Black Death

The Black Death, or the Black Plague, was one of the deadliest pandemics in human history, widely thought to have been caused by a bacterium named Yersinia pestis (Bubonic plague), but recently attributed by some to other diseases.

The pandemic is thought to have begun in Central Asia or India and spread to Europe during the 1340s. The total number of deaths worldwide is estimated at 75 million people; approximately 25-50 million of which occurred in Europe. The Black Death is estimated to have killed 30% to 60% of Europe's population. It may have reduced the world's population from an estimated 450 million to between 350 and 375 million in 1400.

Bubonic plague is thought to have returned to Europe every generation with varying virulence and mortalities until the 1700s. During this period, more than 100 plague epidemics swept across Europe. On its return in 1603, the plague killed 38,000 Londoners. Other notable 17th century outbreaks were the Italian Plague of 1629-1631, the Great Plague of Seville (1647-1652), the Great Plague of London (1665–1666), the Great Plague of Vienna (1679). There is some controversy over the identity of the disease, but in its virulent form, after the Great Plague of Marseille in 1720–1722, the Great Plague of 1738 (which hit eastern Europe), and the 1771 plague in Moscow, it seems to have disappeared from Europe in the 19th century.

The 14th century eruption of the Black Death had a drastic effect on Europe's population, irrevocably changing the social structure. It was a serious blow to the Roman Catholic Church, and resulted in widespread persecution of minorities such as Jews, foreigners, beggars, and lepers. The uncertainty of daily survival created a general mood of morbidity, influencing people to "live for the moment", as illustrated by Giovanni Boccaccio in The Decameron (1353).

The Great Plague
Medieval people called the 14th century catastrophe either the "Great Pestilence"' or the "Great Plague". Writers contemporary to the plague referred to the event as the "Great Mortality".

The term "Black Death" was introduced for the first time in 1833. It has been popularly thought that the name came from a striking late-stage sign of the disease, in which the sufferer's skin would blacken due to subepidermal hemorrhages (purpura), and the extremities would darken with gangrene (acral necrosis). However, the term is more likely to refer to black in the sense of glum, lugubrious or dreadful. The Black Death was, according to chronicles, characterized by buboes (swellings in lymph nodes), like the late 19th century Asian Bubonic plague. Scientists and historians at the beginning of the 20th century assumed that the Black Death was an outbreak of the same disease, caused by the bacterium Yersinia pestis and spread by fleas with the help of animals like the black rat (Rattus rattus). However, this view has recently been questioned by some scientists and historians. New research suggests Black Death is lying dormant.

Plague migration
The plague disease, caused by Yersinia pestis, is enzootic (commonly present) in populations of ground rodents in central Asia, but it is not entirely clear where the 14th century pandemic started. The most popular theory places the first cases in the steppes of Central Asia, although some speculate that it originated around northern India, and others, such as the historian Michael W. Dols, argue that the historical evidence concerning epidemics in the Mediterranean and specifically the Plague of Justinian point to a probability that the Black Death originated in Africa and spread to central Asia, where it then became entrenched among the rodent population. Nevertheless, from central Asia it was carried east and west along the Silk Road, by Mongol armies and traders making use of the opportunities of free passage within the Mongol Empire offered by the Pax Mongolica. It was reportedly first introduced to Europe at the trading city of Caffa in the Crimea in 1347. After a protracted siege, during which the Mongol army under Janibeg was suffering the disease, they catapulted the infected corpses over the city walls to infect the inhabitants. The Genoese traders fled, bringing the plague by ship into Sicily and the south of Europe, whence it spread. Whether or not this hypothesis is accurate, it is clear that several pre-existing conditions such as war, famine, and weather contributed to the severity of the Black Death. In China, the thirteenth century Mongol conquest disrupted farming and trading, and led to widespread famine. The population dropped from approximately 120 to 60 million. The 14th century plague is estimated to have killed 30% of the population of China..

In Europe, the Medieval warm period ended sometime towards the end of the fourteenth century, bringing harsher winters and reduced harvests. In the years 1315 to 1317 a catastrophic famine, known as the Great Famine, struck much of North Western Europe. The famine came about as the result of a large population growth in the previous centuries, with the result that, in the early fourteenth century the population began to exceed the number that could be sustained by productive capacity of the land and farmers.

In Northern Europe, new technological innovations such as the heavy plough and the three-field system were not as effective in clearing new fields for harvest as they were in the Mediterranean because the north had poor, clay-like, soil. Food shortages and skyrocketing prices were a fact of life for as much as a century before the plague. Wheat, oats, hay, and consequently livestock, were all in short supply, and their scarcity resulted in hunger and malnutrition. The result was a mounting human vulnerability to disease, due to weakened immune systems.

The European economy entered a vicious circle in which hunger and chronic, low-level debilitating disease reduced the productivity of labourers, and so the grain output was reduced, causing grain prices to increase. This situation was worsened when landowners and monarchs like Edward III of England (r. 1327-1377) and Philip VI of France (r. 1328-1350), out of a fear that their comparatively high standard of living would decline, raised the fines and rents of their tenants. Standards of living then fell drastically, diets grew more limited, and Europeans as a whole experienced more health problems.

In autumn of 1314, heavy rains began to fall, which led to several years of cold and wet winters. The already weak harvests of the north suffered and the seven-year famine ensued. The Great Famine was the worst in European history, reducing the population by at least ten percent. Records recreated from dendrochronological studies show a hiatus in building construction during the period, as well as a deterioration in climate.

This was the economic and social situation in which the predictor of the coming disaster, a typhoid (Infected Water) epidemic, emerged. Many thousands died in populated urban centres, most significantly Ypres. In 1318 a pestilence of unknown origin, sometimes identified as anthrax, targeted the animals of Europe, notably sheep and cattle, further reducing the food supply and income of the peasantry.

Asian outbreak
The scenario that would place the first outbreak in central Asia agrees with the first reports of outbreaks in China in the early 1330s. The plague struck the Chinese province of Hubei in 1334. On the heels of the European epidemic, a more widespread disaster occurred in China during 1353–1354. Chinese accounts of this wave of the disease record a spread to eight distinct areas: Hubei, Jiangxi, Shanxi, Hunan, Guangdong, Guangxi, Henan and Suiyuan, throughout the Mongol and Chinese empires. Historian William McNeill noted that voluminous Chinese records on disease and social disruption survive from this period, but no one has studied these sources in depth.

It is probable that the Mongols and merchant caravans inadvertently brought the plague from central Asia to the Middle East and Europe. The plague was reported in the trading cities of Constantinople and Trebizond in 1347.

European outbreak


In October 1347, a fleet of Genoese trading ships fleeing Caffa reached the port of Messina in Sicily. By the time the fleet reached Messina, all the crew members were either infected or dead. It is presumed that the ships also carried infected rats and/or fleas. Some ships were found grounded on shorelines, with no one aboard remaining alive.

Looting of these lost ships also helped spread the disease. From there, the plague spread to Genoa and Venice by the turn of 1347–1348.

From Italy the disease spread northwest across Europe, striking France, Spain, Portugal and England by June 1348, then turned and spread east through Germany and Scandinavia from 1348 to 1350. It was introduced in Norway in 1349 when a ship landed at Askøy, then proceeded to spread to Bjørgvin (modern Bergen). Finally it spread to north-western Russia in 1351; however, the plague largely spared some parts of Europe, including the Kingdom of Poland and isolated parts of Belgium and The Netherlands.

At Siena, Agnolo di Tura wrote:

"'They died by the hundreds, both day and night, and all were thrown in … ditches and covered with earth. And as soon as those ditches were filled, more were dug. And I, Agnolo di Tura … buried my five children with my own hands … And so many died that all believed it was the end of the world.'"

Middle Eastern outbreak
The plague struck various countries in the Middle East during the pandemic, leading to serious depopulation and permanent change in both economic and social structures. As it spread to western Europe, the disease also entered the region from southern Russia. By autumn 1347, the plague reached Alexandria in Egypt, probably through the port's trade with Constantinople, and ports on the Black Sea. During 1348, the disease traveled eastward to Gaza, and north along the eastern coast to cities in Lebanon, Syria and Palestine, including Ashkelon, Acre, Jerusalem, Sidon, Damascus, Homs, and Aleppo. In 1348–49, the disease reached Antioch. The city's residents fled to the north, most of them dying during the journey, but the infection had been spread to the people of Asia Minor.

Mecca became infected in 1349. During the same year, records show the city of Mawsil (Mosul) suffered a massive epidemic, and the city of Baghdad experienced a second round of the disease. In 1351, Yemen experienced an outbreak of the plague. This coincided with the return of King Mujahid of Yemen from imprisonment in Cairo. His party may have brought the disease with them from Egypt.

Recurrence
In England, in the absence of census figures, historians propose a range of pre-incident population figures from as high as 7 million to as low as 4 million in 1300, and a post-incident population figure as low as 2 million. By the end of 1350 the Black Death had subsided, but it never really died out in England over the next few hundred years: there were further outbreaks in 1361–62, 1369, 1379–83, 1389–93, and throughout the first half of the 15th century. Plague often killed 10% of a community in less than a year - in the worst epidemics, such as at Norwich in 1579 and Newcastle in 1636, as many as 30 or 40%. The most general outbreaks in Tudor and Stuart England, all coinciding with years of plague in Germany and the Low Countries, seem to have begun in 1498, 1535, 1543, 1563, 1589, 1603, 1625 and 1636.

The plague repeatedly returned to haunt Europe and the Mediterranean throughout the fourteenth to seventeenth centuries, and although bubonic plague still occurs in isolated cases today, the Great Plague of London in 1665–1666 is generally recognized as one of the last major outbreaks.

The plague of 1575–77 claimed some 50,000 victims in Venice. In 1634, an outbreak of plague killed 15,000 Munich residents. Late outbreaks in central Europe include the Italian Plague of 1629-1631, which is associated with troop movements during the Thirty Years' War, and the Great Plague of Vienna in 1679. About 200,000 people in Moscow died of the disease from 1654 to 1656. The last plague outbreak ravaged Oslo in 1654. In 1656 the plague killed about half of Naples's 300,000 inhabitants. Amsterdam was ravaged in 1663–1664, with a mortality given as 50,000.

A plague epidemic that followed the Great Northern War (1700-1721, Sweden v. Russia and allies) wiped out almost 1/3 of the population in the region. An estimated one-third of East Prussia's population died in the plague of 1709-1711. The plague of 1710 killed two-thirds of the inhabitants of Helsinki. An outbreak of plague between 1710 and 1711 claimed a third of Stockholm’s population.

During the Great Plague of 1738, the epidemic struck again, this time in Eastern Europe, spreading from Ukraine to the Adriatic Sea, then onwards by ship to infect some in Tunisia. The destruction in several Romanian cities such as Timişoara was formidable, claiming tens of thousands of lives.

Bubonic plague theory
Plague and the ecology of Yersinia pestis in soil, and in rodent and (possibly and importantly) human ectoparasites are reviewed and summarized by Michel Drancourt in modeling  sporadic, limited and large plague outbreaks. Modelling of epizootic plague observed in prairie dogs suggests that occasional reservoirs of infection such as an infectious carcass, rather than "blocked fleas" are a better explanation for the observed epizootic behaviour of the disease in nature.

An interesting hypothesis about the epidemiology—the appearance, spread and especially disappearance—of plague from Europe is that the flea-bearing rodent reservoir of disease was eventually succeeded by another species. The black rat (Rattus rattus) was originally introduced from Asia to Europe by trade, but was subsequently displaced and succeeded throughout Europe by the bigger brown rat (Rattus norvegicus). The brown rat was not as prone to transmit the germ-bearing fleas to humans in large die-offs due to a different rat ecology. The dynamic complexities of rat ecology, herd immunity in that reservoir, interaction with human ecology, secondary transmission routes between humans with or without fleas, human herd immunity and changes in each might explain the eruption, dissemination, and re-eruptions of plague that continued for centuries until its (even more) unexplained disappearance.

Signs and symptoms
The three forms of plague brought an array of signs and symptoms to those infected. The septicaemic plague is a form of "blood poisoning," and pneumonic plague is an airborne plague that attacks the lungs before the rest of the body. The classic sign of bubonic plague was the appearance of buboes in the groin, the neck and armpits, which oozed pus and bled. Most victims died within four to seven days after infection. When the plague reached Europe, it first struck port cities and then followed the trade routes, both by sea and land.

The bubonic plague was the most commonly seen form during the Black Death, with a mortality rate of thirty to seventy-five percent and symptoms including fever of 38 - 41 °C (101-105 °F), headaches, painful aching joints, nausea and vomiting, and a general feeling of malaise. Of those who contracted the bubonic plague, 4 out of 5 died within eight days. Pneumonic plague was the second most commonly seen form during the Black Death, with a mortality rate of ninety to ninety-five percent. Symptoms included fever, cough and blood-tinged sputum. As the disease progressed, sputum became free flowing and bright red. Septicaemic plague was the least common of the three forms, with a mortality rate close to one hundred percent. Symptoms were high fevers and purple skin patches (purpura due to DIC (Disseminated intravascular coagulation)).

David Herlihy identifies another potential sign of the plague: freckle-like spots and rashes. Sources from Viterbo, Italy refer to "the signs which are vulgarly called lenticulae", a word which bears resemblance to the Italian word for freckles, lentiggini. These are not the swellings of buboes, but rather "darkish points or pustules which covered large areas of the body".

Not bubonic plague?
Although Y. pestis as the causitive agent of plague is widely accepted, recent scientific and historical investigations have led some researchers to doubt the long-held belief that the Black Death was an epidemic of bubonic plague. For example, in 2000, Gunnar Karlsson pointed out that the Black Death killed between half and two-thirds of the population of Iceland, although there were no rats in Iceland at this time. Rats were accidentally introduced in the nineteenth century, and have never spread beyond a small number of urban areas attached to seaports. In the fourteenth century there were no urban settlements in Iceland. Iceland was unaffected by the later plagues which are known to have been spread by rats. However, without a rodent reservoir, pneumonic plague can be transmitted from human to human by respiratory transmission, and bubonic and septicemic plague can be transmitted from human to human by human-biting fleas.

In addition, it was previously argued that tooth pulp tissue from a fourteenth-century plague cemetery in Montpellier tested positive for molecules associated with Y. pestis. Similar findings were reported in a 2007 study, but other studies have yielded negative results. In September 2003, a team of researchers from Oxford University tested 121 teeth from sixty-six skeletons found in fourteenth-century mass graves. The remains showed no genetic trace of Y. pestis.

In 2002, Samuel K. Cohn published the controversial article, “The Black Death: End of the Paradigm.” In the article Cohn argues that the medieval and modern plagues were two distinct diseases differing in their symptoms, signs and epidemiologies. Cohn asserts that the agent causing the bubonic plague, Yersinia pestis, “was first cultured at Hong Kong in 1894.” In turn, the medieval plague that struck Europe, according to Cohn, was not the bubonic plague carried by fleas on rats as traditionally viewed by scientists and historians alike. Cohn’s argument that medieval plague was not rat-based is supported by his claims that the modern and medieval plagues hit in different seasons, had unparalleled cycles of recurrence, and varied in the manner in which immunity was acquired. The modern plague reaches its peak in seasons with high humidity and a temperature of between 50 °F and 78 °F, as rats’ fleas thrive in this climate. In comparison, the Black Death is recorded as hitting in periods where rats’ fleas could not survive, i.e. hot Mediterranean summers above 78 °F. In terms of recurrence, the Black Death on average did not resurface in an area for between five and fifteen years after it hit. Contrastingly, modern plagues often hit an affected area yearly for an average of eight to forty years. Last, Cohn presents evidence displaying that individuals gained immunity to the Black Death during the fourteenth century, unlike the modern plague. He states that in 1348 two-thirds of those suffering from plague died in comparison to one-twentieth by 1382. Statistics contrastingly display that immunity to the modern plague has not been acquired.

Cohn also points out that in the latter part of the nineteenth century buboes appeared mostly on an infected person's groin, while medieval primary sources indicate that the Black Death caused buboes to appear on necks, armpits, and groins. This difference, he argues, ties in with the fact that fleas caused the modern plague and not the Black Death. Since flea bites do not usually reach beyond a person's ankles, in the modern period the groin was the nearest lymph node that could be infected. As the neck and the armpit were often infected during the medieval plague, it appears less likely that these infections were caused by fleas on rats.

In 1984, Graham Twigg published The Black Death: A Biological Reappraisal, where he argued that the climate and ecology of Europe and particularly England made it nearly impossible for rats and fleas to have transmitted bubonic plague. Combining information on the biology of Rattus rattus, Rattus norvegicus, and the common fleas Xenopsylla cheopis and Pulex irritans with modern studies of plague epidemiology, particularly in India, where the R. rattus is a native species and conditions are nearly ideal for plague to be spread, Twigg concludes that it would have been nearly impossible for Yersinia pestis to have been the causative agent of the plague, let alone its explosive spread across Europe. Twigg also shows that the common theory of entirely pneumonic spread does not hold up. He proposes, based on a re-examination of the evidence and symptoms, that the Black Death may actually have been an epidemic of pulmonary anthrax caused by Bacillus anthracis.

An Ebola-like virus?
In 2001, epidemiologists Susan Scott and Christopher Duncan from Liverpool University proposed the theory that the Black Death might have been caused by an Ebola-like virus, not a bacterium. Their rationale was that this plague spread much faster and the incubation period was much longer than other confirmed Y.pestis-caused plagues. A longer period of incubation will allow carriers of the infection to travel farther and infect more people than a shorter one. When the primary vector is humans, as opposed to birds, this is of great importance. Studies of English church records indicate an unusually long incubation period in excess of thirty days, which could account for the rapid spread, topping at 2 miles/day, as this was the average speed a traveler would move across the countryside. The plague also appeared in areas of Europe where rats were uncommon, areas such as Iceland. Epidemiological studies suggest the disease was transferred between humans (which happens rarely with Yersinia pestis and very rarely for Bacillus anthracis), and some genes that determine immunity to Ebola-like viruses are much more widespread in Europe than in other parts of the world. Their research and findings are thoroughly documented in Biology of Plagues. More recently the researchers have published computer modeling demonstrating how the Black Death has made around 10% of Europeans resistant to HIV.

Anthrax and others?
In a similar vein, historian Norman F. Cantor, in his 2001 book In the Wake of the Plague, suggests the Black Death might have been a combination of pandemics including a form of anthrax, a cattle murrain. He cites many forms of evidence including: reported disease symptoms not in keeping with the known effects of either bubonic or pneumonic plague, the discovery of anthrax spores in a plague pit in Scotland, and the fact that meat from infected cattle was known to have been sold in many rural English areas prior to the onset of the plague. It is notable that the means of infection varied widely, from human-to-human contact as in Iceland (rare for plague and cutaneous Bacillus anthracis) to infection in the absence of living or recently dead humans, as in Sicily (which speaks against most viruses). Also, diseases with similar symptoms were generally not distinguished between in that period (see murrain above), at least not in the Christian world; Chinese and Muslim medical records can be expected to yield better information which however only pertains to the specific disease(s) which affected these areas.

Counter-arguments
Historians who believe that the Black Death was indeed caused by bubonic plague have put forth several counterarguments.

The uncharacteristically rapid spread of the plague could be due to respiratory droplet transmission, and low levels of immunity in the European population at that period. Historical examples of pandemics of other diseases in populations without previous exposure, such as smallpox and tuberculosis transmitted by aerosol amongst Native Americans, show that the first instance of an epidemic spreads faster and is far more virulent than later instances among the descendants of survivors, for whom natural selection has produced characteristics that are protective against the disease.

Michael McCormick, a historian offering the idea that bubonic plague was indeed the source of the Black Death, explains how archaeological research has confirmed that the black or "ship" rat was indeed present in Roman and medieval Europe. Also, the DNA of Y. pestis has been identified in the teeth of the human victims, the same DNA which has been widely believed to have come from the infected rodents. He does not deny the point that there exists a pneumonic expression of Y. pestis transmitted by human-to-human contact, but he states that this does not spread as easily as previous historians have imagined. The rat, according to him, is the only plausible agent of transmission that could have led to such a wide and quick spread of the plague. This is because of rats' proclivity to associate with humans and the ability of their blood to withstand very large concentrations of the bacillus. When rats died, their fleas (which were infected with bacterial blood) found new hosts in the form of humans and animals. The Black Death tapered off in the eighteenth century, and according to McCormick, a rat-based theory of transmission could explain why this occurred. The plague(s) had killed a lot of the human host population of Europe and dwindling cities meant that more people were isolated, and so geography and demography did not allow rats to have as much contact with Europeans. Greatly curtailed communication and transportation systems due to the drastic decline in human population also hindered the replenishment of devastated rat colonies.

CCR5 delta 32
About 10 percent of Europeans have a gene mutation known as CCR5 delta 32 that disables a protein the Human Immunodeficiency Virus (HIV-1) uses to slip into immune system cells. Those with one copy of this gene have some immunity to HIV and those with two copies are virtually immune to the virus. This genetic mutation arose about 700 years ago and it has been suggested by some researchers that survivors of bubonic plague may have selected for the mutation. However, work published in 2003 suggests that smallpox was a more likely driver for the rise of the mutation.

A Malthusian crisis
In addition, various historians have adopted yet another theory for the cause of the Black Plague, one that points to social, agricultural, and sometimes economic causes. Often known as the Malthusian limit, scholars use this term to express, and/or explain, certain tragedies throughout history. In his 1798 Essay on the Principle of Population, Thomas Malthus asserted that eventually humans would reproduce so greatly that they would go beyond the limits of food supplies; once they reached this point, some sort of "reckoning" was inevitable. While the Black Death may appear to be a "reckoning" of this sort, it was in fact an external, unpredictable factor and does not therefore fit into the Malthusian theory. In his book, The Black Death and the Transformation of the West, David Herlihy explores this idea of plague as an inevitable crisis wrought on humanity in order to control the population and human resources. In the book The Black Death; A Turning Point in History? (ed. William M. Bowsky) he writes “implies that the Black Death’s pivotal role in late medieval society... was now being challenged. Arguing on the basis of a neo-Malthusian economics, revisionist historians recast the Black Death as a necessary and long overdue corrective to an overpopulated Europe.”

Herlihy examines the arguments against the Malthusian crisis, stating “if the Black Death was a response to excessive human numbers it should have arrived several decades earlier” due to the population growth of years before the outbreak of the Black Death. Herlihy also brings up other, biological factors that argue against the plague as a "reckoning" by arguing “the role of famines in affecting population movements is also problematic. The many famines preceding the Black Death, even the ‘great hunger’ of 1314 to 1317, did not result in any appreciable reduction in population levels”. Finally Herlihy concludes the matter stating, “the medieval experience shows us not a Malthusian crisis but a stalemate, in the sense that the community was maintaining at stable levels very large numbers over a lengthy period” and states that the phenomenon should be referred to as more of a deadlock, rather than a crisis, to describe Europe before the epidemics.

Depopulation
See also: Medieval demography.

Figures for the death toll vary widely by area and from source to source as new research and discoveries come to light. It killed an estimated 75-200 million people in the 14th century. According to medieval historian Philip Daileader in 2007: "The trend of recent research is pointing to a figure more like 45% to 50% of the European population dying during a four-year period. There is a fair amount of geographic variation. In Mediterranean Europe and Italy, the South of France and Spain, where plague ran for about four years consecutively, it was probably closer to 80% to 75% of the population. In Germany and England . . . it was probably closer to 20%."

Asia
Estimates of the demographic impact of the plague in Asia are based on both population figures during this time and estimates of the disease's toll on population centers. The initial outbreak of plague in the Chinese province of Hubei in 1334 claimed up to ninety percent of the population, an estimated five million people. During 1353–54, outbreaks in eight distinct areas throughout the Mongol/Chinese empires may have possibly caused the death of two-thirds of China's population, often yielding an estimate of twenty-five million deaths. China had several epidemics and famines from 1200 to 1350s and its population decreased from an estimated 125 million to 65 million in the late 14th century. Japan and Korea had no outbreak of plague.

Europe and Middle East
It is estimated that between one-quarter and one-third of the European population (35 million people) died from the outbreak between 1348 and 1350. Contemporary observers, such as Jean Froissart, estimated the toll to be one-third—less an accurate assessment than an allusion to the Book of Revelation meant to suggest the scope of the plague. Many rural villages were depopulated, mostly the smaller communities, as the few survivors fled to larger towns and cities leaving behind abandoned villages. The Black Death hit the culture of towns and cities disproportionately hard, although rural areas (where most of the population lived) were also significantly affected. A few rural areas, such as Eastern Poland and Lithuania, had such low populations and were so isolated that the plague made little progress. Parts of Hungary and, in modern Belgium, the Brabant region, Hainaut and Limbourg, as well as Santiago de Compostella, were unaffected for unknown reasons (some historians have assumed that the presence of resistant blood groups in the local population helped them resist the disease, although these regions would be touched by the second plague outbreak in 1360–63 and later during the numerous resurgences of the plague). Other areas which escaped the plague were isolated mountainous regions (e.g. the Pyrenees). Larger cities were the worst off, as population densities and close living quarters made disease transmission easier. Cities were also strikingly filthy, infested with lice, fleas and rats, and subject to diseases related to malnutrition and poor hygiene. According to journalist John Kelly, "[w]oefully inadequate sanitation made medieval urban Europe so disease-ridden, no city of any size could maintain its population without a constant influx of immigrants from the countryside".(p. 68) The influx of new citizens facilitated the movement of the plague between communities, and contributed to the longevity of the plague within larger communities.

In Italy, Florence's population was reduced from 110,000 or 120,000 inhabitants in 1338 to 50,000 in 1351. Between 60 to 70% of Hamburg and Bremen's population died. In Provence, Dauphiné and Normandy, historians observe a decrease of 60% of fiscal hearths. In some regions, two thirds of the population was annihilated. In the town of Givry, in the Bourgogne region in France, the friar, who used to note 28 to 29 funerals a year, recorded 649 deaths in 1348, half of them in September. About half of Perpignan's population died in several months (only two of the eight physicians survived the plague). England lost 70% of its population, which declined from 7 million before the plague, to 2 million in 1400.

All social classes were affected, although the lower classes, living together in unhealthy places, were most vulnerable. Alfonso XI of Castile was the only European monarch to die of the plague, but Peter IV of Aragon lost his wife, his daughter and a niece in six months. Joan of England, daughter of Edward III, died in Bordeaux on her way to Castile to marry Alfonso's son, Pedro. The Byzantine Emperor lost his son, while in the kingdom of France, Joan of Navarre, daughter of Louis X le Hutin and of Margaret of Burgundy, was killed by the plague, as well as Bonne of Luxembourg, the wife of the future John II of France.

Furthermore, resurgences of the plague in later years must also be counted: in 1360–62 (the "little mortality"), in 1366–69, 1374–75, 1400, 1407, etc. The plague was not eradicated until the 19th century.

The precise demographic impact of the disease in the Middle East is very difficult to calculate. Mortality was particularly high in rural areas, including significant areas of Palestine and Syria. Many surviving rural people fled, leaving their fields and crops, and entire rural provinces are recorded as being totally depopulated. Surviving records in some cities reveal a devastating number of deaths. The 1348 outbreak in Gaza left an estimated 10,000 people dead, while Aleppo recorded a death rate of 500 a day during the same year. In Damascus, at the disease's peak in September and October 1348, a thousand deaths were recorded every day, with overall mortality estimated at between 25 and 38 percent. Syria lost a total of 400,000 people by the time the epidemic subsided in March 1349. In contrast to some higher mortality estimates in Asia and Europe, scholars such as John Fields of Trinity College in Dublin believe the mortality rate in the Middle East was less than one-third of the total population, with higher rates in selected areas.

Social and economic effects
The governments of Europe had no apparent response to the crisis because no one knew its cause or how it spread. In 1348, the plague spread so rapidly that before any physicians or government authorities had time to reflect upon its origins, about a third of the European population had already perished. In crowded cities, it was not uncommon for as much as fifty percent of the population to die. Europeans living in isolated areas suffered less, and monasteries and priests were especially hard hit since they cared for the Black Death's victims. Because fourteenth century healers were at a loss to explain the cause, Europeans turned to astrological forces, earthquakes, and the poisoning of wells by Jews as possible reasons for the plague's emergence. No one in the fourteenth century considered rat control a way to ward off the plague, and people began to believe only God's anger could produce such horrific displays. There were many attacks against Jewish communities. In August of 1349, the Jewish communities of Mainz and Cologne were exterminated. In February of that same year, Christians murdered two thousand Jews in Strasbourg. Where government authorities were concerned, most monarchs instituted measures that prohibited exports of foodstuffs, condemned black market speculators, set price controls on grain, and outlawed large-scale fishing. At best, they proved mostly unenforceable, and at worst they contributed to a continent-wide downward spiral. The hardest hit lands, like England, were unable to buy grain abroad: from France because of the prohibition, and from most of the rest of the grain producers because of crop failures from shortage of labour. Any grain that could be shipped was eventually taken by pirates or looters to be sold on the black market. Meanwhile, many of the largest countries, most notably England and Scotland, had been at war, using up much of their treasury and exacerbating inflation. In 1337, on the eve of the first wave of the Black Death, England and France went to war in what would become known as the Hundred Years' War. Malnutrition, poverty, disease and hunger, coupled with war, growing inflation and other economic concerns made Europe in the mid-fourteenth century ripe for tragedy.

The plague did more than just devastate the medieval population; it caused a substantial change in economy and society in all areas of the world. Economic historians like Fernand Braudel have concluded that Black Death exacerbated a recession in the European economy that had been under way since the beginning of the century. As a consequence, social and economic change greatly accelerated during the fourteenth and fifteenth centuries. The church's power was weakened, and in some cases, the social roles it had played were taken over by secular groups. Also the plague led to peasant uprisings in many parts of Europe, such as France (the Jacquerie rebellion), Italy (the Ciompi rebellion, which swept the city of Florence), and in England (the English Peasant Revolt).

Europe had been overpopulated before the plague, and a reduction of 30% to 50% of the population could have resulted in higher wages and more available land and food for peasants because of less competition for resources. However, for reasons that are still debated, population levels declined after the Black Death's first outbreak until around 1420 and did not begin to rise again until 1470, so the initial Black Death event on its own does not entirely provide a satisfactory explanation to this extended period of decline in prosperity. See Medieval demography for a more complete treatment of this issue and current theories on why improvements in living standards took longer to evolve.

The great population loss brought economic changes based on increased social mobility, as depopulation further eroded the peasants' already weakened obligations to remain on their traditional holdings. In the wake of the drastic population decline brought on by the plague, authorities in Western Europe worked to maintain social order through instituting wage controls. These governmental controls were set in place to ensure that workers received the same salary post-plague as they had before the onslaught of the Black Death. Within England, for example, the Ordinance of Labourers, created in 1349, and the Statute of Labourers, created in 1351, restricted both wage increases and the relocation of workers. If workers attempted to leave their current post, employers were given the right to have them imprisoned. The Statute was strictly enforced in some areas. For example, 7,556 people in the county of Essex were fined for deviating from the Statute in 1352. However, despite examples such as Essex County, the Statute quickly proved to be difficult to enforce due to the scarcity of labour.

In Western Europe, the sudden shortage of cheap labour provided an incentive for landlords to compete for peasants with wages and freedoms, an innovation that, some argue, represents the roots of capitalism, and the resulting social upheaval "caused" the Renaissance, and even the Reformation. In many ways the Black Death and its aftermath improved the situation of surviving peasants, notably by the end of the 15th century. In Western Europe, labourers gained more power and were more in demand because of the shortage of labour. In gaining more power, workers following the Black Death often moved away from annual contracts in favour of taking on successive temporary jobs that offered higher wages. Workers such as servants now had the opportunity to leave their current employment to seek better-paying, more attractive positions in areas previously off limits to them. Another positive aspect of the period was that there was more fertile land available to the population; however, the benefits would not be fully realized until 1470, nearly 120 years later, when overall population levels finally began to rise again.

In Eastern Europe, by contrast, renewed stringency of laws tied the remaining peasant population more tightly to the land than ever before through serfdom. Sparsely populated Eastern Europe was less affected by the Black Death and so peasant revolts were less common in the fourteenth and fifteenth centuries, not occurring in the east until the sixteenth through nineteenth centuries. Since it is believed to have in part caused the social upheavals of fourteenth- and fifteenth-century Western Europe, some see the Black Death as a factor in the Renaissance and even the Reformation in Western Europe. Therefore, some historians have cited the smaller impact of the plague as a contributing factor in Eastern Europe's failure to experience either of these movements on a similar scale. Extrapolating from this, the Black Death may be seen as partly responsible for Eastern Europe's considerable lag in the move to liberalise government by restricting the power of the monarch and aristocracy. A common example is that by the mid-sixteenth century, England began the process that ultimately ended serfdom there and gave rise to representative government; meanwhile, Russia did not formally abolish serfdom until an autocratic tsar decreed so in 1861.

Furthermore, the plague's great population reduction brought cheaper land prices, more food for the average peasant, and a relatively large increase in per capita income among the peasantry, if not immediately, in the coming century. Since the plague left vast areas of farmland untended, they were made available for pasture and put more meat on the market; the consumption of meat and dairy products went up, as did the export of beef and butter from the Low Countries, Scandinavia and northern Germany. However, the upper class often attempted to stop these changes, initially in Western Europe, and more forcefully and successfully in Eastern Europe, by instituting sumptuary laws. These regulated what people (particularly of the peasant class) could wear, so that nobles could ensure that peasants did not begin to dress and act as a higher class member with their increased wealth. Another tactic was to fix prices and wages so that peasants could not demand more with increasing value. This was met with varying success depending on the amount of rebellion it inspired; such a law was one of the causes of the 1381 Peasants' Revolt in England.

The increase in social mobility that the Black Death contributed to may have been one means by which the Great Vowel Shift was propagated.

Persecutions


As previously mentioned in reference to the plague's sociocultural impacts, renewed religious fervor and fanaticism bloomed in the wake of the Black Death. Some Christians targeted "various groups such as Jews, friars, foreigners, beggars, pilgrims", lepers and gypsies, thinking that they were to blame for the crisis. Lepers, and other individuals with skin diseases such as acne or psoriasis, were singled out and exterminated throughout Europe. Anyone with leprosy was believed to show an outward sign of a defect of the soul.

Differences in cultural and lifestyle practices also led to persecution. Because Jews had a religious obligation to be ritually clean they did not use water from public wells and so were suspected of causing the plague by deliberately poisoning the wells. Typically, comparatively fewer Jews died from the Black Death, in part due to rabbinical laws that promoted habits that were generally cleaner than that of a typical medieval villager. They also were often socially isolated in Jewish ghettos and, as such, were less likely to be infected This led to lower mortality rates in the Jewish population and raised suspicions in people who had no concept of bacterial transmission.

Christian mobs attacked Jewish settlements across Europe; by 1351, sixty major and 150 smaller Jewish communities had been destroyed, and more than 350 separate massacres had occurred. This persecution reflected more than ethnic hatred. In many places, attacking Jews was a way to criticize the monarchs who protected them (Jews were under the protection of the king, and often called the "royal treasure"), and monarchic fiscal policies, which were often administered by Jews. An important legacy of the Black Death was to cause the eastward movement of what was left of north European Jewry to Poland and Russia, where it remained until the twentieth century.

According to Joseph P. Byrne in his book, The Black Plague, women also faced persecution during the Black Death. Muslim women in Cairo became scapegoats when the plague struck. Byrne writes that in 1438, the sultan of Cairo was informed by his religious lawyers that the arrival of the plague was Allah’s punishment for the sin of fornication and that in accordance with this theory, a law was set in place stating that women were not allowed to make public appearances as they may tempt men into sin. Byrne describes that this law was only lifted when “the wealthy complained that their female servants could not shop for food.”

Religion


The Black Death led to cynicism toward religious officials who could not keep their promises of curing plague victims and banishing the disease. No one, the Church included, was able to cure or accurately explain the reasons for the plague outbreaks. One theory of transmission was that it spread through air, and was referred to as miasma, or 'bad air'. This increased doubt in the clergy's abilities. Extreme alienation with the Church culminated in either support for different religious groups such as the flagellants, which from their late 13th century beginnings grew tremendously during the opening years of the Black Death, and later to a pursuit of pleasure and hedonism. It was a common belief at the time that the plague was due to God's wrath, caused by the sins of mankind; In response, the flagellants travelled from town to town, whipping themselves in an effort to mimic the sufferings of Jesus prior to his crucifixion. Originating in Germany, several miraculous tales emerged from their efforts, such as a child being revived from the dead, and a talking cow. These stories further fuelled the belief that the flagellants were more effective than church leaders. It may have been that the flagellant's later involvement in hedonism was an effort to accelerate or absorb God's wrath, to shorten the time with which others suffered. More likely, the focus of attention and popularity of their cause contributed to a sense that the world itself was ending, and that their individual actions were of no consequence.

Sadly, the flagellants may have more likely contributed to the actual spreading of the disease, rather than its cure. Presumably, there were towns that the flagellants visited or passed through which were largely unaffected by the plague until that point, only to be infected by fleas carried either by the flagellant's followers, or the flagellants themselves. This is a common ironic theme in how individuals at the time dealt with the plague -- that in nearly all cases, the methods employed to defend against the plague encouraged its spread.

The Black Death hit the monasteries very hard because of their proximity with the sick, who sought refuge there, so that there was a severe shortage of clergy after the epidemic cycle. This resulted in a mass influx of hastily-trained and inexperienced clergy members, many of whom knew little of the discipline and rigor of the veterans they replaced. This led to abuses by the clergy in years afterwards and a further deterioration of the position of the Church in the eyes of the people.

Other effects




After 1350, European culture in general turned very morbid. The general mood was one of pessimism, and contemporary art turned dark with representations of death.

In retrospect, it seemed like everything the people thought to do at the time simply made the problem worse. For example, since many equated the plague with God's wrath against sin, and that cats were often considered in league with the Devil, cats were killed en masse. Had this bias toward cats not existed, local rodent populations could have been kept down, lessening the spread of plague-infected fleas from host to host.

The practice of alchemy as medicine, previously considered to be normal for most doctors, slowly began to wane as the citizenry began to realize that it seldom affected the progress of the epidemic and that some of the potions and "cures" used by many alchemists only served to worsen the condition of the sick. Liquor, originally made by alchemists, was commonly applied as a remedy for the Black Death, and, as a result, the consumption of liquor in Europe rose dramatically after the plague. The Church often tried to meet the medical need.

A plague doctor's duties were often limited to visiting victims to verify whether they had been afflicted or not. Surviving records of contracts drawn up between cities and plague doctors often gave the plague doctor enormous latitude and heavy financial compensation, given the risk of death involved for the plague doctor himself. Most plague doctors were essentially volunteers, as qualified doctors had (usually) already fled, knowing they could do nothing for those affected.

Considered an early form of hazmat suit, a plague doctor's clothing consisted of:


 * A wide-brimmed black hat worn close to the head. At the time, a wide-brimmed black hat would have been identified a person as a doctor, much the same as how nowadays a hat may identify chefs, soldiers, and workers. The wide-brimmed hat may have also been used as partial shielding from infection.


 * A primitive gas mask in the shape of a bird's beak. A common belief at the time was that the plague was spread by birds. There may have been a belief that by dressing in a bird-like mask, the wearer could draw the plague away from the patient and onto the garment the plague doctor wore. The mask also included red glass eyepieces, which were thought to make the wearer impervious to evil. The beak of the mask was often filled with strongly aromatic herbs and spices to overpower the miasmas or "bad air" which was also thought to carry the plague. At the very least, it may have served a dual purpose of dulling the smell of unburied corpses, sputum, and ruptured bouboules in plague victims.


 * A long, black overcoat. The overcoat worn by the plague doctor was tucked in behind the beak mask at the neckline to minimize skin exposure. It extended to the feet, and was often coated head to toe in suet or wax. A coating of suet may have been used with the thought that the plague could be drawn away from the flesh of the infected victim and either trapped by the suet, or repelled by the wax. The coating of wax likely served as protection against respiratory droplet contamination, but it was not known at the time if coughing carried the plague. It was likely that the overcoat was waxed to simply prevent sputum or other bodily fluids from clinging to it.


 * A wooden cane. The cane was used to both direct family members to move the patient, other individuals nearby, and possibly to examine the patient with directly.


 * Leather breeches. Similar to waders worn by fishermen, leather breeches were worn beneath the cloak to protect the legs and groin from infection. Since the plague often tended to manifest itself first in the lymph nodes, particular attention was paid to protecting the armpits, neck, and groin.

The plague doctor's clothing also had a secondary use: to intentionally frighten and warn onlookers. The bedside manner common to doctors of today did not exist at the time; part of the appearance of the plague doctor's clothing was meant to frighten onlookers, and to communicate that something very, very wrong was nearby, and that they too might become infected. It's not known how often or widespread plague doctors were, or how effective they were in treatment of the disease. It's likely that while offering some protection to the wearer, they may have actually contributed more to the spreading of the disease than its treatment, in that the plague doctor unknowingly served as a vector for infected fleas to move from host to host.

Although the Black Death highlighted the shortcomings of medical science in the medieval era, it also led to positive changes in the field of medicine. As described by David Herlihy in The Black Death and the Transformation of the West, more emphasis was placed on “anatomical investigations” following the Black Death. How individuals studied the human body notably changed, becoming a process that dealt more directly with the human body in varied states of sickness and health. Further, at this time, the importance of surgeons became more evident.

A theory put forth by Stephen O'Brien says the Black Death is likely responsible, through natural selection, for the high frequency of the CCR5-Δ32 genetic defect in people of European descent. The gene affects T cell function and provides protection against HIV, smallpox, and possibly plague, though for the latter, no explanation as to how it would do that exists. This, however, seems unlikely, given that the CCR5-Δ32 gene has been found to be just as common in Bronze Age tissue samples.

The Black Death also inspired European architecture to move in two different directions; there was a revival of Greco-Roman styles that, in stone and paint, expressed Petrarch's love of antiquity and a further elaboration of the Gothic style. Late medieval churches had impressive structures centered on verticality, where one's eye is drawn up towards the high ceiling for a religious experience bordering on the mystical. The basic Gothic style was revamped with elaborate decoration in the late medieval period. Sculptors in Italian city-states emulated the work of their Roman forefathers while sculptors in northern Europe, no doubt inspired by the devastation they had witnessed, gave way to a heightened expression of emotion and an emphasis on individual differences. A tough realism came forth in architecture as in literature. Images of intense sorrow, decaying corpses, and individuals with faults as well as virtues emerged. North of the Alps, paintings reached a pinnacle in precise realism with the Flemish school of Jan Van Eyck (c. 1385-1440). The natural world was reproduced in these works with meticulous detail bordering on photography.

Contemporary
The Black Death dominated art and literature throughout the generation that experienced it. Much of the most useful manifestations of the Black Death in literature, to historians, comes from the accounts of its chroniclers; contemporary accounts are often the only real way to get a sense of the horror of living through a disaster on such a scale. A few of these chroniclers were famous writers, philosophers and rulers (like Boccaccio and Petrarch). Their writings, however, did not reach the majority of the European population. For example, Petrarch's work was read mainly by wealthy nobles and merchants of Italian city-states. He wrote hundreds of letters and vernacular poetry of great distinction and passed on to later generations a revised interpretation of courtly love. There was, however, one troubadour, writing in the lyric style long out of fashion, who was active in 1348. Peire Lunel de Montech composed the sorrowful sirventes "Meravilhar no·s devo pas las gens" during the height of the plague in Toulouse.

Although romances continued to be popular throughout the period, the courtly tradition began to face increasing competition from ordinary writers who became involved in producing gritty realist literature, inspired by their Black Death experiences. This was a new phenomenon, made possible because vernacular education and literature, as well as the study of Latin and classical antiquity, flourished widely, making the written word steadily more accessible during the fourteenth century. For example, Agnolo di Tura, of Siena, records his experience: "Father abandoned child, wife husband, one brother another; for this illness seemed to strike through the breath and sight. And so they died. And none could be found to bury the dead for money or friendship. Members of a household brought their dead to a ditch as best they could, without priest, without divine offices ... great pits were dug and piled deep with the multitude of dead. And they died by the hundreds both day and night... And as soon as those ditches were filled more were dug ... And I, Agnolo di Tura, called the Fat, buried my five children with my own hands. And there were also those who were so sparsely covered with earth that the dogs dragged them forth and devoured many bodies throughout the city. There was no one who wept for any death, for all awaited death. And so many died that all believed it was the end of the world. This situation continued [from May] until September."

The scene Di Tura describes is repeated over and over again all across Europe. In Sicily, Gabriele de'Mussi, a notary, tells of the early spread from Crimea: "Alas! our ships enter the port, but of a thousand sailors hardly ten are spared. We reach our homes; our kindred…come from all parts to visit us. Woe to us for we cast at them the darts of death! …Going back to their homes, they in turn soon infected their whole families, who in three days succumbed, and were buried in one common grave. Priests and doctors visiting…from their duties ill, and soon were…dead. O death! cruel, bitter, impious death! …Lamenting our misery, we feared to fly, yet we dared not remain."

Henry Knighton tells of the plague’s coming to England: "Then the grievous plague came to the sea coasts from Southampton, and came to Bristol, and it was as if all the strength of the town had died, as if they had been hit with sudden death, for there were few who stayed in their beds more than three days, or two days, or even one half a day."

Friar John Clyn witnessed its effects in Leinster, after its spread to Ireland in August 1348: "That disease entirely stripped vills, cities, castles and towns of inhabitaints of men, so that scarcely anyone would be able to live in them. The plague was so contagious that thous touching the dead or even the sick were immediately infected and died, and the one confessing and the confessor were together led to the grave ... many died from carbuncles and from ulcers and pustles that could be seen on shins and under the armpits; some died, as if in a frenzy, from pain of the head, others from spitting blood ... In the convent of Minors of Drogheda, twenty five, and in Dublin in the same order, twenty three died ... These cities of Dublin and Drogheda were almost destroyed and wasted of inhabitants and men so that in Dublin alone, from the beginning of August right up to Christmas, fourteen thousand men died ... The pestilence gathered strength in Kilkenny during Lent, for between Christmas day and 6 March, eight Friars Preachers died. There was scarcely a house in which only one died but commonly man and wife with their children and family going one way, namely, crossing to death.''"

In addition to these personal accounts, many presentations of the Black Death have entered the general consciousness as great literature. For example, the major works of Boccaccio (The Decameron), Petrarch, Geoffrey Chaucer (The Canterbury Tales), and William Langland (Piers Plowman), which all discuss the Black Death, are generally recognized as some of the best works of their era.

 La Danse Macabre, or the Dance of death, was a contemporary allegory, expressed as art, drama, and printed work. Its theme was the universality of death, expressing the common wisdom of the time: that no matter one's station in life, the dance of death united all. It consists of the personified Death leading a row of dancing figures from all walks of life to the grave – typically with an emperor, king, pope, monk, youngster, beautiful girl, all in skeleton-state. They were produced under the impact of the Black Death, reminding people of how fragile their lives were and how vain the glories of earthly life. The earliest artistic example is from the frescoed cemetery of the Church of the Holy Innocents in Paris (1424). There are also works by Konrad Witz in Basel (1440), Bernt Notke in Lübeck (1463) and woodcuts by Hans Holbein the Younger (1538). Israil Bercovici claims that the Danse Macabre originated among Sephardic Jews in fourteenth century Spain (Bercovici, 1992, p. 27).

The poem "The Rattle Bag" by the Welsh poet Dafydd ap Gwilym (1315-1350 or 1340-1370) has many elements that suggest that it was written as a reflection of the hardships he endured during the Black Death. It also reflects his personal belief that the Black Death was the end of humanity, the Apocalypse, as suggested by his multiple biblical references, particularly the events described in the Book of Revelation.

Thomas Nashe also wrote a sonnet about the plague entitled "A Litany in Time of Plague" which was part of Summers last will and Testament (1592). He made countryside visits to remove himself from London in fear of the plague.

Additionally see Aleksandr Pushkin's verse play, "Feast in the Time of the Plague".

The Black Death quickly entered common folklore in many European countries. In Northern Europe, the plague was personalized as an old, bent woman covered and hooded in black, carrying a broom and a rake. Norwegians told that if she used the rake, some of the population involved might survive, escaping through the teeth of the rake. If she on the other hand used the broom, then the entire population in the area were doomed. The Plague-hag, or Pesta, were vividly drawn by the painter Theodor Kittelsen.

Women during and after the Black Death also benefited from the growing importance of vernacular literature because a broader cultural forum became available to them which had previously been restricted to men by the Latin church. And so, they began writing and fostering through patronage the writings and translations of others. For example, in France, Christine de Pizan (1364-1430) became the first woman in Europe to support herself by writing. She wrote in many different literary forms, such as an autobiography and books of moral advice for men and women, as well as poetry on a wide range of topics. In her treatise The Letter to the God of Love, she effectively rebutted Jean de Meun's anti-feminist diatribes found in his conclusion of Romance of the Rose. Her rebuttal is important because it marked the first instance in European history where a woman wrote about the slanders women had long endured. It also led to a debate among de Meun and Pizan sympathizers which lasted until the sixteenth century.

Modern
The Black Plague has been used as a subject or as a setting in modern literature and also media. This may be due to the era's resounding impact on ancient and modern history, and its symbolism and connotations.

Albert Camus's novel La Peste deals with the coming of a plague to Algeria.

Hermann Hesse's novel Narcissus and Goldmund depicts two monks living during the Black Death, one of whom leaves the monastery to wander around the country, seeing the epidemic's effects firsthand.

Norman F. Cantor's novel "In the Wake of the Plague" New York Times Bestseller "Cantor illuminates intricate connections that alter the course of culture, religion, and peace in incalculable ways." - Boston Globe

Alessandro Manzoni's novel The Betrothed contains an extraordinary description of the plague that struck Milan in 1630. Although a work of fiction, Manzoni's description of the conditions and events in plague-ravaged Milan are completely historical and extensively documented from primary sources researched by Manzoni.

Roger Zelazny's novel Nine Princes in Amber has his protagonist abducted from his birthland and taken to plague-torn England to die.

Edgar Allan Poe's short story "The Masque of the Red Death" (1842) is set in an unnamed country during a fictional plague that bears strong resemblance to the Black Death. This possibility is furthered by the climax of the story taking place in a black room.

Nobel prizewinner Sigrid Undset's novel Kristin Lavransdatter features the outbreak of the plague in 14th century Norway.

Year of Wonders by Geraldine Brooks (2001) is a NY Times and Washington Post Notable Book set in 1666 England. It chronicles the impact of the plague upon the residents of an isolated mountain village, who choose to quarantine themselves rather than contribute to the spread of the disease.

Connie Willis's Hugo Award-winning science fiction novel Doomsday Book imagines a future in which historians do field work by travelling into the past as observers. The protagonist, a historian, is sent to the wrong year, arriving in England just as the Black Death is starting. Also, In Michael Crichton's book Timeline, a character is transported through time to a village that is apparently affected by the Black Death.

In Kim Stanley Robinson's alternate history novel The Years of Rice and Salt, a Black Death with a virtually 100% mortality rate depopulates Medieval Europe; Western Christendom is utterly destroyed as a civilization and Europe plays no major role in world history.

Three novels by Ann Benson play on parallels between the Black Death and emerging diseases in the modern world. In The Plague Tales (1998), Burning Road (2000) and The Physician's Tale (2007), Benson shifts back and forth between the fourteenth century and a world in the near future that has been devastated by an antibiotic-resistant bacterium. She weaves in allusions to many of the contemporary sources, and even modern fiction like Geraldine Brooks' Year of Wonders.

Eifelheim by Michael Flynn depicts the interactions between an isolated German village and a group of stranded extraterrestrials as the plague advances (1348-9).

Temple of the Winds, the fourth book in the fantasy series The Sword of Truth by Terry Goodkind, centers around a plague that is very similar to the Black Death.

Melanie Rawn's fantasy novel, Dragon Prince, shows how a plague-like epidemic affects nobility somewhat less than commoners.

It has been alleged (since 1961) that the Black Death inspired one of the most enduring nursery rhymes in the English language, Ring a Ring o' Roses, a pocket full of posies, / Ashes, ashes (or ah-tishoo ah-tishoo), we all fall down. However, there are no written records of the rhyme before the late 19th century and not all of its many variants refer to ashes, sneezing, falling down or anything else that could be connected to the Black Death.

The relatively new medium of film has given writers and film producers an opportunity to portray the plague with more visual realism. One of the best known and most expansive depictions of the black plague as art is the movie classic The Seventh Seal, a 1957 film directed by Ingmar Bergman. The knight returns from the Crusades and finds that his home country is ravaged by the Black Death. To his dismay, but not surprise, he discovers that Death has come for him too. The final scene of The Seventh Seal depicts a kind of Danse Macabre. The 1988 science fiction film The Navigator: A Medieval Odyssey portrays a group of 14th-century English villagers who, with the aid of a boy's clairvoyant visions, dig a tunnel to 20th-century New Zealand to escape the Black Death.

Panic in the Streets is a black and white, 96-minute film directed by Elia Kazan and released in 1950 by 20th Century Fox. It is film noir semidocumentary shot exclusively on location in New Orleans, Louisiana and featuring numerous New Orleans citizens in speaking and non-speaking roles. The film tells the story of Clinton Reed, an officer of the U.S. Public Health Service (played by Richard Widmark) and a police captain (Paul Douglas) who have only a day or two in which to prevent an epidemic of pneumonic plague after Reed determines a waterfront homicide victim is an index case. It was the film debut of Jack Palance and Zero Mostel.

The Black Metal band 1349 is named after the year the Black Death spread through Norway.

Danse Macabre by The Faint is a techno dance album alluding to the Black Death.

Piers Anthony's 1988 novel, For Love of Evil, is sixth in his Incarnations of Immortality series. In this series, several major forces in mankind's existence are offices held by mortals for various lengths of time before passing to a successor. The Black Death was brought to Europe by Satan to exact revenge on the office of Nature and also discomfited the offices of Death and Fate.

Ken Follett's 2007 novel, World Without End, deals with the lives of four children who live through the Black Death from 1327 to 1361.

The "Bring out your dead!" scene in the Monty Python movie Monty Python and the Holy Grail famously deals with the ubiquity of plague-related deaths in medieval villages, although the film is explicitly set in 932, and King Arthur would suggest an even earlier date than that.

In Garth Nix's book Mister Monday the main characters end up in the Black Death ridden streets. It depicts the roads as covered with piles of the dead.

In the beginning of the videogame Neverwinter Nights the player is in a city which suffers from a fictitious, epidemic disease called the "Howling Death", which bears some resemblance to the Black Death.

Primary sources online

 * Henry Knighton's account
 * Gabriele de' Mussi's account
 * Marchionne di Coppo di Stefano Buonaiuti's account
 * A Petrarch account and More quotes from Petrarch

Secondary sources online

 * Plague - LoveToKnow 1911
 * "Black Death". In Encyclopædia Britannica Online.
 * The History Guide "Satan Triumphant: The Black Death"
 * Symptoms, causes, pictures of bubonic plague
 * Overview of the black death
 * BBC news story on controversy over Black Death origins
 * Examination of "Ring around the Rosy"'s relationship to the plague
 * Black Death Overview from BBC
 * Plague and Public Health in Renaissance Europe. Primary source documents and analysis.
 * Secrets of the Dead . Mystery of the Black Death PBS
 * Pandemics in Eastern Europe

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