Opening the Plague Files

Book Citation: A.P. Cook & N.D. Cook.  The Plague Files: Crisis Management in Sixteenth-Century Seville.  Louisiana State University Press, 2009. 296 pp. ISBN: 978-0-8071-4360-5.

Topic:
Public Health Crisis Management

Time and Place:
Seville, Spanish Empire, 1579-1581.

Audience: 

Those interested in history, crisis management, public health, and political science; written for a general audience.

Discussion:

The Plague Files is an intensive history of the daily challenges and crises dealt with by the royal governor and city council of Seville from 1579 to 1582.  As its title implies, this book is about crisis management and it stays true to this focus. Seville was faced with two very different pandemics, influenza and plague, within the same year compounded by food shortages, economic pressures, response funding difficulties, response fatigue, and the potential of civil unrest. If you ever wondered what it would be like for plague and an influenza pandemic to go (sequentially) head to head in the same population, Seville in 1579-1580 is your ideal test population.  The challenges and limitations of both quarantine and a cordon sanitaire are highlighted throughout the book.

I was impressed by their case investigation and surveillance system.Workers were contracted and paid based on their service, so detailed reports were filed to justify their pay from the plague commission. Using these reports, the authors were able to trace the detailed steps of case investigators as they tracked exposed people and textiles that they viewed as contagious. Dispatched surveillance officers also had to file detailed reports of their efforts and findings to draw their pay. The Count of Villar, the royal governor, handed out penalties including jail time for officials and others who were deemed negligent in their duties.

It was fascinating to see how their concepts of contagion played into their public health response. Textiles were the gravest concern for controlling plague contagion inside the city walls. The trail of dead owners of some clothing or bedding seems to justify their concern. Yet, there is no evidence of personal protective equipment/behavior or concern over grain storage. On the other hand, the city was on the verge of starvation much of the time so they couldn’t be very choosy about grain shipment or storage. Physicians were advisers to the Plague Council but not central to the decision-making process. Most were hired to work for the duration of the plague, often one per hospital or outlying village. The Plague Council was primarily concerned with controlling movements of people, and  providing and paying for the poor and destitute who they knew were kindling for an explosive outbreak. Diagnosis was the physicians most useful duty to the plague council. Plague diagnoses were complicated by concurrent outbreaks of influenza, typhus, other ‘common fevers’ (possibly malaria), and malnutrition. There is no doubt that the plague with all its classic symptoms was the primary pathogen.

One of my take home lessons from The Plague Files is how long and relentless a plague outbreak could be. Response fatigue was a critical problem for everyone. People just get tired of the restrictions and become conditioned to the steadiness of death. Unlike the short, sharp influenza mortality, plague deaths often trickled in at less than ten per week for months punctuated by spikes of death.

Historical  & Scientific Content:

This microhistory draws almost entirely  from a cache of primary source documents in Seville’s Municipal Archive. Surprisingly, quotes from these documents are very short. The focus on Seville is so intense context is often lacking.

The science is anecdotal and kept at the level of sixteenth century understanding. They don’t apply modern understanding of plague or influenza.  Medical treatment is discussed vaguely; few specific treatments are detailed. For example, the council paid for apothecaries to stock and provide plague medicines but the authors didn’t discuss what they stocked or if they had difficulty obtaining medicines. It appears that there was no standard treatment or medication used in the region. They don’t make an effort to accumulate data or do any standard epidemiological analysis. By the end of the book I was craving some data. The volume of anecdotal evidence does provide plenty of evidence that diagnosis was not very secure for many individuals complicating data classification.  Historical epidemiologists will have to cope with other concurrent diseases, significant for plague outbreaks that last months to over a year. Ironically in the case of Seville, I suspect a standard epidemiological chart of total deaths vs time would have highlighted the difference between influenza and plague.

References, Illustrations, and Usability

It has a full bibliography but minimal footnotes, mostly to primary sources. I suspect that it would be fairly difficult to look for more information based on their footnotes and access to the primary sources.  They appear to have made minimal use of the secondary sources, or at least there are very minimal footnotes to them. It does have a glossary for Spanish terms; all quotes are translated. The illustrations were okay. It could have used a few more local maps fit into the text where appropriate.

I recommend this book primarily for biosecurity and crisis managers. Its usefulness to the sciences and humanities is primarily for anecdotal information.

London Plague of 1665 [movie clip]

From the 1995 movie Restoration with Robert Downey Jr:

Health and Healing Sessions at Kalamazoo 2012

Regular readers might remember that last fall I was regularly posting and tweeting a call for papers for a session on health and healing in early medieval Europe for the International Congress on Medieval Studies at Kalamazoo in 2012. The schedule for the Congress is now out so I can tell everyone all about it. As you can see I got a great response to my CFP and the Congress committee let me put together two sessions. So without further ado, here are the sessions co-sponsored by The Heroic Age and Medica: The Society for the Study of Healing in the Middle Ages.

Session 264 (Friday 1:30)
Schneider 1255

Health and Healing in Early Medieval Britain and Ireland
Presider: Deanna Forsman, North Hennepin Community College

• Famine and Pestilence in the Irish Sea Region, 500–800 AD: Michelle Ziegler
• Regional Patterns of Health in Early Medieval Ireland: Distributions of Non-specific Stress Indicators: Mara Tesorieri, Univ. College Cork
• The Experience and Practice of Medicine by the Laity in Anglo-Saxon England: Julia Bolotina, Univ. of Cambridge
• By Rome, or By Spain? Possible Mediterranean Origins of Irish Holy Well Veneration: Silas J. Mallery, North Hennepin Community College

Session 319 (Friday 3:30)
Schneider 1255

Medical Texts of the Early Medieval Mediterranean
Presider: Michelle Ziegler

• Animal-Derived Medicines in Early Medieval Pharmacy: Jayna Brett, Centre for Medieval Studies, Univ. of Toronto
• A Medieval Hippocrates? The construction of the Articella during the eleventh century.: Marco A. Viniegra, Harvard Univ.
• Book-Learning and Medicine in Medieval Byzantium: Theory and Practice in the Alexiad of Anna Comnena: Glen M. Cooper, Brigham Young Univ.

Retrospective Diagnosis in the 21st Century

Black Death at Tourinai, 1349

The way we make and think about retrospective diagnosis is changing. Over the last decade, laboratory results have become the preferred (maybe even mandatory) method of making a retrospective diagnosis [1]. To extrapolate a few positive laboratory results to cover an entire epidemic, it must correlate with reported signs and symptoms and ideally epidemiology. There are pitfalls at every step of the process.

Today, laboratory results focus on identifying species specific biomolecules, aDNA and non-DNA molecules such as specific capsule lipids. I previously posted more detail on the non-DNA biomolecules used in paleomicrobiology. Each of these methods has its critics and proponents. Laboratory results should always be logical with the osteological analysis of the skeletal remains and with at least the majority of the written record. We have to remember that just because an infection was detected, it doesn’t necessarily mean that they died from it. If a skull has a sword wounds, it is unlikely that they died from tuberculosis. There is a significant difference between dying with a disease and dying from it.

For these science reports to be helpful to historians and anthropologists, they need to provide better context on the skeletal remains including how the remains were dated and associated with a particular epidemic. To give one example, a recent letter to Emerging Infectious Diseases reports Yersinia pestis in unerupted teeth from tombs under Sant’ Andrea church in Barletta, Italy [4]. They suggest this identifies the 1656-1657 epidemic as the plague. Although the tombs were said to have been used “since the 14th century” and have been hypothesized to have been used for the 1656-1657 epidemic, they do not give any indication how these five youths were selected for study. They report that their negative control from the same tomb complex dated to before the epidemic, so presumably this could be easily corrected by giving the rationale an archaeologist used to select these youths.

Assessing signs and symptoms and the epidemiology of past disease requires correctly using ancient and medieval documents. Medical treatises are not necessarily as helpful as they may seem. Medieval authors often copied classical texts that were centuries old and their new observations were heavily influenced by contemporary philosophical paradigms [2]. Instead, a variety of documents that can be broadly classified under government records (tax and manor rolls, wills, court records, etc); biographies and hagiographies; chronicles, annals and medieval histories can all be very useful in part because the disease is often not the main focus of the account [2].

Using such an array of ancient and medieval works has plenty of pitfalls even for historians, much less those from other disciplines. Mitchell has outlined a number of pitfalls to retrospective diagnosis from medieval texts that I will try to summarize with a few notes of my own [2].

1. Not enough information in the source for an accurate diagnosis.
2. An apparent eye-witness account is actually copied from an older source.
3. Translation is not representative enough of the original language for diagnosis.
4. Inadequate knowledge (of the researcher) of disease signs and symptoms and how they are represented in this cultural context.
5. Cherry picking symptoms to fit a theory.
6. Failure to understand that a source is not representative of the body of contemporary sources.
7. Not realizing that more than one disease is present. Likewise, assuming that two or more diseases are present when they are not.
8. Assumption that the antique or medieval disease is one that still exists today.
9. Assumption that the characteristics of the disease have not changed from then until now, including transmission methods. Likewise, assuming that characteristics of the microbe must have significantly changed over time.
10. Failure to understand how the environment and living conditions change the epidemiological characteristics of the epidemic.

Epidemiology is the most difficult parameter to assess. For ancient and medieval epidemics, I find it very difficult to consider epidemiology part of the retrospective diagnostic process. There are simply too many variables in the environment and human cultures of the past. Even diseases like malaria and influenza that we think we know so well still throw us surprises today [3]. Not even seasonality is set in stone as the 2009 H1N1 influenza pandemic recently showed us. After now centuries of study, we still can be hard pressed to explain the rise and fall of malaria. By it’s very definition, a pandemic is an extraordinary situation compounded by historical distance for study of historic outbreaks.

Even removing it from the diagnostic process, epidemiology is still one of the most important fields of study for past epidemics. If we can answer the important epidemiological questions on past epidemics then I think we can say that we understand at least the science of the epidemic. For many well-known pathogens like influenza and plague, we have had many outbreaks but very few pandemics to learn from to prepare for future threats.

[1] Little, L. (2011). Plague Historians in Lab Coats Past & Present, 213 (1), 267-290 DOI: 10.1093/pastj/gtr014

[2] Mitchell, P. (2011). Retrospective diagnosis and the use of historical texts for investigating disease in the past International Journal of Paleopathology, 1 (2), 81-88 DOI: 10.1016/j.ijpp.2011.04.002

[3] Raoult D (2011). Molecular, epidemiological, and clinical complexities of predicting patterns of infectious diseases. Frontiers in microbiology, 2 PMID: 21687417

[4] Scasciamacchia S, Serrecchia L, Giangrossi L, Garofolo G, Balestrucci A, Sammartino G, et al. Plague epidemic in the Kingdom of Naples, 1656–1658. Emerging Infectious Disease. 2012 Jan . http://dx.doi.org/10.3201/eid1801.110597

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The Dancing Plague of 1518

John Waller. The Dancing Plague: The Strange, True Story of an Extraordinary Illness. Sourcebooks, 2009 (paperback). Previously published as A Time to Dance, A Time to Die: The Extraordinary Story of the Dancing Plague of 1518 (Icon books, hardback, 2008).

Topic: Dancing Mania, choreomania

Time and Place: Strasbourg, Holy Roman Empire, 1518

Audience: General

Discussion:

This was a good book to wrap up 2011 with – from the Arab Spring, to summer revolutions and the fall’s occupy movement – conditions are approaching those of 1518. Among the peasants of Strasbourg, life in the early 16th century had become miserable. The church and monasteries left the peasants spiritually desolate and literally starving while their tithes of grain were sold at prices they couldn’t afford. Poor harvests and high inflation made famine a real possibility. There were several peasant revolts leading up to 1518 that were brutally put down with public executions and massacres. Ancient ties between the nobility, church and common people had broken down such that secular and ecclesiastic office holders no longer seemed to care for the welfare of the common people.

In July 1518 Frau Toffea was outdoors in the street of Strasbourg when she began to dance. There was no music or joy in her dancing. The spectacle soon became horrifying as it became apparent that she could not stop. Eventually she collapsed from the heat and exhaustion. When she woke up, she began to dance again in the same frenzy. Soon other people in Strasbourg began their trance-like dancing ignoring the heat and the need for food and water. When they were able to speak, they begged bystanders to make them stop. Before long in the July heat, people began dropping not to get up again – did they dance to an exhausted death or was there a pathological cause?

The people of Strasbourg didn’t see this as a psychological disorder but either physical or spiritual. At first they turned to the newly respected, university trained physicians who strangely proscribed more dancing as a cure. They assigned people to make sure the afflicted kept dancing even when they were capable of stopping. It became very apparent that this was not helping the death rate. Before long physicians and townspeople agreed that this was a spiritual ailment that required a pilgrimage to the local shrine of St Vitas. Fascinatingly the people believed that a saint patronized by epileptics could/would also curse people to uncontrolled movements like the dancing if they were displeased. Throughout this region of Germany and the Netherlands there are shrines to Vitas and other saints to prevent epilepsy and the dancing plague. Late medieval people greatly feared epilepsy and similar disorders because it could be perceived as demonic possession or a curse (by victim as well as bystander). Waller argues that this was something like a case of spiritual post traumatic stress disorder. His argument is too complicated for me to explain here but it is a worthwhile and thought provoking discussion.

Narrative: B+ The narrative was well written and kept me eager to continue reading. This is no small feat without a central cast of characters to follow through the book. He tries to use Frau Troffea as a continuing theme but just doesn’t have enough information to really flesh out her life.  There were places that I wished for more scientific context. I wish he had not saved so much of the science for the last chapter.

Historical Content: A- This is not a time period that I am very familiar so it is hard to assess how well he covered the historical questions. While he discussed actions of the church, he apparently didn’t have sources from within the church. This seems strange as the church usually has better resources than secular courts. The discussion of the religious context was good and mostly from the lay viewpoint.

Scientific Content: B-/C+ He seems to be reaching too far in some of the psychological parallels he tries to draw to the choreomania (dancing plague). Practices that intentionally create trances or mystical dancing are not good matches to the unintentional and unwanted dancing in 1518. The contagious nature of the dancing of 1518 is based at least partially upon the fear of the mania. Waller describes all mystical experiences in terms of pathology, which seems unwarranted. His brief discussion of an outbreak of uncontrollable laughing in Tanzania in 1963 left me wanting to know more (p. 216). A recent Ugandan outbreak of “nodding syndrome” where youths display uncontrollable nodding when they try to eat has been associated with a parasite that causes river blindness. In all three outbreaks, these may be related to epileptic-like behavior. My point here is that we can’t jump to the conclusion that initial cases are all psychological, even if some of the contagious nature does seem psychological (people being effected by watching etc).

I also have to take issue with a reviewers quote the publisher put on the back of the book. A quote from New Scientist stated “It’s a book to make you grateful for the historical increase in human sanity.” Part of the author’s argument is that manifestations of stress and PTSD are culturally dependent and that we express stress differently today. When we consider how many people today take medication for anxiety/stress, depression, PTSD or other psychological conditions it is questionable if there has been a “historical increase in human sanity” – not that manifestations of stress are necessarily measures of sanity anyway.

References and Usability: B The bibliography and notes are integrated together. This makes the bibliography much more difficult to use. The notes are consecutively numbered for the entire book and were a little sparse.  There are 238 notes for 231 pages of text. There were plenty of places I would have liked to have seen that he had a reference for a fact.

Illustrations:  B The maps and illustrations included were okay. It could have used a map of the local Strasbourg area that included the shrine of St Vitas.

Overall, I did enjoy the book and it is a very interesting episode in medical history. Community reaction to the outbreak is as interesting and influential as the disorder itself.  The power of the brain is almost always underestimated. Even if it wasn’t completely psychological, it manifested in ways that were surely under the control of the brain.

A tangent:  one of my favorite quotes from Waller’s book is not on the dancing mania at all. “Syphilis was the flagellum Dei, God’s whip, a stark warning about the sinfulness of adultery and fornication.” If it was the flagellum Dei before the invention of the microscope, imagine how they would have reacted to seeing a spirochete!

Contagions Round-up 17: Historic Medicine and Populations

This time I’m going to concentrate on historically important infectious diseases, and historic medicine and populations. So here is what the blogosphere has to offer from the last couple weeks.

Michael Walsh of Infection Landscapes discusses two historically important infections: Salmonellosis and Typhoid fever.

Small Things Considered gives their views on the discovery of Yersinia pestis at East Smithfield, London.

Connor Bamford of the Rule of 6ix discusses new research on the molecular basis of measles transmission.

I wrote about the 19th century meaning of ‘cholera’ here at Contagions.

Kristina Killgrove of Powered by Osteons has been busy over the last couple weeks. Her Roman DNA project has been funded by public donations. Congratulations Kristina! You can read all about her project at the project blog: Roman DNA project. She also wrote about the demography of Republican Rome, the bioarchaeology of crucifixtion, and not-so-ancient concepts of disease.

Rosemary Joyce of Ancient Bodies, Ancient Lives writes about Kristina Killgrove’s work on non-elite Roman demographics especially women, or the 99% of Rome.

Katy Meyers of Bones Don’t Lie takes a look at inequity in the dead in Roman Dorset.

Curt Emanuel, the Medieval History Greek, writes about the use of medieval law codes to understand medieval injuries and weregild for brain injuries.

Tim Clarkson of Senchus writes about the St Andrews Sarcophagus.

The Chirurgeon’s Apprentice brings us a case of Seckel’s syndrome, in a child called the Sicilian fairy, and her exploitation.

Jaipreet Virdi of From the Hands of Quacks writes on 19th century aural diagnostic instruments.

Puff the Mutant Dragon writes about the destruction and death of Soviet botanist Nickolai Vavilov by Stalin’s regime.

CFP: Health and Healing in Early Medieval Medicine

Call for Papers to 47th International Congress of Medieval Studies

May 10-13, 2012
Western Michigan University at Kalamazoo

Health and Healing in Early Medieval Medicine: Influences, Theory and Practices

This interdisciplinary session will explore all aspects of the health and healing in Europe and the Mediterranean world from approximately 400 to 1100 AD. We are open to all ways of measuring health and welfare from archaeology to psychology and literature. Diseases, concepts of healing, and the responses of early medieval populations to disease are of special interest.

This session is co-sponsored by Medica: the Society for the Study of Healing in the Middle Ages and The Heroic Age: A Journal of Early Medieval Northwestern Europe.

We are seeking papers on any of the following topics:
- All aspects of early medieval health including (mal)nutrition, child mortality, aging, health beliefs, and health practices.
- All aspects of the Plague of Justinian and other infectious diseases
- Bioarchaeology of early medieval populations.
- All aspects of early medieval medical practice in art, literature, history, and archaeology.

Abstracts of no more than 300 words and the Participant Information Form should be sent to Michelle Ziegler at ZieglerM@slu.edu by September 15.

The Participant Information Form and additional information be found at http://www.wmich.edu/medieval/congress/submissions/index.html.