The Later Middle Ages

In 1347, the plague began its journey through Europe. When the pandemic ended in 1350, a third of the population of Europe was dead. The population of Europe on the eve of the epidemic has been estimated at 75 million. Although life expectancy at birth was only around 30 years, the very high infant mortality rate artificially lowered this relative to the life expectancy of a person who reached adulthood. Women tended to fare worse, probably as a result of childbirth, although some authors also cite tuberculosis and malaria (Russell 1977). Before the year 1000, no city in medieval Europe had a population exceeding 20,000. In 1340, the largest European cities were Venice, Paris, Florence, and Genoa, each with populations around 100,000. Closely behind were cities such as London, Barcelona, Bologna, Brescia, Ghent, and Cordoba, each of which had populations over 50,000 (Beloch 1937, 1940, 1961;

Keyser 1938; Mols 1954-6; Baratier 1961; Herlihy 1967; Acsadi and Nemeskevi 1970; Russell 1971, 1977). It has been suggested that infant mortality was lower in medieval Europe than in early industrial Europe, because there was less crowding and somewhat superior living conditions (Russell 1977). This is a reasonable argument, but no more than that; there is not a shred of evidence to support this.

Plague left Europe, indeed most of the world, in a catastrophic state. In Venice 75 percent of the nobility was dead (Archivio 1348; Ell 1980). Cities routinely lost over 50 percent of their populations (Carpentier 1962a, 1962b). Strange heresies arose, such as the Flagellants, who traveled about, beating themselves unconscious with whips to repent the sins that had brought the epidemic. Medicine, as usual, was powerless to do anything to stop the disease. More damning, the Church failed to offer much real comfort or practical relief. Infant mortality and the loss of elderly adults are most easily absorbed by any society; however, plague tends to affect young adults and children over 5 years old (Ell 1984a, 1985). Yet careful local studies have not always borne out such a pattern in European plague epidemics of this period. The exact epidemiology remains unclear, or perhaps varied from place to place. When plague left infants and the elderly relatively untouched, but decimated the rest, it could destroy the productive and reproductive present and future of whole societies. This phenomenon has been well documented for Orvieto (Carpentier 1962b). Plague did not visit Europe once and then disappear, as did the Plague of Justinian. Rather, Europe became a site of recurrent epidemics, none as ghastly as the first, but even in 1630-1 Venice still lost a third of its population to the disease (Ell 1989a). It is difficult to give a sense of what this level of loss is like. The worst-hit countries in World War II lost 10 percent of their population. Venice lost 7.5 times that percentage in about one-twentieth the time.

No argument can be made for a hypothesis that the epidemic was triggered by population density. As noted, population was already in decline, and plague returned many times after the population density had plummeted. It is also clear that the pattern these epidemics took does not fit the classical rat-flea model of transmission. In fact, the European experience of plague does not fit the general model derived from India and China by the British Plague Commission around the turn of the century. According to that model, animal foci or reservoirs of plague are established among wild rodents, which can harbor the infection indefinitely, either only among themselves or, as is now more often recognized, among multiple species. The natural history of such foci is that they enlarge. For example, the focus in the United States, which was established in the first decade of the twentieth century, now extends over almost the entire western half of the country (Ell 1980). It is considerably more reasonable to postulate that there was never an enzootic focus of plague in Europe but, rather, that the disease was repeatedly reintroduced, most likely through trade or travelers. The observed epidemiology is much more compatible with in-terhuman transmission via the human flea than with either rat-flea or pneumonic spread (Ell 1984).

Whatever historiographic stance one takes with regard to the points discussed above, the recurrent plague epidemics undeniably mark a major change in the ecology of disease in Europe. For the first time, in an institutionalized way, European governments began to try to alter disease ecology. In 1486 Venice made permanent the Provveditori alia Sanita, a public health board that had first been established in 1348 and was re-formed in response to each epidemic. The invention of the quarantine is credited to Venice, which first tested it in the Venetian colony of Ragusa in 1379. Measures such as quarantine are not always useful against plague, with its complicated transmission pattern, but were valuable against other infectious diseases. More importantly, such measures introduced the concept that human and particularly governmental actions could modify the expression of disease. When plague appeared, city-states, which traditionally were at odds with one another, exhibited a high degree of cooperation, as elegantly documented by Carlo Ci-polla (1981). Much of the future of European disease ecology would follow from this none too successful attempt to control plague, and humans would begin increasingly to modify disease. Yet much of what plague brought was considerably less positive.

Artistic and literary styles in the immediate wake of the epidemic of 1348 were profoundly world-weary and pessimistic. The concept of the macabre arose in this period. The so-called transit tomb style, in which the deceased is sculpted both in his well-dressed idealized appearance and as a rotting corpse, being devoured by vermin, is one of the most striking elements of this deep cultural pessimism. This was a society in which the young and healthy adult could die in a few hours without warning or reason. It is likely that such an atmosphere could produce behavior of so careless or dangerous a nature that mortality from other diseases increased, but we have no real evidence to back up such an argument.

The conventional pillars of Christian faith and doctrine began to change to new, more startling views. People turned away from the belief that reason could lead them to God. Radical nominalism developed, and left an indelible mark upon subsequent philosophy. The Doctrine of Double Truth also emerged. According to this view, individuals could by reason arrive at certain conclusions, but only revelation was the source of ultimate truth. Aquinas had tried to keep the comprehension of truth in this world and available to reason. Postplague Europe made truth something separate from and unattainable from this world.

For totally unclear reasons, leprosy had begun to decline in much of western Europe by 1300 and definitely before plague struck. There is no known explanation. It is claimed that the climate of Europe became colder. It is indeed true that climate can affect the epidemiology of disease as well as much else in human society. A change of 1°C average temperature over a year can change the growing season by 2 weeks in England, for example. It is known that figs were grown in England in the time of Charlemagne. The climatic cooling of the fourteenth and fifteenth centuries has been called the "Little Ice Age" (Russell 1977). Such a shift in climate would certainly affect crops and food supplies, as well as some diseases (e.g., influenza is largely a disease of cold weather, whereas enteric fevers tend to occur in summer). Although climatic cooling has been credited for the decline of leprosy, the fact that the disease thrived in Scandinavia renders this argument at best incomplete and probably irrelevant. Whatever the cause, half the previously occupied beds in leprosaria in England were empty in 1300 (Richards 1977). The argument that plague killed an inordinate number of leprosy victims is not supportable in a direct way because leprosy is considered to confer immunity to plague. Indirectly, through the deaths of those who looked after leprosaria patients, plague may have hastened the decline of leprosy in much of Europe, but it neither initiated nor finished the change (Ell 1987).

Although it itself is highly speculative, let us consider another possible cause of leprosy's decline in much of Europe. The elaborate rituals and merciless rules by which leprosy patients were excluded from contact with normal society have been described extensively (Brody 1974; Richards 1977). If we consider the fact that Japan completely rid itself of leprosy early in this century by strictly separating contagious cases from the population (Saikawa 1981), it seems possible that the less scientific, but still powerful apparatus of medieval Europe may have produced the same end. This hypothesis, however, like so many others, cannot explain the persistence of the disease in Scandinavia. One difference, however, lies in the possibility that the organism is found in parts of Scandinavia outside a human host (in fact, in a type of moss), which would provide a reservoir of the organism able to survive irrespective of what happened to patients with the disease (Huang 1980; Job 1981).

It is often argued (e.g., by Russell 1977) that tuberculosis became the most important infectious disease during this period. Tuberculosis is simply too protean to be identifiable in the Middle Ages and Renaissance, except in rare instances. Its perceived effects on human demography are reasonable, but again real evidence is lacking.

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