October 22, 2014
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Plagues throughout history and the doctors who treated them: Part 1

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With the Ebola crisis in full swing (again), it seems like a good time to review the history of the physician’s responses to various “plagues” throughout history.

All practicing physicians take an oath that, in part, requires the physician to essentially do all they can to help with the suffering of their patients and, in the process, to do no harm. And while it is human nature to stay out of harm’s way, history is replete with examples of physicians who consciously place themselves in great danger for the benefit of their patients, with the courage fitting of the Medal of Honor.

Depending on the context, a “plague” can be a disease, or it may be a calamity of any type that rises to the definition of something that results in the severe detriment to an entire population, such as natural disasters. In Biblical terms, this may include the great flood of the Old Testament. But, for the most part, we will stick to disasters related to diseases. Perhaps in subsequent continuations, we might review the Katrina disaster of 2005 and its effect on the population, including the medical providers. A review of the diseases of human history can include Yellow Fever, Smallpox, measles, polio and HIV. But, we will begin with the original “plague.”

Beginning of the plague

Perhaps no disease has had more impact on human history than “the plague” (aka the Bubonic Plague, Black Death, Black Plague); an infectious disease caused by Yersinia pestis, a Gram-negative bacillus that is transmitted by the bite of the flea, causing either sepsis, suppurative adenitis (bubonic) or the less common pneumonic form, which can be responsible for person-to-person transmission via bacteria-laden secretions. The organism was first isolated by Alexandre Yersin in1894 during an epidemic in Hong Kong; Yersin also showed that the rodent is responsible for its spread. However, long before that discovery, there may have been Biblical references to the plague as far back as 1,000 years BC, by a reference to the Philistines being afflicted by a “plague of mice” that followed them wherever they traveled after seizing the Ark of the Covenant from the Israelites. This unwelcome partner apparently inspired them to return the Ark to the Levites, thinking this plague was their punishment. Obviously, direct evidence for this story is lacking, but what appears to be fact is that the plague appeared to emerge in Ethiopia around 430 BC, from where it spread through Egypt, Libya and Greece. Little is known about the physicians of this time, and how they dealt with the plague.

Fast-forward to the second century AD, when “a pestilence” occurred in Rome. Galen, the most prominent Greek physician of the Roman Empire at that time, described certain features of the epidemic, but with insufficient detail to know what the disease was with certainty. Many believed it to be the plague, but it may have been smallpox, or both at different times. Whatever it was, the disease caused the death of about one-third of the population. Galen’s greatness and influence in the shaping of medical history is unquestioned — from experimental research in the areas of anatomy and surgery, to physiology and pharmacology. However, sometime during the course of the epidemic, he apparently joined others of wealth and prominence, including many of his patients, to flee the city in an attempt to escape the scourge.

The start of a pandemic

The next milestone came in 540, with an outbreak of the plague in Egypt, and a couple of years later found its way to Constantinople (present day Istanbul, Turkey). Looking backward, with the knowledge that rodents and their fleas are the host and means of transmission of the deadly bacteria, it is easy to see that the spread was along trade and shipping routes. But at the time, physicians having little to offer, the cause and treatment became the domain of mysticism, religion and superstition; blaming it on everything from the sins of the afflicted to bad thoughts, etc. In 543, a plague (the plague) devastated the Roman world, as described by Procopius, scholar and historian, who made a point that no one was immune. It attacked all equally, killing up to 10,000 per day in Constantinople. Bear in mind that no physician recorded the details of the outbreak, and the numbers may be greatly exaggerated, but he goes on to point out that half the population of Constantinople perished. There was such ignorance of the disease and associated hysteria that there was a widespread belief that one could acquire the disease by simply a look from the afflicted. The disease was viewed by many as a scourge of God, while some of the more learned attributed it to the certain alignment of the planets. This marked the beginning of the first pandemic, lasting several hundred years.

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Introduction of ‘plague doctors’

The second pandemic lasted from the 14th to the 19th century, originating in China and spreading via trade routes to Europe (the Silk Road), killing tens of millions of people. One of the noteworthy observations of this time was that the personal physician to King Louis XIII (Charles Delorme), became the first to advocate the use of protective clothing (1656) for physicians to wear when attending to plague patients, that included a beak-like mask over the face, a hat, full-length gown and gloves, leaving no exposed skin (much like what is currently being recommended for care of Ebola patients, except for the beak-like feature of the mask). The beak of this mask was supplied with an aromatic substance, thought to clean the air being breathed. The physician was also encouraged to smoke a pipe, as the smoke was thought to ward off the invisible cause. Some writers have been very critical of this odd-appearing “costume” as frightening to patients and serving no real purpose. However, anyone with any knowledge of infectious diseases and infection control knows that anything that covers the visitor is better than the usual clothing at protecting from the contagion. As in previous plague outbreaks, many of the “more learned” physicians were said to have left the city to the presumed safety of the countryside. There is little doubt that this was the case, leaving the people left in the population centers to rely on the services of less-skilled and less-educated practitioners, who happened to have no other options. However, it is highly likely that some of the better physicians stayed behind for the right reasons: to care for their patients. No doubt there were opportunists who filled the void, many of whom were not educated or experienced in the healing arts, but “cashed in” on the relatively lucrative practice of medicine during this time. So called “plague doctors” were actually commissioned at the taxpayers’ expense to take care of plague victims. These “physicians” were often revered as heroes because the times were so emotionally charged. Likewise, they were allowed by the church to perform autopsies (which had not been allowed up to this point) in an attempt to find the cause and cure. Of course, they failed at both and were subsequently found to be a waste of money, but not until many millions had died. And because of this, when history was written, the good guys got lumped in with the bad guys (the charlatans) by many historians who failed to recognize those physicians who did it for the right reason. But there is no question that some of the more reputable (wealthy) physicians “flew the coop” when the going got tough to save their own skin, and maybe I would have, too. A well-educated and trained physician is no good to anyone dead. At least, that was the reason being given.

Having made that point, if one could afford the care of a good physician, your chances of death might have actually been higher, as the treatments for plague, as well as just about everything else, was often phlebotomy (bloodletting) and potions containing mercury. The sicker you were, the more you were bled and the more mercury you got. But, who knew? This impotent approach to medical care continued into the 19th century. In spite of that, the plague became less of a problem, probably due to better living without such close proximity to the mice/rats and their fleas. During the worst of times, the hysteria spilled over to blaming many innocent people and other species, such as dogs and cats, for the plague. During the height of the plague in London, when the death rate was estimated to be as much as 50%, officials outlawed having dogs and cats. Retrospectively, it was noted that those who broke the law and kept their domestic dogs and cats had less plague than those who did not. When this association was made, and the rodent was recognized as associated with outbreaks, it became against the law to kill cats. Another example of cats not getting proper recognition.

‘Knowledge is power’

Sir Francis Bacon once said, “Knowledge is power” (1597), and knowing what causes a disease and how it is spread goes a long way to easing the fear of treating the afflicted patient. But imagine for a minute caring for a patient who is desperately ill with a disease of unknown cause that appears to be contagious. Then imagine that this disease has a mortality rate of up to 50%. It is my contention that there were unsung heroes who stayed on their job, attending to their patients, knowing that they might acquire the disease and knowing that if they did, they might die. In some ways, this is worse than war. At least in war you are fighting an enemy with the same fears as you, and you can see him, and you have a fighting chance. When you are dealing with invisible enemies — even if you could see them, you would not know how to kill them — you can only imagine the fear and anxiety that would cause. By the way, the treatment for the plague is Gentamicin and supportive care.

Next time we meet, we will review another “plague” of historical interest.

For more information:

Wilder A. History of Medicine. New Sharon, Main: New England Eclectic Publishing Co.; 1901.

Mathys F, Schreiber W. Infectio: Infectious Diseases in the History of Medicine. Basle, Switzerland:  Hoffmann-La Roche & Co.; 1987.