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Popular Science Monthly/Volume 57/October 1900/The Bubonic Plague

THE BUBONIC PLAGUE.
By FREDERICK G. NOVY, Sc . D., M.D.,

JUNIOR PROFESSOR OF HYGIENE AND PHYSIOLOGICAL CHEMISTRY IN THE UNIVERSITY OF MICHIGAN.

THE province of Yunnan in China adjoins French Tonkin and British Burmah. It is of interest to the student of epidemiology because from this mountainous and difficultly accessible region there has issued but recently a disease which has been considered as practically extinct. Frightful as have been the ravages of the pest in the middle ages, it is noteworthy that during the past hundred years, with the exception of two slight outbreaks (Noja in Italy in 1815, and Vetlianka in Russia in 1878), the disease has been unknown in Europe. During this time the pest has not been extinct, but has existed to a greater or less extent in certain parts of Asia and in Africa. Four and possibly five of these endemic foci are known to-day. The province of Yunnan is one of these regions. The mountainous district of Gurhwal, lying along the southern slope of the Himalayas, is another center where the pest has continued to prevail. The recent travels of Koch in eastern Africa have brought to light a third region about Lake Victoria, in the British province of Uganda, and the German Kisiba, where the plague has existed from time immemorial, cut off as it were from the outer world. Only last year Sakharoff called attention to a fourth focus in northeastern China, and it is quite likely that a fifth focus exists in Arabia. These regions are of great importance in so far as the existence of permenent endemic foci sheds not a little light upon the development and spread of those great epidemics which, like great tidal waves, have in the past swept over whole countries and even continents. It is not known when or from whence the pest was first introduced into Yunnan. Unquestionably, it has existed in the extreme western parts of the province for many decades. Eventually the disease spread throughout the province, and frightful ravages are known to have occurred in 1871-73. Repeated visitations of this dread disease have taught the natives of Yunnan, as well as those of Gurhwal and of Uganda, to desert their villages as soon as an unusual mortality is found to prevail among the rats. In spite of the frequent recurrence of the plague, it did not spread to neighboring provinces, largely because of the fact that little or no communication exists between Yunnan and the adjoining Chinese states. Recently, however, the plague did succeed in crossing the frontier, and, in so doing, it has given rise to an epidemic which, as will be presently seen, has already made an unenviable record and has a future that no one can foretell.

The way in which the disease spread from Yunnan has been quite clearly established. Along the Tonkin frontier, throughout the provinces of Quan-si and Yunnan, the Chinese maintain a large number of military posts. Mule supply-trains for these posts passed from province to province over the difficult mountain paths. The mule-drivers were natives of Yunnan. In 1892 the plague existed in Yunnan, and it was in the summer of 1893 that the disease appeared at Long-Cheou in Quansi among the Yunnan mule-drivers. These drivers arriving at the post of Lieng-Cheng, after one of their journeys from Yunnan, repaired to the city of Long-Cheou, about ten miles distant. During their sojourn in this city the muleteers developed the first known cases of the plague. From these men the disease spread throughout the city and to the neighboring posts and villages.

From Long-Cheou the plague descended the Canton River and reached Naning-Phu. From thence it followed overland to the seaport Pakhoi, some hundred and fifty miles distant. A few months later, in February, 1894, it reached Canton, either by descending the river from Naning-Phu or by boat from Pakhoi. That the plague at Canton, in 1894, had not lost any of its old-time destructiveness is seen in the fact that it is estimated to have caused not less than one hundred thousand deaths in Canton in the short space of two months.

From Canton the plague spread to Hong Kong in April, 1894. It was during the existence of this epidemic that the first bacteriological studies of the disease were made and resulted in the discovery of the plague bacillus. In the fall of 1894, the disease died out in Hong Kong, but it reappeared in 1895 and 1896. Considering the fact that Hong Kong is one of the most important maritime centers, it is not surprising to find that in the spring of 1896 'the plague was carried by shipping to the Island of Formosa. It is quite certain that about the same time the plague was carried from Hong Kong to Bombay. At all events, the existence of this disease was recognized in Bombay in September, 1896, by Doctor Viegas. Previous to this date, the mortality in Bombay was abnormally high, undoubtedly due to the very unsanitary condition of the overcrowded city.

The existence of famine in India, together with the filthy, overcrowded condition of the population, enabled the plague to gain a firm foothold in a relatively short time. Indeed, there can be no doubt but that the disease was well established at the time it was first recognized. It is no wonder, then, that in spite of the most stringent precautions, it spread like wildfire, so that in a short time the weekly deaths from the plague rose to nearly 2,000. In the face of such a relentless enemy, it is but natural that a large proportion of the population should seek safety in flight. It is believed that fully 300,000 people left Bombay shortly after the plague developed. There can be no doubt but that these refugees, directly or indirectly, carried the disease to the neighboring villages, and thus contributed to the enormous dissemination of the pest throughout Western India. In the Presidency of Bombay there were reported, in less than three years, more than 220,000 cases, with more than 164,000 deaths. When it is furthermore recognized that the natives concealed the existence of the disease as much as possible, it will be evident that these figures reveal a partial but, nevertheless, a grim truth.

With Bombay and the surrounding country thus seriously infected, it became merely a question of time when the disease would be carried to other ports and countries, by vessels and by overland routes. In spite of the sanitary perfection which we may flatter ourselves on having attained in recent years, it is nevertheless a fact that the disease is slowly but steadily and, as it were, stealthily invading port after port. That the sanitary methods, however, are not at fault is seen in the fact that when an early and prompt recognition occurred, the disease has been held in check. The insidious spread of the disease is rather due to the enormous development of commerce and to the rapid means of communication with distant countries.

From Bombay the plague has spread to ports on the Persian Gulf, on the Red Sea, and has reached Alexandria. Aden, Djeddah, Port Said, Cairo, have all had outbreaks of the disease. Beirut and Smyrna have each developed straggling cases. Isolated cases have been met with in London, at St. Petersburg and in Vienna. However, only three appreciable outbreaks have as yet occurred on European soil. The first was that at Oporto in Portugal, where one hundred and sixty cases, with fifty-five deaths, have developed up to the present time. The second outbreak occurred at Kolobovka, a village near Astrakhan. Of the twenty-four cases that developed there in July and August, 1899, twenty-three died. The last outbreak is that at Glasgow, where the disease made its appearance but a few weeks ago.

In addition to following the great international highway of Suez, the disease has insidiously spread to the countries of East Africa. Mauritius and Madagascar, with the adjoining mainland of Mozambique and Lorenzo Marquez, have become more or less infected, and, if reports are to be credited, it has also appeared in one of the Boer towns and also on the Ivory Coast in Western Africa. Last fall the disease reached South America. It apparently was first recognized at Santos, in Brazil, during October, although early in September, according to reports, a peculiar disease, causing swelling of the glands and death within forty-eight hours, was reported at Asunçion, the capital of Paraguay. At the present time Rio Janeiro is infected. The sanitary condition of these South American cities is far from being the best, and, consequently, there is but little hope that the disease will be eradicated or even held in check. With South America more or less thoroughly infected, it is evident that the United States, as well as Europe, are now threatened from all sides. The gravity of the situation is seen in the fact that already last November two cases of the plague were found in New York harbor aboard a coffee ship from Santos. Several cases have also developed on ships bound from the latter city for Mediterranean ports.

The United States is threatened not merely from the East Atlantic and South Atlantic, but also from the Pacific. As a matter of fact, the danger to our Pacific ports is greater, owing to the direct communication with the Orient. It has been already indicated that Hong Kong has continued to be infected ever since 1894. On several occasions it disappeared during the winter months, only to reappear in spring. With the more or less constant prevalence of the plague at this great seaport, it necessarily will lead directly or indirectly to a dissemination of the disease along the entire Pacific. Already it has prevailed at Amoy, and has even extended to other Chinese ports as far as Niu-Chwang. For several years it has already persisted on the island of Formosa. Japan was invaded last fall at Kobe and at Osaka, and although it disappeared during the winter, yet only a few weeks ago it has reappeared at the latter city. Sidney in Australia, and Noumea in New Caledonia, are also infected at the present time.

Manila, Honolulu and San Francisco have successively become infected. In all these places the disease, with but very few exceptions, has attacked the native or Oriental population. The extinction of the plague in the Hawaiian Islands since the end of March is a splendid demonstration of what energetic, vigorous measures can accomplish. The presence of the plague since March 8 in Chinatown, in San Francisco, is readily recognized as a most serious condition, especially after the courts have granted an injunction restraining the health officers from carrying out the necessary vigorous preventive measures.

A few words should be given here to the overland dissemination of the disease. Europe is not merely threatened by infected ships which may come from China, India, Eastern Africa or South America. The overland routes from China and India are fully as grave a source of danger. Indeed, as will be presently shown, these are the routes along which the great epidemics of cholera and plague have always traveled in the past.

One of these great caravan routes leads from Lahore in Punjab through Afghanistan into the Russian province of Turkestan, where it meets the Trans-Caspian railway. This railway begins at Samarcand in Turkestan, and passes through Bokhara, Merv, Askabad and ends at Uzun Ada on the Caspian Sea opposite Baku. Early in 1899 an outbreak of the plague occurred near Samarcand, undoubtedly brought up from India. The precautions taken to prevent the spread were entirely successful, and although no accounts have been officially published as to the means employed, nevertheless it will be seen that the radical procedure employed by Loris Melikoff some twenty years ago was again resorted to. Inasmuch as the entire village was said to be afflicted it was surrounded by troops, and no one was allowed to enter or leave. The village and all that it contained was destroyed by fire. With this route open continually it is evident that fresh importation must be expected sooner or later.

Apparently a new plague focus, independent of that in Yunnan and Hong Kong, has been recently discovered in Manchuria. The plague seems to have existed in this province for more than ten years under the name of Tarabagan plague, and is believed to be spread by a rodent, the Arctomis cobuc, which is subject to a hemorrhagic pneumonia. The presence of such an independent endemic focus in Manchuria indicates the possibility of the spread of the disease by caravan to Lake Baikal, and thence by the Siberian railroad to Russia. Indeed, the epidemic of pneumonic type which began July, 1899, at Kolobovka, in Astrakhan, while it may have been imported from Persia, might also owe its origin to the Mongolian focus.

Russia, however, is not the only country endangered by the overland transmission of the disease. There are commercial highways which lead from Northwestern India through Baluchistan and Persia to the Caucasus, and through Turkey to Constantinople. Grave danger threatens from this source, and more especially from the cities along the Persian Gulf. Two important cities here are already infected, namely, Bushire, in Persia, and Bassorah on the Tigris, in Turkey. It would appear as if Turkey and Persia would escape with difficulty from a visitation of this dread disease.

Such, then, is the geographical distribution of the present outbreak of the plague. This, an apparently extinct disease, has suddenly reappeared and given evidence of its power to spread death and desolation. Fortunately, however, modern sanitary precautions are quite able to restrict its progress, provided they be applied at the proper time and place. Filth and overcrowding, protracted wars and famine, have been the powerful allies of the plague in the past. Through their aid this disease has made a deep impression upon the pages of history. It may not be out of place, therefore, to turn from the present outbreak of the disease and trace its grewsome past.

In ancient writings references are found which would seem to indicate the existence of the plague at a very early date. The Bible contains several such references (Deuteronomy, Chapter 28, paragraph 27. Samuel I, Chapter 5, paragraphs 6, 9). The latter especially deals with the plague which attacked the Philistines after they took the ark. The rôle of rats in the dissemination of the disease is, as some believe, apparently referred to in the trespass offering of "five golden emerods and five golden mice." The return of the ark, together with this trespass offering, brought also the plague, "because they had looked into the ark of the Lord, even He smote of the people fifty thousand and threescore and ten men." Poussin's painting of this Philistine plague, exhibited in the Louvre, shows several dead rats on the streets. It is evident that the susceptibility of the rat to the plague had been noticed even at this early date. The plague of boils visited upon the Egyptians as related in Exodus (Chapter 9, paragraphs 9 and 10) has also been taken to indicate the pest of to-day, but neither of these scriptural references can be said to be sufficiently definite.

The Attic plague, which ravaged the Peloponnesus 430 years before Christ, has been accurately described by an eye-witness, the historian Thucydides. His narration may be considered the earliest exact record of an epidemic. Like all the great epidemics of subsequent ages, it was ushered in by the overcrowding, the misery and the famine consequent upon prolonged wars. The combustible material was there, and all that was necessary was the spark to begin the work of death and devastation. It is noteworthy that the origin of the pest was traced by Thucydides to Egypt or Ethiopia, from whence it spread gradually overland to Asia Minor and thence by boat to Athens. The nature of this first great historic epidemic is and will remain uncertain. There are those who consider the Attic pestilence as one of bubonic plague, but the fact that in the very careful description of the disease no mention is made of buboes and the statement that death occurred from the seventh to the ninth day would indicate that the disease was something else. Buboes are characteristic, it is true, of the plague, but it should be remembered that outbreaks of the pneumonic form, with little or no glandular enlargement, are not uncommon. Death, however, in the case of plague is very common on the second or third day, and is less liable to occur in more protracted cases. These facts lead to the commonly accepted belief that the Attic pest was not the bubonic plague. It may have been typhus fever, possibly smallpox.

The great pestilence which devastated Rome and its dependencies in 166, Anno Domini, is known as the plague of Antoninus or of Galen. This prolonged epidemic was brought to Rome by the returning legions from Seleucia. It was not characterized by buboes, and it is very probable that it was largely smallpox. On the other hand, the plague of Saint Cyprian, which prevailed from 251 to 266 Anno Domini, may have been partly bubonic in nature, since it prevailed during the fall and winter months and ceased during the hot summer. The disease was said to be communicated by means of clothing and by the look. It spread from Ethiopia to Egypt and thence through the known world.

Although the above early epidemics cannot be identified with the bubonic plague, there is nevertheless excellent evidence of the existence of this disease in remote antiquity. The first undoubted testimony on this point is that furnished by Rufus of Ephesus, who lived in the first century of the Christian era. The writings of this author are no longer extant, but they are quoted by Oribasius, the physician and friend of Julian the Apostate, who lived in the fourth century. The writings of Oribasius were discovered in the Vatican Library and were published early in this century by Cardinal Mai. In the forty-fourth "Book of Oribasius" occurs the extract taken from Rufus of Ephesus, from which it appears that "the so-called pestilential buboes are all fatal and have a very acute course, especially when observed in Libya, Egypt and in Syria. Dionysius mentions it. Dioscorides and Posidonius have described it at length in their treatise upon the plague which prevailed during their time in Libya." The description which then follows of the buboes and of the disease is an exact counterpart of the present plague. The writings of the authors quoted by Rufus are no longer extant, but one thing is certain, and that is that the Dionysius referred to lived not later than 300 years before Christ. The other two physicians lived in Alexandria contemporaneous with the birth of Christ. It may, therefore, be considered as an established fact that the plague existed in Egypt, Libya and Syria as early as 300 years before Christ. This is of especial interest in view of the recent discovery by Koch of an endemic plague focus in British Uganda and German Kisiba, at the headwaters of the Nile. Whether it ever invaded European territory prior to the sixth century is unknown.

The great plague of Justinian which broke out in 542, Anno Domini, appeared first in Egypt, and from thence it spread east and west throughout the known world and persisted for more than a half century. So unknown was the plague in Europe at that time that the physicians of Constantinople considered it a new disease. Procopius, who was an eye-witness of the plague at Constantinople, states that the daily mortality in that city was at times over 10,000.

The pandemic of Justinian resulted in the distribution of the plague for the first time throughout the length and breadth of known Europe. From that time on the early chroniclers make repeated mention of devastating plagues consequent upon the miseries of war and famine. The descriptions of these pestilences are, as a rule, insufficient to identify them with the bubonic plague. Typhus, scurvy, smallpox and other diseases undoubtedly alternated in the work of destruction. Of the scores of epidemics thus recorded during the eight centuries following this first visitation few, indeed, can be identified to a certainty with the bubonic plague, and yet there can be no doubt but that this disease occupied no second rank during the dreary darkness of the middle ages. This era in history may be said to have been ushered in by the Justinian plague, and it was closed by an even more disastrous outbreak of this same disease. All the ravages and slaughter consequent upon the great historic battles, when taken together, pale into insignificance on comparison with that dread visitation of the fourteenth century, the 'black death'.

It is noteworthy that this great historic epidemic did not originate in Egypt, as did many of its predecessors. Without exception the contemporaneous writers ascribe its origin to Cathay, or the China of today. This fact is of interest when it is borne in mind that at the present time we know of the existence of two endemic foci in China, besides that of Gurhwal in India, of Beni Cheir in Arabia and of Uganda and Kisiba in Africa. Whatever may have been its source, the fact is that it advanced from the Orient along the three principal routes of travel. One of these led from the Persian Gulf through Bassorah and Bagdad along the Euphrates, across Arabia to Egypt and Northern Africa. Another route passed from India through Afghanistan, and skirting the southern borders of the Caspian and Black Seas, eventually reached Asia Minor. A third route from Turkestan and China led around the northern shore of the Caspian Sea to Crimea, and thence to Constantinople. It was along these several routes that the plague advanced and spread over most of Western Asia and Northern Africa.

The European black death, however, can be traced with accuracy to the Crimean peninsula. Gaffa, a town in Crimea, now known as Theodosia, had been founded and fortified by the Genoese. It, as well as other cities along the Black Sea, was largely populated by Italians. One of these, Gabriel de Mussis, a lawyer in Gaffa, has left a faithful account of his experience and share in the introduction of the plague into Europe. In 1346 in the Orient numberless Tartars and Saracens were attacked with an unknown disease and sudden death. In the city of Tanais, through some excess, a racial struggle ensued between the Tartars and the Italian merchants. The latter eventually escaped and took refuge in Gaffa, which in time was besieged by the Tartars. During the siege, which lasted three years, the Tartar hordes were attacked by the plague, which daily carried off many thousands. The besiegers, despairing of reducing the city by direct attack, attempted to do so in another way. By means of their engines of war they projected the dead bodies into the beleaguered city, which, as a result, soon became infected. The Christian defenders took to their ships, and abandoning Gaffa, sailed westward, touching at Constantinople, Greece, Italy and France.

Wherever the infected vessels touched they left the plague. Constantinople thus became infected early in 1347. During the summer Greece, Sardinia, Corsica and parts of the Italian coast developed the disease. In the fall it reached Marseilles. The following year it spread inland into Italy, France, Spain, and even into England. In another year or two it spread over Germany, Russia, and crossed to the Scandinavian peninsula. Within four years it had completed the circuit of Europe, spreading untold death and misery. No greater catastrophe has been recorded in the history of the world.

The rapidity with which the disease spread among the fugitives from Gaffa, and in the cities visited by their ships, is despairingly narrated by De Mussis, who, returning in one of the ships to Genoa, says: "After landing we entered our homes. Inasmuch as a grave disease had befallen us, and of the thousands that journeyed with us scarcely ten remained, the relatives, friends and neighbors hastened to greet us. Woe to us who brought with us the darts of death, who scattered the deadly poison through the breath of our words." According to this writer 40,000 died in Genoa, leaving scarcely a seventh of the original population. Venice was said to have lost 100,000, Naples 60,000, Sienna 70,000, Florence 100,000. All told, Italy lost half of its population.

Of the contemporaneous writers none has printed the horrors of the plague more vividly than does Boccaccio in his introduction to the 'Decameron.'

"What magnificent dwellings, what notable palaces were then depopulated to the last person! What families extinct! What riches and vast possessions left, and no known heir to inherit! What numbers of both sexes in the prime and vigor of youth, whom in the morning either Galen, Hippocrates, or Æsculapius himself but would have declared in perfect health, after dining with their friends here have supped with their departed friends in the other world!"

From Marseilles the plague spread through Provence with disastrous results. In some monasteries not even a single survivor was left. In one of these Petrarch's brother buried thirty-four of his companions. At Avignon, the seat of the Pope, 1,800 deaths occurred in three days. In Paris more than fifty thousand died of the plague.

In England the black death appeared in August, 1348, and continued till the autumn of 1349, when it disappeared. London, which at that time probably had a population of 45,000, had a mortality of about 20,000. No exact statement can be made of the relative mortality in England, although many undoubtedly extravagant guesses are recorded by contemporaneous writers.

It is estimated that the population of Europe previous to the outbreak of the black death was about one hundred and five millions. One quarter of the population, or about twenty-five millions, are said to have died of the plague. This may be but a mere estimate, it may be grossly inaccurate, but it nevertheless indicates the deadly character of the pestilence. According to a report made to Pope Clement VI, the total mortality for the known world was placed at forty-three millions. One-half the population of Italy succumbed. The Order of Minorites in Italy lost 300,000 members. The Order of Capuchins in Germany lost 126,000 members, while the total of deaths in Germany was placed at 1,200,000.

The invasion of Europe by the black death was sudden and rapid. The seeds of the disease, once planted on European soil, persisted, as might be expected, for no little time. Although the great epidemic was said to have lasted till 1360, it must not be inferred that it then ceased altogether. Diverse localities retained the infection, and, as a result, new outbreaks, though to a less extent, continued to outcrop during the following years. From that time on every decade or two witnessed more or less pronounced outbreaks of the disease in France, England and Italy. The chroniclers of those local outbreaks during the latter half of the fourteenth and during the entire fifteenth century did not always make it clear that the pestilence described was the real plague. It was but natural to include typhus and other diseases under the dreaded term of pest. Nevertheless, the frequency of these outbreaks indicates the persistence and the wide dissemination of the plague during those years.

During the sixteenth century the plague apparently began to show a decrease in its frequency, although during this period, as before, other epidemic diseases were mistaken for it. Germany, Holland, certain cities in France, and especially in Italy were scourged by the plague during this century. The noteworthy outbreak in Italy in 1575-77 was due to fresh importation from the Orient. The disease spread throughout Italy, and the devastation it caused was not inferior to that of the great plague two centuries before. For example, in 1576 in Venice 70,000 died of the disease.

During the seventeenth century the plague asserted itself with great severity. Following a famine, it prevailed in Russia in 16011603, and some idea of its destructiveness may be gained when it is stated that in Moscow alone 127,000 lives were taken. During the following decade even greater epidemics prevailed in Western Europe. France and England were invaded, and in Switzerland it even penetrated to the highest Alps. Basel in 1609-1611 had 4,000 deaths, while London in 1603 yielded 33,000.

The terrible epidemic which ravaged Northern Italy in 1629-1631 deserves more than a passing notice. During those years more than a million died of the disease. Scarcely a town in Northern Italy escaped. The city which, perhaps, suffered the most was Milan, where, in 1630, the deaths from all diseases are said to have amounted to 186,000. The Milan outbreak has been graphically described by Manzoni, in his celebrated 'I Promessi Sposi' Unrecognized, the disease entered Milan in October, 1629. The mild cases which were met with during the winter months lulled the fears of the people and encouraged the mass of physicians to deny the existence of the plague. But in April the disease began to assert itself in terrible earnest. The frenzied populace, blind to the contagiousness of the disease, were possessed with the strange hallucination that obtained during former plague epidemics in other Italian cities, that the pest spread because of poison scattered about by evil-minded persons. Suspicious strangers were, as a result, stoned in the streets, imprisoned and even put to death by legal process because of such fanatical beliefs. To offset the growing pestilence, the people demanded of the Archbishop that a solemn religious procession be held, and that the holy relics of Saint Charles be exposed. At first this was refused, but eventually it was granted. The procession bearing the saintly body was solemnly held on the 11th of June. The fanatical security which these devotions engendered was rudely shattered when, a few days later, the disease burst forth with renewed activity among all classes in all parts of the city. Nevertheless, as Manzoni observes, the faith was such that none recognized that the procession itself was directly the cause of the new outburst of the disease by facilitating the spread of the contagion. Again the belief asserted itself that the 'untori,' or poisoners, mixed with the crowd and with their unguents and powders had infected as many as possible. From that day the fury of the contagion continued to grow to such an extent that scarcely a house remained exempt from the disease. The number of patients in the pesthouse rose from 2,000 to 12,000, and later reached 17,000. The daily mortality rose from 500 to 1,200, then 1,500, and is even said to have reached 3,500. Milan, before the epidemic, was said to have had a population of from 200,000 to 250,000. The loss by death has been variously estimated at from 140,000 to 186,000. All these deaths were not due to the plague. Thus, large numbers of children died as a result of starvation consequent upon the death of their parents from the plague.

The horrors attendant upon such a dreadful visitation can well be imagined. Scarcity of help in removing the dead and in taking care of the sick made itself felt, to say nothing of the lack of food. Enormous trenches, one after another, were filled with the bodies of the victims, carried thither by the hardened monatti, the counterpart of the Florentine becchini, so well portrayed by Lord Lytton in his 'Rienzi.' These bearers of the sick and dead "were naturally recruited from the lowest criminal classes, and it can, therefore, cause but little wonder that an epidemic of the worst of crimes was associated with that of the plague.

In 1656 Italy was again invaded by the plague, and on that occasion Genoa lost 65,000 of its population by death. About the same time terrible epidemics of the disease ravaged Russia, Turkey and Hungary.

London, in 1665, suffered dreadfully from the plague. The disease appears to have been imported from Holland, where it was known to have existed for some time. The progress of the disease in London has been vividly portrayed by Defoe in the 'Journal of the Plague Year' and in the 'Due Preparations for the Plague.'

It is supposed that the pest had been imported in bales of goods from Smyrna into Holland in 1663. From thence it crossed over to London, where the first deaths were reported about the first of December in 1664. Toward the end of that month another death occurred in the same house, but during the following six weeks no new case developed. About the middle of February, however, a person died of the plague in another house. From that time only occasional cases of plague were reported, although the weekly mortality was rapidly rising and was greatly in excess of the usual rate. Thus, while the ordinary weekly mortality ranged from two hundred and forty to three hundred, this was gradually increased, so that in the third week in January it had risen to four hundred and seventy-four. After a slight remission, the mortality again rose, so that early in May plague cases were reported more frequently. It soon became evident that the plague, as in Milan in 1630, had slowly but surely gained a firm foothold. The increased mortality was undoubtedly due to unsuspected plague cases of either the pneumonic or the septicemic type.

During May, and especially during the hot weather in June, the disease continued to spread. At the same time, the panic-stricken people began to leave the city in large numbers. In July the condition was truly deplorable. To quote Defoe:

"London might well be said to be all in tears; the mourners did not go about the streets, indeed, for nobody put on black or made a formal dress of mourning for their nearest friends; but the voice of mourning was truly heard in the streets. The shrieks of women and children at the windows and doors of their houses, where their dearest relations were perhaps dying, or just dead, were so frequent to be heard as we passed in the streets, that it was enough to pierce the stoutest heart in the world to hear them. Tears and lamentations were seen almost in every house, especially in the first part of the visitation; for toward the latter end men's hearts were hardened, and death was so always before their eyes, that they did not so much concern themselves for the loss of their friends, expecting that themselves should be summoned the next hour."

London at this time had a population of nearly half a million. The deaths from the plague during 1665, as reported in the bills of mortality, are 68,596. By far the larger number of these occurred in August, September and October. The weekly mortality from the disease rose from a few cases in May to over 7,000 per week in September. It may, indeed, be close to the truth when Defoe states that 3,000 were said to have been buried in one night.

The great plague of London in 1665 was by no means the only visitation of that kind. From the time of the black death in 1348, London had a continuous record of plague infection. On an average it had an epidemic of plague every fifteen years. Some of these were fully as severe as that of 1665. Thus, in 1603, with a population of 250,000, there were over 33,000 reported deaths from the plague. In 1625, 41,000 died of pest out of a population of 320,000.

One of the most remarkable facts in connection with the great plague is this—that it was the last in England. The great fire of 1666 is supposed to have extinguished the plague, but this cannot be said to be true. The disease continued to a slight extent in 1666 and isolated cases were reported as late as 1679, but after that date it disappeared completely and from that time until this year England has been absolutely free from the plague. The sudden extinction of the plague in England after it had becomes domesticated, so to speak, for nearly three centuries, is indeed difficult to explain. Creighton sees an inhibiting influence in the growth of the practice of burial in coffins. But the absence of famine, together with the cessation of domestic wars and strife and the abeyance of want and misery, had not a little effect. As will presently be seen, the extinction of the plague in England was no more remarkable than its disappearance from Western Europe.

The history of plague in the seventeenth century does not close with the London epidemic. From 1675-1684 the disease ravaged Northern Africa, Turkey, and from thence invaded Austria and even reached Southern Germany. The Vienna outbreak of 1679 can be said to have been no less terrible than that of Milan or of London. The deaths from the plague in Vienna in that year have been variously estimated at from 70,000 to double that number.

From Vienna the plague reached Prague, where in 1861 it is said to have caused no less than 83,000 deaths. It is not to be wondered at that a nation scourged by thirty years of relentless warfare, by religious persecution and finally tried thus severely by the plague should inscribe upon the equestrian statue of their patron saint the heartrending appeal, 'Lord, grant that we do not perish.'

The close of the seventeenth century saw the disappearance of the plague from Western Europe. In Eastern Europe, however, the disease continued to exist even during the eighteenth century. Nevertheless, a change had taken place for the better, and as the years went on the retrogression of the plague became more and more distinct.

During the first two decades of the eighteenth century the plague was widely distributed in Eastern Europe. It was present especially in Constantinople and in the Danubian provinces. From the latter it extended to Russia (Ukraine), and from thence to Poland. The disastrous invasion of Russia by Charles XII. of Sweden, ending in his defeat at Poltawa in 1709, led to its further dissemination to Silesia, Eastern Prussia, the Baltic provinces and seaports, and even to Scandinavia. It was during this epidemic that Dantzic, in 1709, lost 33,000, and Stockholm 40,000 by the plague. During the years 1709 and 1710 the plague mortality in the Baltic provinces exceeded 300,000. Three years later, in 1713, the plague spread up the Danube and reached Vienna, Prague and even Bavaria.

During these two decades Western Europe was entirely free from the dread disease. In 1720 the disease suddenly developed in Marseilles and extended from thence to neighboring towns and the country districts of Provence. Terrible as was this visitation it is of interest, inasmuch as it was the last occurrence of the plague on French soil, and the last in Western Europe until the recent outbreak in Portugal.

The plague was said to have been imported into Marseilles by a merchant vessel, the 'Grand Saint Antoine', from Syria. On its way to Marseilles several deaths occurred on shipboard, but the cause was overlooked. On the 25th of May, 1720, two days after the arrival of the vessel, another death occurred among the crew. The disease was still not believed to be the plague, and although quarantine was instituted, new cases appeared among the crew and the dock laborers employed in unloading the vessel, and it was not until the disease reached the city that its true nature was recognized. The germs of the disease had then been scattered broadcast. Unsanitary a city as Marseilles is to-day, it must have been vastly more so in 1720. The result of the addition of plague germs to the want, misery and filthy condition was at once evident. During August the mortality averaged four and even five hundred per day. In September the daily mortality rose to 1,000. So great was the terror of the populace that it became impossible to secure bearers of the dead, to obtain nurses and attendants. The dead were left in heaps upon the streets, so that it became necessary to transfer to the city 700 galley slaves, who were required to remove the bodies. These same galley slaves were even pressed into service as nurses. The diseased were abandoned by friends and relatives, and under such conditions it need not be wondered at that they received little or no attention from others. Food and water were denied to the unfortunates, and when food was administered to the pesthouses it was thrown into the windows by machinery.

The disease continued in Marseilles until December, 1721, but isolated cases persisted until April, 1722. During the fifteen months of its duration it carried off 40,000 of the population. According to Defoe, there died of the plague in Marseilles and within a league of its walls 60,000.

From Marseilles the plague reached Aix, and in the winter of 1720 and 1721 it carried off 18,000 of its people. It also reached Aries, where, in 1721, out of a population of 23,000, 10,000 died (forty-five per cent). The same year, in Toulon, which had a population of 26,000, the plague attacked 20,000 of the population, and of these 13,000, or about one-half of the original population, died.

The country districts about Marseilles were likewise invaded. Out of a population of 248,000, there died of the plague 88,000, or fully thirty-five per cent.

It is evident from this description that the plague of 1720 was in nowise inferior to that of 1348. Fortunately, the disease did not spread beyond Provence. It is noteworthy that in many instances, in Marseilles, people secluded themselves in their houses, avoiding all communication with the outer world, and in this way escaped. Similar isolation of cloisters, insane asylums, likewise resulted in freedom from the disease which stalked so freely throughout the stricken city. It was experience of this kind in isolation of the healthy which led Defoe to write his 'Due Preparations for the Plague.'

Toward the middle of the century the plague reasserted itself in the Danubian provinces, the constant battleground between the Turks and Russians and Austrians. In 1738 it not only prevailed in Russia but also invaded Hungary. Of more importance than this occurrence is the outbreak of the plague in 1743 in Sicily. The last epidemic of plague had occurred in Messina in 1624. After a lapse of one hundred and twenty years, it reappeared with terrible results. In Messina, as in Marseilles and in London, the first cases were not recognized as plague cases and, as a result, the infection spread until, like a veritable explosion, the disease developed all over the city. The plague, with its attendant misery of lack of food, and even of water, was in vain combated by religious processions. The plague corpses were in heaps in the streets, as in Marseilles, and cremation was resorted to in order to effect their removal. That year 30,000 died of plague in the city of Messina. With the exception of a slight epidemic at Noja in 1815, this outbreak in Messina in 1743 was the last one to appear in Italy.

In 1755, the plague was introduced into Transylvania by an Armenian merchant from the Black Sea. Before it was extinguished, 4,300 deaths were recorded.

Next to that of Marseilles and of Messina, the most noteworthy outbreak of plague was that which occurred in 1771 in Moscow. The disease was introduced by troops returning from the Danubian provinces. As so often has been the history of plague, the first cases were not recognized, and the existence of pest was denied. When the plague was demonstrated to be present, it is said by Haeser that three-fourths of the populace deserted the city. The disease began early in March and increased during the early summer months. In August over 7,000 deaths resulted, while in September the records show that 21,000 died. In October the plague decreased, but still 17,000 deaths attested to its fearful power. Early in January it became extinct, after a duration of ten months, and after having caused the death of more than 52,000 people.

Toward the close of the eighteenth century, at the time of the Napoleonic invasion of Egypt and Syria, the French armies came into contact with the plague. Bonaparte's visit to the pest-stricken soldiers at Jaffa has been perpetuated in the historic canvas which is to be seen at Versailles.

During the nineteenth century the plague ravaged Northern Africa on diverse occasions. Constantinople was invaded in 1802, 1803, 1808. It was also present to a slight extent in the Caucasus and in Astrakhan. A notable plague epidemic appeared in Egypt in 1812, and soon spread through Turkey and Southern Russia. Constantinople and Odessa were severely scourged. In Odessa out of a population of 28,000 there died 12,000.

It is a noteworthy fact that the Napoleonic wars, with all their incident hardships and misery, did not develop or spread the plague in Europe. The outbreaks of the disease were limited during this period to Africa and to Turkey, Bosnia, Roumania, Dalmatia and to Southern Russia. Two exceptions, however, are to be noted. In 1812 the Island of Malta was infected and more than 6,000 of its people yielded to the disease. The epidemic of 1815 at Noja, in Apulia, was the first recurrence of the plague on Italian soil since 1743, and thus far it has been the last.

The Balkan Peninsula and Southern Russia were visited from time to time by the plague up to about 1841. For nearly forty years Europe was wholly free from the disease, which, however, continued its existence in Northern Africa, in Mesopotamia and in India. The Russo-Turkish war of 1878 brought the Russian troops into contact with the disease in the Caucasus, and the epidemic at Vetlianka on the lower Volga was unquestionably introduced by such returning soldiers.

Such, then, has been the history of the bubonic plague. No other epidemic disease can be traced authentically as far back as the 'Black Death.' The characteristic symptoms, the rapid death, the excessive mortality are all features which have been noted through more than twenty centuries. The plague bacillus discovered in 1894 by Yersin, judged by its effect, is neither more nor less virulent than its early progenitors. It has often died out in a given locality or country, it has even been forced back to its original ancestral home, but still the same type, the same species has perpetuated itself unchanged. If the plague on its present world-wide journey does not cause such terrible outbreaks as it has in the past, it will be not because the germ has been altered by time, but because man has changed in so far as he has slowly learned and profited by the lessons of previous epidemics.