Dr. Brien’s Medical History Moment blog explores the varied origins of infectious disease. James H. Brien, DO, is from the Department of Infectious Diseases at McLane Children's Hospital, Baylor Scott & White Health, Texas A & M College of Medicine in Temple, Texas. He is also a member of the Infectious Diseases in Children Editorial Board and a long-time author of the print column What’s Your Diagnosis? seen in the same publication. Brien can be reached at: jhbrien@aol.com.

Plagues throughout history and the doctors who treated them: Part 1

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.