TARRANT COUNTY PHYSICIAN (31)
themselves to the sick for providing them
with some form of care.
The Roman Empire later became
stretched financially by excessive
warfare, rapid emperor turnover,
and increased civil wars. Rome was
eventually sacked by invading Visigoths
in 410, and the last western emperor
was deposed in 476 A.D.
The Eastern branch of the Roman
Empire was then established with
Constantinople as the capital of what
was to become the Byzantine Empire. A
different type of plague appeared in 541
A.D. during the Emperor Justinian’s rule
in Constantinople. Justinian (527- 565
A.D.) is known for military campaigns,
civil law reforms (he wrote Codex
Justinianeus), and for creating important
buildings (Hagia Sophia in 562 A.D.).
It has been claimed that this plague
caused the loss of up to one-third of the
total Mediterranean population. It may
have presented in recurrent intermittent
waves that, lasted up to 200 years. It
has also been suggested that it led to
the waning of the Roman Empire and the
advent of the Middle Ages.11
The historian Procopius (500 - 565
A.D.) described the appearance of
this plague in Pelusium, Egypt, on the
Eastern Nile, and its spread to Alexandria
and later to Constantinople, Asia Minor,
and the Middle East.
Procopius observed subjects with
fever. They had “large painful swellings”
in groins, armpits, and neck followed
by delirium, black blisters, and
vomiting, which frequently led to death.
Occasionally, he noted, “The lumps
start draining pus, the fever subsides,
and the person sometimes may even
recover.” There were similar reports from
other observers at that time, like John of
We know now that rats carrying fleas
were brought in by ships supplying grain
from Africa to Constantinople. Bubonic
plague’s causative organism, Yersinia
After Jenner published his spectacular
results with vaccination in 1798,
smallpox immunization was eventually
adopted all over the world and the
disease was completely eradicated by
Prevention of social gatherings
was applied during the severe 1918
flu pandemic with measures such
as closures of schools, shops, and
restaurants, mandated social distancing,
and home quarantining when needed.
In cities in which these multiple
recommendations were implemented
earlier and kept in place, transmission
of disease and mortality were reduced.
This beneficial result demonstrates that
avoidance of contact between individuals
can be helpful in controlling transmission
of highly contagious disease, which is
why this approach is being used for the
management of the COVID-19 virus.
1RMorkot-HistAtlas Ancient Greece-
Penguin 1stEd 1996
2D Kagan - The Peloponnesian War -
3VHanson-A War Like No Other-
Epidemics in Roman Empire
5RLittman-The plague of Athens.
Epidemiol and Paleopathology.
6HippocraticWritings:The natureof man
7Euripides TheTrojan women Signet classic 1998
8GKohn; Encyclopedia of Plague and
9LMordechai-The Justinian Plague An
Inconsequential Pandemic? PNAS 116-5125546
10D Wagner - Yersinia Pestis and the Plague -
Genomic Analysis Lancet 14 April 2014
11Bassareo - Learning from the past in Covid-19
Era - Post Grad Med J 114:633
1Souza, Philip De, The Peloponnesian War, 431-
404 BC., (Oxford: Osprey, 2002).
pestis, has been isolated and its DNA
sequenced.10 This was obtained from
tombs in sixth century Bavaria. It was
found to represent a distinct genetic
lineage originating from a different rodent
reservoir for this pandemic than the one
occurring in medieval Europe.
A recent detailed research paper
by a multidisciplinary group questions
the Justinian plague as being such
a watershed event in history.9 After
examining a series of independent fields
of study such as papyri, inscriptions,
and coins as well as pollen and burial
sites, the authors conclude there is little
evidence that the Justinian plague was
a major driver of demographic change
in the sixth century Mediterranean area.
These findings indicate this plague
was therefore very different from the
devastating second pandemic that
presented later in the Middle Ages.
We have learned that two ancient
pandemics, the Athenian plague in
early Greece and the Antonine plague
in early Rome, appeared in cities with
overcrowded populations. Their disease
presentation at the time indicated
exposure to a highly infectious, rapidly
spreading agent that caused an acute,
devastating disease of high mortality.
Both epidemics had similar clinical
presentation, in which fever and mucosal
and pustular skin lesions predominated.
We know now that they most likely
represented smallpox, and this disease
became airborne from mucosal lesions
but could also spread by contact of skin
ulcerations. It affected people of all social
classes, including leaders and emperors.
Such a contagious disease would have
made patient care very risky and difficult.
No wonder the corpses piled up on the
streets of Athens!
Smallpox ravaged the entire world.
It reached the Americas, including the
U.S. and Mexico during colonial times. It
decimated the Aztecs when the Spanish
conquistadors arrived in Tenochtitlan, as
the Aztecs had no previous exposure to