The History of Bubonic Plague
Rebecca A. Bishop
Graduate School of Biomedical Sciences
University of Texas Health Science Center at Houston
12/2/03
Was that not sad and painful
to relate,
I died with thirteen of my
house on the same date?
From a tombstone dated 1437 in St. John’s churchyard, Nurembeg, Germany
The writer Petrarch, in speaking of the devastation of Florence by the bubonic plague in the 1300’s, perhaps says it best: “O happy posterity, who will not experience such abysmal woe and will look upon our testimony as fable.” It is true that the world today has forgotten what a pandemic with 40% mortality is like. Through most of history, the bubonic plague would appear with unknown causes and no known cure or treatment. It inspired panic and terror, destroyed economies, and lead to social upheavals. Its history is long and varied, continuing up to the present day.
It is difficult to say what is the earliest recorded outbreak of the bubonic plague. Some scholars believe that the first two outbreaks are reported in the Bible. In one, reported in the book of 1st Samuel and dated approximately 1320 B.C., the Philistine army attacks the Hebrews and seizes the Ark of the Covenant. They take it to the city of Ashdod, then to Gath and Ekron. Each city is stricken with devastating illness which is only cured through the return of the Ark to the Hebrews and the gift of five golden “emerods” and five golden mice. What these “emerods” were is unclear, but they are believed to be either hemorrhoids of the buboes of plague victims.
The second biblical account of plague is chronicled in the books of 2nd Kings, 2nd Chronicles, Isaiah, and in the writings of Herodotus, a Greek historian. Here, the city of Jerusalem, was under siege by the army of the Assyrians, lead by Sennacherib. It is written that one morning the Hebrews awoke to find all of the armies dead, and, according to Herodotus, “multitudes of field mice.” The presence of rodents among the dead could indicate an outbreak of plague, and plague has been known to kill in as quickly as 24 hours.
The first record of bubonic plague that includes medical observations occurred in the 1st century A.D. It occurred in Libya, Egypt, and Syria. Rufus of Ephesus describes it as especially fatal and having “buboes called pestilential.” Pedanios Dioskorides, writer of “Materia Medica”, the undisputed medical reference for nearly 1500 years, talks about the plague that “raged in Libya” and “was accompanied by an acute fever, a terrible pain, trouble throughout the whole body and the appearance of great buboes.” This is almost undoubtedly a chronicle of an outbreak of the bubonic plague.
The first pandemic of plague would not occur until the 6th century A.D. For pandemics to emerge, trade routes must be established so that outbreaks could spread from city to city. While it is not clear where this pandemic originated, it was in the area of Arabia, central Africa, or lower Egypt. It is known that it had reached Egypt by 542. It is described by the medical writer Procopius of Caesarea: “The fever made its attack suddenly. Generally on the first or second day, but in a few instances later, buboes appeared, not only in the groin, but also in the armpits and below the ears.”
From lower Egypt, the plague spread down the Nile to Pelesium and then to Alexandria. It then traveled by ship to Constantinople, seat of power of the Roman Emperor Justinian. Rome had split into two empires (east and west), the western part of which had been conquered by outside forces. Justinian was in the process of rebuilding the Roman empire and reconquering its land when the plague arrived in 542. It killed 40% of the people in Constantinople, where it was described as “a pestilence by which the whole human race came near to being annihilated.”
From Constantinople, the plague spread through Italy to Spain, France, the Rhine Valley, Britain, Denmark, and finally to China in 610. This pandemic was perhaps the most devastating in the history of the world. It is estimated that it killed 100 million people across the world, or 50% of the human population. The shortage in workers lead to massive economic downturn that would progress into the Dark Ages.
Perhaps that best known pandemic of bubonic plague occurred in the 1300’s. It began in Asia in 1347 and from there spread by boat to port cities in Italy. It then moved up the trade routes, reaching England the next year. Its mortality rate was very high, estimated to be between 20 and 40%. It killed an estimated 43 million people worldwide, including 25 million in Europe, or 1/3 of the population there. It devastated commerce, and lead to social upheavals. Peasants rose up when they were denied higher wages which they had demanded due to the massive shortage of workers. Crops died in the fields because there was no one to harvest them.
As the casualty rates skyrocketed, there quickly were not enough people to bury the dead. The Catholic Church was so short on priests to hear confessions of the dying that Pope Clement VI granted remission of sin to all who died of the plague because so many were unable to receive their last rites. Many priests, and many doctors, refused to visit those infected with the plague. Parents abandoned children, children their parents, wives their husbands. People were desperate for a way to protect themselves from the plague and to cure the sick. This lead to the rise of many “quacks.”
Often, the “home remedies” offered to plague victims did nothing but increase the agony of their last days. One example of such a remedy involved pigeons. It was said that one could be cured of plague if they took a pigeon, plucked the feathers off of her tail, and put the tail to the sore. The “venom” would then be sucked out of the bubo into the pigeon, thus killing the bird. One was to repeat this with fresh pigeons until one lived, thus indicating that all of the poison had left the body.
Some people used posies of flowers, fragrant herbs, or spices “believing it would comfort the brain with smells of that sort because the stink of corpses, sick bodies, and medicines polluted the air all about the city.” Some people believed that the plague was caused by impure air itself. Numerous bonfires were lit to purify the air of infection. Still others blamed the epidemic on women lepers, poisoned wells, or the Jews. In reality, there was nothing that medieval doctors could do to help victims of the plague.
The plague would eventually burn itself out, leaving the survivors to attempt to rebuild their lives and nations to rebuild their economies.
In 1665, the bubonic plague reappeared in London. This time, quarantine was imposed on houses known to contain the dead or infected. This was done through the painting of a large red cross on the door and the words “Lord have mercy on us.” Unfortunately, this incarcerated uninfected members of the household with those infected, thus leading to greater casualties. At night, cries of “bring out your dead” could be heard throughout the city. The dead were loaded onto carts and taken to pits where they were buried in mass graves. Two of these pits were the Great Pit at Aldgate and the pit at Finsbury Fields. The mortality rate for this outbreak was high, killing 15% of all London.
The London plague outbreak of 1665 and 1666 ended abruptly. A fire broke out in a baker’s house and, due the fact that London was primarily constructed of narrow alleys and poor timber houses, quickly engulfed the city. Most of London was destroyed. With it died many of the rats that were carrying the plague-infected fleas. The plague quickly died out following this fire and would persist as sporadic outbreaks for three hundred years. It would appear again in Italy, France and Turkey in the 1400’s, in Belgium in 1502, and in Austria in 1542.
The third pandemic of the bubonic plague is the least well known, which is surprising because it was so recent. It began in 1892 in the Yunnan Province of China and from there spread to India and then the rest of the world. It is said to have killed more than 6,000,000 people in India alone.
In the summer of 1899, a ship arrived in San Francisco from Hong Kong with two plague cases on board. The ship was quarantined on Angel Island and eventually allowed to dock. Rats from the ship disembarked and carried the plague into Chinatown. On March 6, 1900, an autopsy was performed on a Chinese man who had unexplainably died. It was found that he had been infected with the bubonic plague. This lead to the total quarantine of all of Chinatown. However, there were many complaints by local businessmen who felt that the admission of plague in San Francisco would be economically harmful. The quarantine was lifter, but house-to-house inspections began in Chinatown. The people living there resisted, hiding their dead and locking their doors. If it was discovered that someone infected with plague was in their house, the house was burned down and the people sent to camps outside the city.
The problems of quarantine in San Francisco were exacerbated by the fact that the governor refused to admit that there were any cases of plague there. The Surgeon General was forced to go directly to President McKinley, where he succeeded in passing new antiplague regulations. Many states stopped trade with California. In April 1901, a cleanup campaign was begun in Chinatown, and in 1903 a new governor was elected who promised help in dealing with the epidemic. However, like London in 1666, what stopped the plague outbreak turned out to be a city-wide disaster. In 1906, a massive earthquake struck San Francisco. Many people were left homeless and moved into refugee camps. Plague continued to smolder until a bounty was placed on rats in 1907. Hundreds of thousands of rats were caught and killed in this effort, and the outbreak finally ended in 1909.
Plague continues to occur in sporadic outbreaks to this day. There have been several outbreaks in the United States in the 20th century, but they have been quickly extinguished due to the use of antibiotics and monitoring. However, plague continues to appear from time to time. In 1965, concurrent with the state of war in Vietnam, a plague outbreak occurred there. There were 25,000 reported cases, although the actual numbers are felt to be in reality much higher. Another outbreak in the U.S. in 1983 killed 40 people.
During the 1980’s, the U.S. averaged 18 cases per year of bubonic plague. Most of the victims were under 20 years old. The mortality rate was 14%, or 1 in 7. Worldwide, there are 1000-2000 cases per year. There are also yearly epidemics in Africa, Asia, and South America associated with domestic rats. Most of these are in rural areas.
The worldwide distribution is interesting. There is no plague in Australia, none in Europe since World War II. Plague still exists in Madagascar, in the Caucus Mountains of Russia, in the Middle East, China, and in Southwest and Southeast Asia. It lives in Africa south of Uganda on the eastern side of the continent and in southern Africa. It survives in the Andean mountain region of South America and in Brazil. It also lives in two regions in the United States: Northern New Mexico/northern Arizona/southern Colorado, and California/southern Oregon/far west Nevada.
There has been no person-to-person transmission in the U.S. since 1924. Victims of plague in the U.S. become infected through rodents, and can become infected by skinning an infected animal. Plague exists in the fleas of rock squirrels, California ground squirrels, prairie dogs, wood rats, chipmunks, and wild rabbits, among others. Highest risk groups in the U.S. are Native Americans (especially Navajos), hunters, veterinarians, campers, hikers, and pet owners who may become infected through an infected cat.
In ancient times, the causes of the plague were unknown. It was not until 1894 that it was proven that the bacteria Yersinia pestis was responsible. This was discovered simultaneously but separately by Shibasaburo Kitasato of Japan and Alexandre Yersin. In 1898, Paul Louis Simmond proved that Y. pestis was spread by fleas, but his work was initially met with ridicule. It was not until a British commission confirmed this in 1908 that it became accepted. Attempts were made to disinfect the sewers of major cities using carbolic acid, but this only succeeded in driving out the rats that lived there, thus leading to more cases of plague infections.
Plague begins with the bite of a common rat flea known as Xenopsylla cheopis. After a 2-6 day incubation period, the first symptoms, generally fever, headache, and general illness, appear. Next, a very painful, very swollen, hot-to-touch lymph node, known as a bubo, appears. Plague can then enter the bloodstream and become septicemic plague, turning the skin black. Finally, the infection can progress further to the lungs, resulting in plague pneumonia. Infection can now be spread person-to-person through the coughing of infected respiratory droplets.
If one catches plague through person-to-person contact, the incubation period is much shorter (only 1-3 days), and the first symptoms are overwhelming pneumonia, high fever (sometimes reaching 107o), cough, bloody sputum, and chills. While mortality rates depend on the type of plague, averaging greater than 50%. Reports from Austria in 1679 described death within 24 hours of the onset of symptoms.
Today, plague is treated with streptomycin or gentamicin. For those exposed but not showing symptoms, the tetracyclines, chloramphenicol, and some sulfonamides are used prophylactically. Plague outbreaks are controlled through monitoring for disease and through the use of insecticides to kill the flea carriers. There is no commercially available plague vaccine in the U.S. All suspected cases must be reported to local and state health departments. All diagnoses in the U.S. are confirmed by the Centers for Disease Control (CDC) and are then reported to the World Health Organization (WHO).
The first use of biological warfare recorded used bubonic plague as its disease. It occurred in 1343 when a Genoese colony was under siege by a khan from the Golden Horde known as Yannibeg. His troops were being ravaged by plague, and he decided to put his catapults to use. He loaded the bodies of plague victims into the catapults and shot them over the walls of the city. Soon, plague broke out within the city. In actuality, this was most likely not due to this “biological attack” (infected fleas would have left the bodies after they died in search of another), but rather due to the fact that cities under siege are ripe for disease.
More recently, Japan developed a biological warfare program between 1932 and 1945. It was directed by Ishiri Shiro. Among other diseases investigated, plague was studied. This lead to the creation of the “flea bomb” (Uji-50). This was a ceramic container containing plague-infected fleas and flour. When dropped on a village, the jar would burst open, spilling the flour out into the street. The village rats would come to eat the flour and would become infected with the fleas. This weapon was tested on villages in Manchuria. One victim recounts:
I was fifteen years old at the time, and I remember everything clearly. The Japanese plane spread something that looked like smoke. A few days later we found dead rats all over the village. At the same time, people came down with high fevers and aches in the lymph nodes. Every day, people died. Crying could be heard all through the village. My mother and father – in all, eight people in my family – died. I was the only one in my family left.
While plague certainly is effective at spreading terror, it is perhaps not the best choice as a biological weapon. Its incubation period is too short to allow spread to many people, and, unless in the pneumonic form, requires fleas and rats to spread. With the use of antibiotics, its mortality rate drops from greater than 50% to 14%. The greatest danger is in the genetic engineering of a form of plague that is resistant to antibiotics and that tends to spread by the pneumonic route. Were this to happen, Petrarch’s writings about posterity never knowing the horror of a pandemic of bubonic plague could be false. The Black Death is sleeping now. May it never awaken again.
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