Causes of death have changed irrevocably across time. In the course of a few centuries we have gone from a world where disease or violence were likely to strike anyone at any age, and where famine could be just one bad harvest away, to one where in many countries excess food is more of a problem than a lack of it. Why have the reasons we die changed so much? In This Mortal Coil: A History of Death, University of Manchester Professor Andrew Doig provides an eye-opening portrait of death throughout history.
Today, we’re featuring an extract from This Mortal Coil on the blog – read on!
Introduction: The Four Horsemen of Siena
And so many died that all believed that it was the end of the world.
—Agnolo di Tura del Grasso The Plague in Siena: An Italian Chronicle , 1348
Six hundred years after the Franks, Goths, Saxons and other invaders brought down the Western Roman Empire, their lands had developed into nations that we still recognise today: France, England, Spain and Germany. Here, from 1000 to 1300 CE, the climate grew warmer, forests were cleared and cultivated, towns were founded, and farming methods improved. New inventions of paper, the compass, windmills, gunpowder and reading glasses, with better ships and mechanical clocks, drove economic growth and trade. Greater wealth funded new universities, spectacular Gothic cathedrals, literature and music. Famine was still present, but the structure of medieval society, with its threefold division into those who pray, those who fi ght, and those who work, remained strong. All this was to be stretched to breaking point by the catastrophic Black Death, which struck Europe in the 1340s.
In 1347, Siena was one of the richest and most beautiful cities in Central Italy, with its prosperity based on moneylending, the wool trade and military strength. Visitors would have seen one of the most impressive cities in Italy, dominated by the seat of government, the Palazzo Pubblico, and a spectacular cathedral, undergoing construction work that was intended to more than double its size. By the thirteenth century Siena was able to match Florence, its great rival thirty miles to the north, and was steadily expanding the size of its republic.
Shoemaker and tax collector Agnolo di Tura del Grasso produced a chronicle of events in Siena from 1300 to 1351, based on his own observations, consultation of public records and personal experience. He provides one of the best contemporary accounts that we have for the deadliest disease that has ever afflicted humanity – plague.
Plague entered Tuscany through the port of Pisa in January 1348. It took two months to travel upstream to Florence, then made its way south to Siena. Di Tura tells us that: ‘The mortality began in Siena in May (1348). It was a cruel and horrible thing … the victims died almost immediately. They would swell beneath their armpits and in their groins, and fall over dead while talking. Father abandoned child, wife husband, one brother another.’
The enormous death rate made normal Christian funerals impossible. No one could be found to bury the dead. Families had to leave their corpses in ditches or take them to great pits, where they were often buried without a priest to officiate. Poor Di Tura lost all his children: ‘And I … buried my five children with my own hands. And there were also those who were so sparsely covered with earth that the dogs dragged them forth and devoured many bodies throughout the city. There was no one who wept for any death, for all awaited death … And no medicine or any other defence availed.’
Di Tura estimated that three quarters of the population of the city and suburbs of Siena died – about 80,000 people in just five months. Society collapsed:
And those that survived were like persons distraught and almost without feeling. And many walls and other things were abandoned, and all the mines of silver and gold and copper that existed in Sienese territory were abandoned as is seen; for in the countryside many more people died, many lands and villages were abandoned, and no one remained there. I will not write of the cruelty that there was in the countryside, of the wolves and wild beasts that ate the poorly buried corpses. The city of Siena seemed almost uninhabited, for almost no one was found in the city. And then, when the pestilence abated, all who survived gave themselves over to pleasures: monks, priests, nuns, and lay men and women all enjoyed themselves, and none worried about spending and gambling. And everyone thought himself rich because he had escaped and regained the world.
The story of plague in Siena and the testimony of Agnolo di Tura del Grasso graphically show the devastation that plague could cause. While the Black Death is an extreme example, sudden death at the hands of various infectious diseases was common for thousands of years, certainly from when we started farming and living in cities. Thankfully, it is now rare. Even though we rightly worry about infections like influenza, pneumonia or Covid-19, their power does not come close to those of cholera, smallpox or plague. Yet the details of the events in Siena reveal two other leading causes of death that we have also largely overcome, namely famine and war.
The harvest failed in Tuscany in 1346 and hailstorms destroyed crops the year after. 2 Hungry, malnourished people moved from the countryside to the city, in search of food, work and charity. Their living conditions would magnify the effects of the Black Death, as the disease was swiftly transmitted in overcrowded and dirty neighbourhoods. Famine kills mainly by promoting infectious disease and magnifying its dangers, so the plague struck Siena at its most vulnerable, following two years of famine.
The city states of Italy, and their powerful neighbours, like France, Spain and the Ottoman Empire, were routinely engaged in conflict with each other. Wars were endemic throughout Italy and the rest of Europe. Rather than using their own citizens as soldiers, Italian wars were typically fought by mercenaries who engaged in sieges, fed themselves by looting, and deliberately destroyed crops, livestock and buildings in enemy territory, reducing peasants to destitution and famine. Armies made use of plague, waiting for the disease to ravage a city before sending in an occupying force.
Siena had been largely successful in warfare for hundreds of years, right up to the fateful 1340s, expanding their state to the coast. All this came to a sudden halt with the plague. Industry, construction, agriculture and government simply stopped. When politics did resume, the city council was reduced in size by one third, as so many of city elite had died. Tuscany was full of abandoned buildings, ghost towns, overgrown fields and returning forest. The oligarchy that had ruled Siena for sixty-eight years was overthrown in 1355, leading to a century of unstable governments and revolutions. Unpaid mercenary companies took control of the countryside, terrorising and looting. Taking advantage of the new situation, rival states began to eat into Sienese territory. The end finally came in 1555, when the republic surrendered to King Philip of Spain, who promptly handed Siena over to their bitter rivals, Florence. It was not until the twentieth century that Siena’s population returned to pre-plague levels, which is one reason why it has preserved its beautiful medieval city centre. The cathedral remains unfinished.
Plague, Famine and War, together with Death itself, were thus the Four Horsemen of the Medieval Apocalypse. Today, our main causes of death are utterly different: namely heart failure, cancer, stroke and dementia. We have gone from a world in which death from disease or violence were likely to strike down anyone at any age, and where famine was just one or two harvest failures away, to one where in many countries an excess of food is more of a problem than a lack of it, and death before sixty is seen as shockingly young. How we live has changed in innumerable ways, reflected in how we die. The aim of this book is to show how this happened.
‘Even though we rightly worry about infections like influenza, pneumonia or Covid-19, their power does not come close to those of cholera, smallpox or plague.’
What are the main causes of death in the modern world? In total, 56,873,804 people died in 2016. Some died in a hospital bed, suffering from cancerous tumours, soothed by morphine and in the company of loved ones. Many had infectious diseases, with their immune systems unable to fight off deadly microbes. Some had only had a few hours of life after birth, due to birth defects, genetic abnormalities or a traumatic delivery. Others had fatal accidents – on the road, by drowning or in a fire. Some took their own lives, using weapons or drugs to end it all. Currently, the most frequent cause of death worldwide is coronary heart disease, more simply known as a heart attack. Stroke is the second biggest killer. Next, we have lung diseases, including asthma, emphysema and pneumonia. Fatal cancers are split into various categories, but if these are all grouped together, then cancer kills almost as many people as heart disease.
This current situation, where people now die mainly from non communicable diseases like cancer, is entirely new. Why have the reasons we die changed so much? Our species evolved when we lived in small bands in a dangerous, violent world, where many died from accidents or at the hands of other people. Farming and the establishment of the first states brought security, but at the dreadful cost of chronic malnutrition, alongside a life devoted to backbreaking and tedious work for the overwhelming majority. In addition, close contact with animals over thousands of years meant that many pathogenic organisms jumped the species barrier, bringing new diseases to literally plague us. Higher population densities and lack of sanitation kept the diseases circulating, so that infectious disease became the leading cause of death.
Success in tackling infectious diseases came from understanding how and why they occurred. It was only in the late nineteenth century that it was finally accepted that disease could be spread by infectious microorganisms, driving the provision of clean water, homes and clothing, free from deadly microbes, vermin and parasites. Combining our understanding of the true causes of infectious disease with a scientific approach gave us vaccines and drug-discovery programmes. The result was a huge decline in infectious disease and a rising life expectancy from the mid-nineteenth century onwards.
While heart disease, stroke, lung disease, diabetes and cancer were bound to become more significant as life expectancy increased, our changing lifestyles also played a major part in promoting them. We now eat too much, particularly junk food, use drugs, smoke cigarettes, overindulge in alcohol, and avoid exercise. Still, we continue to live longer, leading to the growing prevalence of neurodegenerative diseases that are common in the elderly, like Parkinson’s, Alzheimer’s and other forms of dementia.
On top of examining the ways we live and die today, we shall also look to the future and see how we are entering the next healthcare revolution, where many more of the current causes of death will be defeated, using new technologies, like stem cells, organ transplants and genetic modification. The story of the causes of human death and how we have overcome so many of them is, therefore, also a story of growing medical knowledge and social organisation, of achievement and, looking to the future, of promise.
—This Mortal Coil: A History of Death by Andrew Foig (Bloomsbury Australia) is out now.
This Mortal Coil
A History of Death
Causes of death have changed irrevocably across time. In the course of a few centuries we have gone from a world where disease or violence were likely to strike anyone at any age, and where famine could be just one bad harvest away, to one where in many countries excess food is more of a problem than a lack of it.
Why have the reasons we die changed so much? How is it that a century ago people died mainly from infectious disease, while today the leading causes of death in industrialised nations are heart disease and stroke?...
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