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Black Death
The Black Death (also known as the Pestilence, the Great Mortality or the Plague) was a bubonic plague pandemic occurring in Western Eurasia and North Africa from 1346 to 1353. It is the most fatal pandemic recorded in human history, causing the deaths of 75–200 million people, peaking in Europe from 1347 to 1351. Bubonic plague is caused by the bacterium Yersinia pestis spread by fleas, but during the Black Death it probably also took a secondary form, spread by person-to-person contact via aerosols, causing pneumonic plague.The Black Death was the beginning of the second plague pandemic. The plague created religious, social and economic upheavals, with profound effects on the course of European history.
The origin of the Black Death is disputed. Genetic analysis points to the evolution of Yersinia pestis in the Tian Shan mountains on the border between Kyrgyzstan and China 2,600 years ago. The immediate territorial origins of the Black Death and its outbreak remains unclear with some pointing towards Central Asia, China, the Middle East and Europe. The pandemic was reportedly first introduced to Europe during the siege of the Genoese trading port of Kaffa in Crimea by the Golden Horde army of Jani Beg in 1347. From Crimea, it was most likely carried by fleas living on the black rats that travelled on Genoese ships, spreading through the Mediterranean Basin and reaching North Africa, Western Asia and the rest of Europe via Constantinople, Sicily and the Italian Peninsula. There is evidence that once it came ashore, the Black Death mainly spread person-to-person as pneumonic plague, thus explaining the quick inland spread of the epidemic, which was faster than would be expected if the primary vector was rat fleas causing bubonic plague. In 2022, it was discovered that there was a sudden surge of deaths in what is today Kyrgyzstan from the Black Death in the late 1330s; when combined with genetic evidence, this implies that the initial spread may not have been due to Mongol conquests in the 14th century, as previously speculated.The Black Death was the second great natural disaster to strike Europe during the Late Middle Ages (the first one being the Great Famine of 1315–1317) and is estimated to have killed 30 percent to 60 percent of the European population, as well as about one-third of the population of the Middle East. The plague might have reduced the world population from c. 475 million to 350–375 million in the 14th century. There were further outbreaks throughout the Late Middle Ages and, with other contributing factors (the Crisis of the Late Middle Ages), the European population did not regain its level in 1300 until 1500. Outbreaks of the plague recurred around the world until the early 19th century.

Names
European writers contemporary with the plague described the disease in Latin as pestis or pestilentia, 'pestilence'; epidemia, 'epidemic'; mortalitas, 'mortality'. In English prior to the 18th century, the event was called the "pestilence" or "great pestilence", "the plague" or the "great death". Subsequent to the pandemic "the furste moreyn" (first murrain) or "first pestilence" was applied, to distinguish the mid-14th century phenomenon from other infectious diseases and epidemics of plague.The 1347 pandemic plague was not referred to specifically as "black" in the time of occurrence in any European language, though the expression "black death" had occasionally been applied to fatal disease beforehand. "Black death" was not used to describe the plague pandemic in English until the 1750s; the term is first attested in 1755, where it translated Danish: den sorte død, lit. 'the black death'. This expression as a proper name for the pandemic had been popularized by Swedish and Danish chroniclers in the 15th and early 16th centuries, and in the 16th and 17th centuries was transferred to other languages as a calque: Icelandic: svarti dauði, German: der schwarze Tod, and French: la mort noire. Previously, most European languages had named the pandemic a variant or calque of the Latin: magna mortalitas, lit. 'Great Death'.The phrase 'black death' – describing Death as black – is very old. Homer used it in the Odyssey to describe the monstrous Scylla, with her mouths "full of black Death" (Ancient Greek: πλεῖοι μέλανος Θανάτοιο, romanized: pleîoi mélanos Thanátoio). Seneca the Younger may have been the first to describe an epidemic as 'black death', (Latin: mors atra) but only in reference to the acute lethality and dark prognosis of disease. The 12th–13th century French physician Gilles de Corbeil had already used atra mors to refer to a "pestilential fever" (febris pestilentialis) in his work On the Signs and Symptoms of Diseases (De signis et symptomatibus aegritudium). The phrase mors nigra, 'black death', was used in 1350 by Simon de Covino (or Couvin), a Belgian astronomer, in his poem "On the Judgement of the Sun at a Feast of Saturn" (De judicio Solis in convivio Saturni), which attributes the plague to an astrological conjunction of Jupiter and Saturn. His use of the phrase is not connected unambiguously with the plague pandemic of 1347 and appears to refer to the fatal outcome of disease.The historian Cardinal Francis Aidan Gasquet wrote about the Great Pestilence in 1893 and suggested that it had been "some form of the ordinary Eastern or bubonic plague". In 1908, Gasquet said use of the name atra mors for the 14th-century epidemic first appeared in a 1631 book on Danish history by J. I. Pontanus: "Commonly and from its effects, they called it the black death" (Vulgo & ab effectu atram mortem vocitabant).

Previous plague epidemics
Research from 2017 suggests plague first infected humans in Europe and Asia in the Late Neolithic-Early Bronze Age. Research in 2018 found evidence of Yersinia pestis in an ancient Swedish tomb, which may have been associated with the "Neolithic decline" around 3000 BCE, in which European populations fell significantly. This Y. pestis may have been different from more modern types, with bubonic plague transmissible by fleas first known from Bronze Age remains near Samara.The symptoms of bubonic plague are first attested in a fragment of Rufus of Ephesus preserved by Oribasius; these ancient medical authorities suggest bubonic plague had appeared in the Roman Empire before the reign of Trajan, six centuries before arriving at Pelusium in the reign of Justinian I. In 2013, researchers confirmed earlier speculation that the cause of the Plague of Justinian (541–542 CE, with recurrences until 750) was Y. pestis. This is known as the first plague pandemic. In 610, the Chinese physician Chao Yuanfang described a "malignant bubo" "coming in abruptly with high fever together with the appearance of a bundle of nodes beneath the tissue." The Chinese physician Sun Simo who died in 652 also mentioned a "malignant bubo" and plague that was common in Lingnan (Guangzhou). Ole Jørgen Benedictow believes that this indicates it was an offshoot of the first plague pandemic which made its way eastward to Chinese territory by around 600.

14th-century plague
Causes
Early theory
The most authoritative contemporary account is found in a report from the medical faculty in Paris to Philip VI of France. It blamed the heavens, in the form of a conjunction of three planets in 1345 that caused a "great pestilence in the air" (miasma theory). Muslim religious scholars taught that the pandemic was a "martyrdom and mercy" from God, assuring the believer's place in paradise. For non-believers, it was a punishment. Some Muslim doctors cautioned against trying to prevent or treat a disease sent by God. Others adopted preventive measures and treatments for plague used by Europeans. These Muslim doctors also depended on the writings of the ancient Greeks.

Predominant modern theory
Due to climate change in Asia, rodents began to flee the dried-out grasslands to more populated areas, spreading the disease. The plague disease, caused by the bacterium Yersinia pestis, is enzootic (commonly present) in populations of fleas carried by ground rodents, including marmots, in various areas, including Central Asia, Kurdistan, Western Asia, North India, Uganda and the western United States.Y. pestis was discovered by Alexandre Yersin, a pupil of Louis Pasteur, during an epidemic of bubonic plague in Hong Kong in 1894; Yersin also proved this bacillus was present in rodents and suggested the rat was the main vehicle of transmission. The mechanism by which Y. pestis is usually transmitted was established in 1898 by Paul-Louis Simond and was found to involve the bites of fleas whose midguts had become obstructed by replicating Y. pestis several days after feeding on an infected host. This blockage starves the fleas and drives them to aggressive feeding behaviour and attempts to clear the blockage by regurgitation, resulting in thousands of plague bacteria being flushed into the feeding site, infecting the host. The bubonic plague mechanism was also dependent on two populations of rodents: one resistant to the disease, which act as hosts, keeping the disease endemic, and a second that lacks resistance. When the second population dies, the fleas move on to other hosts, including people, thus creating a human epidemic.

DNA evidence
Definitive confirmation of the role of Y. pestis arrived in 2010 with a publication in PLOS Pathogens by Haensch et al. They assessed the presence of DNA/RNA with polymerase chain reaction (PCR) techniques for Y. pestis from the tooth sockets in human skeletons from mass graves in northern, central and southern Europe that were associated archaeologically with the Black Death and subsequent resurgences. The authors concluded that this new research, together with prior analyses from the south of France and Germany, "ends the debate about the cause of the Black Death, and unambiguously demonstrates that Y. pestis was the causative agent of the epidemic plague that devastated Europe during the Middle Ages". In 2011, these results were further confirmed with genetic evidence derived from Black Death victims in the East Smithfield burial site in England. Schuenemann et al. concluded in 2011 "that the Black Death in medieval Europe was caused by a variant of Y. pestis that may no longer exist".Later in 2011, Bos et al. reported in Nature the first draft genome of Y. pestis from plague victims from the same East Smithfield cemetery and indicated that the strain that caused the Black Death is ancestral to most modern strains of Y. pestis.Since this time, further genomic papers have further confirmed the phylogenetic placement of the Y. pestis strain responsible for the Black Death as both the ancestor of later plague epidemics including the third plague pandemic and as the descendant of the strain responsible for the Plague of Justinian. In addition, plague genomes from significantly earlier in prehistory have been recovered.DNA taken from 25 skeletons from 14th century London have shown plague is a strain of Y. pestis almost identical to that which hit Madagascar in 2013. Further DNA evidence also proves the role of Y. Pestis and traces the source to the Tian Shan Mountains in Kyrgyzstan.

Alternative explanations
It is recognised that an epidemiological account of plague is as important as an identification of symptoms, but researchers are hampered by the lack of reliable statistics from this period. Most work has been done on the spread of the disease in England, and even estimates of overall population at the start vary by over 100% as no census was undertaken in England between the time of publication of the Domesday Book of 1086 and the poll tax of the year 1377. Estimates of plague victims are usually extrapolated from figures for the clergy.
Mathematical modelling is used to match the spreading patterns and the means of transmission. A research in 2018 challenged the popular hypothesis that "infected rats died, their flea parasites could have jumped from the recently dead rat hosts to humans". It suggested an alternative model in which "the disease was spread from human fleas and body lice to other people". The second model claims to better fit the trends of death toll because the rat-flea-human hypothesis would have produced a delayed but very high spike in deaths, which contradict historical death data.Lars Walløe complains that all of these authors "take it for granted that Simond's infection model, black rat → rat flea → human, which was developed to explain the spread of plague in India, is the only way an epidemic of Yersinia pestis infection could spread", whilst pointing to several other possibilities. Similarly, Monica Green has argued that greater attention is needed to the range of (especially non-commensal) animals that might be involved in the transmission of plague.Archaeologist Barney Sloane has argued that there is insufficient evidence of the extinction of numerous rats in the archaeological record of the medieval waterfront in London and that the disease spread too quickly to support the thesis that Y. pestis was spread from fleas on rats; he argues that transmission must have been person to person. This theory is supported by research in 2018 which suggested transmission was more likely by body lice and fleas during the second plague pandemic.

Summary
Although academic debate continues, no single alternative solution has achieved widespread acceptance. Many scholars arguing for Y. pestis as the major agent of the pandemic suggest that its extent and symptoms can be explained by a combination of bubonic plague with other diseases, including typhus, smallpox and respiratory infections. In addition to the bubonic infection, others point to additional septicaemic (a type of "blood poisoning") and pneumonic (an airborne plague that attacks the lungs before the rest of the body) forms of plague, which lengthen the duration of outbreaks throughout the seasons and help account for its high mortality rate and additional recorded symptoms. In 2014, Public Health England announced the results of an examination of 25 bodies exhumed in the Clerkenwell area of London, as well as of wills registered in London during the period, which supported the pneumonic hypothesis. Currently, while osteoarcheologists have conclusively verified the presence of Y. pestis bacteria in burial sites across northern Europe through examination of bones and dental pulp, no other epidemic pathogen has been discovered to bolster the alternative explanations.

Transmission
Lack of hygiene
The importance of hygiene was recognised only in the nineteenth century with the development of the germ theory of disease; until then streets were commonly filthy, with live animals of all sorts around and human parasites abounding, facilitating the spread of transmissible disease.By the early fourteenth century so much filth had collected inside urban Europe that French and Italian cities were naming streets after human waste. In medieval Paris, several street names were inspired by merde, the French word for "shit". There were rue Merdeux, rue Merdelet, rue Merdusson, rue des Merdons and rue Merdiere—as well as a rue du Pipi.Pigs, cattle, chickens, geese, goats and horses roamed the streets of medieval London and Paris. Medieval homeowners were supposed to police their housefronts, including removing animal dung, but most urbanites were as careless as William E. Cosner, a resident of the London suburb of Farringdon Without. A complaint lodged against Cosner charges that "men could not pass [by his house] for the stink [of] . . . horse dung and horse piss."One irate Londoner complained that the runoff from the local slaughterhouse had made his garden "stinking and putrid", while another charged that the blood from slain animals flooded nearby streets and lanes, "making a foul corruption and abominable sight to all dwelling near." In much of medieval Europe, sanitation legislation consisted of an ordinance requiring homeowners to shout, "Look out below!" three times before dumping a full chamber pot into the street.Early Christians, who thought self-abnegation a cardinal virtue, considered bathing, if not a vice, then a temptation. "Who knows what impure thoughts might arise in a tub of warm water? With this danger in mind, St. Benedict declared, "To those who are well, and especially to the young, bathing shall seldom be permitted." St. Agnes took the injunction to heart and died without ever bathing.

Territorial origins
According to a team of medical geneticists led by Mark Achtman that analysed the genetic variation of the bacterium Yersinia pestis "evolved in or near China" over 2,600 years ago. Later research by a team led by Galina Eroshenko places the origins more specifically in the Tian Shan mountains on the border between Kyrgyzstan and China. However more recent research notes that the previous sampling had a very heavy East Asian bias and that sampling since then has discovered strains of Y. pestis in the Caucasus region that were previously thought to be restricted to China. There is also no physical or specific textual evidence of the Black Death in 14th century China. As a result, China's place in the sequence of the plague's spread is still debated to this day. According to Charles Creighton, records of epidemics in 14th century China suggest nothing more than typhus and major Chinese outbreaks of epidemic disease post-date the European epidemic by several years. The earliest Chinese descriptions of the bubonic plague do not appear until the 1640s.Nestorian graves dating to 1338–1339 near Issyk-Kul in Kyrgyzstan have inscriptions referring to plague, which has led some historians and epidemiologists to think they mark the outbreak of the epidemic; this is supported by recent direct findings of Y. pestis DNA in teeth samples from graves in the area with inscriptions referring to "pestilence" as the cause of death. Epidemics killed an estimated 25 million across Asia during the fifteen years before the Black Death reached Constantinople in 1347.
The evidence does not suggest, at least at present, that these mortality crises were caused by plague. Although some scholars, including McNeill and Cao, see the 1333 outbreak as a prelude to the outbreaks in Europe from the late 1340s to the early 1350s, scholars of the Yuan and Ming periods remain skeptical about such an interpretation. Nonetheless, the remarkably high mortality rates during the Datong mortality should discourage us from rejecting the possibility of localized/regional outbreaks of plague in different parts of China, albeit differing in scale from, and unrelated to, the pandemic mortality of the Black Death. What we lack is any indication of a plague pandemic that engulfed vast territories of the Yuan Empire and later moved into western Eurasia through Central Asia.
According to John Norris, evidence from Issyk-Kul indicates a small sporadic outbreak characteristic of transmission from rodents to humans with no wide-scale impact. According to Achtman, the dating of the plague suggests that it was not carried along the Silk Road, and its widespread appearance in that region probably postdates the European outbreak. There are no records of the symptoms of the Black Death from Mongol sources or writings from travelers east of the Black Sea prior to the Crimean outbreak in 1346. Finally, the Silk Road had already been heavily disrupted before the spread of the Black Death. Western and Middle Eastern traders found it difficult to trade on the Silk Road by 1325 and impossible by 1340, making spread of the plague less likely.Others still favor an origin in China or even Kurdistan, and not Central Asia. According to the theory of Chinese origin, the disease may have traveled along the Silk Road with Mongol armies and traders, or it could have arrived via ship, but this theory is still contested. It is speculated that rats aboard Zheng He's ships in the 15th century may have carried the plague to Southeast Asia, India and Africa.
Research on the Delhi Sultanate and the Yuan Dynasty shows no evidence of any serious epidemic in fourteenth-century India and no specific evidence of plague in fourteenth-century China, suggesting that the Black Death may not have reached these regions. Ole Benedictow argues that since the first clear reports of the Black Death come from Kaffa, the Black Death most likely originated in the nearby plague focus on the northwestern shore of the Caspian Sea.
Demographic historians estimate that China's population fell by at least 15 percent, and perhaps as much as a third, between 1340 and 1370. This population loss coincided with the Black Death that ravaged Europe and much of the Islamic world in 1347–52. However, there is a conspicuous lack of evidence for pandemic disease on the scale of the Black Death in China at this time. War and famine – and the diseases that typically accompanied them – probably were the main causes of mortality in the final decades of Mongol rule.
Monica H. Green suggests that the reason why other parts of Eurasia outside the west do not contain the same evidence of the Black Plague is because there were actually four strains of Yersinia pestis that became predominant in different parts of the world. Mongol records of illness such as food poisoning may have been referring to the Black Plague. Another theory is that the Black Death originated near Europe and cycled through the Mediterranean, Northern Europe and Russia before making its way to China. Other historians such as John Norris and Ole Benedictaw believe the Black Death likely originated in Europe or the Middle East and never reached China.

European outbreak
Plague was reportedly first introduced to Europe via Genoese traders from their port city of Kaffa in the Crimea in 1347. During a protracted siege of the city, in 1345–1346 the Mongol Golden Horde army of Jani Beg, whose mainly Tatar troops were suffering from the disease, catapulted infected corpses over the city walls of Kaffa to infect the inhabitants, though it is more likely that infected rats travelled across the siege lines to spread the epidemic to the inhabitants. As the disease took hold, Genoese traders fled across the Black Sea to Constantinople, where the disease first arrived in Europe in summer 1347.The epidemic there killed the 13-year-old son of the Byzantine emperor, John VI Kantakouzenos, who wrote a description of the disease modelled on Thucydides's account of the 5th century BCE Plague of Athens, but noting the spread of the Black Death by ship between maritime cities. Nicephorus Gregoras also described in writing to Demetrios Kydones the rising death toll, the futility of medicine, and the panic of the citizens. The first outbreak in Constantinople lasted a year, but the disease recurred ten times before 1400.Carried by twelve Genoese galleys, plague arrived by ship in Sicily in October 1347; the disease spread rapidly all over the island. Galleys from Kaffa reached Genoa and Venice in January 1348, but it was the outbreak in Pisa a few weeks later that was the entry point to northern Italy. Towards the end of January, one of the galleys expelled from Italy arrived in Marseilles.From Italy, the disease spread northwest across Europe, striking France, Spain (the epidemic began to wreak havoc first on the Crown of Aragon in the spring of 1348), Portugal and England by June 1348, then spread east and north through Germany, Scotland and Scandinavia from 1348 to 1350. It was introduced into Norway in 1349 when a ship landed at Askøy, then spread to Bjørgvin (modern Bergen) and Iceland. Finally, it spread to northwestern Russia in 1351. Plague was somewhat more uncommon in parts of Europe with less developed trade with their neighbours, including the majority of the Basque Country, isolated parts of Belgium and the Netherlands, and isolated Alpine villages throughout the continent.According to some epidemiologists, periods of unfavourable weather decimated plague-infected rodent populations and forced their fleas onto alternative hosts, inducing plague outbreaks which often peaked in the hot summers of the Mediterranean, as well as during the cool autumn months of the southern Baltic region. Among many other culprits of plague contagiousness, malnutrition, even if distantly, also contributed to such an immense loss in European population, since it weakened immune systems.

Western Asian and North African outbreak
The disease struck various regions in the Middle East and North Africa during the pandemic, leading to serious depopulation and permanent change in both economic and social structures. As infected rodents infected new rodents, the disease spread across the region, entering also from southern Russia.
By autumn 1347, plague had reached Alexandria in Egypt, transmitted by sea from Constantinople; according to a contemporary witness, from a single merchant ship carrying slaves. By late summer 1348 it reached Cairo, capital of the Mamluk Sultanate, cultural centre of the Islamic world, and the largest city in the Mediterranean Basin; the Bahriyya child sultan an-Nasir Hasan fled and more than a third of the 600,000 residents died. The Nile was choked with corpses despite Cairo having a medieval hospital, the late 13th century bimaristan of the Qalawun complex. The historian al-Maqrizi described the abundant work for grave-diggers and practitioners of funeral rites, and plague recurred in Cairo more than fifty times over the following one and a half centuries.During 1347, the disease travelled eastward to Gaza by April; by July it had reached Damascus, and in October plague had broken out in Aleppo. That year, in the territory of modern Lebanon, Syria, Israel and Palestine, the cities of Ascalon, Acre, Jerusalem, Sidon and Homs were all infected. In 1348–1349, the disease reached Antioch. The city's residents fled to the north, but most of them ended up dying during the journey. Within two years, the plague had spread throughout the Islamic world, from Arabia across North Africa. The pandemic spread westwards from Alexandria along the African coast, while in April 1348 Tunis was infected by ship from Sicily. Tunis was then under attack by an army from Morocco; this army dispersed in 1348 and brought the contagion with them to Morocco, whose epidemic may also have been seeded from the Islamic city of Almería in al-Andalus.Mecca became infected in 1348 by pilgrims performing the Hajj. In 1351 or 1352, the Rasulid sultan of the Yemen, al-Mujahid Ali, was released from Mamluk captivity in Egypt and carried plague with him on his return home. During 1348, records show the city of Mosul suffered a massive epidemic, and the city of Baghdad experienced a second round of the disease.

Signs and symptoms
Bubonic plague
Symptoms of the disease include fever of 38–41 °C (100–106 °F), headaches, painful aching joints, nausea and vomiting, and a general feeling of malaise. Left untreated, of those that contract the bubonic plague, 80 percent die within eight days.Contemporary accounts of the pandemic are varied and often imprecise. The most commonly noted symptom was the appearance of buboes (or gavocciolos) in the groin, neck and armpits, which oozed pus and bled when opened. Boccaccio's description:

In men and women alike it first betrayed itself by the emergence of certain tumours in the groin or armpits, some of which grew as large as a common apple, others as an egg ... From the two said parts of the body this deadly gavocciolo soon began to propagate and spread itself in all directions indifferently; after which the form of the malady began to change, black spots or livid making their appearance in many cases on the arm or the thigh or elsewhere, now few and large, now minute and numerous. As the gavocciolo had been and still was an infallible token of approaching death, such also were these spots on whomsoever they showed themselves.
This was followed by acute fever and vomiting of blood. Most people died two to seven days after initial infection. Freckle-like spots and rashes, which could have been caused by flea-bites, were identified as another potential sign of plague.

Pneumonic plague
Lodewijk Heyligen, whose master the Cardinal Colonna died of plague in 1348, noted a distinct form of the disease, pneumonic plague, that infected the lungs and led to respiratory problems. Symptoms include fever, cough and blood-tinged sputum. As the disease progresses, sputum becomes free-flowing and bright red. Pneumonic plague has a mortality rate of 90 to 95 percent.

Septicaemic plague
Septicaemic plague is the least common of the three forms, with a mortality rate near 100%. Symptoms are high fevers and purple skin patches (purpura due to disseminated intravascular coagulation). In cases of pneumonic and particularly septicaemic plague, the progress of the disease is so rapid that there would often be no time for the development of the enlarged lymph nodes that were noted as buboes.

Consequences
Deaths
There are no exact figures for the death toll; the rate varied widely by locality. In urban centres, the greater the population before the outbreak, the longer the duration of the period of abnormal mortality. It killed some 75 to 200 million people in Eurasia. A study published in 2022 of pollen samples across Europe between 1250 and 1450 was used to estimate changes in agricultural output before and after the Black Death. The authors found great variability in different regions, with evidence for high mortality in areas of Scandinavia, France, western Germany, Greece and central Italy, but uninterrupted agricultural growth in central and eastern Europe, Iberia and Ireland.The mortality rate of the Black Death in the 14th century was far greater than the worst 20th-century outbreaks of Y. pestis plague, which occurred in India and killed as much as 3% of the population of certain cities. The overwhelming number of deceased bodies produced by the Black Death caused the necessity of mass burial sites in Europe, sometimes including up to several hundred or several thousand skeletons. The mass burial sites that have been excavated have allowed archaeologists to continue interpreting and defining the biological, sociological, historical and anthropological implications of the Black Death.According to medieval historian Philip Daileader, it is likely that over four years, 45–50% of the European population died of plague. Norwegian historian Ole Benedictow suggests it could have been as much as 60% of the European population. In 1348, the disease spread so rapidly that before any physicians or government authorities had time to reflect upon its origins, about a third of the European population had already perished. In crowded cities, it was not uncommon for as much as 50% of the population to die. Half of Paris' population of 100,000 people died. In Italy, the population of Florence was reduced from between 110,000 and 120,000 inhabitants in 1338 down to 50,000 in 1351. At least 60% of the population of Hamburg and Bremen perished, and a similar percentage of Londoners may have died from the disease as well, with a death toll of approximately 62,000 between 1346 and 1353. Florence's tax records suggest that 80% of the city's population died within four months in 1348. Before 1350, there were about 170,000 settlements in Germany, and this was reduced by nearly 40,000 by 1450. The disease bypassed some areas, with the most isolated areas being less vulnerable to contagion. Plague did not appear in Douai in Flanders until the turn of the 15th century, and the impact was less severe on the populations of Hainaut, Finland, northern Germany and areas of Poland. Monks, nuns and priests were especially hard-hit since they cared for people with the Black Death.

The physician to the Avignon Papacy, Raimundo Chalmel de Vinario (Latin: Magister Raimundus, lit. 'Master Raymond'), observed the decreasing mortality rate of successive outbreaks of plague in 1347–48, 1362, 1371 and 1382 in his 1382 treatise On Epidemics (De epidemica). In the first outbreak, two thirds of the population contracted the illness and most patients died; in the next, half the population became ill but only some died; by the third, a tenth were affected and many survived; while by the fourth occurrence, only one in twenty people were sickened and most of them survived. By the 1380s in Europe, it predominantly affected children. Chalmel de Vinario recognised that bloodletting was ineffective (though he continued to prescribe bleeding for members of the Roman Curia, whom he disliked), and said that all true cases of plague were caused by astrological factors and were incurable; he himself was never able to effect a cure.The most widely accepted estimate for the Middle East, including Iraq, Iran and Syria, during this time, is for a death toll of about a third of the population. The Black Death killed about 40% of Egypt's population. In Cairo, with a population numbering as many as 600,000, and possibly the largest city west of China, between one third and 40% of the inhabitants died within eight months.Italian chronicler Agnolo di Tura recorded his experience from Siena, where plague arrived in May 1348:

Father abandoned child, wife husband, one brother another; for this illness seemed to strike through the breath and sight. And so they died. And none could be found to bury the dead for money or friendship. Members of a household brought their dead to a ditch as best they could, without priest, without divine offices ... great pits were dug and piled deep with the multitude of dead. And they died by the hundreds both day and night ... And as soon as those ditches were filled more were dug ... And I, Agnolo di Tura ... buried my five children with my own hands. And there were also those who were so sparsely covered with earth that the dogs dragged them forth and devoured many bodies throughout the city. There was no one who wept for any death, for all awaited death. And so many died that all believed it was the end of the world.

Economic
It has been suggested that the plague, like some others in history, disproportionately affected the poorest people, who were already in generally worse physical condition than the wealthier citizens.  Nevertheless, with such a large overall population decline from the pandemic, wages soared in response to a labour shortage. On the other hand, in the quarter century after the Black Death in England, it is clear many labourers, artisans and craftsmen, those living from money-wages alone, did suffer a reduction in real incomes owing to rampant inflation. Landowners were also pushed to substitute monetary rents for labour services in an effort to keep tenants.

Environmental
A study performed by Thomas Van Hoof of the Utrecht University suggests that the innumerable deaths brought on by the pandemic cooled the climate by freeing up land and triggering reforestation. This may have led to the Little Ice Age.

Persecutions
Renewed religious fervour and fanaticism bloomed in the wake of the Black Death. Some Europeans targeted "various groups such as Jews, friars, foreigners, beggars, pilgrims", lepers and Romani, blaming them for the crisis. Lepers, and others with skin diseases such as acne or psoriasis, were killed throughout Europe.
Because 14th-century healers and governments were at a loss to explain or stop the disease, Europeans turned to astrological forces, earthquakes and the poisoning of wells by Jews as possible reasons for outbreaks. Many believed the epidemic was a punishment by God for their sins, and could be relieved by winning God's forgiveness.There were many attacks against Jewish communities. In the Strasbourg massacre of February 1349, about 2,000 Jews were murdered. In August 1349, the Jewish communities in Mainz and Cologne were annihilated. By 1351, 60 major and 150 smaller Jewish communities had been destroyed. During this period many Jews relocated to Poland, where they received a warm welcome from King Casimir the Great.

Social
One theory that has been advanced is that the devastation in Florence caused by the Black Death, which hit Europe between 1348 and 1350, resulted in a shift in the world view of people in 14th-century Italy and led to the Renaissance. Italy was particularly badly hit by the pandemic, and it has been speculated that the resulting familiarity with death caused thinkers to dwell more on their lives on Earth, rather than on spirituality and the afterlife. It has also been argued that the Black Death prompted a new wave of piety, manifested in the sponsorship of religious works of art.This does not fully explain why the Renaissance occurred in Italy in the 14th century. The Black Death was a pandemic that affected all of Europe in the ways described, not only Italy. The Renaissance's emergence in Italy was most likely the result of the complex interaction of the above factors, in combination with an influx of Greek scholars following the fall of the Byzantine Empire. As a result of the drastic reduction in the populace the value of the working class increased, and commoners came to enjoy more freedom. To answer the increased need for labour, workers travelled in search of the most favorable position economically.Prior to the emergence of the Black Death, the workings of Europe were run by the Catholic Church and the continent was considered a feudalistic society, composed of fiefs and city-states. The pandemic completely restructured both religion and political forces; survivors began to turn to other forms of spirituality and the power dynamics of the fiefs and city-states crumbled.Cairo's population, partly owing to the numerous plague epidemics, was in the early 18th century half of what it was in 1347. The populations of some Italian cities, notably Florence, did not regain their pre-14th century size until the 19th century. The demographic decline due to the pandemic had economic consequences: the prices of food dropped and land values declined by 30–40% in most parts of Europe between 1350 and 1400. Landholders faced a great loss, but for ordinary men and women it was a windfall. The survivors of the pandemic found not only that the prices of food were lower but also that lands were more abundant, and many of them inherited property from their dead relatives, and this probably destabilised feudalism.The word "quarantine" has its roots in this period, though the concept of isolating people to prevent the spread of disease is older. In the city-state of Ragusa (modern Dubrovnik, Croatia), a thirty-day isolation period was implemented in 1377 for new arrivals to the city from plague-affected areas. The isolation period was later extended to forty days, and given the name "quarantino" from the Italian word for "forty".

Recurrences
Second plague pandemic
The plague repeatedly returned to haunt Europe and the Mediterranean throughout the 14th to 17th centuries. According to Jean-Noël Biraben, the plague was present somewhere in Europe in every year between 1346 and 1671. (Note that some researchers have cautions about the uncritical use of Biraben's data.) The second pandemic was particularly widespread in the following years: 1360–63; 1374; 1400; 1438–39; 1456–57; 1464–66; 1481–85; 1500–03; 1518–31; 1544–48; 1563–66; 1573–88; 1596–99; 1602–11; 1623–40; 1644–54; and 1664–67. Subsequent outbreaks, though severe, marked the retreat from most of Europe (18th century) and northern Africa (19th century). The historian George Sussman argued that the plague had not occurred in East Africa until the 1900s. However, other sources suggest that the Second pandemic did indeed reach Sub-Saharan Africa.According to historian Geoffrey Parker, "France alone lost almost a million people to the plague in the epidemic of 1628–31." In the first half of the 17th century, a plague killed some 1.7 million people in Italy. More than 1.25 million deaths resulted from the extreme incidence of plague in 17th-century Spain.The Black Death ravaged much of the Islamic world. Plague could be found in the Islamic world almost every year between 1500 and 1850. Sometimes the outbreaks affected small areas, while other outbreaks affected multiple regions. Plague repeatedly struck the cities of North Africa. Algiers lost 30,000–50,000 inhabitants to it in 1620–21, and again in 1654–57, 1665, 1691 and 1740–42. Cairo suffered more than fifty plague epidemics within 150 years from the plague's first appearance, with the final outbreak of the second pandemic there in the 1840s. Plague remained a major event in Ottoman society until the second quarter of the 19th century. Between 1701 and 1750, thirty-seven larger and smaller epidemics were recorded in Constantinople, and an additional thirty-one between 1751 and 1800. Baghdad has suffered severely from visitations of the plague, and sometimes two-thirds of its population had died.

Third plague pandemic
The third plague pandemic (1855–1859) started in China in the mid-19th century, spreading to all inhabited continents and killing 10 million people in India alone. The investigation of the pathogen that caused the 19th-century plague was begun by teams of scientists who visited Hong Kong in 1894, among whom was the French-Swiss bacteriologist Alexandre Yersin, after whom the pathogen was named.Twelve plague outbreaks in Australia between 1900 and 1925 resulted in well over 1,000 deaths, chiefly in Sydney. This led to the establishment of a Public Health Department there which undertook some leading-edge research on plague transmission from rat fleas to humans via the bacillus Yersinia pestis.The first North American plague epidemic was the San Francisco plague of 1900–1904, followed by another outbreak in 1907–1908.

Modern-day
Modern treatment methods include insecticides, the use of antibiotics, and a plague vaccine. It is feared that the plague bacterium could develop drug resistance and again become a major health threat. One case of a drug-resistant form of the bacterium was found in Madagascar in 1995. A further outbreak in Madagascar was reported in November 2014. In October 2017, the deadliest outbreak of the plague in modern times hit Madagascar, killing 170 people and infecting thousands.An estimate of the case fatality rate for the modern bubonic plague, following the introduction of antibiotics, is 11%, although it may be higher in underdeveloped regions.

See also
Black Death in England
Black Death in medieval culture
Crisis of the Late Middle Ages
Flagellant
Globalization and disease
List of epidemics
Second plague pandemic
Timeline of plague
Passage 2:
Christian Ackermann
Christian Ackermann was a sculptor and carver who worked in Estonia.

Life and work
Christian Ackermann was born in Königsberg. He worked in Riga, Stockholm, and Gdańsk, before becoming active in Tallinn from about 1672 until his death in 1710. In 1675, Ackermann moved to Tallinn and worked first in the workshop of Elert Thiele, a local woodcarver. After Thiele's death in 1674, Achermann married the master's widow. He then became a citizen of Tallinn but didn't join the local guild of woodcarvers.  And that was a reason why between him and the guild's masters had begun a strong struggle which finished in court. Ackermann won and got the permission to work alone, he was the first independent sculptor in Estonia and acquired his own workshop at Toompea Hill. He probably died either in 1710 or a short time later from plague.
Christian Ackermann was one of the greatest masters of the Baroque style in Estonia. He brought strong Central European influences to Northeast Europe, in particular the motifs of the Baroque and masterful Acanthus ornaments. The majority of his works consists of almost twenty altarpieces, pulpits and large coat-of-arms epitaphs.

Most important works
Baptistery for the Swedish St. Michael's Church in Tallinn (around 1680)
Altarpiece for the church of Simuna (1684)
Altar and pulpit for the church of Türi (1693)
Pulpit with figures of the apostles (1686) and altarpiece (1696) for St Mary's Cathedral of Tallinn
Emblem for St Mary's Cathedral of Tallinn
Clock for the Church of the Holy Ghost in Tallinn
Altar figures and altarpiece for the church of Martna
Pulpit for the church of Juuru Parish (1695)
Pulpit for the church of Karuse (1697)
Crucifix for the church of Koeru Parish (end of the 17th century)

See also
List of Baltic German artists
Passage 3:
The Martyrdom of Saint Lawrence (Titian)
The Martyrdom of Saint Lawrence is a 1558 painting by Titian, now in the church of I Gesuiti in Venice. It so impressed Philip II of Spain that he commissioned a second version in 1567 for the basilica at El Escorial.

See also
List of works by Titian
Passage 4:
Gastroenteritis
Gastroenteritis, also known as infectious diarrhea and gastro, is an inflammation of the gastrointestinal tract including the stomach and intestine. Symptoms may include diarrhea, vomiting, and abdominal pain. Fever, lack of energy, and dehydration may also occur. This typically lasts less than two weeks. It is not related to influenza, even though in the U.S. it is sometimes called the "stomach flu".Gastroenteritis is usually caused by viruses; however, gut bacteria, parasites, and fungi can also cause gastroenteritis. In children, rotavirus is the most common cause of severe disease. In adults, norovirus and Campylobacter are common causes. Eating improperly prepared food, drinking contaminated water or close contact with a person who is infected can spread the disease. Treatment is generally the same with or without a definitive diagnosis, so testing to confirm is usually not needed.For young children in impoverished countries, prevention includes hand washing with soap, drinking clean water, breastfeeding babies instead of using formula, and proper disposal of human waste. The rotavirus vaccine is recommended as a prevention for children. Treatment involves getting enough fluids. For mild or moderate cases, this can typically be achieved by drinking oral rehydration solution (a combination of water, salts and sugar). In those who are breastfed, continued breastfeeding is recommended. For more severe cases, intravenous fluids may be needed. Fluids may also be given by a nasogastric tube. Zinc supplementation is recommended in children. Antibiotics are generally not needed. However, antibiotics are recommended for young children with a fever and bloody diarrhea.In 2015, there were two billion cases of gastroenteritis, resulting in 1.3 million deaths globally. Children and those in the developing world are affected the most. In 2011, there were about 1.7 billion cases, resulting in about 700,000 deaths of children under the age of five. In the developing world, children less than two years of age frequently get six or more infections a year. It is less common in adults, partly due to the development of immunity.

Signs and symptoms
Gastroenteritis usually involves both diarrhea and vomiting. Sometimes, only one or the other is present. This may be accompanied by abdominal cramps. Signs and symptoms usually begin 12–72 hours after contracting the infectious agent. If due to a virus, the condition usually resolves within one week. Some viral infections also involve fever, fatigue, headache and muscle pain. If the stool is bloody, the cause is less likely to be viral and more likely to be bacterial. Some bacterial infections cause severe abdominal pain and may persist for several weeks.Children infected with rotavirus usually make a full recovery within three to eight days. However, in poor countries treatment for severe infections is often out of reach and persistent diarrhea is common.  Dehydration is a common complication of diarrhea. Severe dehydration in children may be recognized if the skin color and position returns slowly when pressed. This is called "prolonged capillary refill" and "poor skin turgor". Abnormal breathing is another sign of severe dehydration. Repeat infections are typically seen in areas with poor sanitation, and malnutrition. Stunted growth and long-term cognitive delays can result.Reactive arthritis occurs in 1% of people following infections with Campylobacter species. Guillain–Barré syndrome occurs in 0.1%. Hemolytic uremic syndrome (HUS) may occur due to infection with Shiga toxin-producing Escherichia coli or Shigella species. HUS causes low platelet counts, poor kidney function, and low red blood cell count (due to their breakdown). Children are more predisposed to getting HUS than adults. Some viral infections may produce benign infantile seizures.

Cause
Viruses (particularly rotavirus (in children) and norovirus (in adults)) and the bacteria Escherichia coli and Campylobacter species are the primary causes of gastroenteritis. There are, however, many other infectious agents that can cause this syndrome including parasites and fungus. Non-infectious causes are seen on occasion, but they are less likely than a viral or bacterial cause. Risk of infection is higher in children due to their lack of immunity. Children are also at higher risk because they are less likely to practice good hygiene habits. Children living in areas without easy access to water and soap are especially vulnerable.

Viral
Rotaviruses, noroviruses, adenoviruses, and astroviruses are known to cause viral gastroenteritis. Rotavirus is the most common cause of gastroenteritis in children, and produces similar rates in both the developed and developing world. Viruses cause about 70% of episodes of infectious diarrhea in the pediatric age group. Rotavirus is a less common cause in adults due to acquired immunity. Norovirus is the cause in about 18% of all cases. Generally speaking, viral gastroenteritis accounts for 21–40% of the cases of infectious diarrhea in developed countries.Norovirus is the leading cause of gastroenteritis among adults in America accounting for about 90% of viral gastroenteritis outbreaks. These localized epidemics typically occur when groups of people spend time proximate to each other, such as on cruise ships, in hospitals, or in restaurants. People may remain infectious even after their diarrhea has ended. Norovirus is the cause of about 10% of cases in children.

Bacterial
In some countries, Campylobacter jejuni is the primary cause of bacterial gastroenteritis, with half of these cases associated with exposure to poultry. In children, bacteria are the cause in about 15% of cases, with the most common types being Escherichia coli, Salmonella, Shigella, and Campylobacter species. If food becomes contaminated with bacteria and remains at room temperature for a period of several hours, the bacteria multiply and increase the risk of infection in those who consume the food. Some foods commonly associated with illness include raw or undercooked meat, poultry, seafood, and eggs; raw sprouts; unpasteurized milk and soft cheeses; and fruit and vegetable juices. In the developing world, especially sub-Saharan Africa and Asia, cholera is a common cause of gastroenteritis. This infection is usually transmitted by contaminated water or food.Toxigenic Clostridium difficile is an important cause of diarrhea that occurs more often in the elderly. Infants can carry these bacteria without developing symptoms. It is a common cause of diarrhea in those who are hospitalized and is frequently associated with antibiotic use. Staphylococcus aureus infectious diarrhea may also occur in those who have used antibiotics. Acute "traveler's diarrhea" is usually a type of bacterial gastroenteritis, while the persistent form is usually parasitic. Acid-suppressing medication appears to increase the risk of significant infection after exposure to a number of organisms, including Clostridium difficile, Salmonella, and Campylobacter species. The risk is greater in those taking proton pump inhibitors than with H2 antagonists.

Parasitic
A number of parasites can cause gastroenteritis. Giardia lamblia is most common, but Entamoeba histolytica, Cryptosporidium spp., and other species have also been implicated. As a group, these agents comprise about 10% of cases in children. Giardia occurs more commonly in the developing world, but this type of illness can occur nearly everywhere. It occurs more commonly in persons who have traveled to areas with high prevalence, children who attend day care, men who have sex with men, and following disasters.

Transmission
Transmission may occur from drinking contaminated water or when people share personal objects. Water quality typically worsens during the rainy season and outbreaks are more common at this time. In areas with four seasons, infections are more common in the winter. Worldwide, bottle-feeding of babies with improperly sanitized bottles is a significant cause. Transmission rates are also related to poor hygiene, (especially among children), in crowded households, and in those with poor nutritional status. Adults who have developed immunities might still carry certain organisms without exhibiting symptoms. Thus, adults can become natural reservoirs of certain diseases. While some agents (such as Shigella) only occur in primates, others (such as Giardia) may occur in a wide variety of animals.

Non-infectious
There are a number of non-infectious causes of inflammation of the gastrointestinal tract. Some of the more common include medications (like NSAIDs), certain foods such as lactose (in those who are intolerant), and gluten (in those with celiac disease). Crohn's disease is also a non-infectious cause of (often severe) gastroenteritis. Disease secondary to toxins may also occur. Some food-related conditions associated with nausea, vomiting, and diarrhea include: ciguatera poisoning due to consumption of contaminated predatory fish, scombroid associated with the consumption of certain types of spoiled fish, tetrodotoxin poisoning from the consumption of puffer fish among others, and botulism typically due to improperly preserved food.In the United States, rates of emergency department use for noninfectious gastroenteritis dropped 30% from 2006 until 2011. Of the twenty most common conditions seen in the emergency department, rates of noninfectious gastroenteritis had the largest decrease in visits in that time period.

Pathophysiology
Gastroenteritis is defined as vomiting or diarrhea due to inflammation of the small or large bowel, often due to infection. The changes in the small bowel are typically noninflammatory, while the ones in the large bowel are inflammatory. The number of pathogens required to cause an infection varies from as few as one (for Cryptosporidium) to as many as 108 (for Vibrio cholerae).

Diagnosis
Gastroenteritis is typically diagnosed clinically, based on a person's signs and symptoms. Determining the exact cause is usually not needed as it does not alter the management of the condition.However, stool cultures should be performed in those with blood in the stool, those who might have been exposed to food poisoning, and those who have recently traveled to the developing world. It may also be appropriate in children younger than 5, old people, and those with poor immune function. Diagnostic testing may also be done for surveillance. As hypoglycemia occurs in approximately 10% of infants and young children, measuring serum glucose in this population is recommended. Electrolytes and kidney function should also be checked when there is a concern about severe dehydration.

Dehydration
A determination of whether or not the person has dehydration is an important part of the assessment, with dehydration typically divided into mild (3–5%), moderate (6–9%), and severe (≥10%) cases. In children, the most accurate signs of moderate or severe dehydration are a prolonged capillary refill, poor skin turgor, and abnormal breathing. Other useful findings (when used in combination) include sunken eyes, decreased activity, a lack of tears, and a dry mouth. A normal urinary output and oral fluid intake is reassuring. Laboratory testing is of little clinical benefit in determining the degree of dehydration. Thus the use of urine testing or ultrasounds is generally not needed.

Differential diagnosis
Other potential causes of signs and symptoms that mimic those seen in gastroenteritis that need to be ruled out include appendicitis, volvulus, inflammatory bowel disease, urinary tract infections, and diabetes mellitus. Pancreatic insufficiency, short bowel syndrome, Whipple's disease, coeliac disease, and laxative abuse should also be considered. The differential diagnosis can be complicated somewhat if the person exhibits only vomiting or diarrhea (rather than both).Appendicitis may present with vomiting, abdominal pain, and a small amount of diarrhea in up to 33% of cases. This is in contrast to the large amount of diarrhea that is typical of gastroenteritis. Infections of the lungs or urinary tract in children may also cause vomiting or diarrhea. Classical diabetic ketoacidosis (DKA) presents with abdominal pain, nausea, and vomiting, but without diarrhea. One study found that 17% of children with DKA were initially diagnosed as having gastroenteritis.

Prevention
Water, sanitation, hygiene
A supply of easily accessible uncontaminated water and good sanitation practices are important for reducing rates of infection and clinically significant gastroenteritis. Personal hygiene measures (such as hand washing with soap) have been found to decrease rates of gastroenteritis in both the developing and developed world by as much as 30%. Alcohol-based gels may also be effective. Food or drink that is thought to be contaminated should be avoided.Breastfeeding is important, especially in places with poor hygiene, as is improvement of hygiene generally. Breast milk reduces both the frequency of infections and their duration.

Vaccination
Due to both its effectiveness and safety, in 2009 the World Health Organization recommended that the rotavirus vaccine be offered to all children globally. Two commercial rotavirus vaccines exist and several more are in development. In Africa and Asia these vaccines reduced severe disease among infants and countries that have put in place national immunization programs have seen a decline in the rates and severity of disease. This vaccine may also prevent illness in non-vaccinated children by reducing the number of circulating infections. Since 2000, the implementation of a rotavirus vaccination program in the United States has substantially decreased the number of cases of diarrhea by as much as 80 percent. The first dose of vaccine should be given to infants between 6 and 15 weeks of age. The oral cholera vaccine has been found to be 50–60% effective over two years.There are a number of vaccines against gastroenteritis in development. For example, vaccines against Shigella and enterotoxigenic Escherichia coli (ETEC), which are two of the leading bacterial causes of gastroenteritis worldwide.

Management
Gastroenteritis is usually an acute and self-limiting disease that does not require medication. The preferred treatment in those with mild to moderate dehydration is oral rehydration therapy (ORT). For children at risk of dehydration from vomiting, taking a single dose of the anti vomiting medication metoclopramide or ondansetron, may be helpful, and butylscopolamine is useful in treating abdominal pain.

Rehydration
The primary treatment of gastroenteritis in both children and adults is rehydration. This is preferably achieved by drinking rehydration solution, although intravenous delivery may be required if there is a decreased level of consciousness or if dehydration is severe. Drinking replacement therapy products made with complex carbohydrates (i.e. those made from wheat or rice) may be superior to those based on simple sugars. Drinks especially high in simple sugars, such as soft drinks and fruit juices, are not recommended in children under five years of age as they may increase diarrhea. Plain water may be used if more specific ORT preparations are unavailable or the person is not willing to drink them. A nasogastric tube can be used in young children to administer fluids if warranted. In those who require intravenous fluids, one to four hours' worth is often sufficient.

Dietary
It is recommended that breast-fed infants continue to be nursed in the usual fashion,  and that formula-fed infants continue their formula immediately after rehydration with ORT. Lactose-free or lactose-reduced formulas usually are not necessary. Children should continue their usual diet during episodes of diarrhea with the exception that foods high in simple sugars should be avoided. The BRAT diet (bananas, rice, applesauce, toast and tea) is no longer recommended, as it contains insufficient nutrients and has no benefit over normal feeding.A Cochrane Review from 2020 concludes that probiotics make little or no difference to people who have diarrhea lasting 2 days or longer and that there is no proof that they reduce its duration. They may be useful in preventing and treating antibiotic associated diarrhea. Fermented milk products (such as yogurt) are similarly beneficial. Zinc supplementation appears to be effective in both treating and preventing diarrhea among children in the developing world.

Antiemetics
Antiemetic medications may be helpful for treating vomiting in children. Ondansetron has some utility, with a single dose being associated with less need for intravenous fluids, fewer hospitalizations, and decreased vomiting. Metoclopramide might also be helpful. However, the use of ondansetron might possibly be linked to an increased rate of return to hospital in children. The intravenous preparation of ondansetron may be given orally if clinical judgment warrants. Dimenhydrinate, while reducing vomiting, does not appear to have a significant clinical benefit.

Antibiotics
Antibiotics are not usually used for gastroenteritis, although they are sometimes recommended if symptoms are particularly severe or if a susceptible bacterial cause is isolated or suspected. If antibiotics are to be employed, a macrolide (such as azithromycin) is preferred over a fluoroquinolone due to higher rates of resistance to the latter. Pseudomembranous colitis, usually caused by antibiotic use, is managed by discontinuing the causative agent and treating it with either metronidazole or vancomycin. Bacteria and protozoans that are amenable to treatment include Shigella Salmonella typhi, and Giardia species. In those with Giardia species or Entamoeba histolytica, tinidazole treatment is recommended and superior to metronidazole. The World Health Organization (WHO) recommends the use of antibiotics in young children who have both bloody diarrhea and fever.

Antimotility agents
Antimotility medication has a theoretical risk of causing complications, and although clinical experience has shown this to be unlikely, these drugs are discouraged in people with bloody diarrhea or diarrhea that is complicated by fever. Loperamide, an opioid analogue, is commonly used for the symptomatic treatment of diarrhea. Loperamide is not recommended in children, however, as it may cross the immature blood–brain barrier and cause toxicity. Bismuth subsalicylate, an insoluble complex of trivalent bismuth and salicylate, can be used in mild to moderate cases, but salicylate toxicity is theoretically possible.

Epidemiology
It is estimated that there were two billion cases of gastroenteritis that resulted in 1.3 million deaths globally in 2015. Children and those in the developing world are most commonly affected. As of 2011, in those younger than five, there were about 1.7 billion cases resulting in 0.7 million deaths, with most of these occurring in the world's poorest nations. More than 450,000 of these fatalities are due to rotavirus in children under five years of age. Cholera causes about three to five million cases of disease and kills approximately 100,000 people yearly. In the developing world, children less than two years of age frequently get six or more infections a year that result in significant gastroenteritis. It is less common in adults, partly due to the development of acquired immunity.In 1980, gastroenteritis from all causes caused 4.6 million deaths in children, with the majority occurring in the developing world. Death rates were reduced significantly (to approximately 1.5 million deaths annually) by 2000, largely due to the introduction and widespread use of oral rehydration therapy. In the US, infections causing gastroenteritis are the second most common infection (after the common cold), and they result in between 200 and 375 million cases of acute diarrhea and approximately ten thousand deaths annually, with 150 to 300 of these deaths in children less than five years of age.

Society and culture
Gastroenteritis is associated with many colloquial names, including "Montezuma's revenge", "Delhi belly", "la turista", and "back door sprint", among others. It has played a role in many military campaigns and is believed to be the origin of the term "no guts no glory".Gastroenteritis is the main reason for 3.7 million visits to physicians a year in the United States and 3 million visits in France. In the United States gastroenteritis as a whole is believed to result in costs of US$23 billion per year, with rotavirus alone resulting in estimated costs of US$1 billion a year.

Terminology
The first usage of "gastroenteritis" was in 1825. Before this time it was commonly known as typhoid fever or "cholera morbus", among others, or less specifically as "griping of the guts", "surfeit", "flux", "colic", "bowel complaint", or any one of a number of other archaic names for acute diarrhea. Cholera morbus is a historical term that was used to refer to gastroenteritis rather than specifically cholera.

Other animals
Many of the same agents cause gastroenteritis in cats and dogs as in humans. The most common organisms are Campylobacter, Clostridium difficile, Clostridium perfringens, and Salmonella. A large number of toxic plants may also cause symptoms.Some agents are more specific to a certain species. Transmissible gastroenteritis coronavirus (TGEV) occurs in pigs resulting in vomiting, diarrhea, and dehydration. It is believed to be introduced to pigs by wild birds and there is no specific treatment available. It is not transmissible to humans.

See also
Enterocolitis
Passage 5:
Gender symbol
A gender symbol is a pictogram or glyph used to represent sex and gender, for example in biology and medicine, in genealogy, or in the sociological fields of gender politics, LGBT subculture and identity politics.
In his books Mantissa Plantarum (1767) and Mantissa Plantarum Altera (1771), Carl Linnaeus regularly used the planetary symbols of Mars, Venus and Mercury – ♂, ♀, ☿ – for male, female and hermaphroditic (perfect) flowers, respectively. Botanists now use ⚥ for the last.In genealogy, including kinship in anthropology and pedigrees in animal husbandry, the geometric shapes △ or □ are used for male and ○ for female. These are also used on public toilets in some countries. 
The modern international pictograms used to indicate male and female public toilets, 🚹︎ and 🚺︎, became widely used in the 1960s and 1970s. They are sometimes abstracted to ▽ for male and △ for female.

Biology and medicine
The three standard sex symbols in biology are male ♂, female ♀ and hermaphroditic ⚥; originally the symbol for Mercury, ☿, was used for the last. These symbols were first used by Carl Linnaeus in 1751 to denote whether flowers were male (stamens only), female (pistil only) or perfect flowers with both pistils and stamens. (Most flowering and conifer plant species are hermaphroditic and either bear flowers/cones that themselves are hermaphroditic, or bear both male and female flowers/cones on the same plant.) These symbols are now ubiquitous in biology and medicine to indicate the sex of an individual, for example of a patient.

Genealogy
Kinship charts use a triangle △ for male and circle ○ for female. Pedigree charts published in scientific papers use an earlier anthropological convention of a square □ for male and a circle ○ for female.Before a shape distinction was adopted, all individuals had been represented by a circle in Morgan's 1871 System of Consanguinity and Affinity of Human Family, where gender is encoded in the abbreviations for the kin relation (e.g. M for 'mother' and F for 'father'). W. H. R. River distinguished gender in the words of the language being recorded by writing male kinship terms in all capitals and female kinship terms with normal capitalization. That convention was quite influential for a time, and his convention of prioritizing male kin by placing them to the left and females to the right continues to this day though there have been exceptions, such as Margaret Mead, who placed females to the left.

Public toilets
The modern gender symbols used for public toilets, 🚹︎ for male and 🚺︎ and female, are pictograms created for the British Rail system in the mid-1960s. Before that, local usage had been more variable. For example, schoolhouse outhouses in the 19th-century United States had ventilation holes in their doors that were shaped like a starburst Sun ✴ or like a crescent Moon ☾, respectively, to indicate whether the toilet was for use by boys or girls. The British Rail pictograms – often color-coded blue and red – are now the norm for marking public toilets in much of the world, with the female symbol distinguished by a triangular skirt or dress, and in early years (and sometimes still) the male symbol stylized like a tuxedo.These symbols are abstracted to varying degrees in different countries – for example, the circle-and-triangle variants  (female) and  (male) commonly found on portable toilets, to the extreme of a triangle △ (representing a skirt or dress) for female and an inverted triangle ▽ (representing a broad-shouldered tuxedo) for male in Lithuania.In elementary schools, the pictograms may be of children rather than of adults, with the girl distinguished by her hair. In themed locations, such as bars and tourist attractions, a thematic image or figurine of a man and woman or boy and girl may be used.In Poland, an inverted triangle ▽ is used for male while a circle ○ is used for female.In mainland China, silhouettes of heads in profile may be used as gender pictograms, generally alongside the Chinese characters for male (男) and female (女).

Sexual orientation and gender politics
Since the 1970s, variations of gender symbols have been used to express sexual orientation and gender politics. Two interlocking male symbols ⚣ are used to represent gay men while two interlocking female symbols ⚢ are often used to represent lesbians.Since the 2000s, numerous such variants have been introduced in the context of LGBT culture and politics. Some of these symbols have been adopted into Unicode (in the Miscellaneous Symbols block) beginning with version 4.1 in 2005.

Encoding
See also
Alchemical symbol
Astrological symbols
Fertility symbols
LGBT symbols
Miscellaneous Symbols Unicode block

Notes
Passage 6:
Venus with a Mirror
Venus with a Mirror (c. 1555) is a painting by Titian, now in the National Gallery of Art in Washington, DC, and it is considered to be one of the collection's highlights.The pose of the Venus resembles the classical statues of the Venus de' Medici in Florence or the Capitoline Venus in Rome, which Titian may have seen when he wrote that was "learning from the marvelous ancient stones." The painting is said to celebrate the ideal beauty of the female form, or to be a critique of vanity, or perhaps both. It was copied by several later artists, including Peter Paul Rubens and Anthony van Dyck.Titian made a number of paintings of the same subject, but this is believed to be the earliest and the only version to be entirely by the hand of Titian, without additions by his assistants. It remained in his house until his death in 1576.

Painting, and versions
X-rays of the painting have revealed that Titian painted it over a double portrait which he had abandoned. Titian kept the red cloak of one of the figures in the abandoned painting and placed it under Venus's arm. The use of the cloak from the earlier painting probably played a large part in the composition of the new painting.Titian is believed to have made another version of this Venus for the Venetian lawyer Niccolo Crasso, who also commissioned Titian to paint the Retable of Saint Nicholas de Bari at about the same time. A drawing of the other version was included by Anthony van Dyck in the sketchbook made during his trip to Italy. This other version is now lost, but a studio copy exists in the Hermitage Museum.Titian is thought to have made a second copy, which was sent to his regular patron King Philip II of Spain, in 1567. This version was also lost, but a copy of it by Peter Paul Rubens exists, which is in the Thyssen-Bornemisza Museum in Madrid.

Other versions
Provenance
In 1581, five years after Titian's death, the contents of his house in Venice, including the Venus with a Mirror, were sold by his son and heir Pomponio Vechellio to Christoforo Barbarigo. In 1850 the Russian Consul-General in Venice, A. Kvostov, purchased the painting, along with a large number of other masterpieces, from the Barbarigo family, for Czar Nicholas I for the sum of 525,000 francs, and it entered the collection of the Hermitage Museum in Saint Petersburg.In 1931, in order to earn foreign currency for the first of the five-year plans for the national economy of the Soviet Union, Joseph Stalin and the Soviet government secretly sold the painting, along with a number of other masterpieces, to a syndicate of art dealers, who sold it to the American collector Andrew Mellon, who wished to create a national art museum for the United States. Mellon donated it to the United States Government in 1937. It was one of the first masterpieces to be displayed in the National Gallery of Art in Washington when it opened in 1941.

Works that may have influenced Titian
The pose of the painting may have been influenced by Ancient Greek and Roman statues of Venus Titian could have seen in Rome and Florence. He was also influenced by his teacher Giovanni Bellini, who was the leader of the Venetian school of painters, known for their masterful use of color.

Influence of the painting
The theme of the painting was adapted by a number of later artists, including Peter Paul Rubens and Diego Velázquez.
The painting itself was the inspiration for the protagonist Severin's imagination in the 1870 novel Venus in Furs by Leopold von Sacher-Masoch.

Gallery, influences
Notes
See also
List of paintings in the National Gallery of Art, Washington DC, formerly in the Hermitage Museum
Venus in Furs, a novel containing great reference to the painting.

Answer the question based on the given passages. Only give me the answer and do not output any other words.

Question: How many times did plague occur in the place where Venus with a Mirror's creator died?



Answer: 22