Ring a ring o'roses
A pocket full of posies
Atishoo! Atishoo!
We all fall down
Cheerful as this children's rhyme sounds, one theory of its origin is as a description of plague. 'Ring o'roses' referred to the skin changes that resulted from it, and sneezing was a symptom of the respiratory form of the disease. The pleasant smell of a posy of fragrant herbs was believed to prevent contagion from bad smells, and many of those who 'fell down' in real life never got up again. Though the rhyme is now all that remains of the plague in English folk memory, it dominated English life for two-and-a-half centuries, from 1348 to 1679, and left its mark on history and literature.
Plague results from infection with the bacterium, Pasteurella pestis , sometimes called Yersinia pestis , and the incubation period is from two to four days. The illness may take a bubonic, septicaemic of pneumonic form. The bubonic form is characterised by buboes, which are masses of tender, enlarge lymph nodes, usually in the groin or axilla. They are painful until they suppurate and drain, usually one to two weeks after the onset of the illness. The patient has a high fever (102-5 F, 38.89-40.56 C) over this period, with toxic symptoms of headache, vomiting and ataxia. He may also show a bleeding tendency, with petechiae and bruising of the skin and internal, visceral bleeding which may prove fatal. The septicaemic form of the disease is simply an overwhelming infection where the patient dies before the buboes have a chance to develop. The pneumonic form probably occurs in about 5 per cent of patients. Lung lesions develop and break down, so that the patient produces blood-stained sputum teeming with the organism. He is then a dangerous source of airborne droplet infection. The proportion of deadly pneumonic cases seems to have varied in different plague epidemics, and its relation to the commoner bubonic type is not clear. Some authorities believe plague was more likely to take the pneumonic form during the winter; others, however, think winter plague unlikely, and attribute the reported winter deaths to some other overwhelming lung infection, Before antibiotics, pneumonic and septicaemic plague were almost always fatal. Modern antibiotic therapy is usually effective, and deaths now only occur when diagnosis, and hence treatment, are delayed.
The way in which plague spreads is one of the most interesting features of the disease. It is not primarily a disease of man at all, but of rodents. In England the rodent affected was the black rat, Rattus rattus . This is essentially a climbing animal which lives in walls and roofs, always in close contact with man. The plague bacillus is carried from rat to rat by the bite of the rat flea. Like most fleas, the rat flea prefers to feed off a single species of animal, and will only bite humans when an outbreak of rat plague has left insufficient rats to feed off. This means that human epidemics always follow rat epidemics - well described in Camus's novel The Plague . Interestingly, though many signs and portents were thought to herald a plague epidemic, there are no European records of an increased number of dead rats before the humans fell sick. However, the Indian writer, Nawab Mu'tamad Khan, seems to have noticed this in the first quarter of the seventeenth century.
The mouth-parts of the rat flea are a very efficient means of transmitting the plague, and function rather like a combined syringe, needle and blood- culture bottle. When an infected rat is bitten, a bloody suspension of living plague bacilli is drawn up into the flea's stomach, where they multiply and block the gut. The flea becomes hungry, but cannot feed until this blockage is disposed of. It is then termed a 'blocked flea', When it sinks its mouth-parts into the next victim, the flea injects its previous meal, now cultured into a teeming mass of living plague bacilli, into the bitten area. At the same time the flea defecates, and scratching the fleabites helps to inoculate faecal plague bacilli. Within a few days the lymph nodes draining the bitten area form buboes, and a new case of plague becomes clinically apparent.
Though a case of pneumonic plague may infect by droplet spread, the new case is likely to revert to the bubonic form. Pneumonic cases, with person- to-person spread, are rare, therefore, compared to bubonic cases, and person-to-person spread of disease used to be the norm; smallpox and the sweating sickness both produced their havoc in this way. The particular dread of plague above all other diseases may have been due to the mysterious way it seemed to be passed on: there was something inexplicable and almost supernatural about a disease which could not be contained by normaI quarantine measures. Only at the end of the last century, with the discovery of the organism and its mode of passage, was the mystery fully solved.
An epidemic of bubonic plague requires the presence of Pasteurella pestis , a rodent host for the bacillus in close contact with man, and fleas to transmit the germ among rats and eventually among humans. Pasteurella pestis seems to have begun causing disease from at least as early as 300 BC, when descriptions of a plague-like illness are first found. The first pandemic was in the sixth century AD, in the time of the Emperor Justinian. Almost all of Europe was affected, as far north and west as southern France, but England was spared, probably because rats had not yet arrived. The earliest certain reference to rats in English literature is a doodle of two rats hanging a cat at the end of a thirteenth-century genealogical roll now in the British Museum. Rats are notably absent from a tenth-century list of pests from which parish priests were expected to protect the altar bread. By the early fourteenth-century there are many references to rats, and Chaucer (born around 1340) mentions shops that sold rat poison. The English rat population was certainly large enough for England to suffer the next world pandemic of 1347-48, and consisted of black house rats, living close to man.
English plague epidemics showed a tendency to start in spring, reach a peak in late summer and early autumn and decline with the first signs of winter. This is because rat fleas tend to hibernate and may even die when the weather is cold. There has been little bubonic plague in recent times; the last big outbreak was in 1896 and spared England. However, this does mean that almost all our knowledge of the plague is pre-scientific, and heavily coloured both by the opinions of those living and writing at the time, and those who study it now.
Plague first ravaged England in 1348, during the second great pandemic. Since the early nineteenth century this epidemic has been popularly known as the Black Death, though before then it was called the Great Mortality or the Great Pestilence. At that time, the poor lived in single-storey thatched wattle- and-daub hovels. Rats burrowed under the earth floor and climbed the walls to build their nests in the roofs, from which blocked fleas could fail to infect the people below. The houses of the more well-to-do included an upper storey. Infection was therefore less likely to occur via a blocked flea, and plague was correspondingly rarer.
Having spread from India through Asia, North Africa and Europe, plague probably entered England via an infected rat or flea at Melcombe Regis (now called Weymouth) about the end of July or beginning of' August, 1348. It then spread through the south-west to Bristol and then eastwards to Oxford and London, which it had reached by the end of October or the beginning of November. Records suggest that it travelled at the rate of about one-and-a-half miles per day, suggesting a 'creeping epizootic'; in other words the introduced germ established itself in the English rat population, which had not met it before, and gave rise to a rat plague epidemic. The disease then spread to humans as the rats died and rat blood became scarce for the fleas to feed on, It is difficult to know how many people died. Parish registers of baptisms, marriages and burials do not start until 1538, and many were lost, especially those of London in the Great Fire of 1666 and the Blitz. School history books give the impression that only a fraction of the population survived, but doubt has recently been cast on this, and it is time to consider evidence again.
Accurate statistics are available for some affected areas during the last pandemic of 1896. Then, in the crowded towns of India, one-third of the population caught the disease and between 70 per cent and 80 per cent of those affected died - that is, about 25 per cent of the urban population. However, it is difficult to relate these figures to fourteenth-century England, essentially a rural community, and one that, unlike India, was without previous exposure to the plague.
Although deaths were not recorded for the general population in fourteenth-century England, it is possible to estimate figures for deaths among the clergy. Diocesan records note whenever a new incumbent was instituted in any diocese, but unfortunately not the reason for the vacancy. Overall, about 40 per cent of the parochial clergy needed replacing, rising to 66 per cent in the heavily populated wool country of East Anglia, which was a badly affected area. However, we cannot be sure that all the replaced clergy had died of the plague; we do not know how many simply deserted a very lonely and frightening position just as the London Blitz provided opportunities for people to disappear. Even less are we justified in extrapolating from clergy figures to a likely death-rate among the general population, for we have no idea how the likelihood of the clergy's contracting the plague compared with that of their flock, nor of their death-rate in other, non-plague areas.
Pessimists among the commentators on the Black Death put the death-rate as high as 20-50 per cent of the population, that is, of an estimated population of four million, 800,000 to two million died. They base this estimate on the high figure for clergy inductions, and on the many pleas for remission of taxes from all over the country on the grounds that there were insufficient wealth and labour to pay them. They also point out that the clergy extended full absolution without confession to all those dying of the plague, because of the shortage of priests. Also, continental writers describe a high proportion of cases of the deadly pneumonic form of the disease in the same epidemic, and thus a higher than usual death-rate. On the other hand, optimists among historians estimate the death-rate far some areas as low as 5 per cent. They doubt that plague can be transmitted pneumonically indefinitely, being more likely to revert to the less virulent bubonic form, and also note that large parts of the country, mainly the north- east, had a population density of less than twenty to twenty-five people per square mile, probably insufficient for a destructive epidemic. They further point out that though local business seems to have been interrupted by the plague, there do not seem to have been any deserted villages, there was no revolution in agriculture or land tenure and the war with France went on. However, some early medieval churches seem oddly situated with respect to later buildings, suggesting the presence of an earlier community which had since disappeared. The shortage of labourers following a high mortality among the poor may well have contributed to the popular movement culminating in the Peasants' Revolt, and to the hiatus in church building between Decorated and Perpendicular Gothic. Certainly, some monastic communities never regained their pre-plague numbers. There is one very moving personal account of how it felt to be alive in those bleak times. On the wall of a church tower in the village of Ashwell in Hertfordshire is a remarkable series of graffiti. One of these translates as:
1350 - Miserable, wild, distracted. The dregs of the people alone survive to witness.
In summary, what we know of the history of the period would be compatible with a death-rate of very roughly 30 per cent, mainly among the poor, in a time when life expectancy was generally low. No estimate of mortality can however be more than an informed guess.