Infectious Pestilence: Part 1, Coping with Plague in Early Modern Europe

. . . the searchers of the town,

Suspecting that we both were in a house

Where infectious pestilence did reign

Seal'd up the doors . . .

—Shakespeare, Romeo and Juliet (5.2.8–11)

BACKGROUND

 

The Disease

 

Plague is credited with three pandemics, two of which occurred before the down-time Ring of Fire (RoF, 1631): the Justinian Plague (540–750) and the Black Death (1347–1350). The seventeenth century was characterized by more localized epidemics, such as the Great Plagues of London (1665–6), Seville (1647–52) and Vienna (1679). (Riedel).

The RoF took place during the final year of the Italian epidemic of 1629–31. In the old time line (OTL), there were several major plague outbreaks in the 1630s. These included those of Dijon (1631), Nurnberg (1632), Derbyshire (1632), Venice (1633), the Netherlands (1633–37), Hull (1635), London (1636), Newcastle (1636), Nijmegen (1636–37), Northampton (1637–38), Worcester (1637), Bergen (1637), and Prague (1637). For lesser incidents in Germany in 1625–35, see Lammert.

The armies of the Thirty Years' War helped carry the plague from place to place. In OTL 1632, plague broke out among the forces of Wallenstein and Gustav Adolphus at Nurnberg; "in seven weeks 30,000 of the town inhabitants perished and each of the two armies is recorded as losing one-third of its effective strength." (Simpson 303). But even in peacetime, "where ships go, the plague goes," and plague also traveled, albeit less swiftly, by overland trade routes.

In the new time line (NTL), plague strikes Kronach in July 1633. (DeMarce, “In the Night, All Hats Are Gray,” 1634: The Ram Rebellion). Bear in mind that since a single traveler can bring the disease to a city, the Ring of Fire will have a strong "butterfly effect," altering when and where plague strikes in the 1630s. As I wrote in "Second Starts" (Grantville Gazette 11), a plague ship could come to a different port. Thus, the plague epidemic "scheduled" for Swabia in the spring and summer of 1635 according to the history books" (DeMarce, “Make Mine Macrame,” Ring of Fire III) wasn't sure to happen, but there's no doubt that Swabia was susceptible to plague. And by canon, plague was afoot in the western Germanies that year. (Flint, 1635: The Eastern Front, Chapter 1).

The last plague pandemic occurred a little over a century ago. In 1855, there was a rebellion in the Yunnan province of China, which was near a natural plague focus in Burma. The rebels fled into Burma and the Manchu army followed. When they returned home, they brought the plague with them. By 1894, it had reached Canton and Hong Kong. (McNeill 135). Steamships helped spread it quickly; "Within 10 years (1894–1903) plague entered 77 ports on five continents: Asia (31 ports), Europe (12), Africa (8), North America (4), South America (15) and Australia (7)." (WHO 26). In India it penetrated inland, resulting in 6,000,000 deaths.

The affected ports included San Francisco and Los Angeles, and fleas hopped from seafaring rats to resident urban rats and native wild rodents, including ground squirrels, woodrats and chipmunks. As of the up-time RoF (2000), there was a substantial wild animal reservoir of plague in the up-time western United States.

Since the last pandemic, there have been more localized yet severe outbreaks in India (1920, 1954, 1963, 1994) and Viet Nam (1966–72).

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Plague is classified as bubonic, septicemic or pneumonic, depending on the initial (primary) site of infection: the lymph nodes (bubonic), the blood (septicemic), or the lungs (pneumonic). With bubonic plague, as the bacteria multiply, they may escape the lymph nodes and infect other parts of the body, thus leading to subsequent (secondary) septicemic or pneumonic plague. Primary septicemic plague may also lead to secondary pneumonic plague.

In the modern United States, 85–90% of patients have primary bubonic plague, and 10–15% primary septicemic plague; primary pneumonic plague is rare. Bubonic plague leads to secondary septicemic plague in 23% of patients, and to secondary pneumonic plague in 9%. (Anne Arundel County).

Bubonic plague's first manifestation is likely to look like a bad case of flu. In a study of 40 Vietnamese patients, the "presenting symptoms" were fever (100%, mean 102.9°F), chills (40%), headache (85%), prostration (75%), altered mental state (lethargy, confusion, delirium, seizures) (38%), anorexia (33%), vomiting (25%), abdominal pain (18%), cough (25%), chest pain (13%), and rash (23%). (CIDRAP).

The most distinctive symptom is "lymphadenitis" (extremely swollen and painful lymph nodes, called buboes in the seventeenth century), typically in the groin, thigh, underarm or neck. These usually become visible within 24 hours after the first symptoms. (CDC/ERS 2). The buboes are oval, 1–10 cm in length, and the pain so great as to force the patients into protective postures.

As the disease progresses, the patient may experience "prostration, restlessness, confusion, delirium, and a lack of coordination." (3). Speech may be “peculiarly hesitating, stuttering, thick, lisping, indistinct, and monosyllabic, often like that of a drunken man. The memory is confused, and in answering questions the patient forgets half the sentence or syllable of the word which he began to utter.” Death is usually 3–5 days after onset of illness, and the immediate cause of death is often heart failure. (Pollitzer8, 66, 69).

Septicemic plague is an infection of the bloodstream. With primary septicemic plague, by definition, there is no apparent bubo. But it is possible that deep lymph nodes may be involved, perhaps leading to abdominal pain, and to possible confusion with appendicitis, colitis, enteritis, or cholecystitis. (Lutwick 63). It has also been confused with malaria. (Pollitzer8, 97).

Bacterial endotoxins induce an inflammatory response, leading to injury. In a study of 18 cases in New Mexico, the presenting symptoms were fever (100%), chills (61%), vomiting (50%), nausea (44%), headache (44%), malaise (44%), diarrhea (39%), abdominal pain (39%). 72% had at least one gastrointestinal symptom. As the septicemia progresses, you may see bleeding from the mouth, nose or rectum, or under the skin (petecchiae), skin lesions, and gangrene, cyanosis and necrosis (blackening as a result of tissue death) of fingers, toes and nose (hence, the "Black Death"). In 25% of cases, secondary pneumonic plague develops. (CIDRAP).

Pneumonic plague is an infection of the lung. Its symptoms include fever, chills, malaise, muscle weakness, headache, chest and back pain, and cough (perhaps with bloody sputum). There may be gastrointestinal symptoms as for septicemic plague. There may also be loss of muscle coordination (staggering) and mental confusion. In the hours before death, there may be shortness of breath, cyanosis, and bruising (ecchymoses), and the patient may be delirious (even inappropriately cheerful) or comatose. A slight physical exertion (sitting up in bed) can kill. Death is usually 1–3 days after infection, the longest pre-antibiotic survival of record was 9 days. (CIDRAP; FDA 22; Pollitzer8, 68).

In the primary form, the infection generates an intense cough reflex at the onset of systems, and fine droplets are expelled. In the secondary form, the patient may be too morbid to produce an efficient cough.

Pharyngeal plague is the inflammation of the pharynx from plague, typically associated with cervical (neck) buboes, and is usually the result of consumption of infected meat or inhalation of infectious droplets too large to reach the lung. (Abbott 23). It's rare and not much written about.

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The risk of death is dependent on the relative prevalence of the three major forms of plague, and how early an effective drug is administered. Until the turn of the nineteenth century, there were no such drugs, and antibiotics weren't available until the Thirties. If septicemic or pneumonic plague are not timely treated with suitable antibiotics, they are almost invariably fatal.

The case fatality rates (the percentage of those with clinical signs of plague that died) were as follows in Tuscany during the 1631 epidemics: San Gimignano (70%), Sasso (60%), Castel Val Cecina (65%), Cozzile (63%). Other sixteenth- and seventeenth-century rates were Apt, France 1588 (77%), Igualada, Spain 1589 (47%), Basel, Switzerland 1610–11 (59%), Dunquerque, France 1666 (71%), Gravelines, France 1666 (75%). (Cipolla 104–5). These don't distinguish among the types of plague, but the numbers are typical of pre-antibiotic outbreaks of bubonic plague.

The mortality in the US in 1900–1941 was 66% ; CDC). However, in San Francisco, it was 93% in 1900–04 and 50% in 1908; better supportive care made a difference. (Chase 292).

In the modern United States, with treatment, the mortality rates are 13.5% for bubonic, 22% for septicemic, and 57% for pneumonic (FAS).

 

Down-Time Explanations of the Plague

 

Ultimately, of course, the plague was considered to be divine punishment for the collective sins of the place afflicted. However, European physicians advised that it was effectuated by natural means, and capable of mitigation by means other than prayer.

There were two basic theories as to how it spread. The miasma (bad air) theory visualized a cloud of poisonous particles of uncertain origin; perhaps vapors escaping from the depths through cracks in the earth's surface, or rising from stagnant water, human waste, or unburied corpses. This encouraged attempts to purify the city air by bonfires, gunfire, improved sanitation, and even the ringing of bells. Individuals would breathe through perfumed filters or wear bags holding aromatic substances, and rooms might be fumigated (see below).

The contagion theory assumed that the disease was communicated as a result of contact with sick humans but was vague as to the precise mechanism. Touch, breath and even sight were suggested as possible carriers. The contagion theory, of course, encouraged confining the sick.

Because the disease appeared (erroneously) to be capable of transmission merely by contact with objects (particularly clothing) associated with the sick, the "miasmists" argued that the apparent contagion was the result of the absorption and release of poisonous particles by those objects. Vulnerable objects therefore had to be disinfected or destroyed. Room walls and hard objects would be washed down and soft objects fumigated or aired out.

Do not expect unquestioning acceptance of the up-timers' warnings that rats and fleas act together to transmit plague . . . especially after the down-timers realize just how expensive rat and flea control will be. In OTL, the "rat" theory was criticized on the ground that rats and humans live in close proximity in many places, and have done so continuously for centuries, whereas plague outbreaks are occasional and scattered. (Mohr 12). And it took more than a decade for the scientific community to reach a consensus on the role of fleas.

 

Economic and Social Dislocation

 

The adverse effects of the plague were not limited to the direct loss of life. If, say Florence, stopped trading with Genoa of fear of the plague, it would lose access to the goods it normally imported from Genoa, and its dockworkers and merchants would lose the Genoese business. Moreover, if Genoa thought that the action was unjustified, then it might well retaliate by closing Genoa to Florentine goods, as in fact happened in 1652.

If external quarantine failed to hold the plague at bay, the economic dislocations worsened. As word of the city's misfortune spread, import and export would diminish or cease altogether. Even local sales would decline. Residents would find themselves without employment, perhaps while also trying to care for themselves or a family member. This, in turn, would lead to food shortages, impaired nutrition, and reduced resistance to many diseases. Caring for the sick and enforcing quarantine was costly, straining both private and public resources. However, the fact that many residents had lost their regular source of income helps explain why it was possible to find people to do such dangerous jobs as searcher, nurse, corpse carrier or gravedigger.

In 1894 Hong Kong, plague-related quarantine drove food prices up 50%. (Marriott 130).

 

THE PRE-ROF RESPONSE TO THE PLAGUE

 

Public Health Authorities and Laws

 

In the early-seventeenth century, all of the major cities of Northern Italy had permanent Health Magistrates, given legislative, executive and judicial powers, and charged with preventing and controlling epidemics. Moreover, these were in communication with each other about perceived threats. (Cipolla 4, 21).

The smaller Northern Italian population centers would appoint health magistrates on an ad hoc basis when a threat was perceived. For example, Pistoia appointed six health deputies in April 1630; the plague reached inside Pistoia in October. (51ff).

South of Florence, even major cities like Rome only appointed public health officers when they thought an outbreak was imminent (or in progress). (4).

In Seville, if a plague threat were perceived, several city councilmen were named as plague commissioners. (Bowers 344). Bowers (356) is of the opinion that this ad hoc approach rendered Seville’s government more apt to be flexible in balancing public health needs against other public and private interests.

In England, the first national plague order was issued by the Privy Council in 1578, which was also the year of a major London epidemic. It was reissued in 1625 and 1636, likewise famous plague years. (Hall, 94, 110, 114). The front-line responsibility for controlling the plague was placed on the local magistrates (justices of the peace, mayors, aldermen, etc.). (Hall; McKeithen).

In early modern Germany, the city council was responsible for plague control. However, as in Seville, specific councilmen would be assigned to deal with the day-to-day management. (Kinzelbach 380).

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The public health authorities, in turn, relied heavily on the supposed expertise of the local physicians. There weren't many; London had one for about every 4,000 residents, and Venice one for every 2,000. (Byrne 270). In England, medical advice was attached to the plague orders.

On the Continent, municipal officials found that there was a need to hire their own public physicians and not rely exclusively on those in private practice. The first such were hired in the 13th century. In late-sixteenth century Nördlingen, the sick poor were examined by both a physician and a barber-surgeon. However, these did not investigate suspected cases of plague. (Hammond). Rather, in Europe that was the assignment of a different civic employee, the "plague doctor" (medicus pestilentiarus, pestarzt), who specialized in plague cases. However, Johannes Crato von Krafftheim (1510–85) served at various times as a town physician, a court physician, and a plague physician. (Wikipedia).

 

Diagnosis

 

No one wanted to hear that they had the plague, especially at a time when there really wasn't an effective treatment anyway. It meant isolation, perhaps in a vile pesthouse; and one's goods might be destroyed out of fear that they could carry the infection.

If a city had been free of plague for years, announcing the first plague case was a fateful decision. Trade with other cities would come to an abrupt halt as soon as they heard. There would be great economic dislocations. And humans had the tendency to punish the bearer of bad news, to shoot the messenger. Sometimes literally. "The physician who declared the presence of plague in Busto Arsizio in 1630 was shot to death." (Cipolla 92). And at Messina 1743, another reporting physician had a narrow escape. (Simpson 373).

Please do not think that this will be easy to change. In 1900–7 San Francisco, local residents and the state and city authorities stubbornly questioned the diagnosis of plague by the local US public health officers (Chase 47, 70); the governor went so far as to accuse the federal officers of spiking corpses with plague bacteria. (79). Some local doctors made deliberate misdiagnoses or issued false death certificates; patients were coached to remain silent; and bodies were dumped in another locality or simply hidden. (114ff). In Surat 1994, it was made a criminal offense to spread rumors of plague (Marriott 106) and Delhi at first claimed that nothing serious was happening. (206).

Even without social pressures to make a different diagnosis, seventeenth-century medicine was ill-equipped to recognize whether a febrile disease was plague in the absence of buboes. In Seville, doctors, surgeons and apothecaries testified before the health commission as to whether plague had appeared; they didn’t necessarily agree. (Bowers 344).

Yet delay in recognizing the danger could make matters worse. In 1576, Girolamo Mercuriale and several other Paduan physicians challenged public health measures recently adopted by the public health board. They insisted that recent deaths were the result of pestilential fever, not plague. The Venetian leadership was persuaded by the Paduans (no doubt in part because it was what they wanted to hear) and the protective measures were lifted. The outbreak intensified, ultimately claiming the lives of 46,000 of the 180,000 residents. (Byrne 352).

A further possible problem for physicians is that mass hysteria can lead to them being accused of introducing the plague. (Simpson 377–8).

Once plague had appear inside the city, the authorities needed to determine who had contracted the disease. For this, they used searchers (examiners, viewers). (Newman 812).

I will describe the British practice in more detail. According to the 1578 royal plague order, clergymen were expected to report deaths, and viewers, appointed by the parish curate, were sent out to inspect the corpses and determine the cause of death (271). In 1625 London, the searchers were preferably "respectable honest women," and their work was supposed to be checked by surgeons. (Hall 289). A revised edition said that each parish should employ "two sober ancient women." (294).

The sick were also examined. The 1608 order likewise called for appointment, by the alderman, common ward counsel, or justices of the peace, of "respectable people" as "examiners" to determine which houses and people were infected by plague. Doubts were to be resolved in favor of confinement until a clear diagnosis was possible. Examiners served for at least two months, and if they refused to serve, they were imprisoned. (Hall 284). By 1625, they were assisted by surgeons.

The head of household was expected to notify a medical examiner within two hours after appearance of the signs of plague. (Hall 291). However, there were cover-ups—for example, hiding a sick servant.

Both viewers and examiners were punished if they made "inaccurate death reports due either to corruption or favoritism." (271, 294). (The master of the house might bribe the searcher to render an exculpative finding.)

 

Isolation and Quarantine

 

Strictly speaking, isolation is confining someone who is definitely sick with the plague, whereas quarantine is applied to someone who is merely under suspicion, either because of direct contact with a local plague victim, or because they come from outside the city (and especially from some place rumored to have had recent plague cases). However, the two measures complemented each other.

In 1630s Genoa, quarantena brutta was applied to those who had had close contact with plague victims or their goods. This called for complete isolation for 40 days followed by a period of lesser restriction called "convalescence." (In fact, this was the same treatment meted out to the victims themselves.) On the other hand, those who either had suspicious fevers or had come from areas where plague had been recently reported were subjected to quarantena sospetto. I believe that was just 22 days. (Cipolla/Cristofano 120). Marseille (eighteenth century?) had three levels of quarantine: patente brute, for those from epidemic cities; patente soupconnie, for those from a city rumored to have plague; and patent nette, if from a city not under suspicion. (Meli).

A sick resident would either be "shut up" at home, or transferred to a public plague hospital (pesthouse, lazaretto) outside the city walls. A visitor might be taken to the pesthouse or, if come by sea, required to remain on board the vessel.

Quarantine of Incoming Persons and Goods. The concept of quarantining incoming vessels from foreign ports was introduced by Venetian Ragusa in 1377. The period was originally thirty days (trentino), (Mackowiak) but was increased to forty (quarantino, quarentena, quaranta) by Marseilles in 1383. Other periods were used; Dublin in 1625 specified twenty days. (Byrne 305).

Some ports of embarkation were generally deemed safer than others. In seventeenth-century northern Italy, people on vessels that came directly from England or Flanders might be allowed entry after a few days, whereas those from Spain had to do 25 days quarantine. If there were deaths or illnesses during the voyage, or during the quarantine, which weren't clearly attributable to an acceptable cause, the period of quarantine would be extended. (Cipolla 111ff).

In the sixteenth century, a procedure was developed for more rapidly clearing passengers and goods. If their last port was free of disease, and the goods had been purified, the vessel would be given a "clean bill of health" by the local inspectors, and the captain would have this validated by the local consul for the port of destination. On arrival, if there was no reason to doubt the bill of health, the passengers and goods would enter without quarantine, or with an abbreviated one. (Gensini).

But as usual, it depended on circumstances. In 1652, Leghorn admitted passengers from the Levant after three days, if their vessels had "clean bills." On the other hand, Genoa would make them sit tight for 30–40 days, depending upon "information received." (Cipolla 112).

In seventeenth-century northern Italy, if a health magistrate ascertained that there was a plague in a region, it would be placed under a ban. Moreover, other places known to trade with that region might well be placed under suspension (effectively, a temporary ban), especially if the magistrate didn't consider them to be competent at protecting public health themselves.

If a vessel came from a port under ban or suspension, it would have to go through quarantine even if it had a clean bill of health. (Cipolla 19). Indeed, in Genoa, the crew and passengers of a ship coming from a city under ban or suspension (a provisional ban) would not be allowed to disembark at all, and only goods considered not subject to contagion could be offloaded. (Cipolla 19).

There were attempts to trick the system. Plague was brought to Messina 1743 by a merchant vessel from Morea that relied on a clean bill of health from an intermediate stop and also claimed that a plague victim was merely a sailor who had fallen overboard. (Simpson 34).

While maritime travel was faster than overland travel, and thus could disseminate the plague more quickly, towns, of course, were wary of overland visitors, too. If there were rumors of plague in the hinterland, a town would close most of its gates, and subject visitors to strict scrutiny. In particular, the guards wanted to know if anyone in their party was sick or if they had lost anyone earlier to illness, which towns they had passed through.

On Oct. 16, 1617, the authorities in Augsburg were advised that there was plague in Amsterdam and they immediately imposed a ban on persons and goods from Amsterdam. Three days later, they closed the peddlers' market. (Kinzelbach 286).

Just as for vessels, overland travelers to Seville would present health certificates for themselves and their merchandise, indicating their place of origin. (Bowers 340). In 1582, a sheriff in La Rinconada, Spain encountered three men who were heading to Seville to find passage to the New World; they were traveling without papers even though they had heard rumors of plague. They were jailed and fined for this crime. (Bowers 352).

Which gates were closed, and to whom, could be a matter of negotiation. In 1600 Seville, two monasteries whose houses were outside the city walls asked that either the gate nearest them be reopened for part of the day—so city residents could bring them offerings—or the city recompense them for the lost income. The health commission ordered the gates reopened, under guard.

If a city had outgrown its walls, or let them fall into neglect, the walls alone wouldn’t be an effective barrier. In Seville, the Triana district lay outside the walls, and consequently the city had to watch the road and river crossings into Triana. Seville’s plague commissioners also visited outlying towns to investigate possible plague cases, and placed infected towns under a general quarantine (no one leaves!). If a town could make a case that it remained generally healthy, it might get the ban removed.

Goods from plague towns might be destroyed, refused entry, or subjected to a form of quarantine called "purification." In keeping with the "miasma" theory of infection, this involved airing them out or exposing them to fire at a pesthouse. From a modern perspective, the proper procedure is to disinfect (probably by fumigation) those goods that are likely to harbor fleas, either on their own or rat-borne. Merely airing out the goods is at best ineffective and at worst likely to expose them to infestation. Moreover, once the fleas and rats have been dealt with, the goods must be stored under ratproof conditions.

In Seville, it was possible to plead extenuating circumstances and obtain a waiver. When Seville banned entry of persons and goods from nearby Cazalla de la Sierra, the wine merchant Diego de Escobar worked the system. First, he had the wine moved to just outside Seville, and traveled to another outlying town that was not under the ban, and remained there long enough to get a declaration of health. With that in hand, he entered Seville and then pleaded that the wine had been outside of Cazalla for six weeks. A doctor representing Seville inspected the wine, and pronounced it safe; the city council licensed its entry provided it was transferred into new containers furnished by the city and transported on mules from the city. (Bowers 337).

Pesthouses. A pesthouse is a hospital that only cares for those diagnosed with plague.

They are also called lazarettos, although strictly speaking that is a leper hospital. It may be purpose-built, or a conversion of a preexisting building (e.g., convent, leprosarium). It may be a permanent structure, or just a cluster of huts. The largest was perhaps Milan's, into which 15,000 were crowded in 1630. Preferably, the pest house was outside the city walls.

The first permanent pesthouse was that of Dubrovnik (Ragusa), built in 1377, and the Ragusans added another in 1429. In Venice, the Lazaretto Vecchio (1423) was used for isolation and the Lazaretto Nuovo (1468) for quarantine and convalescence. Other permanent European pesthouses include those of Marseilles (1383), Milan (1399, 1451, 1488), Florence (1494), Ulm, Überlingen, Barcelona (1562), Seville (1568), Utrecht (1567), Ghent (1582), Palermo (1576), Paris (1580, never finished), Lyon (1628), Copenhagen (1619), Amsterdam (1636), Florence (1630). During the 1625 outbreak, London just had "cabins in the fields." (Byrne 208ff). On the other hand, in Germany, even small towns such as Überlingen had pesthouses, and indeed separate houses for the sick and for contacts. (Kinzelbach).

The 1636 British plague orders directed the Middlesex and Surrey justices of the peace to determine the taxes necessary to build pest-houses and provision them. (Hall 303). According to the 1636 London order, if a hackney coach is used to carry infected people to the pest-house, it can't be used to transport healthy people until five or six days have elapsed and the coach has been well-aired. (340).

It appears from plans of the lazarettos at Spezia and Livorno that these had many small holding cells, as well as disinfection halls, warehouses, and barracks. (Meli).

During an outbreak, overcrowding was the norm. In 1630, Florence's San Miniato had 82 beds for 412 females, and 93 beds for 312 males. (Byrne 210).

Household isolation/quarantine. When plague afflicted a resident of the town, it was possible to place the resident under "house arrest" rather than send him or her to a pesthouse. The same treatment could be meted out to a mere contract of a plague victim. This shutting-in was first practiced in Milan (1348). In 1631 Pistoia (pop. 8000), 125 houses were shut-up. (Byrne 326).

Unless otherwise stated, my description of household quarantine practice is based on English sources. There, the Privy Council considered confinement in a pesthouse to be more effectual than house arrest. But the capacity of the pesthouses was limited (St. Martin in the Fields parish, London, could only accommodate 66 sufferers in 1636) (Newman 815) and so, as the plague progressed, it was necessary to confine some victims and suspects to their residences.

If a victim was taken to the pesthouse, his or her family members might be taken there too, or quarantined at home. Even if the whole family was moved out, their dwelling place was still quarantined. It is likely that those who lived alone would be sent directly to the pesthouse.

It was recognized that quarantining of family members with victims might cause avoidable deaths. Shutting Up Infected Houses (1665) declared, "Infection may have killed its thousands, but shutting up hath killed its ten thousands." (Byrne 326).

The Dutch appeared to have been more liberal than the British; "some Dutch cities allowed relatives a choice to stay or leave. . . ." But if they stayed, it was for six weeks. (Byrne 325).

Still, in Britain, if plague appeared in a family that had more than one home, the family could isolate the victims in one and quarantine the healthy contacts in the other. If there was only one home, the family would, if possible, keep the victims in one room (perhaps a loft) and the others in another.

The transfer of a victim or suspect, whether to another home or the pesthouse, had to be done at night. The home the person left had to be shut up for a week, to give the remaining people time to develop signs of disease if infected. (Hall 291).

A shut up house was boarded up or padlocked by a constable, and marked as unclean. A one foot long red cross and the words "Lord have mercy on us" were placed on the door. (Newman 812; Hall 286). The constable of the precinct and the beadle of the ward were supposed to check everyday that the warning signs remained up. (294).

On the Continent, the warnings took other forms. In Italy, the sign said "sanita" and at the Hague, "PP" (Plague Present). In Utrecht, a white linen sheet was hung and some Dutch cities specified bundles of straw or straw wreaths. (Byrne 326).

The house was shut up for six weeks (Hall 271), subject to extension if a resident died while shut up, no clothing or the like could be hung out over the street. (292). A curious 1636 addition was that no sound should travel from an infected house without approval. (305).

The orders are not specific as to how food would be provided to the stricken household, but it appears likely that they would be hauled up in a basket to a second story window. (Byrne 325).

Watchmen were appointed to prevent insiders from leaving the house and outsiders from entering it. If the residents were moved out altogether, the watchmen prevented theft. There were two watches, from 10 am to 6 pm, and from 6pm to 10 am. (Hall 285).

Besides preventing unauthorized entry or exit, the watchmen were “to render other services such as the inhabitants require.” If sent away, the watchman was supposed to lock up the house.

If one shut up managed to escape and visit another house, the latter house would also be shut up for four weeks, and those responsible for the escape would be punished. (Hall 286). Likewise, any unauthorized visitor to a shut-up house would be shut-up in turn. (305).

There are instances of both clandestine and open violations of household quarantine; the quarantined could attempt to leave and the healthy could attempt to enter. Doorkeepers were bribed or even assaulted, and this led to criminal proceedings. If healthy people entered a quarantined house or one not fully aired after quarantining, or sat at the door of a quarantined house, they could be shut up with infected people as punishment. (827). This was done even in the case of people acting from highest motives; the English so punished French and Dutch "consolators" sent by their congregations. (828). Ben Jonson violated the law in 1606 by visiting the home of Sir John Roe, who died in his arms. (Byrne 198).

Unlike the British, the Dutch allowed friends and family to visit plague patients, but these then had to carry a long "white rod for six weeks after the patient died or recovered." In 1515 Leiden, violators would either provide 2,000 bricks for the city wall or have a hand cut off. (Byrne 359).

The 1636 British plague order stated that it is lawful to use violence to prevent escape and if the would-be escapee is injured, the guard is not liable. Also, if a sick person with an uncovered sore went into the company of others, the punishment was death, but if there were no visible sore, the punishment was the same as for vagabonds. (Hall 331).

On occasion, the authorities exercised discretion. For example, British law offered concessions to those who lived far from others and had good reasons for leaving their homes. For example, it permitted farmers "to continue caring for their fields and animals, as long as they avoid the company of other humans and wear some mark of plague. . . ." (Hall 271).

I find it interesting that the 1577 plague order asked "if there had been any partiality either in restraining the poor than the rich upon infection, or in sparing the rich who transgress the beneficial measures taken to stay the infection, or if the poorer sort were more severely punished." (269). And, under the 1625 order, "anyone who through guile or cunning circumvents the letter or the intent of these orders shall receive twice the punishment as someone who openly disobeys the orders." (297).

Nursing. Whether in shut-up homes or in pesthouses, the sick required care. The wealthy had servants to do this, the poor had to rely on public charity. In Catholic countries, this was generally provided by orders of uncloistered nursing nuns, such as the Oblates of Mary. In Protestant countries, the nurses were secular, either volunteers or public employees. (Byrne 255). The 1625 British order specified that women ("keepers") would provision and take care of the sick. However, there's at least one instance of a male keeper at the 1636 Newcastle "pesthouse" (really just lodges on the town moor):William Gardiner, age 33. (Wrightson 183n21).

Costs. Quarantine had both social and economic costs. It conflicted with the social and religious obligation to visit with and care for the sick.

The economic burden of quarantine fell most acutely on the middle class: the wealthy could flee the city when plague first appeared, and the poor were subsidized. (And it didn't help that when the wealthy fled, they took their money with them, so tax collection and charitable donations were reduced accordingly.) (Byrne 147).

In England, on the one hand the government acknowledged the obligation to care for the sickly poor (as opposed to expelling them to fend for themselves) and the royal plague orders directed local authorities to levy taxes, either on the town as a whole or on wealthy residents, to pay for poor relief. Moreover, there was provision for expanding the area taxed to neighboring areas, as far as five miles away. (Newman 817; Hall 270, 333). If a person refused to pay these taxes, his goods could be seized, or he could be imprisoned. (330). Constables who failed to collect taxes could be fined ten shillings. (331).

On the other hand, the government was extremely sensitive to the accusation that it was not charitable to isolate the sick and thus deny them consolatory visits by clergy, family and friends; it forbade ministers to so preach on threat of punishment. (Hall 273).

This care was to be paid for, if possible, by the afflicted household. In some cases, the parish advanced the support money and the household paid back the loan after the crisis was over. Of course, paying back the loan might be more difficult in the aftermath of the plague. If the householder sold perishable goods, or goods that were subject to destruction under the plague orders, the stock in trade was lost. And under a 1637 Privy Council order, a previously shut-up house couldn't take in lodgers until one year after it was reopened. (Newman 818).

In other cases, the support was outright charity. In the 1636–37 outbreak, 94% of London's St. Martin's households were "chargeable," that is, they couldn't pay outright the four pence a day per person that the parish charged for support. In Augsburg 1607–8, 5% of the households were supported, and in the greater outbreak of 1628–29, 24%. (Kinzelbach 387).

As to the magnitude of the costs, in 1638, Lowestoft, Suffolk (pop 5,000) had 263 families shut in at an expense of 200 pounds/week. (Byrne 326).

Staffing. The British plague orders increasingly recognized a need for medical expertise. The early orders require appointment of searchers, but say nothing of their training. Then there is call for surgeons to check their work. The 1636 royal order instructs the city (London) to hire some doctors, and that "each of the doctors should be supplied with two apothecaries and three surgeons." (293). There is provision for pensioning the widows if a doctor or surgeon (not an apothecary?) dies in city service. (303).

In July 1636, the London parish of St. Martin's (population ~10,000) employed three nurses, ten doorkeepers, three bearers and two searchers; there were then 100 people in quarantine. (Newman 813, 818–9).

Restrictions on Health Workers. In England, since searchers, plague surgeons, keepers, corpse carriers and grave diggers necessarily came into contact with the victims, they were themselves restricted. Unless visiting a home in the line of duty, they could enter only their own homes; while walking through the streets, they had to conspicuously carry a three-foot red wand, and they were expected to avoid company. (Hall 286). Curiously, the plague orders do not place similar restrictions on the watchmen. The keepers could only pour out waste water between 8 in the evening and 6 in the morning. (293). The 1625 London orders stated that the surgeons are only allowed to treat plague victims, and are paid 12 pence per body searched (by the patient, if possible). (Hall 290). Anyone who came into contact with the infected was expected to change clothes and air them out on coming home. (Hall 274).

There were similar restrictions on health workers on the Continent. Not only were some charged with violating these restrictions, there are cases of them taking advantage of their access to shut-up homes and their occupants by vandalism, theft, assault and rape. (Byrne 93).

Notaries. Given the virulence of the disease, it was prudent to make a will as soon as the diagnosis was clear. The legal formalities required both a notary and witnesses. Obviously, a bedside appearance was dangerous, and in Italy, legal changes were made to reduce the risk: decreasing the number of required witnesses, allowing the will to be dictated "through a doorway or window," or dispensing with a notary altogether. Still, in Orvieto, during one plague outbreak, 24 of 31 notaries died of that disease. (Byrne 254).

Funerals and Burials. In early modern Europe, a funeral was a public affair, often followed by a feast. However, in plague areas, funerals were highly restricted.

I have the most information on British practice. Those who died were buried between sunset and sunrise. By the 1578 royal order, curates were directed to keep their distance from the corpse and the mourners. (Hall 272).

It appears that by 1625, neighbors and friends were not allowed to accompany the corpse to church or to enter the deceased's house. (291). Also, no dead body was allowed to remain in the church or be buried during a common prayer, sermon or lecture. No children were allowed near a corpse, coffin or grave, or even into the church or churchyard at the time of burial (not even the children of the deceased?). There could be no burial dinners or dinners at the home of a plague victim within 28 days of the death (285)—if this rule was violated, the house was shut up for another 28 days.

Even the 1636 order guaranteed that burial would be "not without the services of a minister, clerk, bearers, and constable and overseers." (305). But bells could not be rung (307); I suspect that this went to preserving public morale.

In some parts of Europe, such as Tuscany, it was customary for gravediggers to be tipped with the deceased's clothing. This was a dubious reward when the cause of death was plague, at least if the clothing was still flea-ridden.

They received wages, too, but it wasn't unheard-of for the city officials to be dilatory about payment in the hope that the gravedigger would die in the meantime. There's a case in Montelupo 1631 of two gravediggers refusing to work until they received their back pay. When threatened with impressment into the galleys, they countered that they would toss corpses in front of the mayor's house.

When the "official" gravediggers were killed off, they might be replaced with condemned prisoners. (Byrne 186). Which created its own problems.

When there was a major outbreak, there were further departures from the norm. Corpses might be incinerated, as first happened in Catania (1347), and more recently in Venice (1575–7).

However, the "miasma" theory discouraged this practice; there was fear that the "poisons" in the corpses would thereby be returned to the air.

Burial in mass graves was more common, as a severe outbreak could overwhelm the local capacity for individual burial. The bodies might be laid haphazardly, or one on top of the other, "like layers of cheese in lasagna." (Byrne 225).

Assuming that space was available, in England the deceased were buried in the parish's churchyard or normal burial grounds. In Italy, it was more likely that plague epidemic victims were buried outside the city, in a dedicated plague burial ground. (Harding).

Other Public Gatherings. The 1608 British plague order states that "all plays, ballad singing, buckler play, or other such games and amusements that produce crowds of people are utterly forbidden." They didn't go so far as to prohibit drinking, but they cast an unfriendly eye on "disorderly drinking." (Hall 288). If there were a plague case in an alehouse, it had to take its sign down. The 1625 London order called for "restraint" of "profane spectacles like plays, fencing, and other assemblies and calls to same" within the city. (296).

The 1636 order also criticized bowling alleys, and had the curious provision that "two places of entertainment should be provided, one for the sound and one for the sick." (304). I find this difficult to reconcile with the shutting-up of the sick, unless one place of entertainment is actually attached to the pesthouse.

At least the London orders forbade "public feasts, particularly those hosted by companies of the city," and also "dinners at taverns and alehouses." It was suggested that "the money saved by this frugality should be used to benefit the poor who have been visited by the plague." (341).

In Paris, the decision was made to continue to hold the local fair, on the theory that it was better to allow traders to enter openly, subject to inspection, than to risk that infected goods would be smuggled in. (Byrne 260).

Religious processions might or might not be permitted. On the one hand, a crowd increased the risk of contagion. On the other hand, the appeal to heaven's mercy might, the authorities hoped, save the city.

Clergy. The role of the clergy in caring for the sick varied by place. In the 1629–30 plague in Milan, the clergy were active, and two-thirds were lost. (Byrne 55). In seventeenth-century Cologne (and probably also Trier and Mainz), the Cellites buried the plague dead. This was not without risk; 20–23 brothers died in 1605 of the plague. (Byrne 69).

 

Flight

 

The logical human reaction to hearing that plague had been discovered nearby was to flee to someplace presumed safe. Jenison called this "the common rule of the world." Curiously, the well-to-do would leave the town and go to estates in the country, while rural poor would flee to nearby towns (in Pistoia, about eight times as many of those admitted to the pesthouses were from the countryside as from the town. (Cipolla 58).

When the wealthy fled, they might leave some servants behind to protect their townhouses and their possessions. In Ben Jonson's The Alchemist (1610) , servants thus left to their own devices got involved in a confidence game.

Wealth did not guaranteed that these refugees would be welcomed. The country folk might refuse to let them sleep in inns or even barns. (Byrne 147). (In Surat 1994, some refugees were stoned when they entered a new town. (Marriott 110.)

Licensed physicians were likely to be well-off enough to join the flight, leaving the care of the sick to the "empirics" left behind. (Byrne 130). And those that didn't, often died, in 1347–52, Montpelier lost its entire medical faculty, and Venice, 20 of 24. (269).

So, too, were many of the Anglican and Lutheran clergy, in part because they did not have a duty to hear final confessions or administer last rites. (Byrne 263). After fleeing the 1636 Newcastle outbreak, the lecturer Robert Jenison declared that a minister without a pastoral charge might "withdraw himself, and so reserve himself to better times, merely out of respect to [the] good [of his parishioners], who for the present seem a while neglected." (Wrightson 59).

In the premodern world, there was a religious concern: if the plague was a punishment from God, then was leaving town an impious act? Nonetheless, in Europe the usual advice (attributed to Galen) was "to start early, go far, and return late." (Aberth 45). Amanti argued that since God made it possible to escape the plague by flight, it could not be impious to thus save one's self. (50).

In contrast, in the Islamic World, there was the problem the Prophet supposedly said that if a plague is "in a land, do not approach it; but if it breaks out in a land and you are already there, then do not leave in flight from it." Some jurists took this to be a blanket prohibition, and others said that it was "humane guidance and advice." Still, the bottom line is that there was more prejudice in the Islamic countries against flight than there was in Europe. (44).

Even if flight does not occur, there is the risk that laborers will refuse to do work that places them in proximity to plague sites, even if that work is intended to suppress the disease. This happened even in modern times. (Chase 153).

 

Restrictions on Flight

 

From a public health standpoint, the problem with permitting people to leave a place in which plague cases had been reported was that they might already be carrying the disease (or at least infected fleas), and would therefore carry it to their destination. A central government conceivably could decide not to let anyone leave, or constrain who might depart in some way.

The 1636 British plague order directed that before fleeing, you must obtain a certificate from the parish overseer attesting that you are free from plague, and even then you could flee only to an uninhabited house not more than one day's travel away. (Hall 305). I think, however, that this was not intended to forbid moving to a second house of one's own, as that is expressly permitted by the London order of the same year. (337).

Travel restrictions saved some and doomed others. Tradition holds that the village of Eyam (Derbyshire, England) voluntarily quarantined itself in 1666. The quarantine was observed for the last five months of the fourteen-month epidemic, and no villager was allowed to cross the boundary, one mile in diameter. The mortality rate was 80%, the highest for any British community. (Coleman). Eyam was a mining town and revisionists have suggested that it was required to quarantine itself in return for food. (Wallis).

A similar cordon sanitaire was placed around Sandwich (1610, 1640), Presteigne (1636), Digne (1629), and Girona (1650). The local authorities didn't react quickly enough to the plague outbreak in Marseilles (1720), and the result was that a substantial portion of the French army was employed in sealing off the entire province of Provence. (Byrne 90). Shoot to kill orders were given.

 

Expulsion

 

While some fled a town voluntarily, in the fourteenth century , it was not unusual for the authorities to expel the sick to fend for themselves. By the seventeenth century, as we've seen, towns were more likely to isolate but care for the sick. Still, they might force foreigners and other undesirables to leave.

The 1608 British plague order warned against "wandering beggars." (Hall 287). Pistoia first expelled "all foreigners, mounterbanks and Jews," and later closed the city to "all beggars and all poor people afflicted with any kind of disease." (Cipolla 53). In some cases, the motivation was: fear that they had unclean habits or came from unclean lands where plague might breed, or even that they were deliberately spreading the plague. Sometimes, it was just to avoid having to care for them if they became sick. And plague could be just the excuse. . . . (Naphy 47).

 

Disinfection and Destruction of Clothing and Bedding

 

In the seventeenth century, it was supposed that the noxious components of the miasmas would stick to clothing and bedding, and hence from time to time the authorities decreed that these be disinfected or destroyed.

We now know that plague is not spread by fomites, i.e. , inanimate objects do not normally carry the living bacterium directly. However, clothing and bedding are capable of carrying infected fleas. (Cipolla 13).

In 1630 Florence, the members of the Compagnia di San Michele reported to the Magistracy that the degree of poverty in the lower class neighborhood was much greater than they had suspected, and many of the poor slept on filthy paliasses that could carry disease. The Magistracy ordered 1347 new paliasses purchased and given to the poor, marked so they couldn't be seized by creditors. (Cipolla 16).

The early British plague orders specified that clothes and bedding of the sick were burnt if of little value (Hall 280), and otherwise disinfected with "fire and water" or "well aired." (Hall 273). They also provided for compensating the poor for burnt items. (273). It was forbidden to buy bedding or other stuff from a house within two months of the plague having been there, on penalty of having the buyer's own house shut up for at least 28 days (285). The 1625 orders took this a step further as they said "no clothes or other things from or near the infected people are to be given away or sold; instead they should either be destroyed or completely purified." (297). In the Netherlands, the rule was that the clothing of plague victims couldn't be sold until two months after death. (Byrne 83).

In Germany, goods with smooth surfaces were quarantined for just two weeks, whereas blankets, bedding and clothes had to be aired for a whole year. (Kinzelbach 386).

Many seventeenth-century methods of disinfection were worthless. They included burning aromatic materials in the presence of the suspect items. A few of these (tobacco, rue) (306) might have been of value if the burning had been in a confined area so as to concentrate the fumes, but I don't think that was how it was done. In any event, I know that in 1900 San Francisco, Chinese workers in a cigar factory contracted plague. (Chase 56).

Exposing the item to heat might have been more effective, but it really depends on how hot for how long. Of course, actually burning the material will kill the fleas, but is rather wasteful.

At the Vasa Museum in Stockholm, a placard asserts that in Kalmar 1628, "ships which had dead and sick men on board were fumigated with sulphur and then tarred."

 

Sanitation

 

Some down-time physicians thought that the "miasma" was the result in part of putrefaction, leading to a heightened concern for public sanitation. (Hall 287, 296).

To the extent that this led to reduction in food or harborage for rats, it may have had a modest anti-plague effect. And it would have had more general public health benefits.

 

Animal Observation and Control

 

The Hindu scripture Bhagavata Purana instructed people to leave their rooms if they saw "rats fall from the roof above, jump about and die." (Clemow 345). Unfortunately, early-seventeenth century Europeans did not even become alarmed by a spike in rat deaths, let alone suspect that the rats played a role in spreading the plague.

Unfortunately, the animal culprits were deemed to be cats and dogs, the theory being that their fur captured poisonous particles from the miasma. In Milan (1576?), a cat was reported to have infected a nun. (Simpson 221). The 1608 British plague order directed that "no dogs, cats, conies or tame pigeons should be kept within the city," and no swine were to be allowed to wander loose. (Hall 287). Cats and dogs were also killed in Seville, Rome and Amsterdam. (Byrne 13).

The first European reference I find to rat control as a plague preventative is in Defoe's fictionalized account of the Great Plague of London 1665–6: "All possible endeavors werere used, also, to destroy the mice and rats, especially the latter, by laying ratsbane [arsenic] and other poisons for them. . . ." (Hendrickson 58).

 

Prophylactics

 

The British plague orders were accompanied by collected advice from medical experts (Hall 273ff), and, for the surer protection of the populace, prophylactics were to "be made available for those who might otherwise have difficulty getting them." Also, "recipes using low cost, readily available ingredients [were to] be printed and posted in market-places and churches." (Hall 272).

While the down-time prophylactics were worthless, this practice does create precedent for distributing medical advice from Grantville, and perhaps subsidizing flea repellents, rat poisons, general fumigants, and antibiotics once they come onto the market.

 

Protective Clothing

 

In 1630s Italy, it was customary for doctors in France and Italy to wear red robes made of toile-ciree (a fine linen) coated with a wax containing aromatic substances. Under the miasma theory of disease, it was expected that the wax would keep the "venomous atoms" of the miasma from sticking, and I presume that the aromatic substances were to counter the noxious aromas of that miasma.

While it is fair to say that the color did not fend off the fleas, the coating may have been of real value. In 1657, Father Antero Maria da San Bonaventura, the friar administering the main Genoese pesthouse, reported that "the waxed robe in the pesthouse is good only to protect one from the fleas that cannot nest in it." (Cipolla 12). Believing in the miasma theory, he concluded that the robes were no defense against the plague. So near, yet so far!

Differences in dress probably also explain why colonial officers in India were less likely to contract plague than the urban poor; the former wore long pants and boots, the latter wore short pants and went barefoot. (Mohr 13).

 

Conclusion, Part I

 

DeMarce, "A Gift from the Duchess" (Ring of Fire II) describes how Kronach, a town in Franconia, copes with plague in NTL 1634. Outside, there is a cordon sanitaire. Inside, there is a pesthouse and an ad hoc Magistracy of Public Health. So far, quite traditional.

But up-time knowledge is already having an effect. The three plague doctors sent into town by the Duchess of Tirol have accepted the up-time notion that the ultimate cause is bacteria in the blood rather than poison in the air, and the role of fleas and rats in spreading those bacteria. Rat eradication has been deemed desirable; dogs and cats have been given a reprieve (on the theory that they "gave the fleas a few more options" and can also catch rats) and, most importantly, DDT has been imported from Grantville.

In part 2, I will examine in more detail the impact of up-time knowledge on the battle against the plague.

****

To be continued . . .

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About Iver P. Cooper

Iver P. Cooper, an intellectual property law attorney, lives in Arlington, Virginia with his wife and two children. Two cats and a chinchilla rule the household with iron paws. Iver has received legal writing awards from the American Patent Law Association, the U.S. Trademark Association, and the American Society of Composers, Authors and Publishers, and is the sole author of Biotechnology and the Law, now in its twenty-something edition. He has frequently contributed both fiction and nonfiction to The Grantville Gazette.

 

When not writing (or trying to get an “orange blob” off his chair so he can start writing), he has been known to teach swing dancing and folk dancing, or to compete in local photo club competitions. Iver adds, “I can’t get my wife to read my fiction, but she has no trouble cashing the checks.”

Iver’s story “The Chase” is in Ring of Fire II