Category Archives: medieval healing

Plague Spotting

Of all of the symptoms of plague, the ‘plague spots’ are the most problematic. For some reason historians (and others) have grabbed on to plague spots as a distinguishing characteristic to recognize images of the plague even though they are not an obligate symptom of plague.

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Absolutely NOT plague, but leprosy. James le Palmer, Omne bonum, British Library MS Royal 6E VI, vol 2, fol. 301rb. (Green, Walker-Meikle, Muller 2014; Jones 2016)

The image to the left is one of the most often misrepresented. This illustration of leprosy was discussed in the recent Medieval Globe issue by Green, Walker-Meikle, and Muller (2014). Lori Jones’ talk last month in Kalamazoo highlighted how metastatic these improperly identified images (including the one to the left) have become and how hard it is to correct them (or wipe them off the internet).

Skin spots vary among plague patients because they are a symptom of sepsis, an infection of the bloodstream, often advancing to full septic shock and death. The infectious agent doesn’t have to be plague, and in most cases it isn’t plague. It can be caused by any agent causing sepsis (and some conditions that are not infections at all). These spots can be variously described as hemorrhagic spots, disseminated intravascular coagulation (DIC), or purpura. A recently published case study of three lethal pneumonic plague cases from China in 2014 describes the spots like this:

“Because the basic lesion of plague is vascular endothelial cell injury, acute hemorrhagic and necrotic lesions, haemorrhage spots can be found all over the body in patient 1 at the final period of the disease, at the chest and abdomen in patient 2, but not in patient 3.”(Li et al, 2016)

Among the signs and symptoms listed in the case report for pneumonic plague patients 1 and patient 2 included DIC,  haemorhaggic spots and septic shock. As we would expect given the initial distribution of plague in the mammalian body, they also had “acute liver injury” and “acute kidney damage” along with, of course, pneumonia.  Patient 1 had very low platelets and both had delayed clotting time as expected in cases of blood leakage and clotting in the tissues causing the DIC and hemorrhagic spots.

The most important thing to remember about plague spots is that they are highly variable. Not everyone develops spots at all. When they do develop spots, they are most likely already in septic shock and are unlikely to be mobile, as the people in the above illustration obviously are.

These spots should not be confused with acral necrosis, also called gangrene,  which is the blackening and tissue death at the tips of the extremities (usually fingers and toes). This occurs when blood flow has been cut off from tissue in the extremities. In plague patients this would be due to clotting and/or vascular collapse in the extremities. Amputation is a common treatment for this condition. As with DIC, it happens in many medical conditions, perhaps most commonly today in diabetes mellitus.  Since this type of blackening of the fingers and especially toes would have been fairly common in cases of sepsis or even local infection in the extremities, it is unlikely to be the reason the second pandemic came to be called the Black Death much later.


Green, M., Walker-Meikle, K., & Muller, W. P. (2014). Diagnosis of a “Plague” Image: A Digital Cautionary Tale. The Medieval Globe, 1(1), 309–326.

Jones, L. (2016) “Is that Plague Image Really an Image of the Plague? Tackling the Digital Disconnect between Medieval Witnesses and Twenty-First Century Understandings of Epidemic Diseases in the Middle Ages” 51st International Congress on Medieval Studies, Kalamazoo, MI. Session 297.

Li, Y.-F., Li, D.-B., Shao, H.-S., Li, H.-J., & Han, Y.-D. (2016). Plague in China 2014—All sporadic case report of pneumonic plague. BMC Infectious Diseases, 16(1), 1–8.

National Library of Medicine, Disseminated intravascular coagulation (DIC), Medline Plus.

National Library of Medicine, Purpura, Medline Plus.

National Library of Medicine, Gangrene, Medline Plus.

Winter Reading


Well since spring is officially here, I guess I’m overdue in posting my winter reading. For being snowed in several weekends this winter, I think I must have done more hibernating than reading/work! My reading seemed to be all over the place and more than usual off-topic to be listed here. I shall try to do better this spring!

M.L. Cameron: Anglo-Saxon Medicine. Cambridge University Press, 2006.

Tim Clarkson. Strathclyde and the Anglo-Saxons in the Viking Age, Birlinn Books, 2014

Hamerow, H. (2004). Early Medieval Settlements: The Archaeology of Rural Communities in Northwest Europe, 400-900. Oxford University Press.

PhD Dissertations/Theses

Green, T. (2011). A Re-evaluation of the Evidence of Anglian-British Interaction in the Lincoln Region  (pp. 1–347). Trinity: University of Oxford.

Notable papers

Halsall, G. (2014). Two Worlds Become One: A ‘Counter-Intuitive’ View of the Roman Empire and “Germanic” Migration. German History, 32(4), 515–532. doi:10.1093/gerhis/ghu107

Faure, E. (2014). Malarial pathocoenosis: beneficial and deleterious interactions between malaria and other human diseases. Frontiers in Physiology, 5. doi:10.3389/fphys.2014.00441/abstract

Richard, V., Riehm, J. M., Herindrainy, P., Soanandrasana, R., Ratsitoharina, M., Rakotomanana, F., et al. (2015). Pneumonic Plague Outbreak, Northern Madagascar, 2011. Emerging Infectious Diseases, 21(1).

DeWitte, S. N. (2015). Bioarchaeology and the Ethics of Research Using Human Skeletal Remains.History Compass, 13(1), 10–19. doi:10.1111/hic3.12213

Gonzalez, R. J., Lane, M. C., Wagner, N. J., Weening, E. H., & Miller, V. L. (2015). Dissemination of a Highly Virulent Pathogen: Tracking The Early Events That Define Infection. PLoS Pathogens,11(1), e1004587. doi:10.1371/journal.ppat.1004587.s010

Wang, X., Liang, J., Xi, J., Yang, J., Wang, M., Tian, K., et al. (2014). Canis lupus familiaris involved in the transmission of pathogenic Yersinia spp. in China. Veterinary Microbiology172(1-2), 339–344. doi:10.1016/j.vetmic.2014.04.015

Singer, M., & Clair, S. (2003). Syndemics and public health: reconceptualizing disease in bio-social context. Medical Anthropology Quarterly, 17(4), 423–441.

Rock, M., Buntain, B. J.,Hatfield, J. M., & HallgrImsson, B. (2009). Animal–human connections, “‘one health,’” and the syndemic approach to prevention. Social Science & Medicine (1982), 68(6), 991–995. doi:10.1016/j.socscimed.2008.12.047

Ostrach, B., & Singer, M. (2013). Syndemics of War: Malnutrition-Infectious Disease Interactions and the Unintended Health Consequences of International War Policies.  Annals of Anthropological Practice, 36(2), 257–273. doi:10.1111/napa.12003

Contagion and Pestilence in Isidore of Seville’s Etymologies

Saint Isidore of Seville (c. 560–636). Bishop, confessor and Doctor of the Church. Altarpiece of Saint Isidore. 15th century. Diocesan Museum of Calatayud. Spain.

Before Isidore of Seville became the patron saint of the internet, he was known for over a thousand years as a font of knowledge.  Isidore was not an innovator; he was a master of synthesis. It is through Isidore that we have an orderly account of the learned knowledge of the Late Roman world.  He was conscious of the fact that he was saving information at risk of being lost.  His Etymologies, written in twenty sections between 621 and 636, was both the Latin dictionary and encyclopedia of the entire medieval period. Isidore is not always correct — there is a lot of sounds-like etymology– but his explanations were accepted throughout the medieval period. So, Isidore is an ideal source to gain an understanding of how modern terms like contagion and pestilence were defined from the early seventh century in the midst of the first plague pandemic.

From Book IV: On Acute Illnesses:

17. Pestilence is a contagion that as soon as it seizes on one person quickly spreads to many. It arises from corrupt air and maintains itself by penetrating the internal organs. Although this is generally caused by powers in air, it never occurs without the consent of God. 18. It is called pestilence (pestilentia) as if it were pastulentia, because it consumes (depascere, ppl. depastus) like fire, as Vergil, Aen. 5.683): The pestilence descends on the whole body*. Likewise contagion (contagium) is from ‘touching’ (contingere), because it contaminates anyone it touches. 19. The swellings (inguen) (ie. bubonic plague) are so called from their striking the groin (inguen). Pestilence is also called plague (lues), so called from destruction (labes) and distress (luctus), and is so violent that there is no time to anticipate life or death, but weakness comes suddenly together with death. (p. 110-111).

The general definition of both pestilence and contagion, along with their spellings in Latin, are recognizable to us today. The modern editors note that Vergil is using pestilence as a metaphor for the burning of a Trojan ship. It is on the origin or mechanism of pestilence where we differ. Isidore’s world understood medicine as a function of airs and humors, a topic for another time. He also writes of plague again in his On the Nature of Things, which was less influential than the Etymologies. In a later post I will look at what the Venerable Bede does with both the works of Isidore and Pliny in his own On the Nature of Things.

Inguen as the term for a swelling in the groin is the what draws my attention. Inguen is the root for the modern word inguinal; as in inguinal bubo.  Two of the most important European historians of the first pandemic, Gregory of Tours and Paul the Deacon, used the term inguinaria for the pandemic. Unfortunately, inguinaria is usually literally lost in translation. Rather than leaving inguinaria as the early medieval term for bubonic plague, it is usually translated as the less specific ‘plague’ or a little better ‘inguinal plague’. Even in the translation above, it is translated as swelling with the original word in parenthesis.

Bubo is likewise said to come from the Greek word for groin, boubon (βουβών), but I have not found a source to discuss its earliest use. Isidore does not discuss the term bubo or the Greek term boubon, presumably using inguen instead. Greek boubon translates into Latin as inguen, both meaning groin or swelling the groin. Ironically “inguinal bubo” then duplicates the same meaning. It would be interesting to know if boubon or bubonic is a word used for the first pandemic (541-c. 750) in the Eastern Roman empire.

One of the important inferences from the derivation of inguen/boubon is that it supports the groin as the primary site of early infection. So while buboes can be found in the axilla and neck, and there are other transmission routes, it was recognized from the beginning as a disease of the groin. This in turn supports fleas as the primary transmission vector, since as insects found on the floor most of the time, they usually bite on the legs resulting in an inguinal bubo.

Reference: Barney, SA, Lewis, WI, Beach, JA, and Berghof, O. (trans and ed). The Etymologies of Isidore of Seville. Cambridge, 2006.