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4 Epidemiology of the Black Death and Successive Waves of Plague

Published online by Cambridge University Press:  16 November 2012

Samuel K Cohn Jr
Samuel K Cohn Jr
Affiliation:
Professor Samuel K Cohn Jr, Department of History, University of Glasgow9 University Gardens, Glasgow G12 8QQ, UK
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Medical History , Volume 52 , Supplement S27: Pestilential Complexities: Understanding Medieval Plague , 2008 , pp. 74 - 100
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Copyright © The Author(s) 2008. Published by Cambridge University Press

References

1 See the excellent summary of the first pandemic and its sources, Lester K Little, ‘Life and afterlife of the first plague pandemic’, in Lester K Little (ed.), Plague and the end of Antiquity: the pandemic of 541–750, Cambridge University Press, 2007, pp. 3–32; Ann Dooley, ‘The plague and its consequences in Ireland’, in ibid., pp. 215–29; and other essays in this collection. On evidence that the Justinianic plague and other waves of the “first pandemic” devastated populations in the countryside as in the cities, penetrating entire regions, see Dionysios Stathakopoulos, ‘Crime and punishment: the plague in the Byzantine empire, 541–749’, in ibid., pp. 99–118, p. 127. This and other essays in this collection fail to support Robert Sallares's assertion (‘Ecology, evolution, and epidemiology of plague’, in ibid., pp. 231–89, p. 258) that the distribution of the Justinanic plague (as well as that of the Black Death) was “patchy”, and thus resembled Yersinia pestis simply because some towns and regions were spared during particular plague waves. At least for the Black Death, such an assertion flies in the face of this disease's speed and distribution, as shown by George Christakos, Ricardo A Olea, Marc L Serre, Hwa-Lung Yu, and Lin-Lin Wang, Interdisciplinary public health reasoning and epidemic modelling: the case of Black Death, Berlin, Springer, 2005. See discussion below. Doctors by the sixteenth century (even after the plague had become much less expansive than in 1348–52 and in other plagues of the fourteenth century), distinguished peste from other diseases by the extensiveness of its spread; see for instance, Discorso de Faustino Bucelleni, nel quale chiaramente si mostra da che si causano le infirmità, così delli corpi, come delle anime. Come gli orribili effetti della peste conuengono con quelli delli peccati mortali; et il securissimo porto da saluarsi da tali flagelli, Venice, n.p., 1576 (Biblioteca Apostolica Vaticana [hereafter BAV] pagination), 422v.

2 On speculations that this epidemic continued beyond ad 750, see Michael G Morony, ‘For whom does the writer write?: the first bubonic plague pandemic according to Syriac sources’, in Little (ed.), op. cit., note 1 above, pp. 59–86, p. 67.

3 Vitangelo Morea, Storia della peste di Noja, Naples, A Trani, 1817.

4 For a recent example of this common mistaken assertion, see Mark Harrison, Disease and the modern world: 1500 to the present day, Cambridge, Polity, 2004, p. 44.

5 August Hirsch, Handbook of geographical and historical pathology, trans. Charles Creighton, 3 vols, London, The New Sydenham Society, 1883–6, vol. 1, p. 500, and see numerous articles in the Lancet from 1828 to 1879 describing plagues in Alexandria and other parts of Egypt, Turkey, Jerusalem, Smyrna, Persia, and the Lower Volga in Russia. I thank Professor Lars Walløe for collecting these articles and making them available to me. Some of these plagues may have been Yersinia pestis of the rat–rat-flea variety, others appear to have been more of the contagious and inter-human Black Death sort. Studies of plague in the nineteenth century before Yersin are needed. For now, see Daniel Panzac, La peste dans l'empire ottoman 1700–1800, Leuven, Peeters, 1985, where, despite his conclusions, his descriptions provide testimony of epidemics that spread rapidly throughout vast regions, killing up to 44 per cent of populations, without any evidence of prior or simultaneous epizootics of rodents.

6 See the articles in Little (ed.), op. cit., note 1 above; Procopius, History of the wars, Books I–II, trans. H B Dewing, Loeb edition, Cambridge, MA, Harvard University Press, 1914; Jean-Noël Biraben and J Le Goff, ‘La peste dans le haut moyen age’, Annales, 1969, 24: 1492; John Maddicott, ‘Plague in seventh-century England’, Past and Present, 1997, 156: 7–54, esp. p. 9. For Gregory the symptoms gave the plague its name: it was lues inguinaria, “the groin plague”, Gregory of Tours, The history of the Franks, trans. O M Dalton, 2 vols, Oxford, Clarendon, 1927, vol. 1, pp. 421–2; vol. 2, pp. 119, 141. Procopius, ibid., pp. 11, 22, 19–28.

7 Maddicott, op. cit., note 6 above, p. 28.

8 Cited in ‘Reports on plague investigations in India issued by the Advisory Committee appointed by the Secretary of State for India, the Royal Society, and the Lister Institute’, J. Hygiene, 1907, 7: 696.

9 For existence of rats in Anglo-Saxon England, see Michael McCormick, ‘Rats, communications, and plague: toward an ecological history’, J. Interdiscip. Hist., 2003, 34: 1–25.

10 For such observations during nineteenth-century plagues in China before 1894, see for instance, Wu Lien-Teh, ‘Historical aspects’, in Wu Lien-Teh, J W H Chun, R Pollitzer, and C Y Wu, Plague: a manual for medical and public health workers, [Shanghai], Weishengshu National Quarantine Service, Shanghai Station, 1936, pp. 13–18.

11 The existence of rat remains in various places for sixth century as well as later medieval Europe is not evidence of an epizootic of rats or other rodents accompanying plague outbreaks. Sallares, op. cit., note 1 above, p. 270, tries to explain away the problem of contemporaries’ failure to report rats by comparing this supposed oversight with a failure before the laboratory revolution in connecting mosquitoes with malaria, and lice with typhus. The comparison, however, is forced: a failure to see and understand insects as the vectors of a disease is hardly the same as observing what would have been the sudden death of thousands, even millions, of rats falling from rafters, littering buildings, streets and lanes, not only in 1348, but in numerous other plagues until the nineteenth century. In India and Africa, native villagers could see them and took them as the sign to leave their villages during the plague season: why would Europeans alone have been so blind or ignorant?

12 See Peter Sarris, ‘The Justinianic plague: origins and effects’, Continuity and Change, 2002, 17: 169–82; idem, ‘Bubonic plague in Byzantium: the evidence of non-literary sources’, in Little (ed.), op. cit., note 1 above, pp. 119–32; Hugh N Kennedy, ‘Justinianic plague in Syria and the archaeological evidence’, in Little (ed.) op. cit., note 1 above, pp. 87–95; and Lawrence I Conrad, ‘Epidemic disease in central Syria in the late sixth century: some new insights from the verse of Hassān ibn Thābit’, Byzantine and Modern Greek Studies, 1994, 18: 50–8.

13 Little, ‘Life and afterlife of the first plague pandemic’, op. cit., note 1 above, pp. 9, 11; Morony, op. cit., note 2 above, pp. 79–80; Sallares, op. cit., note 1 above, pp. 243, 276; and Conrad, op. cit., note 12 above, p. 28.

14 Stathakopoulos, op. cit., note 1 above, p. 116. For other examples, see Morony, op. cit., note 2 above, p. 70, for the plague waves of 743 and 744, and p. 84, for the plagues of 744–745 in Mesopotamia, Bostra and the Hawran.

15 Despite these positive identifications (see Little (ed.), op. cit., note 1 above, pp. 2–3, 44, 65, 99, 120, 236, and 238), only the essay by Sallares (op. cit., note 1 above, pp. 231–89) even considers epidemiology; and only that by Michael McCormick expresses any possibility that the case for Yersinia pestis as the agent of the first two pandemics may still be open to further historical and microbiological research (‘Toward a molecular history of the Justinianic pandemic’, in Little (ed.), ibid., pp. 290–312). For another recent but more balanced view that does not presume that discussion has ended, see Peregrine Horden, ‘Mediterranean plague in the age of Justinian’, in Michael Maas (ed.), The Cambridge companion to the age of Justinian, Cambridge University Press, 2005, pp. 134–60, and esp. pp. 143–53.

16 Arturo Castiglioni, ‘Ugo Benzi da Siena ed il “Trattato utilissimo circa la conservazione della sanitate”’, Rivista di Storia Critica delle Scienze Mediche e Naturali, 1921, 12: 75.

17 See Carlo Cipolla, ‘I Libri dei morti’, Le Fonti della Demografia storico in Italia, 1972, 2: 851–66.

18 References to such supposed pre-plague events abound in plague tracts; see for instance, Marsilio Ficino, Consiglio contro la pestilenza, ed. Enrico Musacchio, Bologna, Capelli, 1983, p. 57; Michele Savonarola, I trattati in volgare della peste e dell'acqua ardente, ed. Luigi Belloni, Milan, n.p., 1963, p. 8; ‘Ein italienischer Traktat “De pistelencia”’, in Archiv für Geschichte der Medizin, 1913, 6: 353–55, p. 353; ‘Der Pesttraktat des Pietro di Tussignano (1398)’, in ibid., 1912, 5: 390–95, pp. 394; ‘Der Pesttraktat Meisters Peter von Kottbus’, in ibid., 1919, 11: 121–32, p. 125; ‘Collectorium minus’ (Prague Medical Faculty, around 1406), in ibid., 1916, 9: 120, 128; ‘Aliqua breuia dubia circa materiam de Epidemia in Montepessulano conscripta’ (by a follower of Bernard Gordon, beginning of the fifteenth century), in ibid., 1925, 17: 40–3, p. 40; Il Libro della Pestilenza di Giovanni de Albertis, ed. Arturo Castiglioni, Bologna, in Archeografo Triestino, 1924, ser. 3, 39: 163–229, p. 200; Alessandro Simili, ‘Saladino Ferro da Ascoli’, in Atti e Memorie dell'Accademia di Storia dell'arte Sanitaria, 1963, 29: 26–46, p. 40; and Arturo Castiglioni, ‘I libri italiani della pestilenza’, in idem, Il Volto di Ippocrate: Istorie di Medici e Medicine d'altri tempi, Milano, Società editrice Unitas, 1925, pp. 145–69, p. 165.

19 See, for instance, Giovanni Filippo Ingrassia, Informatione del pestifero, et contagioso morbo, il quale affligge et have afflitto questa città di Palermo & molte altre città e Terre di questo Regno di Sicilia, nell'anno 1575 et 1576, Palermo, Giovan Mattheo Marda, 1576, pp. 67, 228.

20 Christakos, et al., op. cit., note 1 above, pp. 223, 230.

21 Ibid., pp. 205–7, 230.

22 See, for instance, the chronicle of the Franciscan Michele da Piazza or of the Sienese merchant, Agnolo di Tura, Il Grasso, who claimed that victims “died almost at once: with the swelling under the arms and in the groin, they fell dead while talking [favellando]”, Cronaca senese attribuita ad Agnolo di Tura, in Cronache Senesi, ed. A Lisini and F Iacometti Rerum Italicarum Scriptores (hereafter R.I.S.), vol. 15, part 6.1, Bologna, N Zanichelli, 1931–37, p. 555. For the assertions of Susan Scott and Christopher Duncan, see their Return of the Black Death: the world's greatest serial killer, Chichester, Wiley, 2004, p. 155.

23 Christakos, et al., op. cit., note 1 above, p. 231. The authors admit that the descriptions of chroniclers do not match the long incubation period of 32 days and a 37-day infectious period argued by Susan Scott and Christopher Duncan, Biology of plagues: evidence from historical populations, Cambridge University Press, 2001, pp. 24, 128–9; and Return of the Black Death, op. cit., note 22 above, pp. 155–61. Scott and Duncan's conclusions are based on an unexplained sample of nine households in their first book and three (taken from the previous nine) in the second. These have been selected from 242 plague-stricken households reconstructed at Penrith, Cumbria, with a similarly small sample taken from parish burial records during the plague at Eyam. Their results and assumptions about the transmission of infectious diseases are challenged in Samuel K Cohn Jr and Guido Alfani, ‘Households and plague in early modern Italy’, J. Interdiscip. Hist., 2007, 38: 177–205, esp. pp. 181–7. For the Milanese plagues 1452 to 1523 and at Nonantola (Modena) during the plague of 1630, using over a thousand reconstructed households, as much as a quarter of plague deaths within households occurred within twenty-four hours of one another. This interval (zero days) was the mode of plague deaths within households.

24 Richard Mead, A discourse on the plague, 9th ed., London, 1744, pp. 48.

25 Samuel K Cohn Jr, ‘Notions of disease and the Black Death’, paper given at Cambridge to the History of Medicine Seminar, 20 January 2004, organized by Andrew Cunningham. For the use and development of the notion of contagion in the medical literature, see Vivian Nutton, ‘Seeds of disease’, Med. Hist., 1983, 27: 1–34; and idem, ‘The reception of Fracastoro's theory of contagion: the seed that fell among the thorns’, Osiris, 2nd series, 1990, 6: 196–234. By the sixteenth century doctors described a number of diseases as contagious, such as petecchie, but distinguished plague as far more contagious with the added capacity of spreading by distance and not just by contact with infectious persons or infected objects; see, for instance, Giuliano da Marostica, Copia d’ vna lettera dello eccellente … Giuliano da Marostica treuisano in materia di medicar la peste, & le petecchie, & di preseruar dall’ uno, & l’ altro male, Venice, n.p., 1556, 309v; and Girolamo Fracastoro, Il contagio: le malattie contagiose e la loro cura, trans. Vincenzo Busacchi, Florence, Leo S Olschki, 1950, p. 13. These definitions and descriptions will be further developed in a book on plague literature in the sixteenth-century that I am now writing: Evolutions of plague: disease and thought in sixteenth-century Italy.

26 Early on the term was used by scholars for diseases such as leprosy. For the split between scholarly and medical usage of the term, on the one hand, and popular or “superstitious” usage, on the other, in early medieval Muslim culture, see Lawrence I Conrad, ‘A ninth-century Muslim scholar's discussion of contagion’, in Lawrence I Conrad and Dominik Wujastyk (eds), Contagion: perspectives from pre-modern societies, Aldershot, Ashgate, 2000, pp. 163–77.

27 The Brut or The chronicles of England, ed. Friedrich W D Brie, Early English Text Society, no. 136, London, Kegan Paul, Trench, Trübner for the Early English Text Society, 1906 p. 316.

28 Cronica volgare di anonimo fiorentino dall'anno 1385 al 1409 già attribuita a Piero di Giovanni Minerbetti, ed. Elina Bellondi, R.I.S., vol. 27, part 2, Città di Castello, S Lapi, 1915–18, p. 110.

29 Giovanni di Pagolo Morelli, Ricordi, in Mercanti scrittori: ricordi nella Firenze tra medioevo e rinascimento, ed. Vittore Branca, Milan, Rusconi, 1986, p. 207.

30 See, for instance, Paolo Bisciola, Relatione verissima del progresso della peste di Milano, Ancona, Carlo Melisardi, ad instanza di Sebastiano Balestra, 1577, 2r, 3v.

31 See, for instance, Practica Antonii Guainerii papiensis doctoris clarissimi et omnia opera de peste, Venice, J P de Leucho, 1508, 95v; Decem problemata de peste per Victorem de Bonagentibus medicum, Venice, Vicentij Valgrisij, 1565, p. 3; Michele Mercati, Instruttione sopra la peste: nella quale si contengono i piu eletti & approvati rimedij, con molti nuovi e potenti secreti, Rome, Vincento Accolto, 1576, p. 2; De pestilentia Hieronymi Mercurialis Foroliviensis medici praeclarissimi lectiones habitae Patavii, Venice, Paulum Meietum, 1577, pp. 10–11; Andrea Gabrielli, De peste, opus perutile, ac praesidio locupletissimorum, Bologna, Peregrinum Bonardum, 1577[?], 3r, and see note 22.

32 Mead, op. cit., note 24 above, p. xviii.

33 Ibid., pp. 10–11.

34 Ibid., pp. xxxiii, xxxviii, 58, 66–7, 80–99. As with doctors in the late fourteenth and fifteenth centuries, a notion of contagion brought on by direct contact with goods or other persons was not seen as contradicting theories of miasma: “A corrupted State of Air is, without doubt, necessary to give these contagious Atoms their full force,” ibid., p. 66.

35 Ibid. p. 11.

36 For this observation, see Samuel K Cohn Jr, The Black Death transformed: disease and culture in early Renaissance Europe, London, Arnold; and New York, Oxford University Press, 2002, pp. 122–3. In 1897, Brigadier-General W F Gatacre even quantified it in his plague report from the hospitals of the Presidency of Bombay, Report on the bubonic plague in Bombay, 1896–97, Bombay, Times of India, 1897, p. 94: “Of about 400 people … who either visited their sick friends or remained constantly by their bedsides … in not a single instance did any of these persons contract the plague.”

37 On the difficulties of flea blockage and transmission even with ideal conditions of temperature and high humidity, see Albert L Burroughs, ‘Sylvatic plague studies: the vector efficiency of nine species of fleas compared with Xenopsylla cheopis’, J. Hygiene, 1947, 45: 371–96.

38 For the continuation of plague through the winter months in England, 1348–9, see numerous chronicle descriptions and the last wills and testaments from the Court of Husting: of the five highest monthly counts of deathbed wills, three were during the cold months of January to March 1349; see Cohn, op. cit., note 36 above, p. 184. For the Black Death in Bergen, Norway, in January, see Ole Jørgen Benedictow, Plague in late medieval Nordic countries: epidemiological studies, Oslo, Middelalderforlaget, 1992, p. 44. For plague in Trondheim, Norway, that peaked in February 1566 and many other examples of winter outbreaks in Scandinavia, see Lars Walløe, Plague and population: Norway 1350–1750, Avhandlinger (Norske videnskaps-akademi), new series, No. 17, Oslo, University of Oslo, Department of Physiology, 1995, pp. 25 passim.

39 For these seasonal charts of plague, see Cohn, op. cit., note 36 above, pp. 156–73, 182–5.

40 J C Gauthier and A Raybaud, ‘Des variétés de pulicidés trouvés sur les rats à Marseille’, Comptes Rendus hebdomadaires des Séances et Mémoires de la Société de Biologie, 1909, 67: 196–9.

41 Robert Pollitzer, Plague, Geneva, World Health Organization, 1954, p. 30.

42 Gauthier and Raybaud, op. cit., note 40 above, p. 198. From a count at Marseilles between 1906 and 1909, with 10,000 collected fleas on rats, June ranked as the month at the absolute low-point of flea numbers.

43 In northern Italian cities such as Milan and Venice from the late fifteenth to the seventeenth century, the variability in plague season seems to have changed from its Mediterranean pattern during the plague's first hundred years. The Milanese plagues of 1485 and 1503 peaked in October, in 1468 it peaked in May, and in 1523 in July and August (ASM, Fondo popolazione, parte antica, nn. 73, 77, 80, and 87). Great variability, unknown with any two strikes of Yersinia pestis within the same locale, is seen with Venice's last two and perhaps most devastating plagues in 1575–77 and 1630–31. The first peaked in July 1576; the second in November 1630; see Paolo Preto, ‘Peste e demografia: L'età moderna: le due pesti del 1575–77 e 1630–1’, in Venezia e la peste 1348/1797, Comune di Venezia, Venice, Marsilio, 1979, pp. 97–102.

44 Over the past fifty years estimates of the pre-plague population of Florence vary between Giovanni Villani's figure of 90,000 and 133,000. Based on baptismal evidence, food consumption and the scrupulous estimates of the early fifteenth-century diary of Giovanni Morelli, op. cit., note 29 above, p. 209, historians have moved towards the upper figure of 120,000. See David Herlihy and Christiane Klapisch-Zuber, Les Toscans et leurs familles: une étude du “catasto” florentin de 1427, Paris, Fondation Nationale de Sciences Politiques, 1978, pp. 173–7; and William R Day, Jr, ‘The population of Florence before the Black Death: survey and synthesis’, J. Mediev. Hist., 2002, 28: 93–129. According to a tax survey of 1351, the population of Florence was 40,000. Niccolò Rodolico, La Democrazia fiorentina nel suo tramonto (1378–1382), Bologna, Zanichelli, 1905, pp. 38–45, argued, however, that peasants flocking from the countryside during the immediate aftermath of the plague swelled the population of Florence well above its level in the autumn of 1348. He estimated that the plague had cut the Florentine urban population to 25,000 or lower. This figure, moreover, corresponds roughly with the observations of Morelli, who estimated that 80,000 Florentines died in 1348 (p. 209).

45 J Z Titow, English rural society 1200–1350, London, Allen and Unwin, 1969, pp. 69–71; and Francis M Page, The estates of Crowland abbey, Cambridge University Press, 1934, pp. 120–5.

46 Richard Lomas, ‘The Black Death in County Durham’, J. Mediev. Hist., 1989, 15: 127–40, pp. 129–30.

47 Henri Dubois, ‘La dépression: XVIeet XVesiècles’, in Jacques Dupâquier, et al., Histoire de la population française, 4 vols, Paris, Presses Universitaires de France, 1988, vol. 1, p. 321.

48 Cronica B in Corpus Chronicorum Bononiensium, ed. Albano Sorbelli, R.I.S., vol. 18, part 1, Città di Castello, S Lapi, 1906–39, vol. 2, p. 584; Storie pistoresi (MCCC–MCCCXLVIII), ed. Silvio Adrasto Barbi, RIS, vol. 11, part 5, Città di Castello, S Lapi, 1914, p. 235; Historia Miscella Bononiensis ab anno MCIV usque MCCXCIV auctore præsertim Fratre Bartolomæo Della Pugliola Ordinis Minorum. Continatio usque MCCCCLXXI, ed. L A Muratori, R.I.S., vol. 18, Milan, ex typografia Societatis Palatinae, 1732, col. 409; Polyhistoria Fratris Bartholomaei Ferrariensi Ord. Praed. MCCLXXXVIII usque ad annum MCCCLXVII, ed. L A Muratori, R.I.S., vol. 24, Milan, ex typografia Societatis Palatinae, 1723, col. 806.

49 On Genoa and Naples, see Carlo Cipolla, I pidocchi e il Granduca: crisi economica e problemi sanitari nella Firenze del ‘600, Bologna, Il Mulino, 1979, p. 79. Further, the plague of 1630 in Venice killed as many as 80,000. The previous serious plague occurred two generations earlier; S R Ell, ‘Immunity as a factor in the epidemiology of medieval plague’, Rev. Infect. Dis., 1984, 6: 866–79, p. 872.

50 E H Hankin, ‘On the epidemiology of plague', J. Hygiene, 1904, 5: 48–83, p. 58.

51 M Greenwood, ‘Statistical investigation of plague in the Punjab. Third report’, in J. Hygiene: Plague Supplement I, 1911, pp. 62–156; and idem, Epidemics and crowd-diseases, London, Williams and Norgate, 1935.

52 Ole J Benedictow, The Black Death, 1346–1353: the complete history, Woodbridge, Boydell Press, 2004, pp. 284–6, 296, 307, and my review of it in N. Engl. J. Med., 2005, 352: 1054–5.

53 Christakos, et al., op. cit., note 1 above, p. 148.

54 On mortality estimates during the Black Death for Florence, Siena, Pisa, Prato, Pistoia, San Gimignano and other places in Tuscan, see Herlihy and Klapisch-Zuber, note 44 above, pp. 166–7, 177–81.

55 For sixteenth-century England, see Paul Slack, The impact of plague in Tudor and Stuart England, 2nd ed., Oxford, Clarendon, 1990, pp. 99, 110, 152, 159; for France, Jean-Noël Biraben, Les hommes et la peste en France et dans les pays européens et méditerranéens, 2 vols, Paris, Mouton, 1975, vol. 1, pp. 287, 299–302, 307. For notions of contemporary doctors that overcrowding and bad housing were causes of plague in sixteenth-century Italy, see, for instance, Andrea Gratiolo di Salò, Discorso di peste, nel quale si contengono utilissime speculationi intorno alla natura, cagioni, e curatione della peste, con un catalogo di tutte le pesti più notabili de’ tempi passati, Venice, n.p., 1576, pp. 16–18; and Tommaso Somenzi, De morbis, qui per finitimos populos adhuc grassantur, Cremona, Christophorum Draconium, 1576, 31v–32r.

56 Pollitzer, op. cit., note 41 above, p. 133, concluded: “No convincing evidence is available to show that a natural immunity to insect-borne plague exists in man.” And for pneumonic plague: “there can be little doubt that instances of natural resistance to pneumonic plague infection exist; [but] these are of such rare occurrence as to be of no practical importance” (p. 511). Also, see Pollitzer, ‘Immunology’, in Wu Lien-Teh, et al., op. cit., note 10 above, pp. 92–138, esp. p. 114. More recent textbooks have followed Pollitzer's conclusions; for instance, the most used of the manuals for tropical diseases, Manson's tropical diseases, ed. P E C Manson-Bahr, D R Bell, 19th ed., London, Baillière Tindall, 1987, p. 591. “There is no known natural immunity to plague. Acquired immunity is short-lived and there is no protection against second attacks. This is borne out by the short-lived protection provided by vaccination.” Also, see Darwin Palmer, ‘Plague’, in Sherwood L Gorbach, John G Bartlett, Neil R Blacklow (eds), Infectious diseases, 2nd ed., Philadelphia, Saunders,1998, pp. 1568–75, p. 1571. Because of contained V and W antigens, however, the Yersinia pestis organisms are able to grow and resist intracellular killing, with eventual destruction and lysis of the cell. See also Michel Signoli, Elisabeth Carniel, and Olivier Dutour, ‘La peste: aspects épidémiologiques actuels et passés’, in Bruno Bizot, Dominique Castex, Patrick Reynaud, and Michel Signoli (eds), La saison d'une peste: avril–septembre 1590, le cimetière des Fédons à Lambesc (Bouches-du-Rhône), Paris, CNRS, 2005, pp. 69–80, p. 72.

57 For these plague trends, see Cohn, op. cit., note 36 above, pp. 190–1.

58 See the tables in Pollitzer, op. cit., note 41 above, pp. 22–27, 56–9.

59 For the age cluster, 21 to 40, see ibid., pp. 504, 516–17. Some have observed the mode as young as between 10 and 20, but this incidence has been attributed to peculiarities of work and living habits that have exposed this group more fully to plague. No one has yet indicated or argued that Yersinia pestis has become a childhood disease anywhere, and no one has charted a significant change in the age structure of victims over time. In the US 60 per cent of cases have been among men and young males because of their outdoor activities and the skinning of diseased carriers such as ground squirrels (see Palmer, op. cit., note 56 above, p. 1570). By contrast, the 1967 plague in Nepal struck principally women and children, because they were the ones to stay in their homes, which F Marc Laforce, et al., ‘Clinical and epidemiological observations on an outbreak of plague in Nepal’, Bulletin of WHO, 1971, 45: 693–706, speculate were riddled with human fleas. For the plagues in Manchuria, J W H Chun, ‘Clinical features’, in Wu Lien-Teh, et al., note 10 above, pp. 309–33, p. 320, found “few cases of plague among children and women”.

60 Scott and Duncan, op. cit., note 23 above, p. 45.

61 For the mortality trends in the fourteenth and fifteenth centuries, see Cohn, op. cit., note 36 above, pp. 192–203, and for the twentieth century, Pollitzer, op. cit., note 41 above, pp. 16–66.

62 Cited in Hans Zinsser, Rats, lice and history, New York, Little Brown for the Atlantic Monthly Press, 1935, p. 89.

63 The samples of testaments used in Cohn, The Black Death transformed (op. cit., note 36 above), varied in their precision and usefulness. Perhaps the most problematic of these were the Court of Husting wills of London. In his review of this book (Bull. Hist. Med., 2004, 78: 212–14), Michael McVaugh charged that the larger collection of wills of the Commissary Court of London shows a very different picture of the decline in mortality in London, with successive plagues of the late fourteenth century attaining numbers of testaments and thus levels of mortalities almost as high as those seen in 1348. McVaugh, however, misleadingly attributes this analysis to Paul Slack and makes no attempt to examine the documents himself. First, these wills do not survive from 1348 but begin only with the third plague in 1374, when, as seen for other cities, the big declines in mortality had already occurred. Furthermore, McVaugh gives no idea of the proportions of plague wills in 1375, 1382, or 1390 in comparison with non-plague years from this source. Mark Fitch's Index to testamentary records to the Commissary Court of London, vol. 1, 1374–1488, London, 1969, indicates that 1390 is the year when the number of wills mounts to their highest point during the late fourteenth century. This point, however, is hardly the sharp spike in mortality that McVaugh claims and that would approach the 1348 levels of mortality. Instead, it shows an increase of only 24 deaths (of 123 total deaths) over the average mortality of 99 calculated from previous non-plague years. By contrast, counts from wills, necrologies, and burial records for 1348 show the death rolls soaring above previous averages by as much as thirty times. By the commissary court wills, plague mortalities relative to average years appear in fact to have fallen even more steeply by 1374 than the trend charted by the Court of Husting wills.

64 See the charts in Cohn, op. cit., note 36 above, pp. 192–202.

65 Cronaca di Pisa di Ranieri Sardo, ed. Ottavio Banti, Fonti per la Storia d'Italia, no. 99, Rome, Istituto Storico Italiano, 1963, p. 186.

66 Afterwards, in the lesser plagues of 1390 and 1400, the proportion fell to 67 of 151 and 62 of 182, lower than in 1383 but still higher than in the supposed children's plague of 1363; I necrologi di San Domenico in Camporegio (epoca cateriniana), ed. M-H Laurent, Fontes vitae S. Catherinae senensis historici, 20, Siena, Università di Siena, 1937. The reversal in the proportion of children recorded in plagues after 1383 may have resulted from the record keepers’ more precise terminology with terms such as puer parvulus and parvulus et innocens sometimes replacing the vaguer entries of filius or filia without first names. By the late fifteenth and sixteenth centuries with less severe plague and with less frequent strikes, the age of victims drifted upwards. However, as the parish records of seventeenth-century Nonantola and the early modern Milanese necrologies show, the elderly were rarely the victims (see Guido Alfani and Samuel K Cohn Jr, ‘Nonantola 1630. Anatomia di una pestilenza e meccanismi del contagio [con riflessioni a partire dalle epidemie milanesi della prima Età Moderna]’, Population, forthcoming). Moreover, contemporaries of the sixteenth century were cognizant of the relative immunity of the elderly to plague and tried to explain this in Galenic terms (Ragionamento dello eccellentiss. M. Nicolo Massa sopra le infermità, che vengono dall'aere pestilentiale del presente Anno 1555, Venice, per Giovan Griffio, ad instantia di Giordan Ziletti, 1556, 12r; Giovanni Battista Cavagnino, Compilatione delli veri et fideli rimedii da preservarsi et curarsi dalla peste, con la cura delli antraci, carboni & giandusse, Brescia, Vincenzo Sabbio, 1576, p. 8; and Discorso di M. Baldassarre Pisanelli bolognese medico di S. Spirito sopra la peste, Rome, heredi d'Antonio Blado, 1577, pp. 25 and 26; Vincenzo Tranquilli, Pestilenze che sono state in Italia da anni MMCCCXI, Perugia, Baldo Salviani, 1576, p. 11. According to plague tracts, health boards solicited the assistance of the elderly because of their immunity to this disease to attend to the plague-stricken in locked houses and the lazaretti (Ragionamento … Nicolo Massa, 16v; David de Pomis, Brevi Discorsi et efficacissimi ricordi; per liberare ogni città oppressa dal Mal contagioso, Venice, Gratioso Perchacino, 1577, 298r [BAV pagination], and Tranquilli, Pestilenze, p. 20).

67 See the mortality charts for Yersinia pestis in India, Thailand, Brazil and other places during the twentieth century; Pollitzer, op. cit., note 41 above, pp. 16–27.

68 Dubois, op. cit., note 47 above, p. 327. Also see Elizabeth Carpentier, ‘Famines et épidémies dans l'histoire du XIVe siècle’, Annales: E.S.C., 1962, 17: 1062–92, 1076, 1081; and W P Blockmans, ‘The social and economic effects of plague in the Low Countries 1349–1500’, Revue belge de philologie et d'histoire, 1980, 58: 833–63, p. 863, who found the same correlation for the fifteenth century.

69 Among other places, see L Fabian Hirst, The conquest of plague: a study of the evolution of epidemiology, Oxford, Clarendon, 1953, p. 281. For the worsening of economic conditions, drought and famine at Dakar in the early 1940s and “the relatively low endemicity”, see Myron Echenberg, Black death, white medicine: bubonic plague and the politics of public health in colonial Senegal, 1914–1945, Portsmouth, NH, Heinemann, 2002, p. 218.

70 On this data, see Cohn, op. cit., note 36 above, pp. 204–6.

71 In fact, from a meeting at Oslo in October 2005 of scientists working on plague in the twenty-first century, I sense that they now accept that the epidemiology of the Black Death and the bubonic plague of the “third pandemic” are vastly different; ‘Plague: bacteriology, evolution, ecology, epidemiology and its impact on human history’, 9–12 November 2005, CEES/DNVA, Oslo, Norway. As early as 1913, C J Martin, ‘Insect porters of bacterial infections: lecture II: The transmission of plague by fleas’, Br. med. J. [11 January 1913], i: 59–68, and, more recently, Professor Lars Walløe have described the epidemiological differences between medieval and early modern plague on the one hand, and the third pandemic on the other. Scientists have nevertheless continued to argue that the two waves of plague were the same disease; see Walløe's Plague and population, op. cit., note 38 above, an English translation of Pest og foletall 1350–1750 (1982).

72 Only a few such as Lars Walløe have studied thoroughly and systematically the late medieval and early modern clinical evidence from contemporary chroniclers.

73 Macfarlane Burnet, Natural history of infectious disease, 3rd ed., Cambridge University Press, 1962, pp. 5–6, 296.

74 Ibid., p. 323. The fourth edition of 1972, updated by David O White, left this remark intact, p. 225. Lloyd Moote and Dorothy C Moote, The Great Plague: the story of London's most deadly year, Baltimore and London, Johns Hopkins University Press, 2004, pp. 279–80, have claimed that “across centuries” the same symptoms have appeared on plague victims.

75 See Manson's tropical diseases, ed. P H Manson-Bahr, 7th ed., London, 1921, p. 270; Manson's tropical diseases, 19th ed. (op. cit., note 56 above), pp. 359, 594–5; Michael Smith and Nguyen Duy Thanh, ‘Plague’, in Manson's tropical diseases, ed. G C Cook, 20th ed., London, W B Saunders, 1996, p. 920. Also, Ell, op. cit., note 49 above, p. 871; and Thomas Butler, Plague and other yersinia infections: current topics in infectious diseases, New York, Plenum Medical, 1983, p. 75. For descriptions of ulcers and apostemes that were not pestilential, see, among other doctors, Guy de Chauliac (Guigonis de Caulhiaco), Inventarium sive chirurgia magna, 2 vols, ed. Michael R McVaugh, Leiden, E J Brill, 1997, vol. 1, pp. 117–22. Also, the doctors at Milan in the late fifteenth and early sixteenth centuries occasionally observed swellings in lymph nodes on corpses that they did not diagnose as plague because other “pestilential accidents” were absent and because the victims were ill with the disease for long periods, and did not succumb in less than a week as did the vast majority of plague sufferers.

76 For the difficulties in distinguishing plague from other diseases, see Chun, op. cit., note 59 above, pp. 327–31.

77 ‘De obitu ducis Johannis et pestis epidemie’, in Archiv für Geschichte der Medizin, 1922, 14: 138–40, pp. 138–9.

78 Chronicon Galfridi le Baker de Swynebroke, ed. Edward Maunde Thompson, Oxford, Clarendon Press, 1889, p. 100; Morelli, op. cit., note 29 above, p. 207; Galar y beirdd: marwnadau plant/ Poets’ grief: medieval Welsh elegies for Children, ed. and tr. Dafydd Johnston, Cardiff, Tafol, 1993, pp. 53–5. For other chroniclers and doctors who saw the pustules as worse than the buboes, see Cohn, op. cit., note 36 above, pp. 60–2.

79 Such descriptions are omnipresent in the sixteenth-century plague tracts; for an eighteenth-century example, see Mead, op. cit., note 24 above, pp. 5, 153.

80 Manson's tropical diseases, ed. P H Manson-Bahr, 10th ed., London, 1935, p. 254, and 19th ed., op. cit., note 56 above, p. 593. Also, Robert B Craven, ‘Plague’, in Infectious diseases: a treatise of infectious processes, ed. P D Hoeprich, M C Jordan, and A R Ronald, 5th ed., Philadelphia, Lippincott, 1994, pp. 1302–11, esp. p. 1307, maintains that viscular and pustular skin lesions occur rarely but cites no cases of them.

81 Gatacre, op. cit., note 36 above.

82 Ibid., p. 58.

83 [A K Chalmers], Glasgow Medical Officer of Health, Report on certain cases of plague occurring in Glasgow, in 1900, Glasgow, Corporation of Glasgow, 1901.

84 For the upper figure, see Alexandre Yersin's observations from the 1894 plague in Hong Kong, ‘La peste bubonique à Hong Kong’, Annales de l'Institut Pasteur, 1894, 8: 662–67, p. 663; for the lower figure, see Palmer, op. cit., note 56 above, p. 1572: “buboes are most commonly found in the groin (60%) but can be seen in the axilla (30%) or cervical area (10%)” and “buboes at more than one anatomic site are unusual”.

85 See analysis of these sources in Cohn, op. cit., note 36 above, pp. 78–80, 253–4.

86 I am currently working with the death records from Milan (Fondo Popolazione, parte antica) from its earliest ones in 1452 to its last systematic accounts for a major plague in 1523–24. Among other places, see Pollitzer, op. cit., note 41 above, p. 420; and N H Choksy, ‘The various types of plague and their clinical manifestations’, American Journal of the Medical Sciences, 1909, 138: 351–66, p. 351, found only 1.68 per cent of plague swellings outside the principal three lymph nodes from a sample of 13,600 cases and from 16,132 cases W E Jennings reported none.

87 Craven, op. cit., note 80 above, p. 1306.

88 Choksy, op. cit., note 86 above, pp. 351–66. Also, Chun, op. cit., note 59 above, pp. 311, 313, reports that haemorrhages in different parts of the body and “pustules may coalesce and form areas of necrosis, the so-called carbuncles” or “blains” as they were called in the plague of London in 1665, but he did not quantify their frequency. In his tables tallying the positions of buboes and “other situations”, plague pustules do not even appear (pp. 314–15). He later classifies cases with vesicles and pustules as “atypical cases” (pp. 321–23).

89 Atilio Macchiavello, ‘Plague’, Clinical tropical medicine, ed. R B H Gradwohl, Luiz Benitez Soto, Oscar Felsenfeld, London, H Kimpton, 1951, pp. 444–76, p. 460.

90 For instance, for the 1904 plague in Hong Kong, Robert Koch reported the following proportions of plague type—63.6 per cent bubonic, 31.4 per cent septicaemic, and 5 per cent pneumonic, but mentioned nothing about a pustular form. Cited by Choksy, op. cit., note 86 above, p. 352. Similarly, in the 3752 cases described in the hospital reports collected by Gatacre, not a single case was described with pustules spreading across the body.

91 For the comments of Geoffrey le Baker, Giovanni Morelli, a canon from Trent, and other fourteenth and fifteenth-century commentators of plague who saw the pustules as signs that were more deadly than the buboes, see Cohn, op. cit., note 36 above, pp. 59–81. Along with French physicians caring for plague victims at Marseilles in 1719–20, Richard Mead, op. cit., note 24 above, pp. 6–7, divided plague victims into five categories (“classes”) and observed, “Bubo's and Carbuncles, in all of them, except in those of the first class, who were so terribly seized, that they died in a few hours, or at farthest in a Day or two”. Also, the clinical descriptions in the Necrologi of Milan during the plagues of 1452, 1468, 1483, 1485, 1503, and 1523 show spots called by a wide variety of names (cum signis violareis, morbellis et accidentibus pestifecis, morbillis rubeis, morbillis violaceis verminumque multitudine, morbillis violareis, morbilis nigris) forming over the bodies of plague victims. Often these victims were also afflicted with larger buboes—the bubone, carbone, dragonzello, etc.—in the lymph glands and most often in the groin or femoral regions. Of 187 plague deaths in 1452, 98 (52 per cent) had accompanying spots or pustules. In the plague of 1523, 478 of 1434 victims were stricken with morbilli that covered their entire bodies. More than half of these (274) also had larger plague swellings. Archivio di Stato, Milano, Fondo popolazione, parte antica, vols. 73 and 87. On the Milanese records, see Ann G Carmichael, ‘Contagion theory and contagion practice in fifteenth-century Milan’, Renaiss. Q., 1991, 44 (2): 213–56; idem, ‘Epidemics and state medicine in fifteenth-century Milan’, in Roger French, Jon Arrizabalaga, Andrew Cunningham (eds), Medicine from the Black Death to the French Disease, Aldershot, Ashgate, 1998, pp. 221–47; D E Zanetti, ‘La morte a Milano nei secoli XVI–XVIII: Apunti per una ricera’, Rivista Storica Italiana, 1976, 88 (4): 804–52; and Giuliana Albini, Guerra, fame, peste: crisi di mortalità e sistema sanitario nella Lombardia tardomedioevale, Bologna, Capilli, 1982.

92 Macchiavello, op. cit., note 89 above, pp. 444–76, esp. 460. Chile in 1903 was stricken with this variety of plague. Also, see Choksy, op. cit., note 86 above, p. 357; and Chun, op. cit., note 59 above, p. 322.

93 See, for instance, Martin, op. cit., note 71 above, pp. 63–4.

94 Philip Ziegler, The Black Death, Harmondsworth, Penguin, 1970, p. 27; and for others who have made similar arguments, see Cohn, op. cit., note 36 above, p. 46. Most recently, Sallares, op. cit., note 1 above, p. 270, has made similar assertions to explain the absence of rats during the first pandemic; see note 10 above. Moote and Moote, op. cit., note 74 above, p. 281, argue: “Dead rats in the alleys and cellars of London in 1665 may not have been present in sufficient number to capture people's attention.” But for a plague that killed so many more than any plague of Yersinia pestis plagues since 1894, especially relative to population, would not more rather than fewer dead rats have been apparent?

95 After an exhaustive survey of sources, Biraben, op. cit., note 55 above, vol. 2, p. 333, found only three similar references to rats for thousands of plague incidents across towns and villages in Europe from 1348 to the eighteenth century and none of these refer to dead rats, much less a mass mortality of them.

96 See the examples in Walløe, op. cit., note 38 above, pp. 25 passim.

97 See note 42 above.

98 Cohn and Alfani, op. cit., note 23 above, pp. 204–5.

99 Wu Lien-Teh, ‘First report of the North Manchurian Plague Prevention Service’, J. Hygiene, 1913–14, 13: 237–90, expressed doubts about modern and medieval plague as the same but later changed his mind; see also, idem, A treatise on pneumonic plague, Geneva, League of Nations, 1926; idem, ‘Historical aspects’, in Wu Lien-Teh, et al., op. cit., note 10 above, pp. 1–55; and idem, Plague fighter: the autobiography of a modern Chinese physician, Cambridge, W Heffer, 1959.

100 Mark Gamsa, ‘The epidemic of pneumonic plague in Manchuria, 1910–1911’, Past and Present, 2006, 190: 147–84.

101 ‘Potential transmissibility of pneumonic plague’, paper delivered to the University of Warwick, Institute of Mathematics: Mathematics in Medicine Initiative: Bubonic Plague, 27 June 2002; and Raymond Gani and Steve Leach, ‘Epidemiologic determinants for modeling pneumonic plague outbreaks’, Emerg. Infect. Dis., 2004, 10 (4): 608–14.

102 Dileep V Mavalankar, ‘Indian “plague” epidemic: unanswered questions and key lessons’, J. R. Soc. Med., 1995, 58: 547–51, p. 548.

103 Despite his speculation that Pulex irritans may have transmitted the plague in the Middle Ages, Martin, op. cit., note 71 above, p. 63, admitted: “Nevertheless the direct transmission of the disease from man to man cannot, at the present time, be of frequent occurrence … The reason why the human flea is ineffective is because in human cases the average degree of septicaemia before death is so much less than in rats that the chance of a flea imbibing even a single bacillus is small.”

104 Sallares, op. cit., note 1 above, p. 239, mistakenly asserts that all cases of bubonic plague with swellings in the cervical region consistently produce tonsillar plague and therefore are pneumonic. In fact, tonsillar plague has been extremely rare with outbreaks of “typical bubonic plague”. From a study of 13,600 cases of plague in Bombay in 1900, Choksy, op. cit., note 86 above, pp. 351–2, found around 10 per cent of buboes in the cervical region, while only 1.0 per cent were cases of pneumonic plague (either primary with no signs or secondary). Also, see Chun, op. cit., note 59 above, p. 321. Even with the “atypical” plague in Nepal in 1967, when several cases of tonsillar plague were discovered, not all cervical cases were tonsillar or showed pulmonary symptoms; Laforce, et al., op. cit., note 59 above, Table 1, p. 695.

105 Laforce, et al., op. cit., note 59 above, p. 695.

106 After reviewing the arguments for and against human parasites spreading the plague, C Y Wu, ‘Insect vectors’, in Wu Lien-Teh, et al., op. cit., note 10 above, pp. 249–308, on pp. 296–301, concluded: “… in the present state of our knowledge … human parasites, be they fleas, bed-bugs or lice, are, only under particular circumstances, of practical importance in the spread of human plague and, unlike rat-fleas, are unable to lead to widespread and persistent epidemics of bubonic plague” (p. 301).

107 Burroughs, op. cit., note 37 above, p. 394, showed that the Indian rat flea, Xenopsylla cheopis, was three times more efficient than any other flea in transmitting plague. In the laboratory the vector efficiency of Xenopsylla cheopsis was found to be 0.660 +/−0.234, while that of the second most efficient, Nosopsyllus fasciatus, was 0.213 +/−0.157. In not a single case was Burroughs able to induce blockage with the so-called human flea, Pulex irritans.

108 Hirst, op. cit., note 69 above, pp. 238–40, 244, also argued that plague never reached epidemic proportions in Morocco (100 cases per annum) and that there was no evidence to suppose that Xenopsylla cheopis had not been chief vector of plague to humans. Also, see Butler, op. cit., note 75 above, p. 51: “The human flea Pulex irritans is not an efficient plague vector and rarely, if ever, has transmitted plague from man to man.”

109 Graham Twigg, The Black Death: a biological reappraisal, London, Batsford, 1984, p. 170. See also, Pollitzer, op. cit., note 41 above, p. 486, who concurred with Wu Lien-Teh, “human carriers represent … a sidetrack of the infection which ends blindly”.

110 Georges Blanc, ‘Une opinion non conformiste sur la mode de transmission de la peste’, Revue d'Hygiène Médicine Sociale, 1956, 4: 535–62, p. 548.

111 Robert Pollitzer, ‘A review of recent literature on plague’, Bull. World Health Organ., 1960, 23: 313–400, p. 360.

112 Concern and fear for the spread of Yersinia pestis by Pulex irritans appears to have reached a high point with the Bulletin of the World Health Organization's special number on plague in 1960. Pollizter, op. cit., note 111 above, concluded: “Reiterating claims which he had made in the past, Blanc (1956) postulated that human parasites, particularly P. irritans, played the main role in the spread of human plague. Evaluating this thesis, one must admit that in areas like Morocco where … thick layers of clothing and lack of cleanliness tend to increase human infestation with ectoparasites, P. irritans is apt to take an important part in the transmission of plague, the high incidence of this species compensating for what it lacks in vector capacity. At the same time, however, it is certain that in other plague areas, for example, China, India and also Madagascar, the role of this flea is negligible, the transmission of the infection depending upon the rat fleas, particularly X. cheopis” (pp. 360–1). The latest plague manual issued by WHO, by contrast, pays far less attention to Pulex irritans, and concern over this flea as a possible plague vector is much more guarded: “Pulex irritans has been considered as a possible or probable vector of plague” (David T Dennis, et al., Plague manual: epidemiology, distribution, surveillance and control, Geneva, World Health Organization, 1999, p. 67).

113 William Rees, ‘The Black Death in England and Wales, as exhibited in manorial documents’, Proc. R. Soc. Med., 1922–23, 16: Section of the History of Medicine, p. 30.

114 See Samuel K Cohn Jr, Creating the Florentine state: peasants and rebellion, 1348–1434, Cambridge University Press, 1999, pp. 226–8.

115 B Andenmatten and J-D Morerod, ‘La peste à Lausanne au XIVesiècle (1348/49, 1360): étude du chapitre cathédral et des testaments vaudois’, Études de lettres: Revue de la Faculté des lettres de l'Université de Lausanne, 1987, no. 2/3: 19–49; and E A Eckert, ‘Seasonality of plague in early modern Europe: the Swiss epidemic of 1628–30’, Rev. Infect. Dis., 1980, 2: 952–9.

116 David Herlihy, Pisa in the early Renaissance: a study of urban growth, New Haven, Yale University Press, 1958, and John Munro, ‘Medieval woollens: the western European woollen industries and their struggles for international markets, c.1000–1500’, in David Jenkins (ed.), The Cambridge history of western textiles, 2 vols, Cambridge University Press, 2003, vol. 1, pp. 228–324. For the early modern period, see Paolo Malanima, Il lusso dei contadini: consumi e industrie nelle campagne toscane del sei e settecento, Bologna, Mulino, 1900.

117 Susan Crane, The performance of self: ritual, clothing, and identity during the hundred years war, Philadelphia, University of Pennsylvania Press, 2002, pp. 11–15; Chronica Johannis de Reading, in Rosemary Horrox (trans. and ed.), The Black Death, Manchester University Press, 1994, p. 133.

118 See, for example, Ricardo Jorge, ‘Summa epidemiologica de la peste: épidémies anciennes et modernes’, Bulletin de l'Office International d'Hygiène Publique, 1933, 25 (1): 425–50, p. 448: “When plague invaded Europe almost without respite, everyone, even those from the highest social classes, were overwhelmed and eaten by their ectoparasites; everyone was more or less ridden with fleas [puceaux et pouilleux].” Jorge, however, produces no note or any evidence from the Middle Ages or early modern period to substantiate this assertion. (I thank Lars Walløe for bringing this article to my attention.) By contrast, on the great diversity of clothing allowed by sumptuary legislation from place to place and the strict hierarchy of clothing according to social class, see Maria Giuseppina Muzzarelli, ‘Le leggi suntuarie’, in Storia d'Italia Annali, 19: La moda, ed. Carlo Marco Belfanti and Fabio Giusberti, Turin, Einaudi, 2003, pp. 185–220.

119 See references in the previous three notes and Richard Goldthwaite, The building of Renaissance Florence: an economic and social history, Baltimore, Johns Hopkins University Press, 1980, pp. 41–8; idem, Wealth and the demand for art in Italy, 1300–1600, Baltimore, Johns Hopkins University Press, 1993, p.150 passim; Susan Mosher Stuard, Gilding the market: luxury and fashion in fourteenth-century Italy, Philadelphia, University of Pennsylvania Press, 2006; and Evelyn Welch, Shopping in the Renaissance: consumer cultures in Italy, 1400–1600, New Haven, Yale University Press, 2005; for the early modern period, see Patricia Allerston, ‘The market in second-hand clothes and furnishings in Venice, c. 1500–c. 1650’, PhD thesis, European University Institute, 1996; and Storia d'Italia Annali, 19: La moda, op. cit., note 118 above, esp. Patricia Allerston, ‘L'abito usato’, pp. 561–81.

120 See, for instance, the observations of the chronicler of the Grey Friars at Lynn during the plague of 1361; Horrox (trans. and ed.), op. cit., note 117 above, p. 86.

121 Sixteenth-century doctors regularly gave such advice in their plague tracts, see, for instance, Giacomo Filippo Besta, Vera narratione del successo della peste, che afflisse l'inclita città di Milano, l'anno 1576, Milan, Paolo Gottardo and Pacifico Pontij, 1578, 20r; Gratiolo di Salò, op. cit., note 55 above, p. 17; da Marostica, op. cit., note 25 above, 307r-v; Giovan’ Andrea Bellicochi, Avvertimenti di tutto ciò che in publico da signori & in privato da ciascuno, si debbe far nel tempo della peste, Verona, Dalle Donne, 1577, 414v.

122 For the plague in Venice of 1575–77 as one that ripped through all social classes, see Allerston, op. cit., note 119 above, p. 578.

123 ‘Gli ordinamenti sanitari del comune di Pistoia contro la pestilenza del 1348’, in Horrox (trans. and ed.), op. cit., note 117 above, pp. 195–203, esp. pp. 195–6. The second of 36 chapters concerns clothing: “No one, whether from Pistoia or elsewhere, shall dare or presume to bring or fetch to Pistoia, whether in person or by an agent, any old linen or woollen cloths, for male or female clothing or for bedspreads; penalty 200 pence, and the cloth to be burnt in the public piazza of Pistoia.” For similar legislation in Pisa and Lucca, see Gian Maria Varanini, ‘La peste del 1347–50 e i governi dell'Italia centro-settentrionale: un bilancio’, in La peste nera: dati di una realtà ed elementi di una interpretazione. Atti del XXX Convegno storico internazionale, Todi, 10–13 ottobre 1993, Spoleto, Centro Italiano di Studi sull'alto Medioevo, 1994, p. 293; for Valencia, see Agustin Rubio, Peste negra, crisis y comportamientos sociales en la España del siglo XIV: la cuidad de Valencia (1348–1401), Universidad de Granada, 1979, pp. 76–81, 119. In later plagues of the sixteenth century, such legislation and concern over clothing becomes more common.

124 Mead, op. cit., note 24 above, pp. 52, 55–6, 58, 82–92; “I am particularly careful to destroy the Clothes of the Sick, because they harbour the very Quintessence of Contagion” (p. 83). From the late Middle Ages, clothing under suspicion during plague time was burnt, disinfected, or vigorously washed; see Allerston, op. cit., note 119 above, pp. 562, 576–7. Further, soap making was an important trade during the Middle Ages and in cities such as Florence was associated with textile production and the cleaning of cloth.

125 Conversation with Dr Kenneth L Cage, National Center for Infectious Diseases, Fort Colllins, Colorado, USA. While working in Morocco during the plague years of the early 1930s, Ricardo Jorge commented on his astonishment at the high density of fleas in the tent villages (douars). At around the same time, the entomologist L Raynaud “spoke of places where these fleas had become the masters of streets and dwellings”. “In Ecuador, it was also noticed that the abundance of fleas was present in the households stricken by plague”, quoted in Jorge, op. cit., note 118 above, p. 448. By contrast, in late medieval and early modern Europe clothing was under constant scrutiny in connection with plague because of bad smells and thus the corruption of the air; yet, despite such scrutiny, no one pointed to insects of any sort; see Allerston, op. cit., note 119 above, p. 561.

126 Contemporaries did observe insects on the plague dead, but to my knowledge not on those stricken by the disease while they were still alive. In a poem, Eustache Deschamps, Oeuvres complètes, ed. Queux de Saint-Hilaire, 11 vols, Paris, Firmin Didot, 1880, p. 121, described plague corpses around 1400: “carrion for worms, turd putrid and vile, … garnished with lice, louse-eggs, and filth, piss, spittle” (trans. in Rudolph Binion, Past impersonal: group process in human history, DeKalb, IL, North Illinois University Press, 2005, p. 131).

127 See Malcolm Davies and Jeyaraney Kathirithamby, Greek insects, New York, Oxford University Press,1986; and Albert the Great, Man and the Beasts, trans. James J Scanlan, Binghampton, Medieval and Renaissance Texts and Studies, 1987, pp. 437–9. In addition, doctors from the fifteenth to the eighteenth century frequently observed the appearance of worms (vermi) accompanying many cases of plague. Such worms may have been as small or smaller than fleas or lice. Early modern plague writers such as the Abruzzese doctor Sebastiano Tranzi, Trattato di peste, Rome, per gl'heredi di Giovanni Gigliotto, 1587, pp. 9–10, held that the increase in numbers of “flies, frogs, grey mice [sorici], bed bugs, fleas, crickets, butterflies and other such animals born of putrefaction” were a sign of impending plague. Such comments show an awarness of the insect world and a call to observe it in time of plague. Yet, no writer observed insects on plague patients.

128 According to E H Phelps-Brown and Sheila Hopkins, ‘Seven centuries of the prices of consumables compared with builders’ wage rates’, in E M Carus-Wilson (ed.), Essays in economic history, 3 vols, London, Edward Arnold, 1954–1962, vol. 2, pp. 179–96, the real wages of builders did not return to their high point of the mid-fifteenth century until the 1880s. On the decline in standard of living, longevity, and sanitary conditions in Britain, see Eric J Hobsbawm, ‘The British standard of living 1790–1850’, Econ. Hist. Rev., 1957, 10: 46–68; idem, ‘The standard of living during the industrial revolution: a discussion’, in Econ. Hist. Rev., 1963, 16: 119–34; Greenwood, Epidemics and crowd-diseases, op. cit., note 51 above; and George Rosen, A history of public health, New York, MD Publications, 1958, pp. 201–93. On life expectancies from Elizabethan times, see E A Wrigley and R S Schofield, The population history of England 1541–1871: a reconstruction, Cambridge University Press, 1989. On nutritional and environmental deterioration in nineteenth-century Britain, see Deborah Oxley, ‘“The seat of death and terror”: urbanization, stunting, and smallpox’, Econ. Hist. Rev., 2003, 56 (4): 623–56.

129 Pollitzer, op. cit., note 111 above, p. 357.

130 Dakar experienced a major plague in 1914, but there is no evidence that Pulex irritans played any role, despite its possible prevalence as a rat-flea; see Pollitzer, op. cit., note 41 above, pp. 37–8. According to Echenberg, op. cit., note 69 above, pp. 211–43, Dakar's last significant plague occurred in 1944, that is, just before Pulex irritans became the region's most significant rat-flea. Perhaps the increase in Pulex irritans was beneficial in dampening the possibilities of the spread of plague to humans, instead of the opposite as scientists now speculate.

131 M B Prentice, T Gilbert, and A Cooper, ‘Was the Black Death caused by Yersinia pestis?’, Lancet Infectious Diseases, 2004, 4 (2): 72; M Thomas P Gilbert, et al., ‘Response to Drancourt and Raoult’, Microbiology, 2004, 150: 264–5; M Thomas P Gilbert, et al., ‘Absence of Yersinia pestis-specific DNA in human teeth from five European excavations of putative plague victims’, Microbiology, 2004, 150: 341–54; Carsten M Pusch, et al., ‘Yersinial F1 antigen and the cause of Black Death’, Lancet Infectious Diseases, 2004, 4 (8): 484–5.

132 Few have, in fact, corroborated the findings of the Marseilles team; for the latest of these scientists’ results, see G Aboudharam, M Drancourt, O Dutour, H Martin, D Raoult, and M Signoli, ‘Validation de la saisonnalité des décès et authenticité biologique de la nature de l’épidémie’, in Bizot, et al. (eds), op. cit., note 56 above, pp. 63–7.

133 See note 5 above.

134 Pollitzer, op. cit., note 111 above, p. 361.