Category Archives: Black Death

Roundtable on Campbell’s Climate, Disease, and Society in the Late Medieval World

by Michelle Ziegler

Bruce Campbell. The Great Transition: Climate, Disease, and Society in the Late Medieval World. Cambridge University Press, 2016.

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When I first learned that Bruce Campbell was working on this book, I wondered if it would be the first grand synthesis of the new paradigm. Although there have been some very good regional books in the last couple of years, Campbell has indeed brought forward the first analysis of the Black Death and 14th-century crisis using global evidence. Although not entirely clear from the publisher’s description, this is an economic history that draws on interdisciplinary evidence.

I proposed this session and recruited participants without ever seeing the book (though I had seen his Ellen McArthur Lectures). I got very lucky that the panel matched up so well with the book. The five panelists who were able to attend were (from left to right below) Mongolian historian Christopher Atwood, Historian of Medicine Wendy Turner, Evolutionary Biologist Boris Schmid, Archaeologist Carenza Lewis, and Economic/Environmental Historian Philip Slavin.

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Great Transition Roundtable: Christopher Atwood, Wendy Turner, Boris Schmid, Carenza Lewis, and Phillip Slavin. (Photo by Nükhet Varlik, used with permission)

Everyone agreed that Campbell’s book will become the foundation upon which the new synthesis of plague history will be built. Campbell synthesized a vast amount of data with a particular appreciation for the integration of climate and disease data. Most agreed that this was a very high-level view of the crisis, an aerial view if you will, that leaves many details to be filled in. Some missed an analysis of the relationship with cascading levels of analysis down to the level of individuals. On the other hand, Atwood remarked that this is far more detailed than would be possible in Asian studies today. Perhaps not surprisingly, this interdisciplinary panel would have liked to see more evidence from other fields such as archaeology and social history used.  As Lewis noted, archaeology, in particular, could have given more support to the economic and environmental arguments without pulling away from the flow of the book.

The global evidence is primarily limited to climate data. Several panelists remarked that it is still very Eurocentric view, and Anglo-centric on top of that. There is more data that could have been gathered particularly from the Mediterranean. War as a syndemic factor and as a result of climate or disease weakened societies was not given much space in Campbell’s analysis. One effect of such a high-level regional treatment is that causes of local mortality from war (including the environmental destruction of war) can be overlooked because it doesn’t effect a large enough piece of territory. Slavin has also pointed out that Campbell’s interpretation tends to come across as somewhat deterministic, here and there. Thus, in discussing the Great European Famine of the early 14th century, Campbell provided an engaging analysis of the environmental context of the famine as its causation, without considering various intermediate links, demographic and institutional. As a result, Slavin noted that Campbell’s interpretation of the Great Famine as an exogenous disaster stands out as unilateral; famines, across space and time, are incredibly complex phenomena.

Developing a historical paradigm based heavily on scientific data is like building a house on shifting sand. Eventually, the sand will swallow the house. The best you can hope for is to be precariously perched on the ridge of a dune.  Most biological data is out of date by the time it is printed in a book. While there were a few misunderstandings, most of the discrepancies between Campbell’s portrait of the plague and other diseases is simply out of date even though he incorporates information up to about 2015. For example, ancient DNA studies have found evidence for at least one, and probably several, (still unlocated) local reservoirs of plague in or near Europe, so the idea that plague was frequently imported from the East no longer holds (but Boris disagrees on this view).

Some other hypotheses on plague transmission, though proposed several years ago, have failed to gain much traction. While evidence continues to mount that the soil plays a role in Yersinia pestis’ survival and that human ectoparasites could be the primary vector at the pandemic level, these hypotheses are not proven yet. This doesn’t mean that they won’t eventually be accepted, just that we are not yet there.

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Stages in the plague cycle (Figure 3.27, Campbell 2016)

I am reproducing figure 3.27 here because I think this will prove to be popular with teachers. With that being said there are a few comments that need to be made about it. The role of the soil in the enzootic environment of the rodent’s burrow is poorly understood at the moment. However, teachers could just explain that level 1 simply represents the environment of the rodent burrow.  Level 5 is where the real debates are going on now among those who study transmission. Campbell does leave open which ectoparasites are involved, human fleas or lice, but there is not yet general acceptance of human ectoparasites as major vectors. It may yet come, but we aren’t there yet. While local cases of pneumonic plague will occur any time there is bubonic plague, it is unlikely to be a major driver in a pandemic. The red box that I have added to the figure is where the really critical events are happening for human epidemics and pandemics. While I do believe that humans should be considered hosts in pandemic level transition, a variety of other hosts, always including rodents, will continue to be instrumental in the amplification and must be involved for the endurance of an outbreak in a locality.

While working with scientific detail is challenging for historians, after Campbell’s book I think it will be necessary to address scientific information at least to the level where there is a consensus. As long as historians stay with information that has been confirmed by a second study or that has obviously gained scientific consensus, the risks of using scientific information really are manageable. Finding a scientist who has your trust to comment on drafts is a good practice (and the reverse for scientists writing history!).

There were some concerns. There was a feeling that correlation does not necessarily equal causation. Schmid and Slavin would have liked to see more evidence of statistical analysis to support the conclusions drawn. They had a sense that the patterns that Campbell noted in a number of his overlapping time series might prove to be coincidental, rather than significant when tested with robust statistics.

Wendy Turner addressed pedological uses of the book. She found that, at least for a history of medicine course, it could not be used alone as a textbook. It does not have enough social history to address the complete impact of the Black Death. I don’t think that was its purpose, as much as some of us hoped it would be.  “The” Black Death book has yet to be written. When it is it will have to address all the social, medical, scientific, economic, and political impacts — a tall order. It is likely that aDNA studies will have more to contribute to shore up the transmission routes of such a project. Campbell’s book could be a major text (if not the only one) for an economic or environmental history course if it is supplemented by other texts. Archaeology as done by Carenza Lewis or Per Lagerås would support Campbell’s overall argument.  Turner and others agreed that it is not written for introductory students and they wondered how even upper-level students would respond to the density of the material. It should be required reading for graduate students who focus on the 14th century or any of the infectious/famine crises.

Atwood observed that historians tend to recognize a “crisis” about every couple of centuries and wondered if these mostly European events/crises over millennia were not tied to changes that had swept across all of Eurasia. In effect, Campbell’s book lays the supportive groundwork for arguing that the Eurasian land mass should be considered as a whole rather than European only or Asian only.  I think we could make an argument that the Afro-Eurasian landmass is one historic unit. The Indian Ocean is still an underappreciated communication avenue.

The most lively discussion with the audience concerned the terminology for the 14th-century events — transformation, crisis, collapse, etc. Positions seemed to be based at least partially on training, with some rejecting the term collapse under any circumstances, while others were more open to its use in areas like “population collapse”.  For me, this is an internal matter for historians to resolve. Terminology can be a fickle thing, but data is always preeminent. And that is a good place to leave this post. Campbell has done us all a service by compiling a huge amount of data that will be the foundation of a new era of analysis of the 14th century and the Black Death. For this above all else, we must be grateful.

 

Pregnancy, ‘coffin birth’, and the Black Death

by Michelle Ziegler

The Genoese have always been central in the legend of the start of the Black Death, by their own claim, linking a siege of the Genoese at Kaffa to the spread of the epidemic in the Mediterranean. Last month the first confirmed plague graves in the region of Genoa were reported by Cesana, Benedictow, and Bianucci in the cemetery of the ospitali (hospital) of San Nicolo. The hospital of San Nicolo was located at a node along the route connecting the hilly backcountry of Genoa to the main travel routes of medieval Italy.

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Fetus skeleton. Only fragments were found of the skulls and pelvises for all four individuals. (Cesana, Benedictow, & Bianucci, 2017)

The quadruple grave consisted of a woman in her 30s with full-term fetus in the birth canal (a ‘coffin birth’), and two children aged approximately 3 and 12 years, based on their growth and tooth eruption. Dated stratigraphically to the second half of the 14th century, they are a very rare multiple grave for Northern Italy. No plague pits have been discovered in this region.

They were screened for plague with the RDT dipstick (here and here) that detects the F1 antigen of Yersinia pestis (see also Bianucci et al, 2008 and Pusch et al, 2004). This test has proven quite reliable for archaeological material and is a useful tool for modern diagnosis in resource-poor areas. The RDT dipstick is a more sensitive test than aDNA so we should not expect every positive skeleton by the RDT to produce aDNA but it is a good screening tool prior to aDNA surveys and useful for epidemiological purposes. The adult female, the fetus and the oldest child all gave positive results by the RDT dipstick. I would consider these to be positive plague cases with or without aDNA confirmation. Now I do have one caveat at this point, I’m not ready to assume that the fetus is a true positive, although it is certainly possible. Since it was present in a decaying maternal body with lots of F1 antigen around, the protein could have been absorbed into the fetal bones during the decomposition process. If there is enough aDNA to be detected and readable in the fetal bones, then I would consider it a stronger case.  Regardless, the plague was at least the secondary cause of death for the fetus since it claimed the life of its mother.   Without more genetic testing, we will not know the relationship between the two older children and the woman. They could be one family, although at a hospital they could be of no relation to each other.

Without a more precise date or ancient DNA, we can not predict which plague epidemic produced this grave. Raffaella Bianucci has informed me that these graves will be part of a large aDNA project currently underway, so more information will be available eventually. Then the historical analysis of Ole Benedictow in this article will be very helpful in placing them in a more precise context.

My main interest lies with the pregnant plague victim and her fetus. A coffin birth is caused by the build up of gasses in the corpse that pushes the fetus out of the birth canal. Given that plague victims die of septicemia, possibly infecting the placenta, it’s not all that surprising (at least to me).

Given a high medieval birth rate, I am surprised that more pregnant women have not been found in plague graves. Stephen Ell (1989)  found that 8.5% of all women between ages 15 and 50 were reported as pregnant in the death records he analyzed for three days in an October 1630 epidemic in Venice.    So why haven’t fetuses or newborns been found in more plague graves?

There are a few possible reasons for fewer fetuses than expected: early pregnancies are unlikely to leave fetal bones, and in a stacked mass grave, tiny fetal bones would easily get jumbled with all the other bone bits. When fetal bones are found in these mass burials it may be difficult to determine how many fetuses they represent.  Reports from the third pandemic and later may provide a few more clues.

So let’s look at a parallel late-term pregnancy infection from 1975 (Welty et al, 1985, 641-2): a 31-year-old Navajo Arizona woman in her 9th month of pregnancy presented at a clinic with a high fever, headache and a tender right axillary node whose aspirate produced the bipolar safety pin looking bacillus suggestive of Yersinia pestis. This was later confirmed by culture and she was started on Streptomycin. On the first day of admission, the baby’s heart rate was already at 200 beats per minute suggesting fetal distress so she was induced, and she delivered a healthy baby boy.  His cord blood was negative for plague and he never developed a plague antibody titer. Two days later the mother’s two and a half-year-old child was admitted with a fever (104 F), cough, headache, and vomiting. Her axial lymph nodes were also positive for Yersinia pestis and she was started on antibiotics as well. All three were recovering well when released from the hospital nine days after the mother’s original admission.

Clearly, antibiotics and the ability to induce the birth made all the difference in this case. The placental blood barrier seems to have held just long enough for a healthy delivery. In the few other cases in the literature, antibiotic treatment appears to rescue the pregnancy, although induction of delivery is recommended if there are signs of fetal distress at 36 weeks of gestation or later. The pre-antibiotic scenario is much grimmer:

“In the preantimicrobial era, plague reguarly resulted in abortion, and the aborted tissues were occasionally infected with plague bacillus. In 1903 Jennings reported 10,000 cases of plague, 14 of which occurred during pregnancy. Four of the mothers survived, but spontaneous abortions or still births occurred in 13 of the patients, including the four survivors. One of the 14 patients was near her expected date of delivery. The child was born apparently well, but the mother died of postpartum hemorrhage. Ten hours after birth, lymphadenopathy was noted in the infant’s groins and axillae and it died one day later.” (Welty et al, 1985, 645)

In another case report from 1975, Mann and Maskowitz (1977) opined that “fetal wastage resulting from a maternal infection with plague probably results from the systemic effects of illness rather than direct placental or fetal infection, although true intrauterine infection with plague as been described.”  Fetal distress detected in the case described above and in the other case reported by Mann and Moskowitz both support a risk to the pregnancy prior to fetal infection. Infection of the fetus and/or placenta would have been a very grave development without access to antibiotics. I can not imagine how a maternal immune system could clear such an infection. At any rate, it seems likely that most infected pregnant women lost their fetus to miscarriage or stillbirth prior to their own death. This would account for a lower than expected number of pregnant women found in plague burials. Given that fetuses and infants are underrepresented in normal cemeteries, it is possible that many of these unbaptized infants in plague times were not buried with the rest of the community.

All of the modern cases would have been managed slightly differently today. The Navaho woman’s entire family would have been examined and given antibiotics immediately. It is hard to believe today they waited until the two-year-old had a 104-degree fever before being examined. Modern plague management guidelines have detailed instructions for treating pregnant women for bubonic and pneumonic plague to maximize safety and limit side effects of the drugs on the fetus (Inglesby et al, 2000). However, saving the mother’s life trumps all considerations if ideal antibiotics are not available or working sufficiently. Prior to 36 weeks of gestation when it can be induced, this is also the best chance the fetus has for survival.


References

Bianucci, R., Rahalison, L., Massa, E. R., Peluso, A., Ferroglio, E., & Signoli, M. (2008). Technical note: a rapid diagnostic test detects plague in ancient human remains: an example of the interaction between archeological and biological approaches (southeastern France, 16th-18th centuries). American Journal of Physical Anthropology, 136(3), 361–367. http://doi.org/10.1002/ajpa.20818

CESANA, D., BENEDICTOW, O. J., & Bianucci, R. (2017). The origin and early spread of the Black Death in Italy: first evidence of plague victims from 14th-century Liguria (northern Italy). Anthropological Science, 1–10. http://doi.org/10.1537/ase.161011

Ell, S. R. (1989). Three days in October of 1630: detailed examination of mortality during an early modern plague epidemic in Venice. Reviews of Infectious Diseases, 11(1), 128–141.

Inglesby, T. V., Dennis, D. T., Henderson, D. A., Bartlett, J. G., Ascher, M. S., Eitzen, E., et al. (2000). Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense (Vol. 283, pp. 2281–2290). Presented at the JAMA : the journal of the American Medical Association.

Mann, J. M., & Moskowitz, R. (1977). Plague and pregnancy. A case report. Jama, 237(17), 1854–1855.

Pusch, C. M., Rahalison, L., Blin, N., Nicholson, G. J., & Czarnetzki, A. (2004). Yersinial F1 antigen and the cause of Black Death. The Lancet Infectious Diseases, 4(8), 484–485. http://doi.org/10.1016/S1473-3099(04)01099-0

Welty, T. K., Grabman, J., Kompare, E., Wood, G., Welty, E., Van Duzen, J., et al. (1985). Nineteen cases of plague in Arizona. A spectrum including ecthyma gangrenosum due to plague and plague in pregnancy. The Western Journal of Medicine, 142(5), 641–646.

Presentations on the Plague from the European Association of Archaeologists, Vilnius, Lithuania, 2016

I just discovered that most of the presentations from the “Plague in Diachronic and Interdisciplinary Perspective” session of the Europan Association of Archaeologists meeting in Vilnius, Lithuania on 2 September 2016 are now on YouTube.  I think I have collected them all here. Enjoy 3 hours of plague talks!

Introduction-Plague in diachronic and Interdisciplinary perspective by Marcel Keller


From Mild to Murderous: How Yersinia pestis Evolved to Cause Pneumonic Plague by Wyndham Lathem (30 min)


Reconstructing ancient pathogens – discovery of Yersinia pestis in Eurasia 5,000 Years Ago by Simon Rasmussen (15 min)


Plague in the eastern Mediterranean region 1200-1000 BC? by Lars Walloe (15 min)


Placing the Plague of Justinian in the Yersinia pestis phylogenetic context by Jennifer Klunk (15 min)


A demographic history of the plague bacillus revealed through ancient Yersinia pestis genomes by Maria Spyrou (15 min)


Analysis of a High-coverage Yersinia pestis Genome from a 6th Century Justinianic Plague Victim by Michal Feldman (15 min)


Early medieval burials of plague victims: examples from Aschheim and Altenerding (Bavaria, Germany) by Doris Gutsmiedl-Schumann (15 min)


Fleas, rats and other stories – The palaeoecology of the Black Death by Eva Panagiotakopulu (15 min)


Plague in Valencia, 546: A Case Study of the Integration of Texts and Archaeology by Henry Gruber (15 min)


Germany and the Black Death: a zooarchaeological approach by M.A. Paxinos