Unprecedented is a word that we have all heard many times since the scale of the current coronavirus disease pandemic became apparent. The authorities and the media talk of an “exceptional situation” a “unique threat” that is “unheard of in our country”. However, throughout our recorded history, contagions, epidemics and pandemics have been a regular feature of all human societies and often a source of instability and catalyst for change therein. Amid the COVID-19 pandemic, it is perhaps worth reminding ourselves of the magnitude of some earlier disease events and the resilience of societies when confronted with biological catastrophe.
Pandemics, such as the one we are currently enduring, have always been part of humanity’s lot; it is simply that it has, mercifully, been some time since we last experienced such a deadly outbreak. Perhaps the most infamous pandemic event and one that still holds a place in the popular imagination is the Black Death of the Middle Ages; a pandemic of bubonic plague that swept across the Near East, North Africa and Europe between 1347 and 1352. This was the first of a number of recurring plague epidemics between the 14th and 18th centuries known as the Second Plague Pandemic; the First Plague Pandemic having occurred in the 6th through to the 8th centuries.
Bubonic plague is a devastating disease caused by the bacterium Yersinia pestis that circulates among wild rodents. Plague among humans arises when rodents, such as black rats, become infected. Once infected, it can take up to a fortnight before plague has stricken off an entire infected rat colony, making it difficult for the large number of fleas gathered on the remaining dying rats to find new hosts. After three days without blood, the hungry fleas turn to whatever hosts they can find and the infection is transmitted after a flea that has fed from an infected rat then bites a human.
From the bite site, the contagion spreads through the bloodstream to the lymph nodes, where the bacteria replicate, causing the nodes to swell to form buboes or painful tumours as big as an egg in the armpits, groin, neck or thighs. Victims initially manifested symptoms similar to influenza but the appearance of these buboes, which often suppurated and haemorrhaged, would typically have been quickly followed by gastro-intestinal problems, continuous vomiting of blood, gangrene of the extremities and the severe pain brought on by necrosis. The plague delivered a truly terrible way to die; delirium and death finally overtaking the victim within another three to five days. Estimates vary as to the mortality rates of those that caught the plague in the Middle Ages but even a figure of 75 per cent might be an understatement.
The plague was a very virulent and fast moving disease; from the introduction of plague contagion among rats in a human community, it could take just over three weeks before the first human death. The infected fleas travelled great distances, relatively swiftly, on rats aboard ships that plied the trade routes of the Mediterranean littoral and northern Europe. Once ashore, the fleas could find a host travelling inland and so the disease quickly spread exponentially. Even once the initial host had died, the fleas could live for up to a year, transmitting the disease from one generation of fleas to the next and laying up to fifty eggs per day, every day. Additionally, plague bacteria can sometimes spread to the lungs and cause a variant of plague (pneumonic plague) that is spread by infected droplets inhaled from the cough and sneezes of victims.
The plague first reached France, via the southern port of Marseilles, towards the end of September 1347 and quickly spread from this important commercial hub; northwards up the Rhône valley to Lyons and westwards along the coast to Spain. Ships from Bordeaux likely carried infected rats to Normandy where the plague arrived in April 1348 before reaching Brittany towards the end of that year.
At the time of the arrival of the Black Death in Europe, it is believed that some 90 per cent of the continent’s population were rural dwellers, powerless to act in the face of the deadly onslaught of the plague. Accounts regarding the impact of the Black Death in Brittany are very scarce as its arrival coincided with the Breton War of Succession (1341–1364) but historians have discovered a remarkable consistency in mortality levels across Europe during the plague years. Recent estimates suggest that between 50 to 60 per cent of the population of Europe died as a result of the Black Death – a staggering 50 million people. After centuries of land clearance and population growth, hundreds of villages suddenly became virtual ghost towns and were abandoned to be reclaimed by nature.
The plague seems to have gradually diminished after 1353, spreading east of the Volga river and towards the Caspian Sea where it likely originated seven years earlier. However, the plague did not extinguish itself completely, the causal bacteria continued to leap across to humans and strike the people of Europe and beyond once or twice a generation for centuries. Few of the later outbreaks in this Second Plague Pandemic were as devastating as the Black Death but nonetheless are thought to have killed between ten to twenty per cent of the population with each deadly revisit.
The plague (vossen in Breton) returned to Brittany in 1404 and every decade of that century saw periodic outbreaks across the country with over a hundred outbreaks recorded between the years 1478-84 alone. In 1485, the last undisputed ruler of independent Brittany, Duke François II, created the post of Médecin des Épidémies (Doctor of Epidemics) based on the earlier models of specialist doctors created by the Pope and the King of France; the disease was still poorly understood and the medical establishment of the day struggled hard with how best to prevent its arrival and spread in their communities.
In time, the people became accustomed to living with the menace of the plague; it was now the new reality, the new norm. Prayers were widely offered to the 3rd century martyr Saint Sebastian who was held to possess the power to intercede to protect people from plague and special processions seeking his favour are recorded in several Breton towns particularly in the 16th and 17th centuries. The 14th century Saint Roch was also popularly prayed to here in times of plague.
Periodic epidemics of the plague remained a constant feature of life in Brittany throughout the 16th century; in 1501-02 over 4000 people fell mortal victims in the city of Nantes alone and there were further outbreaks recorded in 1514-19, 1522-23, 1529-30, 1563-65 and 1567-70. In 1582-84, the plague made a deadly appearance in both the northern and southern parts of the region with the areas around the towns of Dinan, Dol-de-Bretagne, Nantes, Rennes and Saint-Malo being particularly hard hit. Towards the end of 1583, the authorities closed the busy port of Saint-Malo to shipping and banned foreigners from the city.
At the same time, in the southern city of Nantes, the authorities ordered, under penalty of a fine, that inhabitants clear the pavement outside their dwellings daily. The city authorities also ordered the establishment of new latrines and a more systematic clearing of the old cess pits. Other public heath ordnances were also issued: regular fires were lit at crossroads to purify the air; plague-stricken houses would be cleaned; the sick were instructed to always carry a white stick to mark their presence and their clothes marked, front and back, with a white cross. Doctors and surgeons were also required to carry a white stick warning of their presence while out in the streets visiting the sick. Initially, the sick were taken to the lazarette or quarantine station, established outside the city walls during the previous epidemic in 1569, but this became too over-crowded even by 16th century standards. The white cross was also used in the city of Saint-Malo in 1584 and was daubed on the doors of contaminated houses as a sign prohibiting anyone from leaving or entering in order to limit the contagion.
The plague continued to spread through Brittany in the early 17th century; in June 1598, the north coast town of Morlaix was struck; in July and August over 300 people died in the central Brittany town of Pontivy. In September 1598 the people of the city of Saint-Brieuc were prohibited from trading with the nearby (just 7 miles/10km) town of Châtelaudren in an effort to stop the disease reaching their city. However, the city’s attempts at self-isolation ultimately failed and the city was ravaged in 1601-02, as was Lannion. At the time, many people thought that the plague was caused and spread by a miasma or bad air thus many people left their homes once the plague struck their city. Such a movement of people, of course, accelerated the spread of the disease and with the benefit of hindsight we should not be surprised to note the plague’s return in less than five years.
The south of the region was also hit by small localised outbreaks of the plague in the same year; the town of Quimper, still recovering from the loss of 1,700 people to an epidemic in 1594, was struck again in 1598 when about a third of the population were thought to have perished. There followed a relative respite for some twenty years before the plague re-appeared with an increased intensity.
In 1622, the Parlement of Brittany imposed a state of quarantine on Saint-Malo and three weeks of isolation were imposed on all people suspected of contracting the plague; it also ordered a ban on children from Saint-Malo, Saint-Brieuc, Dinan and Dol from entering the Breton capital Rennes (itself ravaged by plague from 1624 to 1632). An outbreak of plague in the south coast town of Port Louis in 1623 resulted in the nearby and more populous town of Auray imposing a state of quarantine; fishermen were banned from visiting or trading and people arriving by land were firstly held in isolation for three weeks. The authorities ordered the destruction of all stray animals; pigs and pigeons being specifically subject to strict confinement (previously pigs had been free to roam the streets foraging for scraps). Citizens were also ordered to keep the pavement outside their dwellings clean with harsh punishments for the lackadaisical.
Despite these efforts, records show that the plague struck two of the communes surrounding the town in 1630 before later breaking into the town and striking into all surrounding communes. As in other towns hit by the plague, large bonfires were regularly lit in the streets in an attempt to purify the air. This was also done in nearby Vannes where, in the same year, the authorities levied a small tax to pay for the removal of the city’s rubbish and transport it to offshore mudflats. In Auray, a lazarette was established outside the town and a rudimentary medical service organised by the local Capuchin community. Records indicate that the sanitary cordon around Auray was still in force in 1633.
Further along the east coast, the people of the city of Vannes also suffered significantly during the plague epidemics of this time, particularly in 1625, 1634 and 1638. To the west, the town of Quimper recorded scores of deaths in 1639; while, still further along the east coast, Nantes was hard hit by the disease in 1625-26 and 1631 and by this time, plague victims were no longer allowed to be buried within the precincts of the city.
One of the last appearances of the plague in Brittany was in Pontivy in 1696. Attesting to the importance of river traffic at the time, it is possible to track the spread of the disease down the course of the river Blavet to its mouth at Hennebont. Here in the summer of 1699, the plague claimed half a dozen people every day. With no medical solution to halt the spread of the disease, the townsfolk sought divine intervention and prayed to the Virgin to end the epidemic; committing to create a silver statue and undertake an annual procession in her honour (they had similarly promised to build a chapel in honour of Saint Roch during the epidemic of the early 1630s but this was never realised!). It has been noted that instances of the disease in the town decreased rapidly after the town’s wish was announced, disappearing entirely by September 1700. To honour their pledge, the people or Hennebont commissioned the statue and inaugurated the public procession of thanks. Unfortunately, the statue was melted-down during the Revolution but it is today possible to see a substitute statue and even participate in the procession held on the last Sunday in September.
The plague of Marseilles in 1720-1721, which resulted in some 87,000 deaths, is considered to be the last major plague outbreak in Western Europe but cases are still regularly reported in other parts of the world even today. The impact of almost four hundred years of intermittent but deadly plague outbreaks changed Europe forever; demographically, politically and economically. Equally profound were the changed mentalities brought about by the plague and other infectious diseases; governments and the governed appreciated the importance of public health and hygiene programmes, particularly effective sanitary measures.
While the plague and its dreadful death toll might have been consigned to history, other diseases such as cholera, dysentery, typhoid, smallpox, measles and influenza, were responsible for extraordinary devastation in Brittany. In the 18th and 19th centuries, increases in population density, transport infrastructure and mercantile links were all key factors in giving diseases spread by cross-infection between humans powers of spread far greater than those seen in previous centuries.
The first of several deadly outbreaks of cholera that ravaged Brittany in the 19th century was part of a worldwide pandemic that was believed to have started in India in 1826. The seemingly relentless march of this disease westwards saw the French government impose border controls in August 1831 to stop infected people from entering the country. However, the disease reached Paris in March 1832 and the speed which the disease overtook its victims, some dying within a matter of hours, caused widespread panic; some believed that government agents were poisoning the drinking fountains and wells.
It seems that the disease first manifested itself in Brittany in early May 1832, carried by a master mariner from Toulon who disembarked at Nantes before falling ill near Vannes. Victims of cholera can start to display symptoms between one to five days after infection, so, it is impossible to know how many fellow travellers this diseased sailor infected on his two day journey to Quimper. Suffering from severe vomiting and diarrhoea, the patient was taken openly through the busy streets from his lodgings to the town’s hospice where he died. He was buried the next day and a little of his blood was diluted in water and given to birds to drink to see if they were affected by it. While the birds showed no negative reactions to the bloody concoction, two members of the nursing staff were already displaying symptoms; the first of more than 200 cholera fatalities in Quimper that summer.
Cholera is essentially a bacterial disease that causes an infection of the small intestine which swiftly leads to fairly brutal diarrhoea (sometimes as much as 10-20 litres or 3-5 gallons per day) and vomiting, resulting in severe dehydration and low blood pressure in the victims. Such acute dehydration shrivels the skin, sinks the eyes and usually turns the skin a shade of blue; the disease is therefore sometimes known as the Blue Death.
The disease is spread mostly by water and food that has been contaminated with human feces containing the bacteria. At the time, people were at a loss to understand the disease as one side of a street could be hit, while the other was spared and it would be another twenty three years before the English doctor, John Snow, identified waterborne microbes as the culprit (it seems he did know something after all).
Some contemporary doctors believed cholera to be a contagion, others thought it was due to a miasma; one doctor in Quimper even advised the town in the grip of the epidemic that the disease was not contagious. While the medical establishment strived to understand the disease, two main but contradictory treatments were espoused; one held that cholera overstimulated the body and prescribed cold drinks, blood-letting and opium-laced enemas; the other advocated hot drinks, hot baths infused with vinegar and camphorated alcohol to stimulate the system. Amidst this confusion, charlatans profited by selling miraculous but entirely bogus remedies to the desperate people with little enough to spare.
Unlike childhood diseases such as smallpox or measles or influenza which was mainly only fatal to the elderly, cholera killed as many healthy young adults as any other age group; it is estimated that over 100,000 people died of cholera in France in 1832-34 – a shocking mortality rate of between 25 to 50 per cent – and over 5000 in Brittany alone. In many towns it was noted that there were often more female than male fatalities, for example, in Morlaix women represented 65 per cent of cholera deaths. Some believe that this is likely a reflection of the fact that it was women who traditionally collected the family’s water from the communal fountain or well and a prospective source of contagion.
Poor hygienic conditions, lack of adequate sanitation, untended rubbish heaps and poorly sited wells were, in the opinion of many visitors, common features of most Breton cities at the time; all factors which contribute significantly to the spread of cholera. All diseases spread by cross-infection between people gain increasing powers of spread with increasing population density and thus cause the highest mortality rates in urban centres compared to the countryside.
There were further major outbreaks of cholera in France in 1848-50 and again in 1853-54; two epidemics that resulted in some 300,000 deaths across the country. In the latter epidemic, eastern Brittany was particularly badly affected early although it seems that the disease ravaged the region on two fronts; from the east and also from the northern port of Morlaix where it spread to other coastal cities. The epidemic reached Brest towards the end of 1854 and many people claimed to have seen the source of the disease, ‘the Red Woman’, sowing the plague in the valleys; harking back to the superstitions of previous centuries regarding the semeurs de peste (plague sowers) who spread the contagion by witchcraft. At the time, knowledge of the nature of epidemic diseases was scant and most Bretons considered the plague and diseases such as cholera as divine punishment for their sins; and responded with prayer, coupled with either penitential acts to redeem God’s favour or with stoic fatalism to accept God’s will.
The region was again badly hit during an epidemic in 1865 (over 2,500 deaths) and only marginally less so by the epidemics of 1873, 1885-86 and 1893. In the fifty years covering these cholera epidemics, progresses in public health and hygiene programmes, improvements to urban planning and sanitation, coupled with advances in medical understanding and technology, greatly increased our ability to organise efficient countermeasures against epidemics.
Tackling the human cost of such diseases was more problematical, as noted in 1866 by Jean-Baptiste Fonssagrives, Professor at the School of Naval Medicine in Brest: “Among all the chronic diseases that eat away at the social body, misery is certainly one of the most hideous, the most inveterate, perhaps even the least curable”.
At the beginning of the 19th century smallpox was a major global endemic disease, responsible for the deaths of between 50,000 to 80,000 people in France each year. During 1773–74, Brittany experienced a particularly deadly smallpox epidemic which helped highlight the importance of inoculation; then a relatively novel practice and pursued with some vigour in Brittany by an Englishman, Simeon Worlock, who had been summoned from Nantes to work in Brest after the death of some 600 children in that port.
It is therefore not surprising that France was one of the first nations to fully exploit Jenner’s pioneering work on vaccination; teams of doctors spent decades crossing the country inoculating those willing to receive the vaccine, often struggling against public trepidation and hostility. The vaccination programme quickly succeeded in reducing cases of smallpox across France but this highly infectious disease was particularly virulent in Brittany in 1871, resulting in about 20,000 deaths. The last outbreak in Brittany was centred on the cities of Brest and Vannes in 1955 and involved almost a hundred cases, of whom 20 patients died.
It is a little difficult to neatly define dysentery epidemics as the disease is of great antiquity and was an ever present feature of daily life. The disease is usually the result of a bacterial infection which works its way through the bloodstream to the gut, manifesting itself in abdominal pain, sickness and bloody diarrhoea (up to over one litre or a quart of fluid per hour), leading to extreme dehydration, anaemia and often the poisoning of vital organs by bacterial toxins. Like cholera, the bacteria that causes dysentery is most commonly spread by dirty water or foodstuffs having been contaminated with human waste; it is contagious and can be rapidly transmitted from person to person.
The spread of dysentery was facilitated by the rather basic living conditions of the Breton countryside; people and animals typically shared overcrowded dwellings, folks shared boxed beds while the farmyard was rich in dung-heaps and cess pits. In the towns and cities, the health situation was no better; open sewers, streets cluttered with rubbish and foodstuffs’ markets held on busy public roads. All these elements played a part in the rapid transmission of the contagion especially amongst bodies that were generally undernourished. Although, at the time, it was believed that the disease, like so many others, was caused by lethal miasmas and the main medical treatments, for those that could afford them, were purges, emetics and blood-letting.
It is no exaggeration to say that epidemic dysentery was one of the worst blights to affect Europe and the wider world throughout the 18th and 19th centuries. There were major outbreaks in Brittany in 1639, 1676 and 1719. The disease was widespread in Brittany between 1738 and 1740, the epidemic of the latter year was especially fatal amongst children but there was an even deadlier outbreak in 1741 which claimed well over 30,000 lives; in some Breton towns, the mortality rate was over 45 per cent. There were smaller outbreaks in 1749, 1765 and 1777 but in 1779 Brittany and other parts of western France were ravaged by an outbreak that took some 175,000 lives with about 50,000 dead in Brittany alone.
The disease continued to take its heavy toll throughout the 19th century with the last notable outbreak recorded in 1900. Scientists have identified more than 330 strains of the bacteria that cause dysentery but it is worth noting that 99 per cent of strains have now developed a resistance to antibiotics and while dysentery may sound to many of us a disease of the past, it remains a major killer in some parts of the world.
Typhus and typhoid fevers were other diseases that ravished the Brittany of yesteryear. The former is a louse-borne disease that thrives on a host’s poor personal hygiene and can survive on its host for some time. A particularly pernicious outbreak of both diseases spread across Brittany in the years 1741-42 and caused an estimated 40,000 deaths; other major epidemics occurred in 1757 and 1779. In 1793-94 an epidemic of typhus in Nantes is estimated to have resulted in the death of 10,000 people.
Many have described typhoid fever as endemic in Brittany by the mid-19th century but focused improvements in public health and basic hygiene, particularly relating to the supply of clean, uncontaminated water and the evacuation of wastewater meant the death tolls from the epidemics of 1874 and 1892-93 were less severe than those seen in earlier years. The western part of Brittany was particularly affected due to the disease spreading on account of the fairly itinerant habits of agricultural labourers and mariners and the migrations of people from the countryside to the towns. As an example of how significant such urban movements were, between 1856 and 1911 the population of the arrondissement (administrative region) of Quimper swelled from 81,000 to 204,000.
Outbreaks of influenza have always left heavy death tolls, particularly amongst the elderly and poorer sections of society but the virulent virus behind the influenza pandemic of 1918-20 caused the most severe pandemic in recent history. This contagious viral infection attacked the respiratory system and was inexplicably most deadly for young adults; it has been suggested that this might be because older people had built-up a degree of immunity as a result of the earlier flu pandemic of 1889-90. Pneumonia or other respiratory complications brought-on by influenza were often the main causes of death. Estimates vary as to the number of deaths caused by the disease but it is believed to have infected a third of the world’s population and killed at least 50 million people; over 240,000 in France alone.
Despite significant advances in medical treatment and care, influenza remains a public health issue today with annual seasonal outbreaks affecting between 2-8 million people in France every year, with influenza-related deaths estimated at 10,000 to 15,000 per year.
It is important to view the epidemics and pandemics noted above within the context of their time; these diseases took root and spread thanks to the circumstances then existing. Generally poor living conditions and hygiene; undernourished bodies less able to fight infection; low degree of medical knowledge surrounding the nature of bacteria and the transmission of diseases – all conspired to make it an insurmountable task to moderate the impact of a virulent epidemic disease, despite the best efforts of the medical establishment of the time.
Improvements in living standards, town planning, public health, hygiene and sanitation, coupled with massive advances in medical knowledge and technology have helped to greatly reduce the worst ravages of epidemic mortality that were once an accepted part of our ancestors’ lives. Even as late as 1950, the majority of deaths in Europe were due to infectious diseases. Since then, life expectancy has soared and diseases such as polio, diptheria, tuberculosis, tetanus, whooping cough, smallpox, measles, mumps and rubella have been virtually wiped out. Yet, despite the massive leaps in medicine, infectious diseases have been controlled rather than conquered; they remain a threat that can never be truly extinguished.
It is too early to see where the current coronavirus disease pandemic will sit amongst the long history of pandemics but it is clear that the social and economic impact will be profound.