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Bubonic plague

This article is about the disease in general. For information about the medieval European plague, see Black Death.

Bubonic plague
File:Plague -buboes.jpg
An inguinal bubo on the upper thigh of person infected with bubonic plague. Swollen lymph glands (buboes) often occur in the neck, armpit and groin (inguinal) regions of plague victims.
Classification and external resources
Specialty Infectious disease
ICD-10 A20.0
ICD-9 020.0
DiseasesDB 14226
MedlinePlus 000596
NCI Bubonic plague
Patient UK Bubonic plague

Bubonic plague is a zoonotic disease, circulating mainly in fleas on small rodents, and is one of three types of bacterial infections caused by Yersinia pestis (formerly known as Pasteurella pestis), that belongs to the family Enterobacteriaceae. Without treatment, the bubonic plague kills about two thirds of infected humans within four days.[citation needed] In 2013 there was about 750 documented cases of plague which resulted in 126 deaths.[1]

The term bubonic plague is derived from the Greek word βουβών, meaning "groin". Swollen lymph nodes (buboes) especially occur in the armpit and groin in persons suffering from bubonic plague. Bubonic plague was often used synonymously for plague, but it refers specifically to an infection that enters through the skin and travels through the lymphatics, as is often seen in flea-borne infections.

Bubonic plague—along with the septicemic plague and the pneumonic plague, which are the two other manifestations of Y. pestis—is commonly believed to be the cause of the Black Death that swept through Europe in the 14th century and killed an estimated 25 million people, or 30–60% of the European population.[2] Around the Mediterranean Region, summers seemed to be the season when the disease took place. In northern Europe, the disease had its most frequent outbreaks in the autumn.[3] Because the plague killed so many of the working population, wages rose with the demand for labor. Some historians have seen this as a turning point in European economic development.[4][5]

Signs and symptoms

File:Acral necrosis due to bubonic plague.jpg
Acral necrosis of the nose, the lips, and the fingers and residual ecchymoses over both forearms in a patient recovering from bubonic plague that disseminated to the blood and the lungs. At one time, the patient's entire body was ecchymotic. Reprinted from Textbook of Military Medicine.

The most infamous symptom of bubonic plague is an infection of the lymph glands (lymphadenitis), known as buboes, which become swollen and painful. After being transmitted via the bite of an infected flea, the Y. pestis bacteria become localized in an inflamed lymph node, where they begin to colonize and reproduce. Buboes associated with the bubonic plague are commonly found in the armpits, upper femoral, groin and neck region. Acral gangrene (i.e., of the fingers, toes, lips and nose) is another common symptom.

Because of its bite-based mode of transmission, the bubonic plague is often the first of a progressive series of illnesses. Bubonic plague symptoms appear suddenly, usually 2–5 days after exposure to the bacteria. Symptoms include:

  • Gangrene of the extremities such as toes, fingers, lips and tip of the nose.[6]
  • Chills
  • General ill feeling (malaise)
  • High fever (39 °C; 102 °F)
  • Muscle cramps[7]
  • Seizures
  • Smooth, painful lymph gland swelling called a bubo, commonly found in the groin, but may occur in the armpits or neck, most often at the site of the initial infection (bite or scratch)
  • Pain may occur in the area before the swelling appears
  • Skin color changes to a pink hue in some very extreme cases

Other symptoms include heavy breathing, continuous vomiting of blood (hematemesis), aching limbs, coughing, and extreme pain. The pain is usually caused by the decay or decomposition of the skin while the person is still alive. Additional symptoms include extreme fatigue, gastrointestinal problems, lenticulae (black dots scattered throughout the body), delirium, and coma.

Two other types of Y. pestis plague are pneumonic and septicemic. Pneumonic plague, unlike the bubonic or septicemic, induces coughing and is very infectious. It may spread person to person.


File:Flea infected with yersinia pestis.jpg
Oriental rat flea (Xenopsylla cheopis) infected with the Yersinia pestis bacterium which appears as a dark mass in the gut. The foregut of this flea is blocked by a Y. pestis biofilm; when the flea attempts to feed on an uninfected host, Y. pestis from the foregut is regurgitated into the wound, causing infection.

Bubonic plague is an infection of the lymphatic system, usually resulting from the bite of an infected flea, Xenopsylla cheopis (the rat flea). In very rare circumstances, as in the septicemic plague, the disease can be transmitted by direct contact with infected tissue or exposure to the cough of another human. The fleas are often found on rodents such as rats and mice, and seek out other prey when their rodent hosts die. The bacteria began its life harmlessly living in the digestive tracts of mammals. The ability to propagate was dependent only upon its ability to travel from mammal host to mammal host. The bacteria remained harmless to the flea, allowing the new host to spread the bacteria. The bacteria form aggregates in the gut of infected fleas and this results in the flea regurgitating ingested blood, which is now infected, into the bite site of a rodent or human host. Once established, bacteria rapidly spread to the lymph nodes and multiply.

Y. pestis bacilli can resist phagocytosis and even reproduce inside phagocytes and kill them. As the disease progresses, the lymph nodes can haemorrhage and become swollen and necrotic. Bubonic plague can progress to lethal septicemic plague in some cases. The plague is also known to spread to the lungs and become the disease known as the pneumonic plague. This form of the disease is highly communicable as the bacteria can be transmitted in droplets emitted when coughing or sneezing.[citation needed]


Laboratory testing is required in order to diagnose and confirm plague. Ideally, confirmation is through the identification of Y. pestis culture from a patient sample. Confirmation of infection can be done by examining serum taken during the early and late stages of infection. To quickly screen for the Y. pestis antigen in patients, rapid dipstick tests have been developed for field use.[8]


Several classes of antibiotics are effective in treating bubonic plague. These include aminoglycosides such as streptomycin and gentamicin, tetracyclines (especially doxycycline), and the fluoroquinolone ciprofloxacin. Mortality associated with treated cases of bubonic plague is about 1–15%, compared to a mortality of 40–60% in untreated cases.[9]

People potentially infected with the plague need immediate treatment and should be given antibiotics within 24 hours of the first symptoms to prevent death. Other treatments include oxygen, intravenous fluids, and respiratory support. People who have had contact with anyone infected by pneumonic plague are given prophylactic antibiotics.[10] Using the broad-based antibiotic streptomycin has proven to be dramatically successful against the bubonic plague within 12 hours of infection.[11]


First outbreak

Main article: Plague of Justinian

The first recorded epidemic ravaged the Eastern Roman Empire (Byzantine Empire) and was named the Plague of Justinian after emperor Justinian I, who was infected but survived through extensive treatment.[12][13] The pandemic resulted in the deaths of an estimated 25 million (6th century outbreak) to 50 million people (two centuries of recurrence).[14][15] The historian Procopius wrote, in Volume II of History of the Wars, of his personal encounter with the plague and the effect it had on the rising empire. In the spring of 542, the plague arrived in Constantinople, working its way from port city to port city and spreading around the Mediterranean Sea, later migrating inland eastward into Asia Minor and west into Greece and Italy. Because the infectious disease spread inland by the transferring of merchandise through Justinian’s efforts in acquiring luxurious goods of the time and exporting supplies, his capital became the leading exporter of the bubonic plague. Procopius, in his work Secret History, declared that Justinian was a demon of an emperor who either created the plague himself or was being punished for his sinfulness.[15]

Second outbreak

File:Burying Plague Victims of Tournai.jpg
Citizens of Tournai bury plague victims. Miniature from The Chronicles of Gilles Li Muisis (1272–1352). Bibliothèque royale de Belgique, MS 13076-77, f. 24v.
File:Bubonic plague victims-mass grave in Martigues, France 1720-1721.jpg
Bubonic plague victims in a mass grave from 1720–1721 in Martigues, France

In the Late Middle Ages (1340–1400) Europe experienced the most deadly disease outbreak in history when the Black Death, the infamous pandemic of bubonic plague, hit in 1347, killing a third of the human population. It is believed that society subsequently became more violent as the mass mortality rate cheapened life and thus increased warfare, crime, popular revolt, waves of flagellants, and persecution.[16] The Black Death originated in or near China and spread from Italy and then throughout other European countries. Arab historians Ibn Al-Wardni and Almaqrizi believed the Black Death originated in Mongolia, and this was proven correct as Chinese records showed a huge outbreak in Mongolia in the early 1330s.[17] Research published in 2002 suggests that it began in the spring of 1346 in the steppe region, where a plague reservoir stretches from the northwestern shore of the Caspian Sea into southern Russia. The Mongols had cut off the trade route, the Silk Road, between China and Europe which halted the spread of the Black Death from eastern Russia to Western Europe. The epidemic began with an attack that Mongols launched on the Italian merchant's last trading station in the region, Caffa in the Crimea.[11] In the autumn of 1346, plague broke out among the besiegers and from them penetrated into the town. When spring arrived, the Italian merchants fled on their ships, unknowingly carrying the Black Death. Carried by the fleas on rats, the plague initially spread to humans near the Black Sea and then outwards to the rest of Europe as a result of people fleeing from one area to another.

There were many ethno-medical beliefs for avoiding the Black Death. One of the most famous was that by walking around with flowers in or around their nose people would be able to "ward off the stench and perhaps the evil that afflicted them". People believed the plague to be a punishment from God, and that the only way to be rid of the plague was to be forgiven by God.[18] One such method used was to carve the symbol of the cross onto the front door of a house with the words "Lord have mercy on us".[19]

Pistoia, a city in Italy, even went as far as enacting rules and regulations on the city and its inhabitants to keep it safe from the Black Death. The rules stated that no one was allowed to visit any plague-infected area and if they did they were not allowed back into the city. Some other rules were that no linen or woollen goods were to be imported into the city and no corpses were to be buried in the city. However, despite strict enforcement of the rules, the city eventually became infected.[20] People who weren't infected with the plague gathered in groups and stayed away from the sick. They ate and drank with limited food and water and weren't even allowed oral communication because merely talking with one another increased the chance of passing on the disease.[21]

While Europe was devastated by the disease, the rest of the world fared much better. In India, populations rose from a population of 91 million in 1300, to 97 million in 1400, to 105 million in 1500. Also sub-Saharan Africa remained largely unaffected by the plagues.[22]

The next few centuries were marked by several localized or regional outbreaks of lesser severity. The Great Plague of Seville (1647), the Great Plague of London (1665–1666), the Great Plague of Vienna (1679), Great Baltic plague (1708–1712) and the Great Plague of Marseille (1720), were the last major outbreaks of the bubonic plague in Europe.

Traditional treatment

Main article: Miasma theory

Medieval doctors thought the plague was created by air corrupted by humid weather, decaying unburied bodies, and fumes produced by poor sanitation. The recommended treatment of the plague was a good diet, rest, and relocating to a non-infected environment so the individual could get access to clean air. This did help, but not for the reasons the doctors of the time thought. In actuality, because they recommended moving away from unsanitary conditions, people were, in effect, getting away from the rodents that harbored the fleas carrying the infection. However, this also helped to spread the infection to new areas previously non-infected.

Third outbreak

Main article: Third plague pandemic

The plague resurfaced for a third time in the mid-19th century. Like the two previous outbreaks, this one also originated in Eastern Asia.[23] The initial outbreak occurred in China's Yunnan province in 1855.[24] The disease remained localized in Southwest China for several years before spreading. In the city of Canton, beginning in March 1894, the disease killed 60,000 people in a few weeks. Daily water-traffic with the nearby city of Hong Kong rapidly spread the plague there, killing over 100,000 within two months.[25]

From China, the plague spread to the Indian subcontinent around 1896. Over the next thirty years, India would lose 12.5 million people to the bubonic plague. The disease was initially seen in port cities, beginning with Bombay (now Mumbai), but later emerged in Poona (now Pune), Kolkata, and Karachi (now in Pakistan). By 1899, the outbreak spread to smaller communities and rural areas in many regions of India. Overall, the impact of plague epidemics was greatest in western and northern India—in the provinces then designated as Bombay, Punjab, and the United Provinces—while eastern and southern India were not as badly affected. Ultimately, more than 12 million people died from the plague in India (including present day Pakistan and Bangladesh) and China alone.

In 1899, the plague reached the islands of Hawaii.[26] The first evidence of the disease was found in Honolulu's Chinatown on Oahu.[27] It was located very close to the island's piers, and rats in cargo ships from China were able to land on the Hawaiian islands unseen. As the rats, hosts for disease-carrying fleas, made their way deeper into the city, people started to fall ill. On December 12, 1899, the first case was confirmed. The Board of Health then quickly thought of ways to prevent the disease from spreading even further inland. Their solution was to burn down any buildings in Chinatown suspected of containing a source of the disease. On December 31, 1899, the board set the first fire. They had originally planned to burn only a few targeted buildings, and thought they could control the flames as each building was finished, but the fire got out of control, burning down untargeted neighboring buildings. The resulting fire caused many of Chinatown's homes to be destroyed and an estimated 4,000 people were left homeless.[28]

File:A Sydney butchers, 1900 (3100789785).jpg
From a series of images depicting the state of houses and "slum" buildings in Sydney, Australia at the time of the 1900 outbreak and the cleansing and disinfecting operations which followed.

Australia suffered 12 major plague outbreaks between 1900 and 1925 originating from shipping.[29] Research by Australian medical officers Thompson, Armstrong and Tidswell contributed to understanding the spread of Yersinia pestis to humans by fleas from infected rats.[30]

According to the World Health Organization, the pandemic was considered active until 1959, when worldwide casualties dropped to 200 per year. In 1994, a plague outbreak in five Indian states caused an estimated 700 infections (including 52 deaths) and triggered a large migration of Indians within India as they tried to avoid the plague.

Micro levels found in New York subway, 2015

In March 2015 Weill Cornell Medical College reported in a study that researchers found small particles of meningitis, anthrax, and the Bubonic plague in the subway system in New York City.[31][32]

New York has a system known as a “micro biome map”.[31]

Genetic scientists from Weill Cornell swabbed surfaces throughout the subway system. The scientists used their specimens to create a map of the “urban micobiome”. The effort took 18 months.[33] On a positive note, the levels of anthrax and Bubonic plague that the scientists found were at very low levels and were not alive.[31]

The researchers believe that their urban microbiome make it possible to create a larger comprehensive system to detect disease and bioterrorism threats. Researchers have called the idea the “PathoMap” (pathogen map).[31]

Interestingly, the team “could even track the trail of bacteria created by the city’s taste for pizza—identifying microbes associated with cheese and sausage at scores of subway stops,” according to the Wall Street Journal.[32]

Biological warfare

Some of the earliest instances of biological warfare were said to have been products of the plague, as armies of the 14th century were recorded catapulting diseased corpses over the walls of towns and villages to spread the pestilence.

Later, plague was used during the Second Sino-Japanese War as a bacteriological weapon by the Imperial Japanese Army. These weapons were provided by Shirō Ishii's units and used in experiments on humans before being used on the field. For example, in 1940, the Imperial Japanese Army Air Service bombed Ningbo with fleas carrying the bubonic plague.[34] During the Khabarovsk War Crime Trials, the accused, such as Major General Kiyashi Kawashima, testified that, in 1941, some 40 members of Unit 731 air-dropped plague-contaminated fleas on Changde. These operations caused epidemic plague outbreaks.[35]

See also


  1. ^ World Health Organization (November 2014). "Plague Fact sheet N°267". Retrieved 10 May 2015. 
  2. ^ Haensch, Stephanie; Raffaella Bianucci, Michel Signoli, Minoarisoa Rajerison, Michael Schultz, Sacha Kacki,, Marco Vermunt, Darlene A. Weston, Derek Hurst, Mark Achtman, Elisabeth Carniel, Barbara Bramanti (September 2010). Besansky, Nora J., ed. "Distinct Clones of Yersinia pestis Caused the Black Death". PLoS Pathogens 6 (10): e1001134. PMC 2951374. PMID 20949072. doi:10.1371/journal.ppat.1001134. Retrieved 16 November 2010. We confirm that Y. pestis caused the Black Death and later epidemics on the entire European continent over the course of four centuries. Furthermore, on the basis of 17 single nucleotide polymorphisms plus the absence of a deletion in glpD gene, our aDNA results identified two previously unknown but related clades of Y. pestis associated with distinct medieval mass graves. These findings suggest that plague was imported to Europe on two or more occasions, each following a distinct route. These two clades are ancestral to modern isolates of Y. pestis biovars Orientalis and Medievalis. Our results clarify the etiology of the Black Death and provide a paradigm for a detailed historical reconstruction of the infection routes followed by this disease. 
  3. ^ Felipe Armesto (2007). The World History Volume 2:The Revenge of Nature: Plague, Cold, and The Limits of Disaster In The Fourteenth Century. New Jersey: Pearson, Prentice Hall. p. 451. 
  4. ^ Bowsky, William (1971). The Black Death: A Turning Point in History?. Holt, Rinehart and Winston. ISBN 978-0-03-085000-4. 
  5. ^ Bridbury, A.R. (1983). Economic Growth: England in the Later Middle Ages. Greenwood Press. ISBN 978-0-313-24066-9. 
  6. ^ Inglesby TV, Dennis DT, Henderson DA et al. (May 2000). "Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense". JAMA 283 (17): 2281–90. PMID 10807389. doi:10.1001/jama.283.17.2281. 
  7. ^ "Symptoms of Plague". Brief Overview of Plague. Healthagen, LLC. Retrieved November 26, 2014. 
  8. ^ "Plague, Laboratory testing". Health Topics A to Z. Retrieved 23 October 2010. 
  9. ^ "Plague". Retrieved 25 February 2010. 
  10. ^ "Plague". Healthagen, LLC. Retrieved 4 April 2011. 
  11. ^ a b Echenberg,Myron (2002). Pestis Redux: The Initial Years of the Third Bubonic Plague Pandemic, 1894–1901. Journal of World History,vol 13,2
  12. ^ Little (2007), pp. 8–15.
  13. ^ McCormick (2007), pp. 290–312.
  14. ^ Rosen, William (2007), Justinian's Flea: Plague, Empire, and the Birth of Europe. Viking Adult; pg 3; ISBN 978-0-670-03855-8.
  15. ^ a b Moorshead Magazines, Limited. "The Plague Of Justinian." History Magazine 11.1 (2009): 9–12. History Reference Center
  16. ^ Cohn, Samuel K.(2002). The Black Death: End of a Paradigm. American Historical Review, vol 107, 3, pg. 703–737
  17. ^ Sean Martin (2001). Black Death:Chapter One. Harpenden,GBR:Pocket Essentials. p. 14. 
  18. ^ "The Black Death". 2013. Retrieved 2013-11-14. 
  19. ^ "Mee Jr, Charles L. (2011). "The Black Death, a bubonic plague of great dimensions-part 2." Word Focus". Retrieved 2012-12-18. 
  20. ^ "Mee Jr., Charles L. "The Black Death, a Bubonic Plague of Great Dimensions – Part 2 |" | English Vocabulary Words Derived from Latin and Greek Prefixes | Etymology. Web. 02 Dec. 2011". Retrieved 2012-12-18. 
  21. ^ Sean Martin (2001). Black Death: Chapter Two. Harpenden, GBR:Pocket Essentials. p. 26. 
  22. ^ Reaching Out: Expanding Horizons of Cross-Cultural Interaction
  23. ^ Nicholas Wade (October 31, 2010). "Europe’s Plagues Came From China, Study Finds". The New York Times. Retrieved 2010-11-01. The great waves of plague that twice devastated Europe and changed the course of history had their origins in China, a team of medical geneticists reported Sunday, as did a third plague outbreak that struck less harmfully in the 19th century. 
  24. ^ Cohn, Samuel K. (2003). The Black Death Transformed: Disease and Culture in Early Renaissance Europe. A Hodder Arnold. p. 336. ISBN 0-340-70646-5. 
  25. ^ Pryor, E. G. (1975). "The Great Plague OF Hong Kong" (PDF). Journal of the Royal Asiatic Society Hong Kong Branch (Hong Kong: Royal Asiatic Society of Great Britain and Ireland-Hong Kong Branch) 15: 69. ISSN 1991-7295. Retrieved June 2, 2014. 
  26. ^ "Bubonic Plague Originated in China". DNews. 
  27. ^ "Hawaii for Visitors, retrieved on December 6, 2011". Retrieved 2012-12-18. 
  28. ^ "The Honolulu Advertiser, retrieved on December 6, 2011". Retrieved 2012-12-18. 
  29. ^ "Bubonic Plague comes to Sydney in 1900". Sydney Medical School – Online Museum. University of Sydney. 2012. Retrieved 2 August 2012. 
  30. ^ Thompson, J. Ashburton (1901). "A Contribution to the Aetiology of Plague". The Journal of Hygiene (London) 1 (2): 153–167. PMC 2235949. PMID 20474113. doi:10.1017/S0022172400000152. 
  31. ^ a b c d "Study finds anthrax, Bubonic plague in New York City subway system". BioPrepWatch. 6 February 2015. Retrieved 18 March 2015. 
  32. ^ a b Hotz, Robert Lee (5 February 2015). "Big Data and Bacteria: Mapping the New York Subway’s DNA". The Wall Street Journal. Retrieved 18 March 2015. 
  33. ^ "SciCafe: NYC Subways: Mapping the Urban Microbiome, Genome, and Metagenome". American Museum of Natural History. New York, NY. 4 February 2015. Retrieved 18 March 2015. 
  34. ^ "The Independent - 404". The Independent. 
  35. ^ Daniel Barenblatt, A Plague upon Humanity., 2004, pages 220–221.


Further reading

  • Alexander, John T. (2003) [First published 1980]. Bubonic Plague in Early Modern Russia: Public Health and Urban Disaster. Oxford, UK; New York, NY: Oxford University Press. ISBN 0-19-515818-0. OCLC 50253204. 
  • Carol, Benedict (1996). Bubonic Plague in Nineteenth-Century China. Stanford, CA: Stanford University Press. ISBN 0-8047-2661-2. OCLC 34191853. 
  • Biddle, Wayne (2002). A Field Guide to Germs (2nd Anchor Books ed.). New York: Anchor Books. ISBN 1-4000-3051-X. OCLC 50154403. 
  • Little, Lester K. (2007). Plague and the End of Antiquity: The Pandemic of 541–750. New York, NY: Cambridge University Press. ISBN 978-0-521-84639-4. OCLC 65361042. 
  • Rosen, William (2007). Justinian's Flea: Plague, Empire and the Birth of Europe. London, England: Viking Penguin. ISBN 978-0-670-03855-8. 
  • Scott, Susan, and C. J. Duncan (2001). Biology of Plagues: Evidence from Historical Populations. Cambridge, UK; New York, NY: Cambridge University Press. ISBN 0-521-80150-8. OCLC 44811929. 
  • Batten-Hill, David (2011). This Son of York. Kendal, England: David Batten-Hill. ISBN 978-1-78176-094-9. OCLC 
  • Kool, J. L. (2005). "Risk of Person-to-Person Transmission of Pneumonic Plague". Clinical Infectious Diseases 40 (8): 1166–1172. PMID 15791518. doi:10.1086/428617. 

External links