Plagues & People 2005 Plagues & People Howard M. Reisner Professor of Pathology 6-4265...

Plagues & People 2005

Plagues & People

Howard M. Reisner

Professor of Pathology

6-4265 reisner@med.unc.edu

Plagues & People 2005

Imago Mortis

Plagues & People 2005

Plague - the Word

• Plague: from Latin plaga; sudden stroke, plangere; to strike– Bubonic plague (1564 Reg. Privy Council Scot.)

• Pest(e) from Latin pestis; a deadly disease

• Great Mortality (or Pestilence); used during second pandemic 1348-on

• Black Death 19th century - from German medical text, popular novels

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Plague - the Word (2)• Arabic - ta’un (tawa’in pl); to strike or pierce

– specific for bubonic plague since 14th century

– the pricking of the jinn

– waba; more general idea of pain or pestilence

– distinction spelled out by Ibn Hajjar al-Askalani (852/1449)

• Much overlap in the literature

• Hebrew - nega; to touch or strike also deber– note 1 Samuel 5,6

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Plague - the Word (3)

• Chinese – No distinct nosological category– Yi or dayi (epidemic or major epidemic– 18-19 th century yangzibing in Yunnan

• Epidemic disease with death of rats & lumps

– Late 19 th century shuyi (rat epidemic)

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San Sebastiano e San RoccoMarchigiano late 15th century

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Death With an ArrowFrom a French Book of Hours 2nd half 15th century

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The Players

Xenopsylla cheopis Yersinia pestis

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Yersinia pestis - Transmission

Yersinia pestis

Yersinia pseudotuberculosis

Blocked Flea

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Yersinia - Virulence Factors

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Plague - Routes of Transmission

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Cutaneous Manifestations (1)

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Cutaneous Manifestations (2)

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General Bonaparte Visiting the Plague Stricken at Jaffa

Jean-Gros 1804

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The “Little” PlagueRaphael/Raimondi ca 1514

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Doctors Incising Buboes

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Paleodiagnosis of Plague (1)

Mass grave from Marseilles (1720-1722)

Pin implantation to verify death

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Paleodiagnosis of Plague (2)

6/12 “plague teeth +, 0/7 controls - Pulp of unerupted teeth used

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PNAS 96:14043 1999

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Phylogeny of Plague (1)

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Phylogeny of Plague (2)

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Plague in the US

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Plague - Transmission in the US

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Plague - Current Foci

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Some Early Plagues

• Mari-(early 2nd millennium)– The women Nanna is ill with simmum…Give strict orders that no one drink from

her cup, sit on her chair, sleep in her bed…so that she does not infect…simmum is easily caught.

• Hittite - ( Suppiluliuma 1320s BCE) came with Egyptian prisoners of war (under Pharaoh Ay successor to Tutankhamun)– killed successor (Arunwanda II 1321 BCE)

– continued into reign of Mursili II– blamed on gods wrath, Suppiluliuma’s offenses

• Biblical (1 Samuel 5 and 6)– outbreak of opalim; swellings among evil Philistines– also associated with mice (?) ravaging land

– five gold tumors, five gold mice (guilt offering)

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Plague of Athens (430-426 BCE)

• Thucydides’ account serves as a model for subsequent plague narratives

• Very carefully described (but also a “moral tale”)

• May be influenced by the Hippocratic school but not described in Hippocratic corpus

• Additional accounts are late and disputative

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Plague of Athens (2)• Summary (from Peloponnesian War)

– originated in Ethiopia-Egypt Libya Persia Piraeus (sea-born?), during siege of Athens

– overcrowding (during siege), immunity, doctors suffered, all classes

– high mortality rate (33% among Potidea expedition soldiers, perhaps 25% among Athenians (???)

– occurred for two years (Summer 430-summer 428, than

Winter 427/426); not seasonal

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Plague of Athens (3)• Symptoms- (in order)

– 1. Heat in the head, red and burning eyes, throat and tongue red, malodorous breath

– 2. Sneezing hoarseness, violent coughing

– 3. Heart (stomach?) affected, evacuations of bile, empty retching inducing violent convulsions sometimes subside

– 4. Body flushed with effloresence of small blisters & sores – 5. Internal heat high, unquenchable thirst, sleepless

– 6. Bowels attacked, fluid diarrhoea, death from exhaustion

– 7. Loss of tips of fingers, toes, privy parts, eyes

– 8. Loss of memory

– 9. Bodies “toxic to animals” (no birds, dogs perish)

– 10. Fits model of descent from head

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Plague of Athens (4)

• Many etiologic agents suggested:– Epidemic typhus (my favorite)-fits gangrene, memory loss. Has

insect vector-influenced by crowding. Does not fit rash (?) – Bubonic Plague does not fit clinical description.

– Smallpox rash fits well but not gangrene. Lasted too long in closed community. Descriptive Greek word for rash uncertain.

– Also Rift Valley Fever, Lassa Fever, Thucydides syndrome (= influenza + toxic shocklike bacterial superinfection), anthrax (but no sheep?), fungal toxin and probably lots of others, unknown or now lost disease.

– Must remember that the description is literary and hortatory

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First Pandemic of Bubonic Plague• Plague of Justinian (Byzantine Emperor 527-65 CE)

– Started in Pelusium (Egyptian port), Alexandria, Egypt, Palestine, Syria

• Origin said to be Ethiopia (copying Thucydides?)

• Arabic sources suggest Sudan (850 CE), certainly not from Issyk Kul (source of second pandemic) based on Byzantine history

– Killed 40% of population of Constantinople (200,00)

• Also Italy, France, Rhine Valley, Iberia, North Africa

• Reduction in population of Med. Basin by 20-25% 541-544

• Total decline of 50-60% of population 541-700

– Waxed & waned in Middle East, North Africa, through 900s, disappeared from Europe by about 700

– Procopius clearly describes disease as bubonic plague (buboes in groin, armpits and ears)

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First Pandemic-Islam• Plague recognised during early development of Islam. Chronicles

cite five plagues before the 14th century “Black Death)-– Plague at Ctesiphon (Shirawayh) 6/627-8

– Plague at Amwas (Emmaus) Syria 17-18 638-9. In fighting against the Byzantines 25,000 Arabs die.

• Story of Caliph ‘Umar & Abu ‘Ubaydah• Justified fleeing a plague to a healthy place

– Much dispute through Islamic history on permissible response• The plague is a mercy and a martyrdom from God to the faithful, a punishment

for the infidel.• The faithful should neither enter, nor flee, a plague stricken land• There was no contagion of plague, disease comes from God

– But many differing opinions through history

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Islam & the Plague (2)• Galen & Hippocrates influential

– Ibn Sina (980-1037)-miasma theory• “The pestilence resulted from a corruption of the air due to heavenly and

terrestrial causes”• A sign of an approaching plague epidemic-rats and subterranean animals

flee to the surface of the earth behave as intoxicated and die (source of observation is unknown!)

– Andalusian writers influential in 14th Century (Black Death).

• Ibn al-Khatib (1313-75) believed contagion immediate cause of plague. Denied fatwa against contagion “The existence of contagion is well established through experience, sense perception, autopsy and authenticated information-this is the proof”

• He was killed in prison (heresy? Political malfeasance?)• Ibn al-Khatimah-more orthodox but good clinical evidence for contagion

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Black Death - Routes of Spread

• Black Death spread from SW Turkestan

• Land routes to Kaffa• Sea Routes to Venice• Entered England 1348

– From Calais

– Melcombe Regis (Weymouth SW Coast)

– Bristol-Oxford-London

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Black Death Spread (2)

Greenland was reached by 1350

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Black Death - Social Upheaval

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Economics of Black Death 1347-55

In opinion of Herlihy and many others, the Black Death had a critical role in the early industrial development (and social change) in Europe

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Black Death - Family Structure

The young died -the population aged

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Plague by Dwelling (Bristol)

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Plague of 1665 - London (1)

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Plague of 1665 - Demographics

Detailed demographic studies possible-confirms Defoe

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Plague of 1665 - Eyam

5/6 of Eyam died (or did they ?)

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Plague of 1665 – Eyam (2)