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Plague: History and Epidemiology by MAX J Plague: History and Epidemiology By MAX J. MILLER* History JN the history of disease, no other single disease has inspired the terror of a plague epidemic. For the suddenness of its attack, the frightfulness of its manifestations, and the multitude of its deaths it has had few equals. Such a disease, if it did occur in antiquity, could not help but have been noted in the writings of the ancients, and, certain diseases mentioned in the Bible are very suggestive of plague. Thus it is written that during the military campaign of the Philistines against the Israelites, the in- habitants of Ashdod, Goth and Ekron were attacked with tumours in their secret parts, the pestilence causing a deadly destruction. In the city of Beth-shemesh over 50,000 are related to have died. The Assyrian invasion of Egypt attempted by Sennacherib was prevented by the deaths of large numbers of his soldiers due to an epidemic of disease which is thought to have been plague. The early Greeks make no direct reference to this disease although Hippocrates wrote that all diseases associated with "Buboes' are bad. The record of plague for the first four centuries of the christian era are collected in the writings of Oribasius. In his compilation of the works of ancient authors, plague is shown to have occurred especially in Syria, Libya and Egypt, regions which played an important part in the history of plague in later centuries. The epidemic in Libya is described as ac- companied by an acute fever, intense pain, perturbation of the whole body, delirium, eruption of large Buboes, hard and with suppuration. This des- cription leaves no doubt as to the identity of the disease. The tirst well authenticated pandemic had its origin in Pelusium Egypt, in the year 542 A. D. From this great world trade centre it spread out over'the greater part of the populated world. Procopius, who has left a very illuminating account of this pandemic, writes that in Byzantium, where the plague lasted four months, as many as 5,000 and later 10,000 per- sons were dying each day of the disease. Plague quickly spread to Europe, and in the latter half of the sixth century it ravaged the inhabitants of Ireland. This epidemic is thought to have been brought over from Italy with which Ireland was in constant communication. Plague struck Ireland one hundred years later and spread over into England in 664. Sporadic outbreaks of plague are recorded from the Mediterranean littoral in the 7th and 8th centuries. However, in the two hundred years preceding the 11th century the disease practically disappeared. In 1032, a, devastating epidemic of plague occurred in India which spread through Asia Minor and Europe. This epidemic continued to rage in the armies of the crusaders, several of which it wiped out almost entirely. *Institute of Parasitology, McGill University, Macdonald College [183] Canadian of July 1940 [1844I ComparativeJournalMedicine *Vol.Plague:IV-No. History and Epidemiology The second great pandemic of plague occurred in the 14th century. It was, from the standpoint of its destructiveness, the most deadly the world has ever seen. It originated in China in the year 1333 during a period of famine. Thirteen million persons are reported to have perished there. From China it spread through Central Asia, Persia and Asia Minor, reaching Constantinople in 1347, whence it was distributed to Europe and Africa. In three years it swept over all of Europe taking the lives of at least one fourth of the entire population. England was invaded in 1348. Starting from the sea-coast towns it spread inland. Le Baker de Swynebroke has left a good account of the epidemic, and states that the death toll was so great "scarcely one in ten of either sex was left alive". This is probably an exaggeration. In London the death toll reached 100,000. Nor were the more northerly countries spared. Denmark and Norway suffered severely, and in the latter country two-thirds of the population are reported to have died. This second epidemic is commonly referred to as "the great black death". During the 15th, 16th and 17th centuries, plague continued to manifest itself throughout Europe, Asia and Africa in circumscribed areas. Certain of the outbreaks appeared to be recrudescences of the disease which had become endemic, whereas others were carried over from the old endemic areas in Asia Minor. In the 18th and early 19th centuries plague prevailed mainly in Turkey, Syria and Egypt. However, it was still being carried from these countries to parts of Europe, particularly large coastal towns. Thus in 1720 it was imported into Marseilles from Tripoli, by a merchant vessel. A de- scription of the terrible conditions occurring during a plague epidemic in early times, is presented in the following short account published in 1806, of the Marseilles plague of 1720: "the houses throughout all their recesses and apartments were strewn with the dead and the dying. All the streets were covered with carcasses. The grave diggers had disap- peared. Undertakers and sextons were not to be found. About a thousand corpses were thrown daily into the streets to putrefy until at length, a passenger could hardly walk without treading on them. In the public walks, and before the church doors, they were piled up in large heaps, men, women and children. Persons of all ages and conditions were under- going corruption, as they overspread the pavements, and filled the at- mosphere with their noxious exhalations". Plague ravaged the armies of Napoleon during his disastrous Egyptian military campaign, in the last years of the 18th century. A good account of this is presented by P. Assalini who accompanied the troops. The main purpose of his publication was, however, to refute the arguments in favour of the infectious nature of plague. During the latter half of the 19th century the levantine regions were practically free of plague, and only isolated spots throughout the world reported the disease. However, the last decade of the 19th century brought forth the third great pandemic which seeded plague throughout the entire world. Canadian iJounal of History and Epidemiology July 1940 Comparative Plague: - [18515 MedicineVo.I . [1 The early history of this pandemic takes us back to 1871, when M. Rocher reported plague in Yunnan, China, while travelling there. From Yunnan it spread slowly eastward, reaching Canton in 1894 with disastrous results. From Canton it swept into Hongkong. These two centres now became foci of infection for the rest of the world. Plague reached Bombay in 1896 and spread to other parts of India. By 1904, plague was present in Australia, South Africa, western and eastern ports of South America, West Indies, Mazatlante in Mexico, San Francisco, Glasgow, Spain, and of course, China, India, Japan, Asia Minor and the Mediterranean littoral. Plague first appeared in the United States in 1900 when San Francisco suffered an epidemic which took 22 lives, and from that time until 1937 California has had at least one case of plague each year. It appeared in New Orleans in 1914 and persisted until 1921. Beaumont and Galveston, Texas, had an epidemic in 1920 with the loss of 19 lives, and Pensacola, Florida, suffered a minor epidemic the same year. In more recent years it has occurred sporadically, and only in the western states. In 1937 there were 3 cases of plague in California, one in Utah and one in Nevada. The last reported case occurred in Utah in 1939. At the present time this disease still claims a considerable number of lives in Manchuria, in Fukien Province in China, in India, in Java, in Madagascar, and in South Africa. Senegal in West Africa has a few cases each year, as has Egypt. South America, Brazil, Peru, Ecuador and Argentina report cases every year. The Belgian Congo has a small plague focus, and Tanganyika, Kenya and Uganda report plague cases not in- frequently. Burma and Siam have a few plague cases each year. Other regions report it sporadically and still others are potential plague areas. In recent years with the introduction of control measures, the extent of infections in many areas has decreased. Thus, India which had 240,000 deaths from plague between 1929 and 1933, lost only 7000 lives in 1938. Java has had a steady decrease in the number of cases; in 1938, only some- what over 2000 lives were claimed by plague as compared with more than 6000 for 1936. Brazil which had 1344 cases from 1934 to 1936, had only 35 in 1937. However, in discussing a rise or fall in its intensity, the distinc- tion between rat-transmitted plague and plague carried by wild rodents must be made. In those areas where plague is dependent on wild rodents, control becomes a very difficult task. The elimination of the wild rodent population from an entire area is practically impossible, and in such syl- vatic plague areas the number of human cases depends primarily on the intimacy between the wild rodent and the human population, and the factors which lead to plague epizootics. Epidemiology Most early writers realized the contagious nature of the disease and had numerous, if erroneous, ideas regarding its cause. One of the favourite explanations was the "pestiferous emanations from the soil contaminating the air". Hecker in 1837 writes: "This disease was a consequence of violent commotions in the earth's organism". Assalini, as mentioned pre- Canadian [186] ComparativJuMediioneofelaueiHstryanPlague: History and Epidemiology Vol. IV-No.July 19407 viously, considered the disease to be non-infectious. Kircher as early as I685, however, considered the causative agent of plague to be a living entity.
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