By the middle of March 1348, eleven thousand people had gone into the new cemetery at Avignon, and by the end of April the figure had climbed past that. The man who wrote the number down sang for a living. Louis Heyligen was a musician in the household of Cardinal Giovanni Colonna, a Fleming a long way from home. On the 27th of April he sat down and wrote to friends in Bruges to tell them what he was watching.

Half the city was dead, he said. The Pope had bought a field for the overflow, and it had filled inside six weeks. The doctors had told him the sickness took three forms, and he set them out one by one. There was the one in the lungs that killed within two days and spared nobody.

There was the one with swellings under the arms and in the groin. And there was the one with fever and swellings together. He added that the sick were fleeing the well and the well were fleeing the sick, and that he did not know, as he wrote, whether he would live to see the letter delivered. He did.

Most of the people he was describing did not. His letter is one of the few pieces of writing from the Black Death that sounds like a man talking rather than a chronicler summing up. He was writing from inside it, and the inside view is the whole subject. The plague took the biggest share, but the plague was only one door out of a house with a great many doors.

Leprosy took the feeling from your hands so gradually that people lost fingertips to rats in their sleep. A fungus in the bread turned your legs black and let them come away at the knee. A fever arrived at breakfast and had you in the ground by nightfall. What any of that felt like from the inside, hour by hour, for the person lying there, is the question underneath all of it.

Those doctors were working from a map, and germs were nowhere on it. Nobody had seen a bacterium. Nobody would for three hundred years. What a trained doctor believed in 1348, and what your parish priest believed, and what you believed lying in the bed, was a layered thing.

Underneath everything sat the four humors inherited from Galen and the Greeks: blood, phlegm, yellow bile, and black bile. Health was balance. Sickness was one of them running hot or cold or wet or dry. The cure was to drain off the excess or fight it with its opposite.

The bleeding came out of that idea, and so did the purges that emptied you from both ends. Above the humors sat the air itself. Corrupted air, miasma, rising off swamps and rotting bodies and open graves, could poison a whole city, and people believed you could smell it coming. Above the air sat the stars.

When the medical faculty at the University of Paris was asked by the French king to explain the pestilence, they pointed to a conjunction of Saturn, Jupiter, and Mars in the sign of Aquarius in March of 1345, which in their view had drawn foul vapors up out of the earth and the sea. And above the stars sat God, who had every reason to be angry. So the moment you got sick, all four layers came down on you at once. Your body was out of balance.

The air around you was poison. The heavens had turned. And somewhere in your past was the sin that had earned all of this. A physician might treat the first.

A priest might treat the last. Nobody could do a thing about the two in the middle except run. The running began in October of 1347, when twelve Genoese galleys came into the harbor at Messina on Sicily and the sailors on board were dying. Michele da Piazza, a Franciscan writing on the island, describes a sickness that seemed to cling to the very bones, with swellings on the thighs and arms and a fever that killed inside days.

He says the Messinians drove the ships back out of port, though far too late. Behind those galleys was the Black Sea. Gabriele de’ Mussi, a notary from Piacenza, wrote the account everyone quotes about the trading post at Caffa in the Crimea, where a Tatar army besieging the Genoese walls was itself being destroyed by the disease. The Tartars, in his telling, loaded their dead onto catapults and hurled the corpses over the walls, and the stench in the crowded city became unbearable, and the Genoese who fled by sea carried the sickness home with them.

Historians like Mark Wheelis have looked hard at that story and find it plausible as an act of war, while doubting it was the only way the plague got out, since Caffa was one port among many on a coast that was already sick. But that image of corpses arcing over a wall is, one way or another, the beginning of the western end of the story. From Messina it went everywhere. Genoa and Pisa by the turn of the year.

Marseilles by November. Avignon, where the Pope lived, by January of 1348. Florence and Siena in the spring. Paris by the summer.

It came ashore in England at Melcombe in Dorset around the end of June 1348, was in Bristol by August and London by the autumn, and worked north through the whole of 1349. Norway got it, so a later tradition says, from a ship that drifted into Bergen with everyone aboard already dead. By 1352 it was in Moscow. The generally accepted numbers, rough as they are, put the dead somewhere between a third and three-fifths of Europe in five years: 25 to 50 million people.

Whatever figure you settle on, if you had stood in any village square in 1347 and looked at the faces around you, roughly half of them would be in the ground before the decade turned. What was it physically that killed them? We have an unusually direct answer. In 2011, a team including Kirsten Bos, Verena Schuenemann, and Hendrik Poinar took teeth from four skeletons in the East Smithfield burial ground in London, the emergency cemetery the city opened in 1348 when the churchyards filled, and pulled Yersinia pestis DNA out of the dried pulp inside.

They rebuilt the whole genome. The bacterium that emptied medieval London differs from the modern strain by only about 97 letters out of four and a half million. It is near enough the same organism that still kills a few hundred people a year in Madagascar and the American Southwest. That sharpens the question rather than settling it.

Same bug, wildly different body count. The difference sat in the people and in the world they lived in. The disease came in three forms, and medieval doctors could tell them apart even without knowing why. The first and most common was bubonic.

It went like this. A flea, usually one that had fed on a dying rat, though there is a live argument now about how much human fleas and body lice did the work, bites you somewhere on the leg or the ankle. Nothing happens for a while, two days, sometimes as many as seven. You go about your business.

Then it arrives, and the chroniclers are consistent that it arrived suddenly, the way a door slams. A fever that shoots past 39 degrees. A headache so severe that people described it as a blow. Shivering fits.

Aching in the back and the thighs. Vomiting, sometimes with blood in it. Light becomes painful. Within about a day came the thing that gave the disease its name.

The bacteria have traveled from the bite up the lymph channels to the nearest lymph node, and the node has begun to swell. If the bite was on the leg, that is the groin. If on the arm, the armpit. If on the face or scalp, the neck behind the ear.

The node fills with bacteria and dead white cells and swells to the size of an egg, then an apple, and the skin over it stretches tight and turns red, then purple, then in the worst cases black. Boccaccio opening the Decameron describes these swellings, which the Florentines called gavoccioli, growing in groin and armpit to the size of an ordinary apple or an egg and then spreading, and after them black or livid blotches appearing on the arms and thighs and everywhere else, some large and scattered, some small and thick together. Those blotches were bleeding under the skin. The English called them God’s tokens.

Everybody who saw them understood what they meant. The pain of the bubo comes up in every source that bothers to describe it. Physicians who actually touched them say it was beyond anything they had a scale for. A hard, hot, exquisitely tender mass in the fold of the groin, so painful that patients could not bear the weight of a sheet on it, could not straighten the leg, could not be moved on the bed without screaming.

Some buboes stayed hard and closed. Some softened over days and burst on their own, releasing a thick greenish-yellow pus with a smell that people wrote about specifically, a smell of rot coming out of a body that was still alive. Others in the sources turned black and the flesh around them died and sloughed away in sheets. Agnolo di Tura in Siena wrote that the victim swelled under the arms and in the groin and fell over dead while talking mid-sentence, and that it seemed to pass through breath and sight alone.

Alongside the bubo, the infection was spreading into the blood. The delirium came from that. Within two or three days, a patient who had been lucid and terrified became confused, then incoherent, then unconscious. The accounts include the dying wandering out into the street in their nightshirts, and people who had to be tied to their beds.

The tongue swelled and turned white, then dark. The lips cracked. In the last hours, the extremities went cold and dusky as the circulation failed. The breathing went shallow and fast.

And then it stopped. From the first shiver to that point was most commonly three to five days. Guy de Chauliac, who was the Pope’s own physician at Avignon and who caught the disease himself and lived to write about it, gave two timelines from what he had watched at the bedside. Fever with buboes in the armpits and groin killed within five days.

The other form killed within three. Untreated bubonic plague, going by the best modern figures, killed somewhere between 30 and 60 percent of the people who caught it. Call it a coin flip. And that shaped the medieval streets in a particular way.

Everyone who lived through the Black Death had watched people survive it. They had seen a bubo soften and drain and the fever break and a neighbor stagger back into the daylight a week later, thin and gray but breathing. To them it felt like a lottery being drawn in front of them twice a day, with their own children’s names in the bowl. The second form was the one de Chauliac said killed in three days, and it was the true horror.

Pneumonic plague happens when the bacteria get into the lungs, either because a bubonic case has gone septic and seeded them from inside, or far more dangerously, because you have breathed in droplets coughed out by someone who already has it. The incubation drops to a day or two. You wake up with a fever and a headache and a tightness in the chest and you start to cough. At first it is dry.

Then the sputum comes up thin and watery. Then it is streaked. And by the second day you are coughing up bright red frothy blood, mouthfuls of it, foaming. The air sacs of your lungs are filling with blood and fluid, and every breath is churning it.

de Chauliac describes it exactly as continuous fever and spitting of blood. Heyligen’s letter says of this one that whoever has the corruption in the lungs to any degree cannot escape and will die within two days. That is about right. Untreated pneumonic plague is as close to universally fatal as any disease we know.

Modern medicine says that if antibiotics do not go in within roughly 24 hours of the first symptom, the patient dies. In 1348, they all died. What the dying felt was suffocation, slow and then fast. The lips and fingernails went blue.

The chest heaved, and each breath brought up more blood and less air, until the patient was drowning, sitting up, clawing at the bedclothes in a bed soaked with what they had coughed. And every cough sprayed the room. This is the form that made de Chauliac right that people caught it not only by living in the same house but merely by looking at one another. And it is the form behind Agnolo di Tura’s line about breath and sight.

They were describing airborne transmission four hundred years before anyone had a word for it, from the plain fact that you sat with a coughing man in the evening and by the next night you were coughing too. The third form is one explanation for the pandemic’s later name, though nobody in 1348 called it the Black Death. That phrase turns up centuries afterward, and it may owe as much to a Latin word for dreadful as to any color. Septicemic plague happens when the bacteria flood the bloodstream directly, sometimes from a bubo, sometimes from a bite that never formed one.

The body’s clotting system goes haywire. Doctors now call it disseminated intravascular coagulation, meaning that tiny clots form everywhere at once, choking off the small vessels while at the same time the blood runs out of clotting factors and starts leaking. So you bleed and you clot simultaneously. Blood seeps under the skin in purple sheets.

Blood comes out of the nose, the gums, the bowel, the bladder, and out at the edges of the body where the small vessels have clotted shut. The tissue dies. Fingers go black, toes go black, the tip of the nose goes black, the ears. That is gangrene, and it is behind the descriptions of blackened stinking corpses that turn up in some of the accounts.

The septicemic form killed almost everybody it touched, and it could kill within a day, before a bubo ever had time to rise. People spoke of victims going to bed healthy and being found dead in the morning, and this is the most likely explanation. Marchionne di Coppo Stefani in Florence wrote that a person could be well at dinner and dead by morning. Two more things about the physical experience that the chroniclers keep returning to.

One is the smell. The sweat of plague victims. The discharge from open buboes. The blood and froth from the lungs.

The gangrenous tissue. The vomit. The loosened bowels of the dying. And then the corpse itself in a warm room in a Mediterranean summer, sometimes for a day or more before anyone would come for it.

Several writers say the stench alone was enough to make people believe the sickness lived in the air of the house. Given what they knew, that was a perfectly reasonable conclusion. The other is the speed. Stories of people struck while talking.

Of a priest giving the last rites and dying before the patient did. A physician at Avignon is quoted as saying the doctors could not attend the sick without being contaminated, and that the ones who tried mostly died with them. About the fleas. The classic model worked out in India around 1900 has the disease living in black rats, carried by the rat flea Xenopsylla cheopis, which bites people only when its rats have died and it is hungry.

That explains the pattern where rats died first in a house and people followed. It explains less well how the disease crossed medieval Europe faster than a rat population can be replaced, or how it raged through Iceland, where there may have been no rats at all. Some researchers modeling the spread argue that the human flea Pulex irritans and the body louse were doing much of the work, jumping straight from one person to the next in crowded houses and shared beds. Others hold that the rat model still fits best once you account for grain shipments and river trade.

Both sides have a case. What both camps agree on is the picture inside the house. One room, sometimes two. Rushes on the floor, changed rarely.

A family sleeping together on a straw mattress alive with insects. Grain stored under the roof where rats nested. A privy in the yard or a bucket. When the plague came into that house, it did not come for one person.

A typical sequence, assembled from the accounts rather than quoted from any single one, would go something like this. A child falls ill first, feverish, complaining of a lump in the groin. Two days later the mother is shaking with cold and cannot stand. The father sends for the priest and the priest does not come.

The priest is dead, or has fled, or has forty other houses ahead of his. By the fourth day the child is delirious, and the mother is dead in the same bed, and the father has begun to cough. Neighbors will not enter. The corpse-bearers, who charge whatever they like, come on the sixth day for the mother and the child together, and on the eighth for the father.

And if there is a surviving infant, it is carried off by an aunt, or it is not. Boccaccio wrote that in Florence, brother abandoned brother, uncle abandoned nephew, and hardest for him to believe, fathers and mothers refused to visit or tend their own children, as if they were strangers. Two groups the chroniclers single out. Pregnant women were especially likely to die, and physicians in later plague outbreaks remarked on it.

The fever brought on labor, or the woman miscarried, and the bleeding that followed, in a body already going into septic shock, finished what the plague had begun. And the child, if it was born alive, was born into a house where the mother was dead and the plague was in the bedding. Children who in a normal year died of everything died of this at the same rate as their parents or higher. A child’s body has less to fight with.

So the trenches at East Smithfield hold children in every row. The disease also, in the Italian cities, seems to have gone hardest through the crowded parishes near the river: the wool workers and the dyers, the people who shared beds and drank from the same wells and had the least to eat. What survives of the Florentine records suggests those quarters lost the most. de Chauliac gives us the view from the other side of the bed.

He says the plague was most humiliating for the doctors, since they could do no good and dared not visit the sick for fear of infection, and when they did visit they earned nothing since all who caught it died. He himself waited it out at Avignon out of what he called a determination to avoid infamy, and caught it, and ran a fever, and grew a bubo, and spent, on his own account, six weeks in mortal danger before he recovered. His description of his own illness is one of the very few first-person accounts we have from someone who understood what he was watching. Medicine had failed, and he knew it had failed, and he wrote it down anyway.

Why was it so much worse then than now? Part of the answer is simply antibiotics. Streptomycin did not exist until 1944. But part of it is in the bones.

Sharon DeWitte and James Wood looked at 490 skeletons from East Smithfield and compared them with people buried in ordinary medieval cemeteries. What they found was that the plague had not killed at random. The people in the plague pit were, on average, already frail before they got sick. Their bones carried the marks of childhood malnutrition, of earlier illness, of years of stress.

The Black Death arrived thirty years after the Great Famine, in a population where a great many adults had spent their childhood starving, and it went through those bodies hard. Someone well-fed and healthy had a chance. Someone who had grown up on famine bread mostly did not. Avignon had the Pope in it, and the people who wrote things down, so it is the place to stand for a while.

Heyligen’s letter has more in it than the numbers. The Pope’s new field was on top of everyone already crammed into the old churchyards and the hospital of St. Anthony. When even that filled, Clement consecrated the river Rhône so that bodies could be thrown into it with a clear conscience, and the current carried them south.

The cardinal Heyligen served, Giovanni Colonna, died that summer. Heyligen says the dead were being buried without priests and without candles in pits, and that the physicians would not go near the sick for fear of catching it. Clement himself did survive, and the way he did it says a fair amount about the medicine of the moment. On de Chauliac’s advice, he shut himself in his chamber in the palace through the summer with a large fire burning on either side of him, and he sat between the two fires day and night in the Provençal heat, seeing almost no one.

The idea was that the flames purified the corrupt air before it could reach him. Whether or not the fires kept the fleas away, and it has been suggested they might have, the Pope came through. While the Pope sat between his fires, a woman he had probably never noticed was dying a few streets away. Petrarch had first seen Laura in the Church of St.

Clare in Avignon on the 6th of April, 1327, and had written about almost nothing else for twenty-one years. On the 6th of April 1348, to the day, she died of the plague. Petrarch was in Verona and heard about it weeks later from a friend. In the margin of his copy of Virgil, the book he carried everywhere, he wrote a note recording the hour and the place of her death, and the fact that her body, which he calls chaste and lovely, was buried the same evening in the church of the Franciscans, since plague corpses were not kept overnight.

He adds that he was far away and knew nothing of it while it was happening. She was, if the usual identification with Laura de Noves holds, around 38 and the mother of eleven children. What her last days looked like we have no idea, except that they looked like everyone else’s in Avignon that spring. A bubo.

A fever. A bed nobody would sit beside for long. A cart at the door. Florence.

Boccaccio’s opening to the Decameron is the most famous description of the plague ever written, and it earns the reputation. He says that at the height of it, corpses were carried out of houses and left at the doors in the morning for the bearers to collect. That one bier would go by with two or three bodies on it, husband and wife, or a father and his sons. And that the funeral a man had expected, with candles and neighbors and a proper mass, had shrunk to a couple of hired men and a priest who wanted to be elsewhere.

Then even that stopped. The churchyards filled. The Florentines dug trenches beside the churches, enormous ones, and bodies went into them by the hundred. Marchionne di Coppo Stefani, who lived through it as a boy and wrote his chronicle decades afterward, gives the detail everyone remembers.

The trench was dug down to the water table. Bodies were laid in and covered with a little earth. Then more bodies on top and more earth, layer on layer, just, he says, the way you put layers of cheese in a lasagna. The men who did this work, the becchini, the gravediggers, got rich.

They charged what they liked. Stefani says they would carry the dead the moment they were asked, for a price. And if the price was not there, the dead stayed where they were. Boccaccio also tells one small story as an eyewitness, and it stayed with the people who heard it.

The rags of a poor man who had died of the plague had been thrown into the street, and two pigs came along and did what pigs do, rooting in them and tossing them about with their snouts. And within the hour, he says, both pigs went into convulsions and dropped dead on the rags, as if they had been poisoned. He offers it as proof of how the sickness clung to whatever the dead had touched. Whether or not the pigs died of plague, the Florentines watching them drew the obvious lesson about their own clothes and beds.

Boccaccio reckoned that more than a hundred thousand people died inside the walls of Florence between March and July of 1348. That is higher than most modern estimates for the city’s whole population, so the number is doing the work of a feeling rather than a census. But the tax records and the guild rolls that survive suggest the city lost something like half its people, and the ones who lived through it never entirely stopped talking about it. Giovanni Villani, the great chronicler of Florence, the man whose Nuova Cronica is the backbone of nearly everything we know about the city’s rise, wrote his last entry about the plague, and in the middle of a sentence about how long it would last, stopped.

The space after the words is still blank. He had died of it. His brother Matteo took up the chronicle afterward and carried it on. South of Florence in Siena, Agnolo di Tura kept a record that is harder to get through than Boccaccio’s.

He had no interest in being literary. He was a shoemaker who did some tax collecting on the side. He writes that the mortality began in Siena in May of 1348. That it was a cruel and horrible thing, that the victims died almost at once, swelling under the armpits and in the groin and falling over while they spoke.

Fathers abandoned children, he says. Wives abandoned husbands. Brothers abandoned each other. And nobody could be found to bury the dead for money or for friendship.

So people carried their own dead to the trenches without a priest, without an office, and tossed them in, and the bells did not ring for anyone. The dead were too many. Members of a household would drag the bodies to the ditch as best they could. The ditches were shallow.

He says that dogs came at night and pulled corpses out and ate them in the streets. Then, in the middle of all that, one plain sentence. And I, Agnolo di Tura, called the Fat, buried my five children with my own hands. He goes on.

He says that many bodies were so poorly covered that the dogs got at them all over the city. He says nobody wept for any death, as everybody expected to die, and that people believed and said it was the end of the world. Siena’s great cathedral, which the city had been enlarging into the biggest church in Christendom, had its workforce wiped out and the project was abandoned. The unfinished walls are still standing.

A great arcade of arches with nothing behind them. Agnolo put the city’s losses at more than half. Cross the water now to England, where the disease came ashore in Dorset around midsummer of 1348 and reached London in the autumn. One chronicle says that in Bristol the living could barely bury the dead, and a later account has grass growing in the streets.

Henry Knighton, a canon at Leicester, was more interested in the countryside. He describes sheep and cattle wandering untended through the fields and crops rotting where they stood, with nobody left to bring them in. In one pasture alone, he says, five thousand sheep died and lay putrefying so foully that neither bird nor beast would touch them. Prices collapsed.

A good horse that had been worth forty shillings went for six and a half. A fat ox for four. Nobody wanted anything. Nobody expected to live to use it.

Later, when the survivors started to want things again, no hands were left to make them, and wages doubled, and Knighton, a landowner’s man to his bones, found that almost as scandalous as the deaths. He also records what happened to the Scots. Hearing that the plague was destroying the English, they gathered an army in the forest of Selkirk in 1349 to take advantage of it, and in his telling laughed at the English for their misfortune and swore by the foul death of England. Then the plague reached the camp.

Knighton says about five thousand died there in a short time, and the survivors broke up and went home to their villages and took it with them, so that the sickness that had been an English affliction became a Scottish one within the year. That is Knighton’s version, and he enjoyed telling it. But the Scottish sources agree that the plague came north in 1349 and that it was as bad there as anywhere. The church in England saw it coming and said so.

In July of 1348, before the disease had reached his province, William Zouche, the Archbishop of York, sent a letter to his clergy warning of a great mortality that had come out of the east and was already in the neighboring kingdoms, and ordering processions and prayers every Wednesday and Friday to turn it aside. In January of 1349, the king postponed Parliament on the stated grounds that the plague had grown so bad in Westminster and the surrounding towns that it would be too dangerous for the Lords and Commons to gather. Processions did not stop it, and postponement did not either. At Rochester, a cleric called William Dene wrote that bodies lay unburied in the churchyard, since the laborers refused to work for the old wages and the bishop’s own tenants could not be compelled.

He wrote that the plague seemed to take the young and strong and to leave the old. Similar things were being said in Ireland and in Italy. Modern epidemiologists think that is partly a trick of perspective, since the old were dying of everything anyway and the young dying was the shock. But DeWitte’s East Smithfield work does suggest the disease was harder on the frail than on the robust.

So the picture is muddled. Somewhere between a third and half of the benefited clergy of England died in the space of a year. That figure comes from bishops’ registers, which recorded every vacancy, so it is one of the more solid numbers we have. Priests died for the same reason physicians did.

They went into the rooms. And when they stopped going in, or were dead, a problem arose that terrified medieval people far more than the physical pain. Dying unshriven. Dying without confession and absolution and the last anointing meant, for most people in 1348, facing judgment with your sins still on you.

In January of 1349, Ralph of Shrewsbury, the bishop of Bath and Wells, put out a letter to be announced in every parish of his diocese. He wrote that the plague was leaving many parishes without priests, that the sick were dying without the sacrament of penance since no priest could be found, whether out of fear of infection or otherwise. And he instructed that anyone in danger of death should make their confession to any lay person who was to hand. And, he added, to a woman if a man was not available.

That was an astonishing thing for a bishop to write. It means that across the west of England that winter, dying men and women were whispering their sins to a neighbor, a servant, a child, whoever was in the room and had not run, and trusting that God would accept the arrangement. The pit at East Smithfield is where you can still see all of this, or at least what the shovels found. The city bought the land in 1348 when the parish graveyards were full.

When it was excavated in the 1980s, the archaeologists found long trenches with the bodies laid in rows up to five deep, most of them in shrouds, some in coffins, children tucked in beside adults. They counted something over 2,400 individuals, and the ground almost certainly holds more. What struck the excavators was how orderly it was. Somebody had kept the rows straight.

Somebody had faced the bodies east. In the middle of the worst thing that had ever happened to the city, men were still standing in a trench doing the job properly. Put that image alongside the dogs in Siena. Both are true.

Two royal deaths. Princess Joan, the daughter of Edward III, was traveling south in the summer of 1348 to marry Pedro, the heir to Castile. She was fourteen. Her fleet was four ships, one of which carried nothing but her clothes and furnishings, including a wedding dress of thick silk woven with gold.

The party landed at Bordeaux, English territory then, and the mayor warned them the sickness was in the city, and for reasons nobody wrote down, they stayed. Her retinue started dying. Robert Bourchier, a veteran of Crécy who was escorting her, died on the 20th of August. Joan herself had died before that, on the 1st of July, in a house in the town.

Her father wrote to Alfonso of Castile that he had lost a daughter in whom all the virtues had been gathered, and that he could not write of it without grief. No record survives of her body ever coming home to England. Some later accounts say the quarter where she died was burned. Her intended father-in-law, Alfonso, refused to lift the siege he was conducting at Gibraltar when the plague appeared in his camp, and it killed him on the 27th of March 1350.

The only reigning king in Europe to die of it. His army broke up and went home, carrying the disease into every town on the road. And it did not leave either. People tend to forget that.

It came back in 1361 and in 1369 and in 1375 and in the 1390s, and it kept coming back somewhere in Europe every few years for three hundred years. Archaeologists have pulled Yersinia pestis DNA out of skeletons in Bavaria and the Netherlands and France and England across that whole span. A man born in 1400 could expect to see the plague come through his town four or five times in his life. And each time he would watch the buboes and the black fingers and the carts, and each time it was a lottery again.

The Black Death was only the first draw. What could a physician actually do for you once the fever was up? He could bleed you. That was first and always.

The theory said that the pestilential poison had corrupted the blood near the heart and that the body was trying to push it outward, and that was why the swellings rose in the groin and armpits. The doctor’s job was to help that along. So he would open a vein with a small blade called a fleam or a lancet on the side of the body where the bubo was, and let the blood run into a bowl until you fainted. Physicians argued in print about which vein for which bubo, since bleeding the wrong side, they thought, might pull the poison back across the heart and kill you outright.

In a body already going into shock from sepsis, losing a pint of blood on top of it did nothing kind. Some patients were bled repeatedly over several days. Cupping was the gentler version, a heated glass set on the skin to draw blood to the surface. Leeches, gentler still.

None of it helped, but it was something being done, and a physician who did nothing had no reason to be in the room. The bubo itself came next. If it came to a head, the surgeon would open it. A mass the size of an apple in your groin, so tender you had screamed when the blanket touched it, and a man with a knife pressing on it to see if it had softened.

If it had, he would cut, and pus would come out under pressure, thick, foul, sometimes mixed with blood and dead tissue, and the room would fill with the smell. Then he would cauterize the wound with a hot iron to stop the bleeding, and in his mind, burn out the corruption. If the bubo had not softened, he might try to hurry it with a poultice to draw it. The recipes survive.

Figs and onions cooked soft with yeast and butter. Lily root and tree sap. One that appears in more than one manual mixes those with dried toad and human excrement, and binds the whole thing over the swelling and leaves it there for the bubo to fester and break. Whatever else it did, that poultice guaranteed a second infection on top of the first.

At the top end of the market was theriac. An ancient thing credited to Mithridates and refined by Nero’s physician. A paste of anywhere from forty to seventy ingredients that included viper flesh, cinnamon, myrrh, and a serious quantity of opium. Genuine theriac from Venice or Milan was ruinously expensive and had to age for years before it was thought fit to use.

Most people who believed they were taking it were taking something else. But the opium in the real article did do one thing that nothing else in the plague pharmacy could do. It took the edge off the pain, and it let you sleep. If you were rich enough, you could die drugged instead of screaming.

And the dying appreciated the difference. Then the chickens. A physician standing over a man whose armpit had risen into a hard purple lump about the size of a hen’s egg might take a living bird, pluck the feathers away from its backside, and press that bare patch of skin onto the swelling and hold it there. The reasoning, traced by the historian Erik Heinrich back through Avicenna’s Canon of Medicine and repeated in plague manuals for roughly three hundred years after the Black Death, went like this.

A chicken breathes through its rear. Held against a plague sore, it would pull the poison out of the patient and into its own body. The cure was working when the bird began to droop, and finished when the bird died. Some versions have the physician reaching for a second chicken and a third, and carrying on until one finally lived.

A surviving chicken meant the man’s poison had run out. One later English recipe adds a warning more or less in these words: throw the dead bird on the fire, and whatever you do, do not eat it. The man in the bed usually died anyway. Further down the scale, it got stranger.

People were advised to drink their own urine in small doses as a preventive. Some were told to sit in latrines and sewers for hours, on the theory that the worst stink would drive out the plague stink. Others carried posies and pomanders of herbs to breathe through, or burned rosemary and juniper in the house. Some manuals warned against bathing, as a bath opened the pores and let the poison in, and against sleeping on your back, where it could settle in the lungs.

Amulets were sold. Crushed emerald went into the drinks of those who could afford it. And arsenic too, which at least would have taken the patient’s mind off the plague. The Paris faculty, the same professors who had blamed the planets, also produced a regimen for staying alive, and it circulated all over Europe.

It gives a fair picture of what a careful person tried to do. Stay indoors when the wind is from the south. Keep the windows shut and the fire lit. Do not bathe, it opens the pores.

Do not exercise, it makes you breathe deeply and pulls in more of the corrupt air. Do not eat fish or anything that rots easily, or fruit, or anything too hot or too moist. Do eat sour things, vinegar and pickled lemons, as sourness resists putrefaction. Sleep on your right side, then on your left, never on your back.

Avoid sexual intercourse. And in a line that turns up in nearly every one of these manuals, avoid fear and sadness and anger and too much thinking about death, since a troubled mind weakens the body and opens it to the poison. So the dying were told by the best medical minds in Europe that their fear was part of what was killing them. A man watching his wife’s bubo turn black across the room was advised to think cheerful thoughts.

The physicians meant it kindly. The one piece of advice that actually worked was the oldest. Flee quickly. Go far, come back late.

The Latin tag for it was cito, longe, tarde. Boccaccio’s ten storytellers do exactly that, decamping to a villa in the hills to tell each other stories for two weeks while the city dies below them. The trouble was that most people could not flee, and the ones who could often carried it with them. Cities on the Adriatic learned this first.

In 1377, Ragusa, the city we call Dubrovnik, ordered that anyone arriving from a plague area had to wait on an island for thirty days before entering. Venice later stretched that to forty, a quarantina, and the word quarantine grew out of that. It was the first real defensive measure anyone in Europe hit on, and it came from watching ships rather than from any theory of medicine. Some cities tried rules of their own in the first months, and the ordinances of Pistoia, passed in May of 1348, survive in full.

Nobody was to travel to Pisa or Lucca, where the plague already was, and nobody from there was to be let in. No used cloth or linen was to be brought into the city. The dead were to be put in wooden coffins nailed shut before they left the house, and the coffins carried straight to the church and buried at least two and a half arm’s lengths down, and no body was to be moved from one place to another for burial. The bells were not to be tolled for the dead.

Mourners were limited, and the town criers were forbidden to announce a death aloud. Butchers were told to keep their stalls clean, and tanners to move their work outside the walls. It was a sensible list given the theory behind it, and it did nothing at all. The plague went through Pistoia that summer like everywhere else, and the council that had written the ordinances lost most of its members.

The beaked plague doctor, the figure in the long waxed coat and the wide-brimmed hat and the mask stuffed with herbs, belongs to the 1600s, to Rome and Paris and Venice three centuries later, when the disease was still coming round and cities had started paying physicians to attend the poor. The doctor at a Black Death bedside wore an ordinary gown, and if he took precautions at all, it was a sponge soaked in vinegar held to his nose. He looked like anyone else in the room. He died like anyone else in the room, too.

Now the fires. As the disease spread, a story spread ahead of it that the Jews were poisoning the wells. The story seems to have started in the south of France in the spring of 1348, and it was fed by confessions extracted under torture. In September of that year, at the castle of Chillon on Lake Geneva, a Jewish man called Agimet, under torture, confessed that a rabbi in Chambery had given him a packet of poison to drop into the wells of Venice and other cities.

Copies of that confession were sent around the Rhineland towns as evidence. Whether the people who acted on it believed it, or wanted to believe it, or simply owed money to the people they were about to burn, the outcome was the same. Strasbourg is the case that is best documented, and the sequence there matters. The plague had not yet reached the city.

The bishop and the town’s governing magistrates, led by a mayor called Peter Schwarber, had looked at the poisoning stories and refused to act on them. So on the 9th of February 1349, the guilds rose, threw out the magistrates, and put in a new council. Five days later, on St. Valentine’s Day, the Jews of Strasbourg were rounded up and taken to their own cemetery, where a wooden platform had been built, and they were burned alive on it.

The priest and chronicler Jakob Twinger von Königshofen, writing within living memory of it, says around two thousand died. Other accounts put it nearer nine hundred. Those who agreed to be baptized were spared. Königshofen adds that some townspeople pulled small children out of the fire against their parents’ will and baptized them.

The debts owed to the Jews were declared cancelled, and the money and pledges they had held were shared out among the guildsmen. The chronicler says in as many words that the money was the poison that killed the Jews. Within the year the same thing happened in Basel, in Freiburg, in Mainz, in Cologne, in Erfurt, in Frankfurt. In some towns, the Jewish community, seeing the crowd coming, set fire to their own houses and died inside rather than wait for the platform.

In Mainz, they are said to have fought first. Clement from Avignon issued two bulls that year, one in July and one in September, ordering the clergy to protect the Jews. He pointed out that Jews were dying of the plague at the same rate as everyone else, and that the disease was raging in places where no Jews lived at all. And he called the people spreading the poison story deceived by the devil.

Very few towns listened. But it was said, in the middle of 1348, and by the pope. That deserves a mention. The whipping went alongside the killing.

The flagellants began in Austria and Hungary in the autumn of 1348 and moved across Germany and into the Low Countries through 1349. They traveled in bands of a few hundred, sometimes far more, dressed in white with red crosses, and they would come into a town, go to the market square, strip to the waist, and beat themselves with leather scourges tipped with iron spikes twice a day in public for thirty-three and a half days, one day for each year of Christ’s life. The blood ran down their backs and onto the cobbles. Townspeople wept and dipped cloths in it to keep.

The idea was that if enough pain was offered up, God might take the plague away. The movement got big enough, and unruly enough, and hostile enough to the clergy, that Clement banned it in October of 1349, and it broke up fairly quickly after that. A great many flagellants also died of the plague. A band of several hundred sweating, bleeding men sleeping in a heap is about the best arrangement you could design for it.

For the person in the bed, all of this meant that the culture around them was building an entire way of dying while they lay there. The Ars Moriendi, the art of dying, was a set of manuals that circulated after the plague, some of them with woodcuts, and they set out what the dying man should expect. Five temptations came at the deathbed. Doubt in his faith.

Despair over his sins. Impatience with his pain. Pride in his own goodness. And clinging to the things of the world, his money and his children.

In the woodcuts, demons cluster around the bed, shouting these at him, and angels stand behind them with the answers. The point was that dying was a contest you could lose at the last minute, and the manuals were there to help you win it. What a good death actually looked like, when it could be managed, went something like this. The dying person was propped up in bed facing east if the room allowed it.

The priest came with the host in a box, and a boy with a bell walking in front, and the household knelt as it passed in the street. Confession first, whispered, with everyone else sent out. Then the anointing oil on the eyes and ears and nostrils and lips and hands and feet, for the sins each had committed. Then the viaticum, the last communion, the bread for the journey.

A blessed candle was put into the dying person’s hand and held there, sometimes by a relative when the grip failed, and a crucifix was held up before the eyes, and the litany was said over and over while the breathing slowed. The will had been made already, ideally with a notary at the bedside taking it down. The notaries of Marseille kept working through 1348, their registers showing wills drawn up at a pace nobody had seen before. And when it was over, the women washed the body, and it was wrapped and watched through the night and buried the next day with the bell ringing.

That was the death everyone hoped for and paid for and prepared for. Almost nobody got it in the summer of 1348. And the people who did not get it knew exactly what they were being denied. Death also started showing up on the walls.

The danse macabre, the dance of death, where a skeleton takes the pope by the hand, and the emperor, and the knight, the merchant, the plowman, the child, and walks them all off in a line, appears in the decades after 1348. Jean Le Fèvre, a French poet, wrote the earliest surviving line linking the word macabre with the dance in 1376, in a poem he wrote while recovering from the plague himself. The great mural at the cemetery of the Holy Innocents in Paris went up in 1424 and 25, on a wall that people walked past every day on the way to market, above ground where the bones from the overflowing graves were stacked in open galleries. A story called The Three Living and the Three Dead had three young noblemen out hunting meet three rotting corpses who tell them, in the usual version, something close to this.

What we were, you are. What we are, you will be. And from the 1380s onwards, the wealthy started ordering tombs that showed them as they would look after a year in the ground. The tomb of Guillaume d’Aragnies, a physician at Laon, dated 1394, is a carved corpse with the skin drawn tight over the ribs and the belly sunk in.

People paid a great deal of money to be remembered that way. A generation that had carried its own children to the trench had no use for a prettier version of the body. Burial went the same way as everything else. In most of Europe, the dead were supposed to be washed, wrapped, watched over for a night, carried to church, sung over, and buried facing east.

By the summer of 1348 in the worst-hit cities, the sequence had collapsed to this. The body was left in the doorway. The bearers came when they came. They wore no gloves.

They lifted the corpse by the ankles and the armpits, and if the buboes had burst, the fluid ran down onto their hands, and they threw it on a cart with the others, and it went to the pit, sometimes with a priest walking behind saying the office over the whole cartload at once, sometimes with nobody. The families that stayed behind then had to deal with the bedding. And the bedding was soaked with everything the body had produced in its last three days. And in a house with one mattress, there was no other bed.

So they slept on it, and the fleas in it were hungry. When the plague came into a house, it came for the household. And that mattress is the reason. Leprosy ran on the opposite clock.

The plague gave you five days. Leprosy gave you twenty years. And it spent them taking you apart a piece at a time while everyone you knew watched. The bacterium Mycobacterium leprae is a cousin of the one behind tuberculosis, and it is astonishingly slow.

It can sit in the body for years before anything shows. When it does show, it starts at the surface, in the skin and in the nerves that run just under it, where the temperature is a little lower than in the core. And that preference explains the whole shape of the disease. Cool places first.

Fingers, toes, the tip of the nose, the ears, the eyebrows. Early on, a patch of skin loses its color and its feeling. You can prick it with a needle and the patient does not flinch. Medieval diagnosis panels knew this test and used it.

Then the nerves running to the hands and feet begin to thicken and die, and the muscles they served waste away, and the fingers curl inward into a claw that will not open. The foot drops at the ankle. And the loss of feeling is where the real damage happens, since it turns out that losing the sense of pain is one of the worst things that can happen to a body. A man with dead nerves in his hands picks up a pot from the fire and does not feel it burn.

He walks on a foot with a stone in the shoe until the sole is an open ulcer. He sleeps, and a rat gnaws his fingertip, and he wakes with a wound he cannot explain. The wounds do not heal properly. They get infected.

The bone underneath is eaten away. And over years, the fingers and toes shorten and are absorbed or come off. Medieval accounts describe lepers with stumps for hands. That is how the stumps got there.

Meanwhile, the face is changing. In the lepromatous form, the severe one, the skin of the face thickens into nodules. The forehead and cheeks swell and fold. The earlobes hang heavy.

The eyebrows fall out. And the whole face takes on a look that physicians for centuries have called leonine, lionlike. The bacteria colonize the lining of the nose and destroy the cartilage, so the bridge collapses and the nose sinks back into the face. The nasal discharge is thick and bloody and constant.

They get into the larynx, so the voice goes hoarse and nasal, and medieval examiners listened for exactly that. They get into the eyes, where the loss of feeling in the cornea means the patient stops blinking properly, and the surface dries and scars and ulcerates, and they go blind. And the ulcers everywhere on the legs, the hands, the face, do not stop discharging. The smell of a person in the late stages of untreated leprosy was, by every account, something you could pick up across a room.

The medieval horror of the leper was at least in part a physical reaction to a body that looked and smelled as if it were rotting while it walked. And it went on like that for years. A leper diagnosed at twenty-five might not die until forty-five. And the thing that killed him in the end was usually something else.

An infected ulcer. A chest infection. Kidney failure. While the disease itself simply went on remodeling him.

Diagnosis was a formal event. In many towns, a panel would be convened. Sometimes physicians. Sometimes a priest with a barber surgeon.

Sometimes a jury of lepers themselves, who were thought to know the disease better than anyone. They would examine the skin for patches and nodules, test it with a pin, look at the eyebrows and the nostrils, listen to the voice, sometimes bleed the patient and inspect the blood for grittiness. The stakes were enormous, and everyone in the room knew it. A false diagnosis stripped a man of his home and his trade.

A missed one, in the thinking of the time, left a source of corruption loose in the town. Records survive of people appealing, of second examinations, of accusations that a rival had bribed the panel to get someone declared leprous. If the panel said yes, the law took over, and the law had been thinking about lepers for a very long time. The Lombard King Rothari, in his edict of 643, ruled that a person found to be a leper and expelled from the community was to be treated as if dead, tamquam mortuus.

He could not sell or give away his property, the dead not owning things, though the community was still obliged to feed him. That idea, the living corpse, ran through leprosy law for eight hundred years. By the later Middle Ages it had a liturgy, the separatio leprosorum. The rite varied from place to place, but in its fullest form, and the Sarum version from England is one of the fullest, the leper was brought to church wearing a black cloth, and mass was said for him as if he were dead, with him kneeling under a black pall in the place where a coffin would go.

Then the priest walked him out to the churchyard, to an open grave, and threw three spadefuls of earth over his head, and said the words: sis mortuus mundo, vivens rursus Deo. Be dead to the world, and alive again to God. Then came the list. He was forbidden to enter a church, a mill, a bake house, a market, or a tavern.

Forbidden to wash in a spring or a stream, or to drink from a well except from his own cup. Forbidden to touch anything he wished to buy except with a stick, and forbidden to touch children. Forbidden to walk barefoot. Forbidden to speak to anyone downwind.

Forbidden to eat with anyone but lepers. He was given a clapper or a bell or a rattle to sound as he came, so people could clear the road ahead of him. In some places, a gown of a particular color, gray or russet, was specified, though the historian Carole Rawcliffe has shown that this varied so much that no single leper’s uniform ever existed, and that the picture of a hooded figure in gray is more a modern shorthand than a rule. Where the rite was used in full, the heart of it was the grave and the words.

You were buried while you stood there. Your wife was, in most places, free to remarry. Your children inherited. You were, as far as the parish records went, gone.

Where you went afterward depended on money and luck. Across Europe stood the leper hospitals, lazar houses named for Lazarus. The thirteenth-century chronicler Matthew Paris put the number at nineteen thousand across Christendom. Historians treat that figure carefully, and Rawcliffe argues it may originally have counted the manors of the Knights Hospitaller rather than leper houses at all.

For England alone, the count of documented houses is closer to three hundred. And for a country of a few million people, that is still a great many. The picture inside them is more mixed than the horror story would suggest. Some were foul.

Some were places of prayer and regular meals and a bed, with a chapel and a garden and a rule of life, funded by townspeople who wanted the credit in heaven. And lepers sometimes fought for admission. The Third Lateran Council in 1179 ruled that lepers could have their own churches and priests and cemeteries, since they could not use anyone else’s. A leper in a well-run house would rise for prayers, eat bread and pottage, and on feast days meat, have his ulcers washed and dressed by the brothers or sisters, and be buried in the hospital’s own ground when the time came, among the others.

It was a life. A small one, walled, with the clapper hanging on a nail by the door for the days he was allowed out to beg. Sherburn, outside Durham, gives an idea of what a good house looked like on the inside. Bishop Hugh du Puiset founded it around 1181 for sixty-five lepers, and the rule he laid down for them survives.

Each got a daily loaf and a measure of ale, meat three days a week, fish or eggs or cheese on the others, and on the great feasts something better. A fire in the common hall. Their own priest and chapel, with a burial ground behind it. They rose for the offices like monks, and were expected to pray for the bishop’s soul, which was, after all, the point of the endowment.

The rule set out penalties for anyone who broke it, up to expulsion, back onto the road. It was a strict place, and by the standards of the time a kind one. And the men and women inside it were among the luckiest lepers in England. Many of them had come there by way of a churchyard and a spadeful of earth.

Plenty of lepers never got a bed. Those who did not walked to the roads and begged at the town gates and slept where they could, and the chronicles are full of them. St. Francis of Assisi is supposed to have kissed a leper on the road as the beginning of his conversion, and the story is told for the distance everyone hearing it understood between that and what a normal man would do.

The other side of that coin came in 1321 in the south of France, when a rumor spread that the lepers had conspired with the Jews and with Muslim rulers overseas to poison the wells and springs of Christendom, so that everyone would become a leper. Lepers were arrested across the region, tortured into confessions, and burned. In some towns they were burned in batches. King Philip V ordered lepers who confessed to be put to the fire, and the rest locked up for life.

The whole business collapsed within a year, and the lepers who had survived were let out. But no one counted the dead. And the pattern, the poisoned wells, the confessions under torture, the platforms in the fire, would come back for the Jews twenty-seven years later, almost word for word. The bones back up the sources.

At the leper hospital of St. Mary Magdalene outside Winchester, excavators found a young man buried with a scallop shell, the badge of a pilgrim to Santiago, dating from around the end of the eleventh century. His bones showed only slight changes, but the DNA pulled out of them was unmistakably Mycobacterium leprae, of a strain associated with the eastern Mediterranean and western Asia. He had come a long way, and he had brought it with him, and he ended up in a leper house on the edge of an English town.

And at Næstved in Denmark, whole leprosy cemeteries have been dug, and the skeletons show the collapsed nasal bones and the eaten-away fingers and the ulcerated shins in numbers that leave no doubt about what the disease did to a body over time. Bergen in Norway kept its leper hospital going into the twentieth century, and it is a museum now. The pathology drawings on the walls are not for the squeamish, and the last patients died there within living memory. The most famous leper of the Middle Ages was a king, and his tutor noticed the first sign.

William of Tyre, who taught the young Baldwin of Jerusalem, tells of the boy playing with other children who were pinching each other’s arms, as boys do, and noticing that Baldwin never cried out. When William looked, the child’s arm had lost all feeling. He knew what that meant, and he wrote that he could hardly bear to. Baldwin was crowned at thirteen in 1174.

By sixteen he was fighting Saladin. And at Montgisard in 1177, with his right arm already too damaged to use, he led a charge that routed the Egyptian army. Over the following years, the disease did what it does. His face changed.

His hands lost their fingers. Ulcers opened on his body. He went blind. By his early twenties he could not ride or walk, and was carried into the field in a litter, still giving orders, still refusing to give up the crown to men he did not trust.

He died in 1185, aged twenty-three. Piers Mitchell, a medical historian who has gone through the sources, puts it as lepromatous leprosy that had spread over the course of about a decade. And that fits the pattern exactly. It means that for the last years of his life, the king of Jerusalem was rotting in public, while the chroniclers who admired him wrote down every stage of it.

Robert the Bruce is the other royal name that comes up. The Scottish king died in 1329 after a long illness that the chroniclers describe as disfiguring and wasting. Jean Le Bel, writing in France, calls it la grosse maladie, the great sickness, a common way of saying leprosy without saying it. A cast taken from a skull believed to be his in the 1800s shows changes around the upper jaw and nose that some have taken as leprous.

Others point out that no contemporary Scottish source uses the word, that a king with leprosy would hardly have been allowed to keep his throne or his wife, and that the skull changes could be something else entirely. So he might have died a leper. And he might not. Ergotism is a stranger thing altogether.

It came out of the bread. Rye grows well on poor northern soil, and in wet years a fungus called Claviceps purpurea infects the ears and replaces individual grains with hard purple-black growths called sclerotia, which look a little like a rat’s droppings, or like the spur on a cockerel’s leg. The French name ergot comes from that spur. Ground into the flour with the rest, they carry alkaloids that clamp down the blood vessels, and in a different dose act on the brain.

A village that had a wet summer and a good rye crop and ate its own bread all winter could poison itself in slow motion without ever knowing why. The poor got it worse, as the poor ate rye and the rich ate wheat. And nobody in the village would have thought to blame the loaf, since the loaf was the one thing keeping them alive. A household that ate from the same sack of rye through a winter could go through the whole course of it in a few months.

And the shrine of St. Anthony, if one was in reach, was where they went when they could still walk. The gangrenous form is the one the sources called the holy fire, ignis sacer, or St. Anthony’s fire.

It began with a burning sensation in the hands and feet, a sense that the limb was on fire from inside, or that insects were crawling under the skin. Then the limb went cold. The blood vessels feeding it had narrowed until nothing came through. The skin went pale, then blue, then black, and the flesh dried and hardened and shrank onto the bone.

And the sufferer could feel, or by then could not feel, the line creeping up from the toes to the ankle to the shin. Then the dead part came away. Sometimes at the joint, cleanly, with almost no blood, there being none left in it. Accounts describe people whose feet fell off while they were walking, whose hands separated at the wrist.

Others lost fingers one at a time over weeks. Sigebert of Gembloux, a monk writing of the year 1089 in Lorraine, describes a plague of fire that consumed the entrails and ate away the limbs, and says the limbs putrefied and fell off, and that the sufferers were consumed by an invisible flame until they died. Rodulfus Glaber, writing about the Limousin toward the end of the 900s, says the fire burned inside the body and the limbs blackened like charcoal and dropped away, and that many died in agony over a few days, and the rest were left as cripples. An outbreak around Limoges in 994 is said in later accounts to have killed as many as 40,000 people, a number that sits on thin sources and should be held loosely.

But the scale of the thing is not in doubt. It recurred across the north for five hundred years. And every recurrence started in a kitchen. The convulsive form is what happened when the alkaloids went for the nervous system instead.

Violent muscle spasms. The arms and legs bent and locked, the back arching, the jaw clamped, twitching that went on for hours. Fits and hallucinations, vivid ones, of demons and animals and fire, of things crawling on the walls. And this is one reason some historians look at ergot when they try to explain outbreaks of apparent mass madness in medieval towns.

The dancing plagues. The visions. The villages where everyone saw the same thing at once. It is suggestive rather than settled.

The sufferers in this form often did not die, but they came out the other side with the memory of what they had seen and no way to explain it to anyone. The cure, when it came, was an accident of geography. Around 1095, near Vienne in the south of France, a nobleman named Gaston of Valloire saw his son recover from the fire at the shrine of St. Anthony the Hermit, and founded a hospital order in gratitude.

The hospital brothers of St. Anthony spread across Europe over the next two centuries and specialized in exactly this disease. The hospitals were recognizable by what hung over the door. Amputated limbs, blackened hands and feet left by the cured as offerings.

Inside, the patients were washed, given a balm made from pork fat and herbs, sometimes a wine steeped in the saint’s relics, and above all fed on the hospital’s own bread, made from clean grain the brothers grew themselves. So they got better, and the brothers got credit for a miracle. And in a sense they had earned it, since they had noticed that people who came to them stopped rotting, even if they had not worked out why. The pigs the Antonines kept, which were allowed to roam the towns with bells on their necks, were a privilege granted to the order, and also a source of the fat for the balm.

A patient who had already lost a foot got a crutch and a place to sit. A patient whose gangrene was still climbing had the dead part cut away above the line, with no anesthetic beyond wine, and the stump seared. Snorri Sturluson, in his history of the Norwegian kings, describes the death of King Magnus, son of Harald Hardrada, a few years after 1066, in terms that some historians have matched to ergot poisoning. Nobody in Norway would have called it that.

They would have called it what everyone called it. The fire. The English sweating sickness is the one that still puzzles historians of medicine most. It came from nowhere, killed like nothing else, and left.

It arrived in 1485, in the same season Henry Tudor landed to take the crown from Richard III, so that the first Tudor king came to London with a new disease at his back. His coronation was delayed by it. Two Lord Mayors of London died of it within a week of each other that autumn, along with several aldermen, and the Crowland chronicler wrote of a sickness that could kill within a day. It came again in 1508, in 1517, in 1528, and in 1551.

And after that it never came again. Five visits in sixty-six years, mostly confined to England, though the 1528 outbreak got loose on the continent and went through Hamburg and the Baltic and up into Scandinavia and toward Russia, killing on the same scale everywhere it landed, and then everywhere stopping. What it felt like was described best by John Caius, a physician who lived through the last outbreak and wrote a small book about it the following year. The onset was sudden and total.

A feeling of dread, an apprehension that Caius and others put before any physical sign. Then a cold shivering that shook the whole body. Then pain in the head, in the neck and shoulders, in the limbs. Then, within an hour or two, the heat and the sweat.

It poured off the body. Caius describes the patient soaked through, the bedding drenched, and the sweat itself foul-smelling. The heart raced. Breathing became hard.

Some people felt an overpowering urge to sleep. And Caius believed, as did most physicians, that if you let them sleep, they died. So relatives were told to keep the patient awake by any means for a full day and night, talking to them, shaking them, slapping them if it came to that. Within a day it was over, one way or the other.

Death came in three hours, or six, or twelve, rarely more than a day. Edward Hall, the chronicler, has the phrase that everyone quotes. People married at dinner were dead at supper. If you survived the first day, you generally survived, though survival gave no immunity, and you might catch it again in the next outbreak.

And some did, and died the second time. What most disturbed contemporaries was who the sweat chose. Plague went for the poor and the crowded. The sweat went for the healthy, the young, the well-fed.

And it went for men more than women. It went through the gentry and the court and the universities. In 1517 it emptied Oxford and Cambridge, and is said to have killed half the population of some towns. The 1517 outbreak got into the court as well.

Andrea Ammonio, the king’s Latin secretary and a friend of Erasmus, was well one day in August and dead within hours. And Erasmus, who had shared lodgings with him, wrote of the loss with disbelief. The king shut himself up at Windsor with a handful of attendants and a physician and let nobody in, and several of his pages died. In 1528 it got into Henry VIII’s household, and the king, who was terrified of illness in general, fled from house to house for weeks, hearing mass several times a day, taking confession constantly, and changing lodgings whenever a case appeared near him.

Anne Boleyn caught it at Hever and lived. And the king wrote to her that his most trusted physician was away, and sent another. Her brother-in-law, William Carey, caught it and died within hours. Cardinal Wolsey caught it and survived.

The French ambassador du Bellay wrote home that the deaths in London were beyond counting, and that he expected to catch it himself. Nobody knows what the sweating sickness was. A paper in 1991 suggested an enterovirus. A reassessment in 2014 leaned toward a hantavirus, which fits the speed and the lung involvement and the way it seems to have traveled with rodents in a wet summer.

Neither is proven. And the organism, whatever it was, has left no trace anyone has found. It simply stopped. Its last outbreak began at Shrewsbury in April of 1551.

Caius, who watched it, says it killed several hundred there in the first weeks before it moved east toward London and the universities. It took two brothers in a single afternoon. In July of 1551, Henry Brandon, the young Duke of Suffolk, was at Cambridge with his brother Charles. Henry was fifteen.

Charles was thirteen or fourteen. They were the sons of Charles Brandon, Henry VIII’s oldest friend, and of Catherine Willoughby, and they were being educated for the court. When the sweat appeared in Cambridge, they were moved to the Bishop of Lincoln’s house at Buckden, out in the country, to be safe. On the 14th of July, both boys fell ill.

Henry died first. Charles, who had just become Duke of Suffolk by his brother’s death, lived for somewhere between half an hour and an hour longer, and then died too. The dukedom passed through him and went extinct in the same afternoon. Their mother had lost her husband six years before and now had no children left.

She had them buried together at Buckden. And their tutor, who had watched the whole thing, wrote a Latin elegy that nobody remembers. Half a century earlier, another royal teenager had died at Ludlow on the Welsh border, and the sweat is one of the usual suspects. Arthur, Prince of Wales, the elder son of Henry VII, had married Catherine of Aragon in November of 1501 and been sent to Ludlow to learn to govern.

That spring, both of them fell ill. Catherine recovered. Arthur died on the 2nd of April 1502, aged fifteen, after a short illness that the sources describe only as a sickness that took him quickly. Sweating sickness, tuberculosis, and some form of plague have all been suggested.

The chroniclers did not name it. What they recorded is his father being told in the middle of the night by his confessor, and sending for the queen, and the two of them comforting each other, and the queen going back to her own room and breaking down so badly that the king had to come and comfort her in turn. Their second son became Henry VIII, and married his brother’s widow. And a great deal of English history turns on a fever at Ludlow that nobody could identify.

Smallpox is older and better understood. Medieval doctors had a clear account of it from the Persian physician al-Razi, who wrote a treatise around 910 separating smallpox from measles, and who interestingly thought measles the more dangerous of the two. In some ways the two diseases got confused for centuries. Smallpox came on with fever and backache and vomiting, and then the rash.

First in the mouth and throat, then on the face, then spreading down the body. Over about a week, the spots rose into pustules, tense and hard, filled with a thick, opaque fluid. In the ordinary form they stood separate on the skin, hundreds of them. And after another week or so, they crusted and fell away and left the pitted scars that marked survivors for life.

In the confluent form, the pustules ran together into sheets, so that the whole face was one raw weeping surface. The eyelids swelled shut. The skin peeled away in patches. And the smell, which every account mentions, was of a body decaying while alive.

Confluent smallpox killed most of the people it touched. Those who lived through it often lost their sight, since the pustules formed on the surface of the eye and scarred the cornea over. A great many of the blind beggars on the roads of medieval Europe were there because of smallpox. And a great many of the faces in any crowd were pitted with it.

One treatment has a royal patient attached. John of Gaddesden, a physician at Oxford and later to the English court, wrote a medical compendium called the Rosa Medicinae in the early 1300s. In it he describes how he treated a son of the king of England, which king is not certain, for smallpox. He had the boy wrapped entirely in scarlet cloth, and the bed hung with red, and the walls of the chamber covered in red.

And he gave him red pomegranate to suck, and red mulberry wine to gargle. And he says the boy recovered without a single mark. Red for smallpox turned up all over Europe and Asia and lasted for centuries. When Elizabeth I took it in 1562, she was wrapped in red flannel and set by the fire.

Whether the color did anything, the wrapping and the warmth may have. And the boy lived. And that was what Gaddesden was paid for. Dysentery killed more soldiers than most battles did.

And it killed several kings. The bloody flux they called it. Whether it was Shigella or an amoeba, and both were common, the mechanism was the same. Something in the water or on the hands got into the gut and destroyed its lining.

First came cramping and a fever. Then the bowels let go, and kept letting go. Twenty times a day. Thirty more.

Until nothing was left to pass but mucus and blood and shreds of the bowel wall itself. The urge never stopped, even when the bowel was empty. So the sufferer strained on nothing, in agony, sometimes until the rectum turned inside out and prolapsed. Meanwhile, the body was losing water faster than it could drink.

And the eyes sank, and the skin went loose, and the pulse went thin, and the mind clouded. In a camp, this happened to hundreds of men at once, lying in their own filth in the mud, with the latrine trenches overflowing and the water they drank drawn from the same river the trenches drained into, so that every day more men caught it. Men died in a week, or lingered for a month and died anyway, thin as sticks, their skin hanging off them. King John of England died of it in 1216.

The way the story is usually told has him gorging on peaches and new cider at a monastery and coming down with the flux the same night. The peaches may be a later flourish. What the record supports is a king in the middle of a losing civil war, already ill, crossing the Wash estuary and losing his baggage train, and so the story goes, his treasure to the incoming tide, and then being carried in a litter to Newark Castle, where he died on the night of the 18th of October, with the flux still running out of him. Edward I, his grandson, died of the same thing in 1307 at Burgh by Sands on the edge of the Solway, on his way to fight the Scots one more time, at the age of sixty-eight, so weak, the accounts say, that he could ride only a couple of miles a day, and in the end could not ride at all.

The crusader camps outside Acre in 1190 and 1191, during the Third Crusade, were the same thing on a bigger scale. The besieging army sat for two years in a marsh between the city walls and Saladin’s army, eating what it could get. And disease and hunger went through it so thoroughly that some estimates have a majority of the men who arrived dying before the city fell. Queen Sibylla of Jerusalem died there in the summer of 1190, in a fever that took her two small daughters in the same weeks.

Frederick of Swabia, the son of the emperor, died there in January. The counts and archbishops who died of the flux at Acre make a long list. And the ordinary men who died of it make no list at all. Henry V’s army at Harfleur in 1415 is the clearest English case.

The siege lasted five weeks, in a wet late summer, in marshy ground, and the flux went through the English camp. Contemporary sources reckon he lost something like five thousand men to it, around a third of the force he had brought from England, before a sword was raised. And the sick were shipped home by the boatload. The Earl of Suffolk died of it.

The bishop of Norwich died of it. What was left of the army went on to Agincourt and won. And the men who won were men who had spent September squatting in the mud with blood coming out of them. Seven years later, Henry himself was besieging Meaux in another wet season, and he caught it.

By the summer of 1422 he could not sit a horse. He was carried in a litter to the castle of Vincennes outside Paris. And there, on the 31st of August, he died, aged thirty-five. A king who had never lost a battle, shrunken and fouled in a bed.

A French chronicler called it St. Fiacre’s disease, since St. Fiacre was the patron of hemorrhoids and bowel complaints, and Henry had, the chronicler says, offended the saint’s shrine. By some accounts his body was boiled to strip the flesh from the bones, so the bones could be carried home for burial at Westminster, and the flesh was buried in France.

That practice had a name, mos Teutonicus, the German custom. And it was how you brought a king home from a distant war when there was no way to preserve him. The body was cut into pieces, and the pieces boiled in wine or water until the flesh came away, and the bones were cleaned and wrapped and sent home, and the rest was buried where the king had died. Louis IX of France got the same treatment.

In 1270 he took a crusade to Tunis, and the army sat in the heat outside the city with no clean water, and dysentery went through it. His son John Tristan died first. Then Louis, on the 25th of August, lying on a bed of ashes that he had asked for as a penitent, and the accounts say murmuring the name of Jerusalem in the grip of the flux. He was canonized within thirty years.

His father Louis VII had died of dysentery on his way home from a campaign in the south of France. His son Philip III would die of it on his way home from a campaign in Aragon. Three French kings in a row, and the same disease each time, and each time an army in a hot place with bad water. Edward the Black Prince, the great English soldier of the fourteenth century, took years to die of what most sources call the same thing.

His army in Spain in 1367, after the victory at Nájera, was destroyed by disease, and one chronicler claims four-fifths of it died. Edward came home ill and never fully recovered. By 1370 he was being carried on a litter to the siege of Limoges, too weak to stand, giving the orders for the sack of the town from a stretcher. He wasted for six more years in and out of his bed, sometimes well enough to attend parliament, and died on the 8th of June 1376, aged forty-five, the year before his father.

Chronic amoebic dysentery is the usual explanation. A study in 2022 proposed malaria, or brucellosis, or an inflammatory bowel disease instead, going by the pattern of remission and relapse in the records. A nine-year decline with bloody flux and recurring fever in a man who had campaigned in Spain could be several things. What the sources agree on is the litter and the wasting and the years.

Scurvy belongs with the crusaders too. Jean de Joinville, who went with Louis IX on the earlier crusade to Egypt in 1250, has left the clearest eyewitness description of it in the medieval record, and he does not know what it is. The army had been in the Nile Delta for months, eating salt meat and biscuit and fish from a river full of corpses. And then, he says, a sickness went through the host.

The flesh of the legs dried up, and the skin became covered in black spots, brown and black, and he compares it to an old boot. The gums swelled and rotted and grew over the teeth, so that men could not eat. And to eat at all, they had to have the barber surgeons cut the dead flesh away from their gums. And Joinville says that when the barbers were doing this, the whole camp could hear the men crying out.

And he compares the sound to women in labor. Their breath stank. Their teeth loosened and fell out. Old wounds that had healed years before opened up again and bled.

And they died, hundreds of them, in a camp that was also being cut down by dysentery and by the Egyptians. Joinville says the king himself was so ill with the flux that the seat of his breeches had to be cut away. A jawbone believed to be Louis’s own, kept at Notre Dame, was examined a few years ago by a team led by Philippe Charlier, and it showed the bone loss and the signs of severe scurvy. And that fits Joinville’s account of the king losing pieces of his own gums.

So the most saintly king in Europe spent the spring of 1250 with his mouth rotting and his bowels running, in a camp being cut down around him. And he went back and did it again twenty years later. The marshes had their own fever. Ague, the English called it, and it was malaria, carried by mosquitoes in the standing water of the fens and the Kent and Essex marshes, and far worse in the Roman Campagna in Italy.

It came in cycles that the doctors named for their timing: tertian fever spiking every third day, and quartan every fourth. The shaking fit came first, a cold so violent the teeth chattered and the bed shook. Then a burning fever. Then a drenching sweat and collapse.

And then, two or three days later, the whole thing over again. It went on for weeks. The spleen swelled until it could be felt as a hard mass under the ribs, and in children it could rupture. Children in the marsh parishes died of it in large numbers, and the survivors carried it in their blood for life and had it come back on them every summer.

Parish records from the sixteenth and seventeenth centuries show Essex marsh farmers burying several wives in succession, since the women they brought in from the uplands had no resistance and died within a few years, and the men who had survived it as children went to the uplands and married again. Rome was so malarial that the papal court moved to the hills every summer, and cardinals from the north who came for a conclave in the wrong season sometimes did not go home. Dante puts the shivering of the quartan fever into the Inferno as a thing everyone would recognize. A man shaking so hard in the shade that he looks for the sun.

Typhus rode on lice, and it lived wherever people were packed together and unwashed. Jail fever they called it, or camp fever. It began with headache and high fever, and then a rash spread over the trunk and the arms, and the mind went, so that patients raved and had to be tied down. And in the worst cases, the skin over the pressure points and the fingers and toes went gangrenous and stank.

The first outbreak that is clearly described in Europe is at the siege of Granada in 1489, where the Spanish army lost about three thousand men to the Moors and seventeen thousand to the fever, and where soldiers were found dead in their tents with the rash on them and their bodies gone dark. Girolamo Fracastoro, who also gave syphilis its name, separated typhus from plague in 1546. So through most of the Middle Ages it simply got folded in with everything else as the pestilence. And some of the deaths in the plague years that showed no buboes may well have been this.

Tuberculosis was the slow one. Consumption. It sat in the lungs for years, and the sufferer coughed and lost weight and woke at night soaked in sweat, and then one day coughed up blood, bright red, foaming from the lungs. Sometimes a cupful.

Sometimes a sudden hemorrhage that filled the mouth and killed in minutes, in bed, beside a wife who woke up next to it. Along the way, the disease could go into the bones. When it got into the spine, it ate away the front of the vertebrae, so they collapsed forward and the back bent into a sharp hump. Medieval skeletons show that hump.

They also show, much more commonly, the marks of the glandular form, where the lymph nodes of the neck swelled into lumps that softened and broke through the skin and discharged for years, leaving the neck a mass of scars and open sinuses. That was scrofula, the king’s evil. And it had a cure that no other disease had. The king would touch you.

The ceremony went back in England to the time of Edward the Confessor, and in France to Robert the Pious around the year 1000. And by the later Middle Ages it was a regular event. On a set day, the sick would gather, hundreds of them, and be brought one by one before the throne, and the king would lay his hands on the swellings in the neck, and a chaplain would pronounce a blessing. And from the reign of Henry VII, each person would be given a gold coin on a ribbon to hang round the neck as a charm.

Scrofula has a habit of going into remission on its own. So enough people got better that the ceremony kept its reputation for five hundred years. Edward I’s household accounts show him touching around a thousand people a year and paying each one a penny. Charles II touched something over ninety thousand people in the 1660s and 70s.

Whatever a modern physician makes of that, from the sufferer’s side, it meant that a peasant with running sores on his neck could stand in a line and have the king of England put his bare hands on him. For a good many of them, that must have been the most extraordinary thing that ever happened to them. And the sores kept running afterward, all the same. A few more killers before the birthing chamber.

They do not get their own chapters, but they filled a great many graves. Measles, which al-Razi had separated from smallpox, came through the towns in waves and killed children mostly, with pneumonia and with the swelling of the brain that sometimes followed. Diphtheria, which they did not have a name for, grew a gray leathery membrane across the back of a child’s throat until the child strangled on it over two or three days, in full view of its parents, and nothing on earth could be done except to hold it. Whooping cough, and croup, and fevers with no name that killed in a week.

Somewhere between a quarter and a third of children born in medieval Europe died before they were five. And most of them died of things like this, in the ordinary years, without a chronicle noticing. A mother in a village who buried three of her seven children was not unusual. She was average.

Rabies was rarer and worse. A bite from a mad dog, or a wolf, or a fox. And then nothing for weeks, sometimes months, while the virus crept up the nerves toward the brain. Then a tingling at the site of the old bite, and a fever, and a restlessness.

And then the thing that gave the disease its old name, hydrophobia, fear of water. The throat went into spasm at the sight of a cup. The sufferer, dying of thirst, could not swallow, and the attempt brought on convulsions so violent that the back arched and the face twisted. Between fits, the mind was clear, and that was the cruelest part.

The patient knew exactly what was happening and could talk about it. Then came the raving and the biting and the foaming, and death within a few days from paralysis of the breathing. Medieval Europe had no treatment except cautery. So a man bitten by a mad dog would have the wound burned out with a hot iron, in the hope that the poison had not yet gone deep.

In the Ardennes, the shrine of St. Hubert offered a different cure. A thread from the saint’s stole inserted under the skin of the forehead through a small incision, and a strict regimen afterward. And pilgrims came to it from across the north.

Some of them, the ones whose bite had not taken, went home cured. The rest died on the road, or after they got there. And the shrine kept its reputation either way. Tetanus came out of any dirty wound.

A cut from a plowshare. A splinter. A nail through the foot. A battlefield gash packed with earth.

A week or so later, the jaw stiffened and would not open, and the neck went rigid. And then the whole body clamped into spasms so severe that the spine bowed backward until only the head and heels touched the bed, and the muscles tore themselves, and the bones cracked. And the sufferer, fully conscious, died over days of exhaustion and suffocation. Lockjaw.

Every village knew it, and nobody knew where it came from. An ordinary wound infection, gangrene of the wet kind, often killed more soldiers after a battle than died in it. An arrow wound in the thigh that turned red and hot and then began to smell, and then turned black at the edges, with the pus running and the fever climbing, and the surgeon’s only tools a knife and a hot iron and a poultice. If the leg came off in time, and the stump did not rot, you lived one-legged.

If it did not, the black line climbed toward the trunk, and you died raving, and the surgeon moved on to the next man. The maggots that got into the wound in summer, which everyone found disgusting, were in fact doing a better job than the surgeon, since they ate only the dead tissue. But that went unrecognized for centuries. The hospitals of the period, where they existed, were places to die more than places to be cured.

The Hôtel-Dieu in Paris, the great hospital beside Notre Dame, had beds that held two, three, sometimes four patients at once, head to foot, the dying beside the recovering beside the woman in labor. And the sisters who ran it nursed everyone alike. The dead were carried out in the morning. The linen was changed when it could be.

A traveler who was taken ill in a strange town and carried to the hospital would be confessed first, since the confession was the point, and then put in a bed with a stranger who might be coughing blood, and fed, and prayed over. And if he lived, it was noted as the mercy of God. And if he did not, it was noted too. It was better than the street, and not by a great deal.

Most people, though, never saw a hospital. Most people died at home, on the family mattress, with whoever was left in the house to watch. Turn now from the sick room to the birthing chamber. Childbirth killed women at every rank, and the deaths were as bad as anything in this story.

The numbers are argued over. The old picture of a woman with something like a one-in-three chance of dying in childbed across a lifetime has been pushed back in recent work. Rachel Podd, going through the records of just over a hundred aristocratic English women from the mid-1200s to 1500, found that childbirth was not the main thing killing them. And the parish registers of the 1600s, when they begin, put maternal deaths at something like five or six percent of the women in the group sampled.

Five or six in a hundred is still a great many mothers. And across a village over a generation, it meant that everyone knew a woman who had died that way. And a great many pregnant women made their wills before their time came. The chamber was closed, windows shuttered, fire lit, men excluded.

The midwife and the neighbor women in attendance. And on the woman’s belly, if the family could get one, a birth girdle: a strip of parchment written over with prayers to St. Margaret, who had been swallowed by a dragon and burst out of it unharmed, and was therefore the saint you wanted. If the birth went well, it went well, and most did, and the girdle got the credit.

If it did not, almost nothing could be done. A child lying crossways could not be turned by anyone who did not know how, and few did. A head too large for the pelvis, in a mother whose own bones had been bent by childhood rickets, would not pass, and the labor went on for a day, then two, then three, with the contractions never stopping and the child dying inside her and the mother’s tissues tearing and dying under the pressure, until she died of exhaustion or of the infection that followed. Some women lived through that and came out with a hole worn between the bladder and the birth canal, so that they leaked urine constantly for the rest of their lives, and stank, and were shunned for it.

If the child was dead and stuck, the midwife, or a barber surgeon if one could be got and the family could bear to have a man in the room, would reach in with a hook and bring the child out in pieces. That was the only way to save the mother. And it often did not. If the afterbirth did not come away, or the womb did not clamp down afterward, she could bleed out onto the straw in minutes, the blood pooling and running through the mattress and onto the floor.

And the women around her could only pack her with cloths and pray. And if she came through the birth, the danger was not over, since childbed fever was waiting. Two or three days after delivery, a mother would begin to shiver, and the belly would swell and become exquisitely tender, and the fever would climb, and the discharge would turn foul. And within a week she would be dead of an infection carried into her body on the unwashed hands of the very women trying to help her.

Nobody understood that for another four hundred years. A midwife who went from laying out a corpse to a laboring woman in the same afternoon killed without knowing she had done it, and was thanked for her care. Cesarean section existed, and it was performed only on the dead. If a mother died with the child still inside her, the priest or the midwife would open her belly with a knife to get the infant out before it died too.

And the point was baptism. An unbaptized infant, in the theology of the day, did not go to heaven. So the child was cut from its dead mother, and if it was still breathing, baptized on the spot with whatever water was to hand, and usually died a few minutes later, and could then be buried in consecrated ground beside her. Some accounts describe the midwife keeping the dead mother’s mouth propped open so the child might get air.

If the child died before it could be baptized, it went into unconsecrated ground outside the churchyard wall. And the mother who had died delivering it went inside. And they were apart for good. The theology sounds cold from here.

In the room, it meant that a woman who was dying knew her baby had a chance of salvation. And that mattered to her more than we can easily grasp. Two queens are on record. Elizabeth of Rhuddlan, a daughter of Edward I, died in 1316 giving birth to her ninth child, at thirty-three.

Elizabeth of York, the wife of Henry VII and the mother of Henry VIII, gave birth to a daughter in the Tower of London in February of 1503, and the fever took her nine days later, on her 37th birthday, the 11th of February. The baby, Catherine, died as well. Her coffin was carried through London under white banners, the sign of a woman dead in childbed. Her husband, who was not a demonstrative man, shut himself away for weeks and would see no one.

And their son Henry, who was eleven, seems never to have entirely got over it. One more grave, in Italy, that no chronicle mentions at all. At Imola, near Bologna, archaeologists opened a burial from the seventh or eighth century and found a woman in her twenties with a cluster of tiny bones between her thighs. The bones were a fetus, and it had been partly pushed out of her body after she was in the ground by the gases of decomposition, in what is called a coffin birth.

Her skull had a hole drilled in it neatly, and the bone edges had begun to heal. So she had lived about a week after someone bored into her head. The best guess is that she had eclampsia, the seizures of late pregnancy, and that somebody tried to relieve it with the only surgery they had, and that she survived the surgery and died anyway, and was buried with her child still inside her, and gave birth to it in the dark. The famine came thirty years before the plague, and the frail bodies in the East Smithfield trench were made in it.

The rain started across northern Europe in the spring of 1315, and it did not stop. It rained through the summer, and the crops rotted in the fields. The hay could not be cut, so the animals had nothing for the winter. The next year was as bad, and the year after not much better.

And on top of it, a disease went through the cattle, the great bovine pestilence, that killed herds wholesale and left the carcasses lying in the mud. The chroniclers described the beasts dying within days, the carcasses too many to bury, and the poor, who had nothing else, cutting meat from the dead animals and sickening on it. On some manors of Ramsey Abbey in the English Midlands, the count of cows dropped from forty-five to two. Sheep died of the wet in their thousands.

So the bread was gone, and the milk, and the meat, and the seed corn for the next year too, eaten already. Grain prices went up threefold and fourfold. Salt, which you needed to keep anything, became unaffordable, since the salt pans could not dry in the rain. In August of 1315, King Edward II stopped at St.

Albans, and his household could not find bread to buy for the king of England at any price. What people ate, the chroniclers list. Dogs. Cats.

Horses, which was a scandal in itself. The bark of trees, ground up. Grass. Roots.

Town paupers died in the streets and were buried in pits. The city of Ypres kept a count and buried 2,794 bodies at public expense between May and October of 1316. Something like one person in ten. Bruges buried around two thousand.

Jean de Venette and the annals of Ghent and the English chroniclers all record the same things, and the chroniclers give them as they set them down. Parents abandoned their children. Children were sold. Crime went up sharply.

And in more than one place, the chroniclers write that people ate the dead, or killed to eat, and that the bodies of hanged criminals were taken from the gallows in the night for food, and that in some parts of the north, parents killed and ate their own children. Whether every one of those reports is literally true, nobody can now say. But they were written by men who expected to be believed. And the same reports come from places hundreds of miles apart.

The urban death toll across the famine years is usually put at somewhere between one in ten and one in four. Starvation itself has a course, and the chroniclers watched it. The body burns its fat first, and then its muscle. And the belly swells with fluid while the limbs shrink to sticks.

And the skin goes loose and gray and hangs in folds. And the hair falls out. And the sufferer grows cold all the time and cannot get warm. The gums bleed.

Wounds do not heal. Diarrhea sets in, watery and constant, and the sufferer cannot stop it. The mind slows and then dulls and then goes strangely calm. And in the last stage, people lie still and do not ask for food anymore.

Children go first. They have the least to burn. The chroniclers speak of whole households dying together. And those who lived through it on bark bread and grass came out of it with bones that showed it for the rest of their lives.

You can watch what it did in a single family, the best-fed family in England. Life expectancy in the royal house, worked out from their well-recorded births and deaths, was around thirty-five for those born in the 1270s. For those who were children during the famine, it dropped to under thirty. For those who lived through the Black Death and its aftershocks, it collapsed to about seventeen.

Those are princes. Beneath them was everyone else. And the children who survived the famine on bark bread grew up with the marks of it in their teeth and their shin bones. And those were the bodies that went into the East Smithfield trenches thirty years later.

The famine and the plague were one event with a gap in the middle. The gap had its own dead too. Between 1320 and 1347, in the ordinary years, the years nobody writes a video about, people went on dying of everything described here in the usual proportions in every parish. And the chroniclers barely mention it.

It was simply how things were. A village of three hundred would bury perhaps ten or twelve people in a normal year, and most of those would be children. The churchyard filled at that rate for centuries. A man of forty had buried his parents, and probably at least one sibling, and probably at least one child, and had a fair idea of what his own death would look like, since he had watched so many.

That background hum of dying is what the Black Death landed on. People knew the grave well. The plague filled it with forty years’ worth in one summer. Some places were passed over on the way through.

The plague did not stop at the edge of Christendom, and the accounts from the other side of the Mediterranean are some of the most vivid we have. Ibn Battuta, the great Moroccan traveler, was in Damascus in the summer of 1348 and watched the whole city go out beyond the walls to pray. The governor ordered a fast of three days. And on the fourth morning, everyone came out barefoot.

The Muslims with their Quran, the Jews with their Torah, the Christians with their gospels. All of them weeping and calling on God together. And they went to the Mosque of the Footprints outside the city and stayed there till the sun was high. He says the death toll in Damascus had reached 2,400 a day by then.

In Cairo, according to the historian al-Maqrizi, writing decades later from the records, the daily dead were counted in the thousands at the peak. The mosques could not wash the bodies fast enough, and corpses were left along the roads for want of anyone to carry them. Ibn al-Wardi, a scholar in Aleppo, wrote an essay about the plague as it came toward him, describing the swellings and the spitting of blood and the way it seemed to move like an army that no city could shut its gates against. And he died of it himself in 1349, a few months after he finished writing.

The Muslim world lost roughly the same proportion of its people as Europe did. And it had no wells to blame, and mostly no one to burn. Back in Sicily, where the whole thing had started for the West, Michele da Piazza gives a closer account of Messina in the autumn of 1347. He says the disease spread from the sailors to anyone who spoke with them, and from those to their families, and that within days the swellings appeared, the size of a lentil at first on the thigh or the arm, and then grew to the size of a walnut, and then of an egg.

And the victim spat blood for three days and died. He says the Messinians, in terror, ran to the countryside and to Catania. And the people of Catania at first took them in, and then, when the Catanians began dying too, refused to let any more in and would not speak to them. And the Messinian refugees died in the vineyards and along the roads, with nobody to bury them.

The Messinians begged the Archbishop of Catania for the relics of St. Agatha to be brought to their city. And the people of Catania rioted rather than let their saint leave. So instead the relics were dipped in water, and the water was sent.

And the disease came into Catania anyway, and the archbishop died of it. And the friar says the disease was in Catania by the spring. The saints came into it everywhere. St.

Sebastian, shot full of arrows and surviving, had been the plague saint since the seventh century, since the arrows stood for the darts of pestilence God fired at the sinful. And his image went up in churches across Europe. St. Roch, who is supposed to have caught the plague himself on the road to Rome and been fed by a dog while he lay dying in the woods, is shown pulling up his robe to display the bubo on his thigh.

And that image, the saint pointing at his own sore, was in front of the eyes of people who had the same sore. And it must have helped a little to see it on a saint. Processions went round the town walls with the relics. Bells were rung to break up the corrupt air.

In some towns, a candle was made the length of the walls and burned in the cathedral. None of it stopped anything. All of it was done anyway. The manor records show what the plague did away from the cities and the famous chroniclers.

Cuxham in Oxfordshire was a small place belonging to Merton College, and its accounts survive in unusual detail. Between March and June of 1349, every one of the customary tenants of the manor, the villein families who worked the lord’s land, died. All of them. The reeve died, and the man appointed in his place died, and the man after him.

The college’s officials, going through the rolls afterward, recorded holding after holding fallen vacant by death, with nobody to take it up. At Halesowen in Worcestershire, where the court rolls let historians count, something like four in ten of the tenants died in the same months. At the Cistercian Abbey of Meaux in Yorkshire, the chronicle of the house records that the abbot and most of the community died, leaving ten survivors out of nearly fifty who had been singing the office together at Easter. And the bishop of Lincoln, going through his register in the same year, was ordaining new priests in far larger numbers than usual, many of them barely trained, since the men who had held the parishes were dead and someone had to say the words over the dying.

The city physicians, meanwhile, were dying with their patients. Gentile da Foligno, one of the most celebrated doctors in Italy, was called to Perugia in the spring of 1348 and wrote a treatise on the pestilence for the city, full of sensible advice about diet and air and bleeding, and then went on attending the sick and died of it in June. A poem written in 1350 by a Paris physician called Simon de Covino says the doctors were so frightened that they refused to go near the sick, and that when they did go they could offer nothing but words, and that the whole art of medicine had been shown to be useless. Across the sea at Almería in Muslim Spain, a doctor named Ibn Khatima watched the disease so carefully that he wrote down what it took to catch it.

That you caught it from the clothes and bedding of the sick. That you caught it from being near the breath of someone with the lung form. That the healthy who fled the sick were spared, and the ones who nursed them were not. He had the mechanism nearly right.

And he had no way to act on it beyond telling people to run. Petrarch, who had lost Laura, and his patron, and most of his friends inside a year, wrote a letter that spring to Louis Heyligen, the musician from the start of this story. He asks where his friends have gone, the ones they had sat with and talked with only months before. And he says they go about looking for them in the empty houses and cannot find them.

He says the year has spared nothing, that people are dying in every town and every house is a tomb, and that anyone in the future who hears of it will refuse to believe it and take the whole account for a fable. He calls posterity happy. It will never see what he has seen. Then he asks his friend what use it is to have lived, if this is what living comes to.

And he does not answer his own question. He was in his mid-forties. He lived another twenty-five years. And the plague came round twice more in his lifetime.

And it took his son in the second wave. That second wave, in 1361, was called the pestis puerorum, the children’s plague, in England. And the chroniclers were struck by how it seemed to take the young and spare the old. The likeliest explanation is the obvious one.

Anyone alive in 1361 who had been an adult in 1349 had already been exposed, and either died or come through it with some resistance. The children born in the twelve years since had nothing. So the second pestilence went through the nurseries. A family that had lost its grandparents and its uncles in the first wave lost its children in the second.

And the parents in the middle, who had survived both, buried their own mothers and then their own sons. Knighton, the Leicester canon, says it took men more than women, and children and the young more than the old, and that the mortality was great but less than the first. He also says, in the same breath, that a great many of the rich died in it. And he lists them, as if that was the surprising part.

Sound is another piece of it. A plague town in 1348 went quiet in a particular way, and the chroniclers recorded it almost by accident. The passing bell, rung for every death so the parish could pray, stopped. Agnolo di Tura says the bells of Siena did not ring for anyone.

At Pistoia, the town council wrote it into the plague ordinances of May 1348, forbidding the bells to be tolled for the dead, so that the sound would not frighten the living. At Tournai, where the abbot Gilles li Muisis kept a record even though he had gone blind and had to dictate it, the magistrates ordered in the summer of 1349 that no bell was to be rung for anyone, that the dead were to be coffined and buried at once, that the number of mourners was to be limited and no wake held. And li Muisis notes the numbers dying each day going past anything the city had known. And the chroniclers themselves went quiet in their own way.

People got used to it, and the writers say so. Boccaccio says that in the end no more notice was taken of a dead man than would be taken now of a dead goat. Agnolo di Tura says nobody wept. When the chroniclers themselves stop describing individual deaths and start giving numbers, which most of them do sooner or later, you are watching the same thing happen on the page.

The last disease in the catalog arrived just as the Middle Ages were ending, and the men who saw it said nothing like it had ever been seen. In 1494, Charles VIII of France marched an army of thirty thousand or so into Italy to claim the Kingdom of Naples, with mercenaries from every country in Europe in it, and camp followers. And in the spring of 1495, while that army was in and around Naples, a new sickness appeared in it. Where it came from is one of the old arguments.

One school says Columbus’s sailors brought it back from the Caribbean in 1493, and it went straight into the port brothels of Spain and from there to Naples. Another says it was in Europe already in a milder form and something changed. The bones lean one way and then the other, depending on who has dug them up. When Charles retreated north and the army broke up, the mercenaries went home to Germany and Switzerland and France and Spain and England and Scotland.

And they took it with them. Within five years it was everywhere in Europe. The Italians called it the French disease. The French called it the Neapolitan disease.

The Poles called it the German disease. And the Russians the Polish disease, and the Turks the Christian disease. Girolamo Fracastoro gave it the name it kept, syphilis, in a poem in 1530 about a shepherd who offended Apollo. The early form was far more savage than what the disease later became.

First a sore at the point of contact, painless and easy to ignore. Then within weeks a rash, and then the pustules, which rose all over the body from the scalp to the knees and burst and ran and crusted over and broke open again, so that the sufferer was covered in a foul crust that stuck to the clothes and bedding and tore away when he moved. The flesh of the face was eaten away. Noses went.

Lips went. The palate rotted through, so that food and drink came back out through the nose when the sufferer tried to swallow. The bones ached, deep and grinding, worst at night, so that sufferers could not lie down and sat up screaming till dawn. And the pain went on for months.

The smell of the sores was such that the sick were driven out of the hospitals that took plague victims, and cities began to set up separate hospitals for the incurabili, the incurables, to take them in. And they died, often within a year or two, which the disease, as it settled into the population over the following century, gradually stopped doing. Joseph Grünpeck, a German scholar who caught it himself and wrote about it, said it was so cruel and so revolting that nothing so horrifying had ever been known on Earth. And he describes his own body breaking out in sores the size of acorns that stank so badly he could not bear himself.

Alessandro Benedetti, a Venetian surgeon with the army, described men who had lost their hands, their feet, their eyes, and their noses to it, and said that the whole body became so repulsive to look at, and the suffering so great, that death was preferable. Albrecht Dürer made a woodcut of a sufferer in 1496. A man in fine clothes with his face and legs covered in sores, standing under a globe marked with the fatal conjunction of the planets, since the stars were being blamed for this one too. The Emperor Maximilian had issued an edict the year before blaming blasphemy.

The treatment, when one was found, was mercury. Rubbed into the sores as an ointment, or breathed in as a vapor in a closed tent while the patient sweated. And it did do something to the sores. And it also loosened the teeth and rotted the gums and made the mouth pour with saliva, pints of it a day, and turned the breath foul, and drove some patients mad, and killed others outright.

The saying went that you spent a night with Venus and a lifetime with Mercury. Later came guaiacum, a wood from the Caribbean boiled into a bitter tea, which was expensive and did nothing, and which the Fugger banking house, who held the import monopoly, promoted with enthusiasm. The sculptor Benvenuto Cellini, who caught it in his twenties, wrote that he was cured by an attack of fever and by drinking guaiacum, and lived into his seventies. So perhaps the shepherd’s disease was already turning gentler by then.

The men who caught it in Naples in 1495 got no such mercy. One last strangeness from the same years, and nobody has ever explained it. In July of 1518 in Strasbourg, the same city where the Jews had been burned 170 years before, a woman called Frau Troffea walked out into the street and began to dance. She danced for hours.

She danced through the night. Within a week, thirty-four people had joined her. And within a month, so the city records say, around four hundred, dancing in the streets and the squares without music, with bloody feet, with their eyes rolled back, unable to stop. The city fathers, on medical advice, decided the cure was more dancing.

And they hired musicians and built a stage in the market and cleared the guild halls, so the dancers could dance it out. People collapsed. Some died, of heart failure or strokes or plain exhaustion. And the chroniclers put the toll at up to fifteen a day at the worst, though that figure has been questioned.

It went on for about two months, and then it stopped. Ergot has been suggested, since it was a hungry year after a bad harvest, and the convulsive form of the fire can produce something like this. Mass hysteria in a city crushed by famine and disease has been suggested too. And a cult of St.

Vitus, whose curse was supposed to be exactly this. Whatever it was, four hundred people danced themselves half to death in a European city the year after Luther nailed up his theses. And the authorities responded by hiring musicians. The villages that the plague emptied mostly never refilled.

Across England there are something like three thousand deserted medieval villages, humps and hollows in the grass where the houses stood. And Wharram Percy in Yorkshire is the one that has been dug the most thoroughly. Wharram came through 1349 thinned rather than emptied, and the survivors carried on, and the village limped through the 1400s getting smaller, and by around 1500 the last families were gone, and the lord turned the fields over to sheep. Sheep did not need feeding in a famine, and did not die of the plague, and did not ask for higher wages.

The church stood on alone for centuries. The bones from its churchyard have been studied in detail, and they show what a normal medieval village looked like from the inside. The childhood malnutrition. The tuberculosis.

The healed and unhealed fractures. The women dead in their twenties. The children dead before they could walk. A quiet place now, with a ruined church and a pond, where about seven hundred years of people lived and died in the ordinary way, and then simply were not there anymore.

One more voice, from the plague years, from Kilkenny in Ireland in the summer of 1349. A Franciscan friar called John Clyn was keeping the annals of his house, and he kept them through the pestilence. He wrote that in Kilkenny scarcely a house could be found in which only one had died. That the priest and the man he had confessed were often carried to the grave together.

That many died of boils and abscesses and pustules on their shins and under their arms, and others frantic with pain in the head, and others spitting blood. He counted the friars who died at Drogheda and at Dublin, twenty-five in the one house and twenty-three in the other. He wrote that he had seen so much evil and so many prodigies that he had put it all in writing while waiting among the dead for death to come, in case anyone of the race of Adam should survive it. And he asked any man who lived to carry on the work he had begun.

Then he left a stretch of blank parchment for them. After the blank, in a different hand, is one line. It says that here, it seems, the author died.