. In war-torn nations, censorship caused a lack of communication and transparency regarding the decision-making process, leading to confusion and misunderstanding of disease-control measures and devices, such as face masks (ironically named "muzzles" in Italian) (35).

During the second influenza pandemic of the twentieth century, the "Asian flu" pandemic of 1957-1958, some countries implemented measures to control spread of the disease. The illness was generally milder than that caused by the 1918 influenza, and the global situation differed. Understanding of influenza had advanced greatly: the pathogenic agent had been identified in 1933, vaccines for seasonal epidemics were available, and antimicrobial drugs were available to treat complications. In addition, the World Health Organization had implemented a global influenza surveillance network that provided early warning when novel influenza (H2N2) virus, began spreading in China in February 1957 and worldwide later that year. Vaccines had been developed in Western countries but were not yet available when the pandemic began to spread simultaneously with the opening of schools in several countries. Control measures (e.g., closure of asylums and nurseries, bans on public gatherings) varied from country to country but, at best, merely postponed the onset of disease for a few weeks (38). This scenario was repeated during the influenza A(H3N2) pandemic of 1968-1969, the third and mildest influenza pandemic of the twentieth century. The virus was first detected in Hong Kong in early 1968 and was introduced into the United States in September 1968 by US Marines returning from Vietnam. In the winter of 1968-69, the virus spread around the world; the effect was limited and there were no specific containment measures.

A new chapter in the history of quarantine opened in the early twenty-first century as traditional intervention measures were resurrected in response to the global crisis precipitated by the emergence of SARS, an especially challenging threat to public health worldwide. SARS, which originated in Guangdong Province, China, in 2003, spread along air-travel routes and quickly became a global threat because of its rapid transmission and high mortality rate and because protective immunity in the general population, effective antiviral drugs, and vaccines were lacking. However, compared with influenza, SARS had lower infectivity and a longer incubation period, providing time for instituting a series of containment measures that worked well (39). The strategies varied among the countries hardest hit by SARS (People's Republic of China and Hong Kong Special Administrative Region; Singapore; and Canada). In Canada, public health authorities asked persons who might have been exposed to SARS to voluntarily quarantine themselves. In China, police cordoned off buildings, organized checkpoints on roads, and even installed Web cameras in private homes. There was stronger control of persons in the lower social strata (village-level governments were empowered to isolate workers from SARS-affected areas). Public health officials in some areas resorted to repressive police measures, using laws with extremely severe punishments (including the death penalty), against those who violated quarantine. As had occurred in the past, the strategies adopted in some countries during this public health emergency contributed to the discrimination and stigmatization of persons and communities and raised protests and complaints against limitations and travel restrictions.

More than half a millennium since quarantine became the core of a multicomponent strategy for controlling communicable disease outbreaks, traditional public health tools are being adapted to the nature of individual diseases and to the degree of risk for transmission and are being effectively used to contain outbreaks, such as the 2003 SARS outbreak and the 2009 influenza A(H1N1)pdm09 pandemic. The history of quarantine-how it began, how it was used in the past, and how it is used in the modern era-is a fascinating topic in history of sanitation. Over the centuries, from the time of the Black Death to the first pandemics of the twenty-first century, public health control measures have been an essential way to reduce contact between persons sick with a disease and persons susceptible to the disease. In the absence of pharmaceutical interventions, such measures helped contain infection, delay the spread of disease, avert terror and death, and maintain the infrastructure of society.

Quarantine and other public health practices are effective and valuable ways to control communicable disease outbreaks and public anxiety, but these strategies have always been much debated, perceived as intrusive, and accompanied in every age and under all political regimes by an undercurrent of suspicion, distrust, and riots. These strategic measures have raised (and continue to raise) a variety of political, economic, social, and ethical issues (39,40). In the face of a dramatic health crisis, individual rights have often been trampled in the name of public good. The use of segregation or isolation to separate persons suspected of being infected has frequently violated the liberty of outwardly healthy persons, most often from lower classes, and ethnic and marginalized minority groups have been stigmatized and have faced discrimination. This feature, almost inherent in quarantine, traces a line of continuity from the time of plague to the 2009 influenza A(H1N1)pdm09 pandemic.

The historical perspective helps with understanding the extent to which panic, connected with social stigma and prejudice, frustrated public health efforts to control the spread of disease. During outbreaks of plague and cholera, the fear of discrimination and mandatory quarantine and isolation led the weakest social groups and minorities to escape affected areas and, thus, contribute to spreading the disease farther and faster, as occurred regularly in towns affected by deadly disease outbreaks. But in the globalized world, fear, alarm, and panic, augmented by global media, can spread farther and faster and, thus, play a larger role than in the past. Furthermore, in this setting, entire populations or segments of populations, not just persons or minority groups, are at risk of being stigmatized. In the face of new challenges posed in the twenty-first century by the increasing risk for the emergence and rapid spread of infectious diseases, quarantine and other public health tools remain central to public health preparedness. But these measures, by their nature, require vigilant attention to avoid causing prejudice and intolerance. Public trust must be gained through regular, transparent, and comprehensive communications that balance the risks and benefits of public health interventions. Successful responses to public health emergencies must heed the valuable lessons of the past (39,40).

Prof Tognotti is a professor of the history of medicine and human sciences at the University of Sassari. Her primary research interest is the history of epidemic and pandemic disease in the modern era.

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Acknowledgments

I thank my colleagues for their helpful suggestions, and I thank Eric Milner for his help with English language editing.

This work was conducted with financial support from the Department of Biomedical Sciences, Università degli Studi di Sassari.

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Cite This Article
DOI: 10.3201/eid1902.120312
Table of Contents - Volume 19, Number 2-February 2013
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Page created: January 22, 2013

Page updated: January 22, 2013

Page reviewed: January 22, 2013

The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.

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