Bubonic plague is one of three types of plague caused by bacterium
Yersinia pestis. One to seven days after exposure to the bacteria,
flu like symptoms develop. These include fever, headaches, and
vomiting. Swollen and painful lymph nodes occur in the area closest
to where the bacteria entered the skin. Occasionally the swollen
lymph nodes may break open.
The three types of plague are the result of the route of infection:
bubonic plague, septicemic plague, and pneumonic plague. Bubonic
plague is mainly spread by infected fleas from small animals. It
may also result from exposure to the body fluids from a dead
plague-infected animal. In the bubonic form of plague, the bacteria
enter through the skin through a flea bite and travel via the
lymphatic vessels to a lymph node, causing it to swell. Diagnosis
is made by finding the bacteria in the blood, sputum, or fluid from
Prevention is through public health measures such as not handling dead
animals in areas where plague is common. Vaccines have not been
found to be very useful for plague prevention. Several antibiotics
are effective for treatment, including streptomycin, gentamicin, and
doxycycline. Without treatment, plague results in the death of
30% to 90% of those infected. Death, if it occurs, is typically
within ten days. With treatment the risk of death is around 10%.
Globally there are about 650 documented cases a year, which result in
~120 deaths. In the 21st century, the disease is most common in
The plague is believed to be the cause of the
Black Death that swept
through Asia, Europe, and Africa in the 14th century and killed an
estimated 50 million people. This was about 25% to 60% of the
European population. Because the plague killed so many of the
working population, wages rose due to the demand for labor. Some
historians see this as a turning point in European economic
development. The term bubonic is derived from the Greek word
βουβών, meaning "groin". The term "buboes" is also used to
refer to the swollen lymph nodes.
1 Signs and symptoms
5.1 First pandemic
5.2 Second pandemic
5.3 Third pandemic
6 Society and culture
6.1 Biological warfare
7 See also
9 Further reading
10 External links
Signs and symptoms
Acral necrosis of the nose, the lips, and the fingers and residual
ecchymoses over both forearms in a person recovering from bubonic
plague that disseminated to the blood and the lungs. At one time, the
person's entire body was ecchymotic.
The best-known symptom of bubonic plague is one or more infected,
enlarged, and painful lymph nodes, known as buboes. 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
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 a few days after exposure to the bacterium.
General ill feeling (malaise)
High fever >39 °C (102.2 °F)
Smooth, painful lymph gland swelling called a bubo, commonly found in
the groin, but may occur in the armpits or neck, most often near the
site of the initial infection (bite or scratch)
Pain may occur in the area before the swelling appears
Gangrene of the extremities such as toes, fingers, lips and tip of the
Other symptoms include heavy breathing, continuous vomiting of blood
(hematemesis), aching limbs, coughing, and extreme pain 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.
Oriental rat flea
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 flea is parasitic on
house and field rats, and seeks out other prey when its rodent hosts
die. The bacteria remain 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
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
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.
Samples taken for testing include:
Buboes: Swollen lymph nodes (buboes) characteristic of bubonic plague,
a fluid sample can be taken from them with a needle.
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.
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.
Using the broad-based antibiotic streptomycin has proven to be
dramatically successful against the bubonic plague within 12 hours of
Epidemiology of plague
Epidemiology of plague and Timeline of plague
Main article: Plague of Justinian
The first recorded epidemic affected the Eastern Roman Empire
(Byzantine Empire) and was named the
Plague of Justinian
Plague of Justinian after emperor
Justinian I, who was infected but survived through extensive
treatment.  The pandemic resulted in the deaths of an
estimated 25 million (6th century outbreak) to 50 million people (two
centuries of recurrence). 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
Black Death and Second plague pandemic
Tournai bury plague victims. Miniature from The Chronicles
Gilles Li Muisis (1272–1352). Bibliothèque royale de Belgique,
MS 13076-77, f. 24v.
People who died of bubonic plague in a mass grave from 1720–1721 in
Late Middle Ages
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.[where?] Some historians believe that society subsequently
became more violent as the mass mortality rate cheapened life and thus
increased warfare, crime, popular revolt, waves of flagellants, and
Black Death originated in Central Asia and spread
from Italy and then throughout other European countries. Arab
historians Ibn Al-Wardni and Almaqrizi believed the Black Death
originated in Mongolia. Chinese records also showed a huge outbreak in
Mongolia in the early 1330s. Research published in 2002 suggests
that it began in early 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 merchants' last
trading station in the region,
Caffa in the Crimea. In late 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.
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,
most likely in Yunnan Province of China, where there are several
natural plague foci. The initial outbreaks occurred in the second
half of the eighteenth century. The disease remained localized
Southwest China for several years before spreading. In the city of
Canton, beginning in January 1894, the disease killed 80,000 people by
June. Daily water-traffic with the nearby city of
Hong Kong rapidly
spread the plague there, killing over 2,400 within two months.
Also known as the modern pandemic, the third pandemic spread the
disease to port cities throughout the world in the second half of the
19th century and early 20th century via shipping routes. The
plague inflicted people in Chinatown in San Francisco from
1900-1904, and the people of Oakland and east bay again from
1907-1909. During the outbreak from 1900-1904 in San Francisco is
when authorities made permanent the Chinese Exclusion Act. This law
was originally signed into existence by President
Chester A. Arthur
Chester A. Arthur in
Chinese Exclusion Act
Chinese Exclusion Act was supposed to last for ten years but
was renewed in 1892 with the
Geary Act and subsequently made permanent
in 1902 during the outbreak of plague in Chinatown, San Francisco. The
last major outbreak in the United States occurred in Los Angeles in
1924, though the disease is still present in wild rodents, and can
be passed to humans that come in contact with them. 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.
For over a decade since 2001, Zambia, India, Malawi, Algeria, China,
Peru, and the Democratic Republic of the Congo had the most plague
cases with over 1,100 cases in the Democratic Republic of the Congo
alone. From 1,000 to 2,000 cases are conservatively reported per year
to the WHO. From 2012 and to 2017 and reflecting political unrest
and poor hygienic conditions, Madagascar began to host regular
Between 1900 and 2015, the United States had 1,036 human plague cases
with an average of 9 cases per year. In 2015, 16 people in the Western
United States developed plague, including 2 cases in Yosemite National
Park. These US cases usually occur in rural northern New Mexico,
northern Arizona, southern Colorado, California, southern Oregon, and
far western Nevada.
In November 2017, the Madagascar Ministry of Health reported an
outbreak to WHO (World Health Organization) with more cases and deaths
than any recent outbreak in the country. Unusually most of the cases
were pneumonic rather than bubonic.
Society and culture
Black Death in medieval culture
The scale of death and social upheaval associated with plague
outbreaks has made the topic prominent in a number of historical and
fictional accounts since the disease was first recognized. The Black
Death in particular is described and referenced in numerous
contemporary sources, some of which, including works by Chaucer,
Boccaccio, and Petrarch, are considered part of the Western canon. The
Decameron, by Boccaccio, is notable for its use of a frame story
involving individuals who have fled Florence for a secluded villa to
escape the Black Death. First person, sometimes sensationalized or
fictionalized, accounts of living through plague years have also been
popular across centuries and cultures.
Later works, such as Albert Camus's novel
The Plague or Ingmar
The Seventh Seal
The Seventh Seal have used bubonic plague in settings,
such quarantined cities in either medieval or modern times, as a
backdrop to explore a variety of concepts. Common themes include the
breakdown of society, institutions, and individuals during the plague,
the cultural and psychological existential confrontation with
mortality, and the allegorical use of the plague in reference to
contemporary moral or spiritual questions.
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
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
Imperial Japanese Army Air Service bombed
Ningbo with fleas carrying
the bubonic plague. During the Khabarovsk War Crime Trials, the
accused, such as Major General Kiyashi Kawashima, testified that, in
1941, 40 members of
Unit 731 air-dropped plague-contaminated fleas on
Changde. These operations caused epidemic plague outbreaks.
List of cutaneous conditions
List of epidemics
^ a b c d e f g h i j k l m n o p q r s t World Health Organization
(November 2014). "Plague Fact sheet N°267". Archived from the
original on 24 April 2015. Retrieved 10 May 2015.
^ a b "Plague Symptoms". 13 June 2012. Archived from the original on
19 August 2015. Retrieved 21 August 2015.
^ a b c d e Prentice MB, Rahalison L (2007). "Plague". Lancet. 369
(9568): 1196–207. doi:10.1016/S0140-6736(07)60566-2.
^ a b "Plague Resources for Clinicians". 13 June 2012. Archived from
the original on 21 August 2015. Retrieved 21 August 2015.
^ "Plague Ecology and Transmission". 13 June 2012. Archived from the
original on 22 August 2015. Retrieved 21 August 2015.
^ Keyes, Daniel C. (2005). Medical response to terrorism :
preparedness and clinical practice. Philadelphia [u.a.]: Lippincott
Williams & Wilkins. p. 74. ISBN 9780781749862.
^ a b c "Plague History". 13 June 2012. Archived from the original on
21 August 2015. Retrieved 21 August 2015.
^ LeRoux, Neil (2007). Martin Luther As Comforter: Writings on Death
Volume 133 of Studies in the History of Christian Traditions. BRILL.
p. 247. ISBN 9789004158801.
^ Edman, Bruce F. Eldridge, John D. (2004). Medical Entomology a
Textbook on Public Health and Veterinary Problems Caused by Arthropods
(Rev.. ed.). Dordrecht: Springer Netherlands. p. 390.
^ "Symptoms of Plague". Brief Overview of Plague. iTriage. Healthagen,
LLC. Archived from the original on 4 February 2016. Retrieved 26
^ 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.
doi:10.1001/jama.283.17.2281. PMID 10807389.
^ "Plague, Laboratory testing". Health Topics A to Z. Archived from
the original on 17 November 2010. Retrieved 23 October 2010.
^ "Plague - Diagnosis and treatment - Mayo Clinic".
www.mayoclinic.org. Retrieved 2017-12-01.
^ "Plague". Archived from the original on 5 March 2010. Retrieved 25
^ "Plague". Healthagen, LLC. Archived from the original on 6 June
2011. Retrieved 4 April 2011.
^ a b Echenberg, Myron (2002). Pestis Redux: The Initial Years of the
Third Bubonic Plague Pandemic, 1894–1901. Journal of World History,
^ Little, Lester K. (2007). "Life and Afterlife of the First Plague
Pandemic." In: Little, Lester K. editor. (2007), Plague and the End of
Antiquity: The Pandemic of 541–750. Cambridge University Press.
(2007). ISBN 978-0-521-84639-4 pp. 8–15
^ McCormick, Michael (2007). "Toward a Molecular History of the
Justinian Pandemic." In: Little, Lester K. editor. (2007), Plague and
the End of Antiquity: The Pandemic of 541–750. Cambridge University
Press. (2007). ISBN 978-0-521-84639-4 pp. 290–312.
^ Rosen, William (2007), Justinian's Flea: Plague, Empire, and the
Birth of Europe Archived 25 January 2010 at the Wayback Machine..
Viking Adult; pg 3; ISBN 978-0-670-03855-8.
^ a b Moorshead Magazines, Limited. "
The Plague Of Justinian." History
Magazine 11.1 (2009): 9–12. History Reference Center
^ Cohn, Samuel K.(2002). The Black Death: End of a Paradigm. American
Historical Review, vol 107, 3, pg. 703–737
^ Sean Martin (2001). Black Death:Chapter One. Harpenden, GBR:Pocket
Essentials. p. 14.
Nicholas Wade (31 October 2010). "Europe's Plagues Came From China,
Study Finds". The New York Times. Archived from the original on 4
November 2010. Retrieved 1 November 2010. 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
^ Benedict, Carol (1996).
Bubonic plague in nineteenth-century China.
Stanford, Calif.: Stanford Univ. Press.
^ Cohn, Samuel K. (2003). The
Black Death Transformed: Disease and
Culture in Early Renaissance Europe. A Hodder Arnold. p. 336.
^ 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.
^ "History Plague CDC". www.cdc.gov. Retrieved 26 November
^ Porter, Dorothy (2003-09-11). "Book Review". New England Journal of
Medicine. 349 (11): 1098–1099. doi:10.1056/NEJM200309113491124.
^ "On This Day: San Francisco Bubonic Plague Outbreak Begins".
www.findingdulcinea.com. Retrieved 2017-11-25.
^ Griggs, Mary Beth. "30,000 People In Quarantine After Bubonic Plague
Kills One in China". Smithsonian. Retrieved 2017-11-25.
^ "Maps and Statistics Plague CDC". www.cdc.gov. 2017-10-23.
^ a b Filip, Julia. "Avoiding the Black Plague Today". Retrieved
^ Regan, Michael. "Human Plague Cases Drop in the US". Retrieved
^ "Plague in the United States Plague CDC". www.cdc.gov.
2017-10-23. Retrieved 2017-12-01.
^ "Emergencies Preparedness, Response, Plague, Madagascar, Disease
Outbreak News Plague CDC". www.who.int. 2017-11-15. Retrieved
^ "The Independent - 404". The Independent. Archived from the original
on 12 September 2011.
^ Daniel Barenblatt, A Plague upon Humanity., 2004, pages 220–221.
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.
Carol, Benedict (1996). Bubonic Plague in Nineteenth-Century China.
Stanford, CA: Stanford University Press. ISBN 0-8047-2661-2.
Biddle, Wayne (2002). A Field Guide to Germs (2nd Anchor Books ed.).
New York: Anchor Books. ISBN 1-4000-3051-X.
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.
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.
Kool, J. L. (2005). "Risk of Person-to-Person Transmission of
Pneumonic Plague". Clinical Infectious Diseases. 40 (8): 1166–1172.
doi:10.1086/428617. PMID 15791518.
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