DEFINING FEATURE 3: BUBOES AS A NORMAL CLINICAL FEATURE IN EPIDEMICS - Brill
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CHAPTER NINE
DEFINING FEATURE 3: BUBOES AS A NORMAL
CLINICAL FEATURE IN EPIDEMICS
General Introduction
The great pioneers of the modern study of plague epidemiology and
medicine saw thousands of cases of bubonic plague in the field and in
hospitals. They were certain that the disease they observed had to be
the same disease as they saw described in historical sources about the
Black Death. There is a curious contradiction between their under-
standing and the opinions of the advocates of alternative theories who
have never seen a plague case in their lives and are, nonetheless, entirely
sure that historical plague could not have been bubonic plague. One
of the central arguments of the pioneers of modern plague medicine
and epidemiology for the identity of historical and modern plague was
the descriptions of buboes and their accompanying clinical features
which they met in historical sources. Advocates of alternative theories
(must) make great efforts to disprove that the usual or normal appear-
ance of buboes in diseased persons is a unique and therefore a defining
feature of bubonic plague for the simple reason that this would rule out
or invalidate their alternative theories. In these endeavours, they argue
either that
(1) buboes are not a characteristic clinical feature of historical plague
epidemics and consequently do not constitute a defining feature, or
(2) buboes are not a defining feature of bubonic plague because
buboes are more or less a characteristic clinical feature of at least
one other disease which corresponds closely to their own alterna-
tive theory, or
(3) that the incidence or locations of buboes in historical plague or the
clinical panorama within which buboes occur in historical plague
epidemics are so different from those characterizing modern epi-
demics of bubonic plague that they must be two different diseases.
Karlsson and Morris follow the first type of approach which cannot
be taken as a serious position. Nonetheless, a fresh look at Karlsson’s
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theory will be taken below in Part 4 since it has found favour with the
Journal of Medieval History as a serious publishable theory.
The term “bubonic plague” reflects the characteristic development of
buboes on persons suffering from the disease. When a person is bitten
by an infective flea, plague contagion is discharged in the bite site at a
subcutaneous level suitable for normally draining it along a lymph ves-
sel to a lymph node that consequent upon the infection swells to form
a bubo.1 Occasionally, the infection may be drained to glands, espe-
cially the parotid glands.2 The element of reservation expressed in the
choice of the word “normally” stems from the fact that one form of
bubonic plague does not exhibit buboes. In a small percentage of cases,
infective fleas bite directly into a blood vessel so that the plague bacte-
ria will be discharged directly into the blood stream and avoid the lym-
phatic system which constitutes the body’s first line of defence, and in
these cases the infection will not give rise to buboes. Since the infection
is discharged directly into the blood stream, this form is designated
primary septicaemic plague in order to differentiate it from secondary
septicaemic plague when contagion enters the blood stream secondar-
ily after having broken down the bubonic tissue by the effects of toxins.
Primary septicaemic plague is so fulminant that the diseased usually
dies the same day; the course of illness lasts an average of c. 15 hours,3
which means that the course of illness is exceptionally short. This form
accounts for the many terrified observations of dramatic brief courses
of the disease and physicians who remark that plague without buboes
is the most dangerous form.4 However, as an epidemic disease, bubonic
plague is characterized by the normal occurrence of buboes on those
who contract the disease.5
1
Historians commonly and physicians occasionally use the anatomical term
(lymphatic) gland instead of node, however, by definition glands produce something,
e.g. hormones, enzymes or saliva, but lymph nodes do not, they constitute part of the
body’s immunity apparatus.
2
Choksy 1909: 352. It is the major salivary glands that are called parotid, the sub-
mandibular and sublingual glands. The parotid glands are thus, found in association
with mouth and throat. Cf. also the preceding footnote.
3
Philip and Hirst 1917: 529–30, 534–5.
4
See, for instance, G. Block, the Swedish physician, who wrote a remarkable proto-
scientific study of a plague epidemic in his home town of Norrköping in 1710–1, Block
1711: 21, 24–5: “That plague is the most dangerous which leaves no external signs, at-
tacking directly the spirits of life in the heart itself.” My translation from the original
Swedish edition of 1711.
5
Epidemics of bubonic plague include also a tiny incidence of primary pneumon-
ic plague rising from cases of secondary pneumonic plague by cross-infection with
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Plague can affect the lymph nodes in any part of the body,6 but will
for obvious reasons tend to affect concentrations of lymph nodes, espe-
cially in the groin or nearby femoral area, in the axillas or on the neck,
in the latter case often under the jaw or ear. Since bubonic plague is
(normally) transmitted by rat fleas, this mode of transmission will
decisively affect the distribution of sites of buboes, although one must
take into account that the distribution of sites is variable as it can be
affected by various local customs of clothing and footwear.7 A typical
distribution of the sites of buboes, according to Pollitzer and two stud-
ies based on ample evidence which are cited by him, would be: in the
groin or nearby femoral area around 55 per cent (with a somewhat
higher proportion in the femoral area, about 31 per cent), in the axillas
around 24 per cent, and on the neck around 9 per cent.8
Cohn maintains that the proportion of buboes in the groin can be as
high as 75 per cent; the assertion is not supported by a footnote on page
64 where it is made, but he states thirteen pages later9 that this figure is
given by A. Yersin in a paper of six pages on the plague in Hong-Kong
from 1894. In this brief paper, Yersin reports on his discovery of the
plague bacterium which was since named after him and provides
impressionistically quantified figures on the location of buboes, figures
that are not the outcome of systematic clinical observation.10 This is
the very beginning of modern medical plague research,11 and this paper
is cited at the expense of leaving unmentioned later studies of the loca-
tions of buboes which show substantially different figures. In fact it is a
factually misleading reference which could permit raising the question
of motives (see below).
Cohn also refers to the 19th edition of 1987 of Manson’s Tropical
Diseases, the general standard work on tropical epidemic diseases,
where the proportion of inguinal-femoral buboes is estimated at 70
per cent,12 which has been a consistent piece of information at least
since the seventh edition of 1921,13 the oldest edition I have found any
plague-infected droplets which will likewise not develop buboes. Davis’s assertion to
the contrary is commented on below: 321.
6
Butler 1983: 90. See also illustration in Sticker 1910: 382–3.
7
Pollitzer 1954: 421; Chun 1936: 315.
8
Pollitzer 1954: 420.
9
Cohn 2002: 77.
10
Yersin 1894: 663.
11
Cohn 2002: 64.
12
Manson’s Tropical Disease 1987: 593. 1921: 267, 1982: 340.
13
Manson’s Tropical Disease 1921: 267; 1982: 340.
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reason to consult. One should keep in mind that the chapters on plague
in such general standard works on infectious disease are tiny summa-
ries of the material presented in general standard works on plague, in
this case, it constitutes, for instance, just 2.2 per cent of Pollitzer 1954.
However, since Manson’s Tropical Disease up to this edition of 1987 is
not a specialist standard work in the sense that most of the chapters on
various infectious diseases are not written by specialists on plague, and
since no supporting footnote is given in the first nineteen editions
which would allow confirmation of sources, I do not understand the
significance which Cohn attributes to it and why he avoids the stand-
ard works on plague.
However, in the 20th edition of 1996, which Cohn has also used and
refers to elsewhere in his monograph, chapters are written by special-
ists and equipped with footnotes. In the small chapter of 6.5 pages on
plague representing less than 1 per cent of Pollizer 1954, the two authors
state in a general way that 70–80 per cent of buboes are located in
the groin.14 For support of this assertion, they refer to Butler 1972:
“A Clinical Study of Bubonic Plague. Observations of the 1970 Vietnam
Epidemic with Emphasis on Coagulation Studies, Skin Histology and
Electrocardiograms.” The title reveals immediately that this must be a
very restricted paper with respect to area and number of cases. In fact,
it is based on forty Vietnamese cases who, the author explicitly states,
“were not a representative sample of the epidemic” for a number of
reasons. Also importantly, the number of cases is much too small to
warrant statistical stability and representativeness.15 Perhaps even the
authors became uneasy confronted by their figures which showed that
in 88 per cent of the thirty-five cases the buboes were located in the
inguinal-femoral area,16 since they arbitrarily reduce the percentage to
70–80 per cent. A couple of years later in 1974 Butler et al. published a
paper based on the study of twenty-two Vietnamese plague cases in
which 66 per cent (14) of the patients presented with inguinal-femoral
buboes.17 A paper relating to the study of twenty-one Vietnamese
patients presented a very different distribution of the locations of
buboes.18 Obviously, the materials are too small to provide statistical
14
Smith and Thanh 1996: 918–24.
15
Butler 1972: 274.
16
Butler 1972: 272.
17
Butler, Bell, Linh et al. 1974: S78–9.
18
Legters, Cottingham and Hunter 1970: 639–40
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stability and relate to a specific Vietnamese cultural background
that could also affect the distribution of buboes for various reasons
which the researchers under the circumstances have not studied.
Unsurprisingly, Cohn must admit that “Manson, his successors, and
Yersin have not tabulated or quantified the positions of the plague
scars,” nor have they provided the material basis for their quantifica-
tions, but the numbers involved are, as we have seen, very small.
Given this background, it is necessary to increase the level of empiri-
cal documentation and mention that Chun cites four studies on the
location of buboes according to mass materials from China and India
around 1900, but none of them show 70–5 or 70–80 in the groin plus
femoral area. Instead, they show the proportion of femoral-inguinal
buboes varies between 48 and 68 per cent; in Mumbai in 1900, two
independent studies provide figures of 55 per cent and of 68 per cent.
Chun comments on the considerable difference between these figures:
“It may be that this discrepancy is due to the difference in the style of
dress adopted by Indians and northern Chinese,” and he goes on to
address this issue in considerable detail.19
Yersin’s impressionistic guesstimate and Butler’s small study of
Vietnamese cases which is explicitly characterized as an unrepresenta-
tive sample cannot be used for generalization, as Cohn appears to
assume; these studies do not provide alternative evidence which allows
one to neglect or ignore or override the statistical materials for Mumbai
and Hong Kong provided in the special standard works on plague
which also have in common that they are meticulously annotated. The
only statistically valid material Cohn refers to on p. 74 is also from the
infancy of modern medical plague research, namely, reports from
Mumbai’s plague hospitals for the plague year 1896–7, the first plague
year in India and Mumbai. In this study 58 per cent of the patients who
developed buboes had them in the groin or nearby femoral area, a fig-
ure which agrees with the data given by Pollitzer and Chun. Cohn’s
predilection for obsolete data and disassociation between argument
and data are typical features of his monograph.
The reason that buboes arise more frequently in the groin or nearby
femoral area than anywhere else on the body is not that a flea “can bite
no higher than just above the ankles” as Cohn asserts.20 However,
19
Chun 1936: 314–5.
20
Cohn 2002: 64.
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people can be bitten by fleas not only when they walk about or sit down
but also when they lie down to rest or sleep. This is the obvious reason
that plague buboes also develop on the upper part of the body and that
persons can develop two or more buboes at various locations of the
body. Plague buboes develop most commonly in the groin or femoral
area because the legs constitute a large part of the body’s surface and
because people can be bitten in the legs both during the day when
walking about or sitting down and also when lying down to rest or
sleep: legs have a twenty-four-hour exposure to flea bites, but the rest
of the body only around one-third of this time. Not only ethnic and
historical differences of clothing and footwear can affect the distribu-
tion of the location of buboes but also sleeping arrangements. For
this reason, contrary to what Cohn may seem to assume, variation in
the statistical distribution of the location of buboes is of little or mod-
est significance for identification of the disease or at least present
some stringent demands for empirical explanation. The crucial fact
remains that buboes as a regular manifestation of an epidemic disease,
according to present medical knowledge, are associated only with
bubonic plague. The causes of this fact will now be considered more
thoroughly.
Together with its numerous other functions, the skin protects the
human body from invasion, including by infectious agents. If the skin
is broken, infection may enter, but it will encounter the body’s first line
of defence against invasion, namely the lymphatic system. Most infec-
tions can under varying circumstances and by varying mechanisms
enter through abrasions or cuts in the skin and be drained through a
lymphatic tract to a lymph node and occasionally cause a swelling and
the development of a bubo. However, this means that infection by the
cutaneous route is dependent on the presence of a cut or abrasion in
the skin before exposure to contagion and that contagion accidentally
meets the skin exactly at the point where it is punctured, cut or broken.
These circumstances produce the typical pattern of rare, occasional or
episodic occurrence of buboes. Thus Twigg is certainly correct when
he states that “buboes may occur in other bacterial and viral diseases.”
Surprisingly, he goes on to maintain that this is “notably” the case
with “anthrax and small pox.”21 For this important assertion, he does
21
Twigg 1984: 36.
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not provide a supporting reference to any scholarly study, and it there-
fore unavoidably takes on the character of an arbitrary assertion.
The reason is probably that he advocates anthrax as an alternative
microbiological theory of historical plague and is concerned about the
conspicuous role of buboes as an ordinary clinical feature of epidemic
bubonic plague, a clinical criterion of identification that anthrax can-
not satisfy. This is not accidental, it is due to a crucial difference in the
modes of infection:
(1) in the case of bubonic plague, infection is transmitted by the bite
of infective flea(s) which combines puncturing of the skin with the
depositing of contagion at a subcutaneous level suitable for being
drained from the bite site through a lymphatic tract to a lymph node,
thus, the puncturing of the skin is a part of the process of transmission;
(2) in the case of anthrax, smallpox and other infectious diseases,
in order to produce buboes the contagion must by chance meet with
an accidental portal through the skin and then be moved by some
mechanism through the broken skin to a subcutaneous level suit-
able for being drained to a lymph node. These two points explain
that buboes can be a regular feature of plague and not of other infec-
tious diseases, specifically the anthrax and smallpox mentioned by
Twigg, although buboes can be a rare contingency in these diseases. In
epidemic form, anthrax is ordinarily contracted by the eating of
contaminated un(der)cooked flesh, while smallpox is transmitted by
inhalation of contaminated droplets. Since there are no lymph nodes
in the gastro-intestinal system or in the lungs, epidemics of these dis-
eases are not associated with buboes; instead other defensive functions
of the human immune apparatus are activated. Twigg significantly
and misleadingly understates the difference in the relative incidence
of buboes when he reduces it to buboes being “more regularly pres-
ent in bubonic plague than in any other disease.”22 If Twigg wishes
to maintain that anthrax or smallpox quite often present with buboes,
he cannot neglect to explain how these infections could be often—
or usually—transported from the normal site of introduction, the
gastro-intestinal tract or the lungs, to lymph nodes. In the case he
cannot find support in the medical literature for the frequent inci-
dence of buboes in cases of anthrax or small pox or other diseases
22
Twigg 1984: 36. See also Sallares 2007: 237.
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transmitted by similar mechanisms, together with a medical explana-
tion of how this could occur in any standard work on epidemic dis-
eases, he must obviously have a very poor case. The crucial fact remains
that bubonic plague is the only epidemic disease known by medical
science which presents with buboes as a normal feature of the clinical
panorama. This fact is based on hard evidence. For this reason, it must
be addressed by all advocates of alternative theories of the microbio-
logical nature of historical plague. In order to be viable theories,
they must contain specific empirical explanations for why infected per-
sons should regularly present with buboes; if not they are ipso facto
falsified.
A generally overlooked point of considerable importance is that
another disease is characterized by the development of buboes, namely
tularaemia. Tularaemia is a bacterial disease of wild rodents, especially
of beavers, hares, muskrats, rabbits and squirrels and is mainly con-
tracted by hunters. In Europe, this disease is associated with rabbits
and hares on the Continent, in the Nordic countries with hares and
lemmings, and is also called “lemming fever” or “hare pest.” In infected
persons, this disease presents in a number of ways dependent on the
route of infection: it may occasionally infect by ingestion of contami-
nated water and also of un(der)cooked meat or by inhalation. The main
form characterized by “fever and a bubo” is transmitted by ticks or
deer-flies, but hunters can occasionally also contract infection and
develop a bubo in the process of skinning sick animals if they have cuts
or abrasions in the skin of their hands.23 Helpfully, Butler presents the
clinical and epidemiological elements of bubonic plague and tularae-
mia in a table for immediate comparison and differentiation: tularae-
mia is easily distinguishable from bubonic plague according to a
number of criteria, for instance: (1) it is restricted to wilderness
and hunters (today occasionally also campers) and, thus, ordinarily
exhibits an endemic or episodic type of occurrence; (2) the course
of illness is “usually indolent and self-limited”; (3) the buboes are
normally located on the upper part of the body in the axillas or on the
neck (reflecting the position of ticks or deer-flies in the vegetation);
(4) the level of mortality is much lower, and so on. These two diseases
cannot be confused at the epidemiological level or at the level of clinical
23
Butler 1983: 90–1; Manson’s Tropical Disease 1982: 355–9.
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analysis. Since epidemics of bubonic plague definitionally spread in
human societies in sharp contrast to tularaemia, bubonic plague is
the only epidemic disease in human habitats, rural or urban, which is
characterized by the typical formation of buboes. Therefore, this fea-
ture constitutes a defining feature of bubonic plague.
Recent genetic research has also revealed that Yersinia pestis target
“lymph tissues during infection and carry a virulence plasmid, pCD1,
which is required for infection in these tissues, as well as to overcome
the hosts’ defence mechanism.”24 This contributes to explaining why
buboes constitute a predominating and definitional clinical feature of
bubonic plague.
An important fact should now be clear, which is that the only other
case of a disease characterized by the usual development of buboes is
directly associated with insect bites and bacterial infection. The crucial
point is that the development of buboes results from insect bites which
deposit contagion at a subcutaneous level which is then normally or
usually drained through a lymphatic tract to a lymph node. In such
diseases, and according to present medical knowledge only in such dis-
eases, the appearance of buboes is an ordinary or usual clinical feature
because it is systematically related to the mode of transmission of infec-
tion by insect bites. Bubonic plague and tularaemia have in common
the fact that they do not spread by interhuman cross-infection but are
transmitted by ectoparasites conveying contagion from rodents to
human beings.
It is of crucial significance in this context that for technical reasons
associated with the mode of transmission no disease spread by inter-
human cross-infection can be characterized by ordinary epidemic
occurrence of buboes. This corresponds completely and without excep-
tion with observed fact. Conspicuously, the advocates of alternative
theories make no attempt to explain how normal manifestation of
buboes should be physically realized in persons contracting the alter-
native type of epidemic disease they advocate. The fact that they pass
by in silence this crucial problem must be taken as an indication that
they are unable to provide reasonable medical explanation. Their
silence on this point constitutes therefore crucial evidence of the unten-
ability of their assertions and the incompatibility of their alternative
theories with this basic fact. All alternative theories of historical plague
24
Dongsheng, Yanping, Yajun, et al. 2004: 1229.
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based on microbiological contagion spread by cross-infection are ipso
facto invalid; this is the case with the alternative theories of Karlsson,
Morris, Scott and Duncan and Cohn. Karlsson and Morris who advo-
cate theories of primary pneumonic plague must ignore the obvious
fact that buboes are the most usual clinical feature mentioned by con-
temporaries from the Black Death to the last plague epidemics more
than 300 years later.
Davis, who recognizes the inherent danger, makes a disquieting
attempt at doing away with this problem by asserting that
Buboes can occur in cases of pneumonic transmission and cannot be
construed as proof of transmission by fleas that infest either rats or
humans.25
In support of this statement, he refers in the accompanying footnote
to an impressive number of works on plague, among them the fol-
lowing standard works: Wu Lien-Teh 1936b: 409, Hirst 1953: 29,
Pollitzer and Li 1943: 161/212–6.26 All of these fine works on plague
have in common that they do not contain anything that supports
Davis’s assertion, neither on the indicated pages nor elsewhere—they
are spurious references (who was the journal’s consultant?). Davis
leaves out the only standard work on primary pneumonic plague,
Wu Lien-Teh 1926. The reason is clear: no such case is mentioned.27
In this footnote, Davis goes on to refer also to historical plague
works, Biraben 1975: 73, 129, and Nohl 1961: 18. These works like-
wise contain no support for this assertion on the indicated pages, and
to anyone knowing these works it will be obvious that support is not to
be found anywhere else in them, and that these references are also spu-
rious. Davis does not attempt to explain medically how plague conta-
gion could spread from the lungs to the lymph nodes nor does he
explain how a non-episodic, regular pattern of incidence could occur.
All assertions to the effect that the epidemic occurrence of buboes is
associated with any other epidemic disease than bubonic plague are
untenable.
25
Davis 1986: 461.
26
The discrepancy in number of pages is due to my use of the version published in
Chinese Medical Journal 1943: 212–6, while Davis refers to a somewhat shorter version
published at the same time in Journal of Infectious Diseases 1943: 160–2.
27
Wu Lien-Teh 1926: 241–73.
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Contemporary Notions and Observations of Buboes (and
Associated Secondary Clinical Manifestations)
Sticker’s ambitiously broad account of all historical plague epidemics in
his old but impressive two-volume work on plague28 has inevitably
become partly obsolete at least in the sense of having become increas-
ingly incomplete as new research has been published. However, some-
what disappointingly it still provides more concrete information on
clinical features than any other history of plague, and as a physician
Sticker exhibits strong interest in medical or epidemiological concepts
and terminology. Having studied plague in India at the beginning of
the twentieth century and having contracted and survived plague, he is
in a unique position to put his seemingly boundless energy into good
scholarly use. His standard work will be supplemented from later works
in the following discussion.
“There was little appreciation that individual diseases were separa-
ble entities before 1600,” Slack states,29 I would rather say before 1550.
In his diary for the years 1550–72, Absalon PederssØn, the Norwegian
humanist, identifies a number of diseases with specific terms: plague
(“pestilence”), syphilis (“pocks”), small pox (“small pocks”), tuberculo-
sis (“consumption”), exanthematic typhus (“spotted fever” or “soldiers’
disease”), dysentery (“flux”) and leprosy (“[ho]spital disease”).30 This
development appears to be closely related to a growing recognition
from about 1510–20, associated with the Renaissance, of the conta-
giousness of epidemic diseases. In Norway and Denmark this develop-
ment is noticeable from the 1520s at the latest and was apparently
influenced by the University of Rostock and presumably other institu-
tions of learning in northern Germany where students of these coun-
tries often studied at the time.31 The famous pioneering physician
J. Fracastoro systematically discerned plague from exanthematic typhus
in Italy around 1530.32
28
Sticker 1908: 42–107.
29
Slack 1985: 25.
30
Benedictow 2002: 204. The term “[ho]spital disease” for leprosy in the Nordic
languages refers to the early establishment of particular hospitals for lepers in the High
Middle Ages. In English it may have a certain parallel in the contemporary term “la-
zarhouse disease.”
31
Benedictow 2002: 179–86.
32
Sticker 1908: 106; Ackerknecht 1963: 30.
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Against this background, it is a very noticeable fact that when the
subject is broached of how late medieval and early modern historical
plague disease presented to contemporaries, there is broad agreement
among scholars that one clinical manifestation in particular impressed
itself on their minds. From the beginning of the Black Death in the
Crimea and Constantinople, and as it spread all through Europe, con-
temporary commentators who generally had at best very confused
ideas about the nature of epidemic disease mention with conspicuous
regularity, if they present even minimal clinical detail, buboes as the
distinguishing clinical feature. This was also the case in connection
with plague epidemics in the following centuries. This clinical feature
impressed itself so strongly on contemporaries and distinguished this
disease so sharply from all other epidemic diseases ravaging contem-
porary populations that contemporaries from the very beginning con-
structed specifying designations or identifications of plague epidemics
which reflect the appearance of buboes as a conspicuous characteristic
and distinguishing clinical manifestation.33
The clinical manifestations which impressed themselves on contem-
poraries and led to the development of generalizing terminology can
be seen in Matteo Villani’s chronicle, for example, where he relates in
connection with the Black Death in Florence in 1348: “in most [of the
infected] there were growths in the groin, and with many in the pits
under the arms, under the right and the left, with others in other parts
of the body, so that almost generally some single swelling manifested
itself on the body of the infected.”34 Clearly, Villani was of the opinion
that buboes were a general and characteristic feature of the disease
which distinguished it from all other diseases known to him and his
contemporaries, and this is the basis of the generalizing terms which he
goes on to form. When he reverts to the subject in connection with the
second plague in Florence in 1362, he can avail himself of generalized
33
Cohn 2002: 63–4, 68–9, has also to some extent noted this development, but since
his aim of necessity is to reject the possibility that this proves that the disease was
bubonic plague, although he knows of no other disease characterized by this clinical
feature, his presentation becomes episodic and his discussion superficial and tenden-
tious. Of course, this development was not especially associated with Florence, it is his
narrow perspective that associates it with Florence and Italy.
34
Matteo Villani, Cronica 1995–1: 9: “e a’ piu ingrossava l’anguinaia, e a molti sotto
le ditella delle braccia a destra e a sinistra, e altari in alter parti del corpo, che quasi
generalmente alcuna enfiatura singulare nel corpo infetto si dimostrava.” My transla-
tion of the chronicle’s text. Cf. ibid.: 11.
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terms referring to buboes for identification of the disease and as the
same disease as the Black Death (see below). It is also noteworthy that
he gives main locations of buboes which are similar to those observed
in cases of modern bubonic plague.
These generalizing designations focus on buboes of the groin area
(in Latin inguen, in modern Italian “inguinàia” or “inguine”/ “inguinale,”
in contemporary northern Italian often slightly changed into
“anguinaia”/ “anguen”), or provide more generalized expressions of a
disease characterized by buboes, especially in the groin area, and great
mortality: “pestis inguinaria”35 (= inguinal pestilence, Modena 1348),36
glandular plague, “mortalité des boces”37 (= mortality of buboes,
Rheims 1349), “l’épidémie des boces” (Narbonne 1349),38 “sterffde van
den droesen” (= mortality of the buboes, Cologne 1350),39 or charac-
terized by “dolor ignitus in inguine” (= a fiery pain in the groin, France,
Paris).40
Cohn 2002: 64, cites three generalizing expressions “inguinarie,”
“pietolenzia dell’anguinaia” (= pestilence of the groin), and “mortalità
dell’anguinaia” which I have not mentioned above as associated with
“Florence after 1348.” In the accompanying footnote 51, Cohn refers to
Matteo Villani, Cronica con la continuazione di Filippo Villani 1995,
Volume 1: 273, 300, 514, 585–6, 660–1, 663. However, on these pages
nothing is said about plague or buboes—all of these page references are
erroneous. As we shall see, the second and third of the medical terms
for plague that Cohn cites are instead associated with the second vol-
ume of Matteo Villani’s chronicle and with the next plague epidemic in
Florence of 1362; the first term may be associated with the second
plague epidemic in Siena in 1363 and a different source (see below).
Cohn also asserts in this connection that the development of terms to
describe plague in connection with the Black Death which were
“derived from the boil’s position in the groin” took place “particularly
in Florence.” As we have seen this was not the case; this assertion
depends on false references to Matteo Villani’s chronicle and a narrow
35
Sticker 1908: 51, without specification of source.
36
Cohn 2002: 64.
37
Desportes 1977: 794.
38
Sticker 1908: 59. For his account of the Black Death in Narbonne, Sticker refers to
works which I have not had occasion to get hold of, namely Cayla 1906 and Martin
1859.
39
Sticker 1908: 75.
40
Littré 1840–1: 202, 232. Cf. Gasquet 1908: 40–1.
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Florentine or Tuscan perspective. Such terms arose in connection with
the Black Death elsewhere in northern Italy and also in France and
Germany and also in connection with subsequent plague epidemics
elsewhere, in Ireland, Belgium, and Russia.
In the subsequent plague epidemics, the use of generalized designa-
tions continued to be developed, strengthened and familiarized. Matteo
Villani comments on plague in Germany and Brabant in 1358 calling it
“pistolenzia dell’anguinaia” and mentions in another chapter “moria
dell’anguinaia” in Brabant which also spread to some areas in Italy, and
he refers to the second plague in England also with the characteristic
expression “pistolenzia dell’anguinaia.”41 Matteo Villani makes it clear
that the plague of 1362 was the same disease as the Black Death, calling
the first chapter on it “How the Mortality of the Groin Recommenced
in Various Parts of the World,”42 and after having used the expression
“mortality of the groin” in the chapter’s title, he goes on to state in the
first line of the text: “the mind-boggling disease of the groin recom-
menced this year, similar to that which had begun in 1348.”43 He reverts
to this plague epidemic later in his chronicle using in the chapter’s title
the expression “mortalità dell’angunaia” and in the opening text of the
chapter the expression “pistolenza dell’ anguinaia (= pestilence of the
groin area, Florence 1362).44
In the Necrology of the Dominican cemetery in Siena it is casually
written in the margin in 1363 when there is a huge increase in inter-
ments: mortalitas generalis inguinarie45 (= general inguinal mortality).
Also elsewhere in Europe such expressions or terms were developed
41
Matteo Villani Cronica 1995–2: 273, 300, 514.
42
“Come mortalitá dell’anguinaia ricominció in diverse parti del mondo,” my
translation.
43
“la moria mirabile dell’anguinaia in questo anno ricominciata, simile a quella
che prencipio ebbe nel MCCCXLVIII […],” my translation. Matteo Villani Cronica
1995–2: 448.
44
Matteo Villani Cronica 1995–2: 585–6, see also pages 660, 663. Cohn 2002: 138,
makes a free translation of the introductory passage, again showing, as pointed out by
Carmichael, a strange reluctance to use the word buboes, perhaps because of its strong
association with bubonic plague, instead translating the expression “pestilence of the
groin area,” with “pestilence of the glandular swellings” which ignores the original
text’s unambiguous association of the disease with the groin and indication that it was
characterized by clinical features associated with the groin.
45
I Necrologi di San Domenico in Camporegio 1937: 95. Written rather casually
in the margin of the necrology, which in this case is a burial register, this expression
indicates quite a widespread term and notion. Cohn erroneously includes this source
in his reference to the development of such terminology in post-Black Death Florence
(see above).
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to designate plague: disease of buboes or mortality of buboes (Russia
1360, 1387),46 pestis inguinaria (Cologne 1365),47 pestis glandium/
glancium (Ireland 1369), disease of buboes (Liège, “Belgium” 1370),48
infirmitas carbunculi et glandulae (= disease of carbuncles and glands,
Parma 1371),49 peste anguinaia (Florence 1449),50 and so on. The proc-
ess of familiarization with the specificity of bubonic plague can be
illustrated by Marchionne Stefani’s statement on the plague of 1374
which was to him the “usual pestilence of inguinal or axillary swell-
ings,” and in 1383 commented that the plague killed “in the same way
as the other mortalities, with that sign of great swelling under the arm
and over the leg at the groin.”51
Another related development is that bubonic plague was considered
such a conspicuously specific disease that a distinguishing term for this
disease was needed according to the medical notions of the time. First,
the term “epidemic” was employed for specific designation of bubonic
plague in order to distinguish it notionally and terminologically from
other contagious diseases which generally were called “pestilence” or
“pestilential.” The generalized expression “l’épidémie des boces” was
used in Narbonne to designate the Black Death in 1349,52 under the
influence, as it may seem, of the medical faculty of Montpellier. In Paris
physicians called the Black Death “épidémie,” as also was the case with
a chronicler discussing plague in the area around Trier in western
Germany (epidemia).53 This terminological development appears in
strengthened form when the plague in Hesse and Westphalia in 1371
was characterized by the term pestilentia epidemiarum54 = the epidem-
ics’ pestilence, implying that that plague was considered the essence of
epidemic disease, the highest and most dangerous refinement of mias-
matic poison, the King Death of epidemic diseases. A related term, pes-
tis epidemialis was used in Thuringia, especially in Frankfurt and
Eisenach.55 The link becomes obvious with the expression inguinaria
46
Sticker 1908: 76, 80.
47
Sticker 1908: 77.
48
Sticker 1908: 77.
49
Cohn 2002: 61.
50
Herlihy and Klapisch-Zuber 1978: 375.
51
Carmichael 1986: 11.
52
Sticker 1908: 59. The Black Death was recognized as present in Narbonne around
1 March 1349, Benedictow 2004: 101.
53
Sticker 1908: 60, 67.
54
Sticker 1908: 77.
55
Sticker 1908: 81.
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pestis seu epidemiae morbus = “inguinal pestilence or disease of epi-
demic” used to designate the plague which reigned in Wittenberg in
1535.56 Thus, logically the term “epidemie van die pestilentie”57 = “epi-
demic of pestilence” was developed, showing that “pestilence” could be
used as a specific term for bubonic plague, producing, therefore, a need
for another general term for contagious diseases, a role which was
increasingly filled by epidemia or “epidemic,” which has retained this
position to this day, while the form “pest” has retained its position as a
specific word for bubonic plague. In English, the word “plague” reflects the
fact that the English found another solution to the need for specificity
in the designation of this disease, taking this term slowly into specific
use as an Anglicized form of Latin plaga with the meaning of “a blow,”
which originally was a general term for a dangerous disease, a develop-
ment that was becoming pronounced by the late sixteenth century.58 In
a document of September 1349, Magnus Eriksson, King of Norway and
Sweden, used the word plaga to designate the Black Death.59
This perception of plague as dominated by buboes did not start with
the Black Death; it has been a consistent feature of how people of the
past perceived plague and what really characterized the disease, besides
the exceptional mortality. Twigg rejects the fact that Gregory of Tours
uses the term lues inguinaria = “disease of the groin” to designate the
first plague epidemic of the Justinianic pandemic of 541–76660 which
spread over southern France and conquered Old Gaul in the years
543–4.61 However, he does not point out any alternative specific disease
which could fit this clinical descriptive term, presumably because every
specification easily could be rejected by anyone knowledgeable of epi-
demic disease or with access to a standard textbook on epidemic dis-
eases. Since small pox (variola maior) was probably not present in
Europe at the time or for a long time to come,62 the alternative Twigg
has in mind would have to be anthrax. Any reader interested in the
matter is encouraged to look up anthrax (or smallpox) in any standard
work on epidemic disease and see whether buboes are mentioned at all
or as more than episodic individual occurrences that would never give
56
Sticker 1908: 92.
57
Sticker 1908: 99.
58
Slack 1985: 64–5.
59
Benedictow 2002: 22, 96–7; Benedictow 2004: 152, 160, 171–2.
60
Twigg 1984: 35–6.
61
Simpson 1905: 15; Sticker 1908: 30: Little 2007: 11.
62
Cartwright 1977: 76–7; Greenwood 1935: 227; Copeman 1960: 127–8.
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rise to a generalized designation of the disease as involving this symp-
tom. Twigg ignores the accounts of the violent plague epidemics in
Constantinople given by the Byzantine physician Procopius which
contain quite detailed clinical information on buboes,63 for instance:
“On a sudden they became feverish […] in some cases, on the same
day, in others on the next, in others in a few days after there arose a
bubo, not merely on what is called the groin, but under the armpit; in
some cases the bubo appeared behind the ears and in other parts.”64
Also in this pandemic of plague, similar generalized terms referring
directly to the ordinary occurrence of buboes as a characteristic clini-
cal feature of the epidemics are in frequent use: inguinarium (550),
inguinarium morbum, fever with buboes, glandulae (561), morbus
inguinarius (582), clades65 inguinaria, pestis inguinaria (589), lues ingui-
naria (591), pestis inguinaria (599), clades glandolaria (600), and so
on,66 which about exhausts the potential of Latin for forming clear des-
ignations of a disease characterized by the formation of buboes, espe-
cially in the groin and nearby femoral area. Buboes in the axillas or on
the neck are also specifically noted quite often.67
Recently, M.G. Morony has supplemented and corroborated this
with information from Syriac sources on the Justianic pandemic focus-
ing on epidemics specified by the use of the clinical term “sharcūṭā”
“which refers both to the swellings or tumors and to the disease itself,”
and the term “mawtānā de sharcūṭā” meaning epidemic of tumors.68
Also the corresponding Arabic term “ṭācūn” is used in this meaning.
The terms (“mawtānā de) sharcūṭā” or “ṭācūn” were used to designate
the first plague epidemic of 541–4, next in connection with epidem-
ics of 562, 573–4, 600, 639, 686–7, 698–9, 713, 744–5.69 One should
note that a plague focus running in quite a broad territorial band from
the Persian Gulf up to eastern Syria and south-western Turkey was
established at the latest during the Justinianic pandemic and would
give rise to local outbreaks of plague.70
63
See, for instance, Simpson 1905: 6–14.
64
Cited after Simpson 1905: 7–8. Cf. Little 2007: 8–9.
65
The word clades here has the meaning of “mortality”; it usually has the related
meaning of military losses.
66
Sticker 1908: 31–4; Simpson 1905: 15–16.
67
Ibid.
68
Morony 2007: 61.
69
Morony 2007: 61, 65–6, 70, 73, 76.
70
See for instance Benedictow 2004: 37–40, 44–8.
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By now, quite a number of scholarly studies on this pandemic pro-
vide ample material for the identification of the disease as bubonic
plague.71 Importantly, new developments in paleomolecular analysis of
DNA have in recent years given rise to several papers reporting recla-
mation of DNA of Yersinia pestis from skeletal remains of the time of
the Justinianic pandemic a.d. 541–766, from the second half of the
sixth century or later, from Sens in northern France, Aschheim near
Munich in Upper Bavaria and from Vienna,72 providing independent
and substantial, even decisive evidence to the effect that Gregory of
Tours’s use of the term lues inguinaria, disease of the groin, refers to
bubonic plague.
The tendency towards generalized designation of the epidemics with
reference to buboes is reflected in numerous accounts or descriptions
of buboes from the very beginning of the Black Death to the final par-
oxysm of plague in southern France in 1720–2. When the inhabitants
of the north-eastern French city of Rheims in 1349 use the term “mor-
talité des boces” (= mortality of buboes) to designate the Black Death,
the reason must be that plague cases in this city conspicuously and
ordinarily presented with this clinical feature. This is corroborated by a
list established in order to register by name, approximate age, and social
status persons who had been miraculously healed from plague disease
by prayer to St Remi, in which list some of the entries include some
basic clinical description as proof that the disease really was plague. A
mother declared to have seen her small boy be healed from three
buboes, two buboes in the groin (area), and one in an axilla; at the time
of Ascension Day (21 May), a young girl first had a bubo under her
arm, and then a second bubo appeared on her neck; a married man had
an enormous bubo on his neck 17 July; Jehan de Blanzy, a man of some
learning, related that his wife’s disease began with strong fever, next
buboes appeared in the groin (area) and her condition began to improve
29 July after intercessory prayer to St Remi had been said. The local
canon and poet Guillaume de Machet emphasizes buboes as the distin-
guishing feature of the disease. All information about the locations of
buboes on the body is consistent with modern bubonic plague. Thus,
not only the general terminology but also all the individual pieces of
clinical information provided by contemporaries are consistent with
71
See for instance Russell 1968; Biraben and Le Goff 1969; Allen 1997; Keys 1999;
Sarris 2000.
72
See below: 389–90.
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bubonic plague—only with bubonic plague and with no other disease.
This is also the case with the seasonality of the epidemic in Rheims,
arriving in the autumn of 1348, being suppressed by cold winter
weather, developing rapidly with the advent of warmer spring weather,
and fading away in the autumn.73
Correspondingly, the inhabitants of Narbonne not only used the
generalized term of an epidemic of buboes (“l’épidémie des boces”) but
also used more individualized clinical information to the effect that
plague cases started abruptly with fever and headache and then devel-
oped buboes in the groin (area) and in the axillas,74 again a description
which is entirely compatible with modern bubonic plague both with
respect to the start of illness, the typical early symptoms of high fever
and severe headache, and the development of buboes and their loca-
tion.75 In Strassbourg a local chronicler relates that all victims died
from buboes or (enlarged) glands which swelled under the arms or
high up on the legs, and when the bubo appeared, they died on the
second, third or fourth day.76 When Dubois concludes with respect to
the Black Death that “everywhere in France, the plague has taken on
the bubonic form with secondary manifestations,” he has a solid empir-
ical foundation for this summary of the evidence.77
In “Germany” it is stated in the Upper Palatinate (Ober Pfalz) that
persons developed a bubo and died on the third day, and in Cologne
there was a “great mortality from the buboes.”78 In addition to the pres-
entation of more generalized terms and expressions used by contempo-
rary Florentines, it can be mentioned that in the north-eastern Italian
provinces of Friuli and Istria the diseased generally presented with
three main clinical manifestations “in glantia (= in the glands), carbun-
cle et sputo sanguinis (= carbuncle and bloody expectoration).”79
Carbuncles are a normal part of the clinical panorama of modern
bubonic plague: they may either develop at the bite site as a local infec-
tion caused by remaining plague bacteria, often called primary plague
73
Desportes 1977: 794–9. Cf. Dubois 1988: 320.
74
Sticker 1908: 59.
75
Simpson 1905: 263; Chun 1936a: 310; Pollitzer 1954: 411; Butler 1983: 73.
76
Sticker 1908: 67.
77
Dubois 1988: 316. My translation from French. With the term secondary mani-
festations he has probably in mind bloody expectoration in cases of secondary
pneumonia.
78
Sticker 1908: 75. My translation from contemporary German: “groß sterffde van
den droesen.”
79
Sticker 1908: 50.
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carbuncles, or may, like pustules, be due to an invasion of the skin
through the blood-stream, and may, thus, be considered secondary and
consequent upon the development of septicaemia.80 Carbuncles as a
usual clinical feature of an epidemic disease cannot be associated or
explained by any of the alternative theories, although they occur epi-
sodically in relation to anthrax in cases where contagion is contracted
through abrasions in the skin. As a usual clinical feature carbuncles
could probably represent a defining feature or a very strong indication
of the nature of the disease as bubonic plague. This explains why car-
buncles are not entered as a clinical feature of any epidemic disease in
the indices of general textbooks on epidemic diseases,81 in contrast to
the standard works on (bubonic) plague where this is an ordinary
entry.82
In his historical presentation of plague, Sticker cites a great number
of historical sources in which buboes are mentioned, often with speci-
fication of locations on the body, that buboes were associated with
sharp intense pain, and other clinical manifestations that are consistent
with modern bubonic plague: severe headache, spitting of blood, rapid
course and brief duration of illness, and so on. For sceptics it can be
mentioned that, in the case of the pandemic that started with the Black
Death and petered out in the seventeenth century and ended (except
in Eastern Europe) at the beginning of the eighteenth century with a
couple of explosive outbreaks, Sticker provides such information in the
first volume for the Black Death on pages 45, 47, 49–54, 57–60, 64, 65,
67–8, covering most of Europe, from Kaffa on the Crimea and
Constantinople to Northern Germany and Poland, but misses out
England (see below). For the next wave of plague epidemics of 1361–5,
see pages 76–7, also with great geographical distribution, for the third
wave of 1368–71, see page 77, and so on through the centuries. The
total amount of evidence is massive.
80
Pollitzer 1954: 206, 425.
81
See, for instance, Manson’s Tropical Diseases 1982, Jawetz, Melnick and Adelberg
1982, with their indices.
82
Usually carbuncles are associated with boils or abscesses caused by yellow staphy-
lococci and have an individual type of occurrence. The cutaneous type of anthrax may
develop into carbuncle-like forms, but will be closely associated with a few occupations
using wool or hides where workers with abrasions on their hand will be exposed to
infection by the cutaneous route. Carbuncles with this background are for obvious
reasons unlikely to appear in epidemic form or to assume the character of a usual clini-
cal feature. See also below: 556–8.
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British chroniclers and other contemporary observers and commen-
tators provide little clinical detail on the Black Death, however, when
they do, it is consistently compatible with bubonic plague. The most
informative chronicler is the Irish friar John Clyn of the monastery of
Kilkenny:
[…] many died of boils and abscesses, and pustules on their shins [= legs]
and under their armpits; others frantic with pain in their head, and
others spitting blood […].83
As can be seen, John Clyn refers to buboes (boils), and specifies the
characteristic and usual locations on the legs and under the armpits.
However, the friar is perhaps shy when it comes to identifying the sex-
ually sensitive area of the groin and the nearby femoral area, but feels
free to specify the location in the armpits. The excruciating headache
which tends to drive people out of their minds is also a characteristic
accompanying clinical feature of bubonic plague.84 John Clyn’s obser-
vation that some died spitting blood cannot be taken as evidence to the
effect that the Black Death was an epidemic of primary pneumonic
plague as asserted by Morris (see below). The strongly restricted refer-
ence to the occurrence of cases with bloody expectoration, i.e., the fact
that only some developed this feature, indicates clearly the normal pro-
portion of plague cases which develops secondary pneumonic plague
in epidemics of bubonic plague. The friar also mentions abscesses and
carbuncles,85 and he mentions pustules which are quite a usual cutane-
ous manifestation.86 This account contains, then, a good description
(for the time) of an epidemic of bubonic plague, and is thus a good
source on the medical and epidemiological character of the Black
Death in England.
Other accounts and descriptions are compatible with John Clyn’s but
contain fewer details. Galfrid le Baker states, for instance:
Swellings suddenly breaking out in various parts of the body, racked the
sick. So hard and dry were they that, when cut, scarcely any fluid matter
83
Hirst 1953: 13.
84
Simpson 1905: 263; Chun 1936a: 310; Pollitzer 1954: 411; Butler 1983: 73;
Benedictow 2002: 208, where two cases in the epidemic in Bergen of 1565–6 are
described in Absalon Pederssøn’s diary: “A man was ill with pestilence, he raged, he
stood up in his rage and ran to L. Lundegaard where he drowned himself.” A clergyman
of one of the Hanseatic congregations in Bergen died in the plague “and raged some-
what in his head in his illness.” My translations from contemporary Norwegian.
85
Pollitzer 1954: 424.
86
Pollitzer 1954: 427. See below: 557.
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