Life Before Medicine: The Plague
And lo, the plague came, and despite our penance and prayers, we were all slain.
Update: Deliver Us from Evil Pt 4 is delayed, so in the meantime, please accept the first in a new series, Life Before Medicine.
Inspired by
and her note:This series is a chance for us to have a little chat about what being sick was like in a time before modern medicine. We - particularly those of us in the "developed world" - seem to forget just how great it is not to die of diarrhoea, smallpox, or measles.
So let us take a look at how people experienced these diseases, and the various treatments and preventatives from the benign to the downright toxic.
Starting with, of course...
Then I looked and saw a pale green horse. Its rider’s name was Death, and Hades followed close behind. They were given authority over a fourth of the earth, to kill by sword, by famine, by plague, and by the beasts of the earth.
Revelation 6:8
Yersinia Pestis, known variously as "the Angel of Death" and "the Scourge of Mankind", the cause of various forms of the disease known as Plague, is a vicious and deadly bacterium. It is so self-confident, humans aren't even its intended target. Before modern medicine and sanitation, it kept finding its way into human populations and decimating them entirely by accident.
Yersinia Pestis much prefers a good rat to a stinking ape-man.
For most of recorded history, outbreaks of plague have been a well-documented occurrence. In Europe, they were quite rare, but seemed to increase in frequency as global trade increased. Sometimes a plague outbreak would be heralded by the coming of a "plague ship", whose crew would start dying mysteriously after coming ashore.1
On occasion, a "ghost ship" would run aground, its crew already long dead.
Nevertheless, even with the crew long gone, the disease could remain. Not even if God himself smote those poor sailors before landfall could the spread be stopped. Within days, bodies begin to hit the floor, so to speak. The outbreak has begun. It might already be too late to escape it.
As human agriculture became more advanced, and we became adept at stockpiling grain supplies, we continued to gain ground over an ancient foe: starvation.
We had no idea we were simultaneously creating the perfect breeding grounds for rats, which carried fleas, which spread the great pestilence which would come to be known as The Plague.
Plague comes in 3 forms, depending on how it enters the body and which system it infects. Each type increases in the overall severity of the disease, and a Yersinia infection can in fact start in one system and progress to others later on.
The most common and well-known type:
Bubonic Plague
Most cases of plague are transmitted by the bite of an infected flea.
The flea’s gut is so full of bacteria, it blocks anything from entering the digestive tract, causing the flea to starve slowly. This drives it to bite everything it can in a desperate attempt to feed. When it bites you, and tries to swallow your blood, it just vomits it back out again immediately, along with some of the bacteria, back into your blodstream.
Usually your immune system manages to round up these unwelcome visitors, taking them to your lymph nodes where they would normally be disposed of - if this were any normal pathogen.
Yersinia Pestis is no normal pathogen.
Once the plague is in the lymphatic system, it just replicates, and replicates, and replicates. This proliferation turns your lymphatic system - your body’s most powerful defensive system against pathogens - into the Plague’s home base, where it can spread out to the rest of the body.
It's hard to describe just how insulting this is; it's like if the ancient Gauls were to conquer Rome by just walking into all the Roman army camps, garrisons and quarters, setting themselves up in the Roman tents and fortifications, and making themselves at home, eating the Romans food, wearing their clothes, while the Roman legions could do nothing but stare, slack-jawed, immobilised by the sheer audacity of these barbarians.
From there, it expands exponentially, the enormous population of bacterium causes the lymph nodes to swell like balloons, causing the infamous physical signs: dark lumps protruding through the skin, called “buboes”.
Eventually, it can swell up so much it literally bursts open through the skin, and quantities of pure liquid plague pour forth from the god-forsaken body of the victim, spilling onto everything.
The stench alone could induce anyone not firm of continence to faint, throw up, or both.
It is possible to survive bubonic plague. Some such stories have been shared down the ages. It is estimated that the mortality rate for Bubonic plague was between 50% and 80%, so more than 1 of every 2 people infected were likely to die. That alone is a terrifying mortality rate, worse even than smallpox.
For the other two types, in the time before antibiotics, your chance of death was roughly 100%. To survive these forms without antibiotics would have been miraculous.
Septicaemic Plague
The rarest and most exquisitely lethal to the infected host. Sometimes, when an infected flea vomits bacterium back into your bloodstream, the immune system can’t round them all up for whatever reason, and it stays in your bloodstream, proliferating endlessly until you end up with more bacteria than blood in your veins.
If that happens, and it's the 18th century or earlier (so there are no antibiotics), you are dead. It might just take you a bit of time to realise it, maybe less than 24 hours, or at most, a couple of days.
If you do somehow survive beyond 24 hours, and a time traveller appears out of nowhere and gives you a shot of the best antibiotics of the modern day, you're still almost certainly dead.
Not a lot to go on. Luckily, you still need fleas to spread it around.
That brings us to our third, and final form:
Pneumonic Plague
It swallowed up many good things of civilization and wiped them out. It overtook dynasties at the time of their senility, when they had reached the limit of their duration. It lessened their power and curtailed their influence. It weakened their authority. Their situation approached the point of annihilation and dissolution. Civilization decreased with the decrease of mankind. Cities and buildings were laid waste, roads and way signs were obliterated, settlements and mansions became empty, dynasties and tribes became weak.
The entire inhabited world changed.
Ibn Khaldun
This is the only form which no longer requires a flea bite: it can spread directly from person to person, through the air. When Yersinia Pestis reaches into your lungs, it turns the very air you breathe into a vector for spreading the pathogen.
Not only does it spread with astonishing rapidity, it kills rapidly, too. Often it would burn itself out, killing victims too quickly before they could infect new hosts with the airborne bacterium.
Sometimes, population dynamics, density, and average prognosis seemed to fit together in such a way that the most perfect storm would emerge, where Pneumonic Plague could explode across an entire continent. One such perfect storm broke across Europe in the 14th century.
It was forever known as The Black Death.2
Black Death
It is believed that the Black Death, which first landed in Europe in 1346 and peaked around 1350, killed 25-30 million people, or 1/3rd of Europe’s estimated 75 million population.
It is also estimated that the total human population of the Earth at that time was less than 470 million.
Worldwide, it is believed to have wiped out anywhere between 75 million and 200 million people, or between 1/6th and one-half of human kind on this planet.3
The scourge was intercontinental. It raged through Europe, the Middle East and Asia around the same time, and may have originated from the Mongolian Steppes.
The Black Death only lasted 2 - 4 years, but managed to depopulate cities and towns across the settled world. Although relatively quick, these weren't good deaths, either. Plague infection, no matter the type, is an agonising way to die.
If you caught Pneumonic plague, you coughed up blood and liquid bacteria until your last breath.
Septicaemic plague blocks up your circulation, due to the overwhelming proliferation of plague bacteria simply out-numbering red blood cells, and starves your organs of nutrients and oxygen, turning your skin black and gangrenous and sending you into seizures.
Bubonic Plague left you with horrendously painful lumps that would burst open and spill plague onto everything around you.
Some people could end up with all 3 types at once.
Cause?
Religious fanatics asserted that human sins had brought the dreadful pestilence; they roamed from place to place, scourging [whipping] themselves in public. […]
There was panic everywhere, with men and women knowing no way to stop death except to flee from it.
George Childs Kohn, Encyclopaedia of Plague and Pestilence (2022)
No one had any idea how Plague actually worked, what it was, or where it came from, nothing, so attempts to cure it or improve disease outcomes were literally just throwing stuff at the wall to see what sticks.
They ranged from the benign to the downright deadly: all too many so-called cures could be fatal in their own right.
Many causes were proclaimed in that time. Here’s a list borrowed from the Encyclopaedia of Plague and Pestilence by George Childs Kohn:
corrupted air and water,
hot and humid southerly winds,
proximity of swamps,
lack of purifying sunshine,
excrement and other filth,
putrid decomposition of dead bodies,
excessive indulgence in foods (particularly fruits),
God's wrath,
punishment for sins,
the conjunction of stars and planets,
cripples, nobles, and/or Jews poisoning the wells
Cure?
With such a wide range of theories came an even wider array of folk remedies and arbitrary concoctions. For example:4
Blood-letting, which was the medieval cure-all used for all manner of ailments, by using leeches or simply slicing open a vein;
Rubbing of chopped raw onions on the swelling buboes, which was thought to draw out the toxins somehow;
Rubbing ones-self with vinegar (this one may have actually had a minor protective effect, but certainly not a curative effect)
It gets worse, though; and much more bizarre.
Vicary Method
So in medieval times, it was believed chickens breathed through their buttholes. Yup. So, obviously, what better way to cure plague than to use the suction power of chicken butt to draw out the evil toxins?
I’m not kidding. You’d take a live chicken, pluck out all the feathers from its behind, and press its now de-feathered buttocks to the patients buboes, making sure to hold it in place with rope or fabric.
Did it work?
Uhh, no.
Whipping
Not in a kinky way, either. Well, maybe a little.
Groups of people would wander down the road, stripped to the waist, and would whip themselves thoroughly as they went along. It was a kind of public penance, believing that sinfulness had caused the plague; so if they simply punished themselves hard enough, maybe God would forgive them and they would be healed.
Did it work?
Ouch. No.
Smearing faeces
Ok, you may want to skip this part if you’re squeamish.
Some people sought relief in the form of a paste made from human excrement mixed up with… I dunno, lilly root and tree sap, apparently. After slicing open the buboes with a blade, this foul paste was smeared into the open wound and bound tightly with a strip of cloth.
Y’know, to really let the faecal matter sink in to the bleeding, pus-infused open sore.
This would be left for several days, until the patient presumably died from frikkin everything.
Did it work?
Oh my god, no!
Urine-baths
Can we just skip this one please? Yes they did this, too. Some folks were paid well to collect enough urine to bathe in. Some people drank it. From “healthy” persons, of course. Ew. Ew ew ew.
Prevention?
The Arabs placed a great emphasis on anatomy, which was beneficial to the medical profession. Catholic education in general emphasized philosophy and was only mildly practical, so scholars relied on Greek and Arabic medical treatises.
The first thing that was typically attempted: prayer and repentance. This, unfortunately, didn't help, as was quickly proven when the reapers visits did not discriminate on the basis of religion. Plague is an equal-opportunity pathogen.
Throughout the medieval and enlightenment ages, the prevailing theory of disease was Miasma. Essentially, the idea is that disease is the result of inhaling bad or foul air, known as "miasmatic air". Such miasmas, it was thought, could be deflected by pleasant air.
It was a nice thought.
You know the song “Ring-a ring o’ Rosies"? A “pocket full of posy” was a bundle of flowers you carry to ward off the pestillence. Sometimes also called a "nosegay". As in, "happy nose".
This didn't help a whole lot either, but it must have smelled nice, and that has its own benefits.
Then again, garlic was used to extract evil spirits from the body of a person, so some folks - especially the early-day physicians, and later on, plague doctors - would constantly chew garlic as they went about their day; just in case.
Toothpaste is only a recent invention, so try and imagine that smell.
The only thing that helped? Quarantine.
The most effective prevention to have been tried through most of history was to quarantine anyone who was trying to enter a town from the outside. Simple as that. Introduced initially in the town of Dubrovnik on the Dalmatian Coast in 1377, it was far from perfect, as people had a dislike of quarantine back then just as much as they do now, and were often reluctant to abide by the rules.
It was also mainly effective against person-to-person spread. Rats, however, do not understand human rules, and were thus prone to completely ignore quarantine.
We seem to think it’s a modern thing, but throughout history, “You can’t tell me what to do!” has been a common refrain by fully-grown adults against most sensible public health policies. How dare you inconvenience me for the purpose of saving lives? Do you know who I am??
There was also lack of standardisation, even within the same state. Some towns had a 30-day quarantine, others had 40-days. Some towns built special plague quarrantine facilities, located either on a nearby island, or with a man-made moat around the entire building and armed guards. Some towns refused entry to Jews, believing they were somehow special carriers of plague. Although implemented in parts of France, Italy and the Middle East in times of plague, they were rare, haphazard, and rarely implemented with the rigor and honesty such a policy required to be truly effective.
The Revolution in Public Health
We close out this episode with a note on how humanity finally wrested control of our destiny out of the hands of a bacterium over the last 150 years, and it comes down to 2 things: Sanitation, and Antibiotics.
Clearing the cities, towns, farms and merchant ships of rats and other rodents proved to be essential to preventing plague. Getting rid of these rodents also got rid of the fleas, which were the main vector of transmission.
Early treatment with antibiotics once infected also reduced your mortality rate against Bubonic plague from 40%-60%5 to about 10%, a big drop. Very early treatment against Pneumonic plague or Septicaemic plague could reduce mortality form near-100% to roughly 50%.
Now, if you still think modern medicine hasn’t absolutely revolutionised humanity for the better (yes I know you are out there, I see you), just take a look at the following chart.
Max Roser (2020) - “It’s not just about child mortality, life expectancy increased at all ages” Published online at https://ourworldindata.org/its-not-just-about-child-mortality-life-expectancy-improved-at-all-agesEdward Jenner discovered Smallpox variolation (precursur to vaccines) in 1796, and that could arguably be considered a point which marks the beginning of modern scientific medicine. In 1820, Quinine was discovered as effective against Malaria. Asprin was discovered in 1897. Penicillin was discovered in 1911.
Watch how the graph responds.
In the end, the data speaks for itself. That’s the whole point of science.
Fun side-note on Plague Doctors
Plague Doctors in Italy were quite well paid individuals, who provided services to all classes, especially the poor and destitute, free of charge. They were paid by the state, and because their mission was so insanely dangerous, they were sometimes paid more in a single month than the average artisan might make in a year.
Their task wasn’t really to cure patients, because no one knew how to do that. Instead, it was to try and make them comfortable as best they could, and to record mortality statistics and demographics.
What was unique about plague doctors wasn’t their expertise - which was often limited or entirely lacking - nor their amazing beaked-nose masks - although they helped somewhat - it was their dress.
A plague doctor was almost always covered from head-to-toe in leather and waxed-cloth garments, which essentially prevented fleas from being able to reach the skin to bite.
They also used a wooden stick to push infected people away if they got too close, and to point at things and move clothing of patients.
They were also protected from infected blood and lymph splatters.
Of course, no one knew of this protective effect at the time. It wasn’t until much later that scholars managed to tease this out mainly through deductive reasoning. Also, records weren’t kept on the survival of plague doctors. They were a fairly rare sight overall, but made it into the public imagination when their likeness began appearing as characters in the theatre.
Stay healthy my friends.
Oeding P. Svartedauden i Norge [The black death in Norway]. Tidsskr Nor Laegeforen. 1990;110(17):2204-2208. The stories of “ghost ships” come mainly from Icelandic and Norwegian accounts.
Glatter KA, Finkelman P. History of the Plague: An Ancient Pandemic for the Age of COVID-19. Am J Med. 2021;134(2):176-181. doi:10.1016/j.amjmed.2020.08.019
History’s Seven Deadliest Plagues, https://www.gavi.org/vaccineswork/historys-seven-deadliest-plagues
Pretty much all of these “cures” are detailed here: https://www.worldhistory.org/article/1540/medieval-cures-for-the-black-death/
Sebbane F, Lemaître N. Antibiotic Therapy of Plague: A Review. Biomolecules. 2021;11(5):724. Published 2021 May 12. doi:10.3390/biom11050724
NAY! WE PERSIST TO RESIST! I’M SCREAMING! Join us!
Though it took a long time plague seems to have caused the demise of the Byzantine empire. It’s had an outsize role in history.