History The History of Plague – Part 1. The Three Great Pandemics John Frith Plague is an acute infectious disease caused by Pastorien and a French naval doctor, demonstrated the bacillus Yersinia pestis and is still endemic in that the Oriental rat flea was the vector for the indigenous rodent populations of South and North bacillus and the sources of the bacillus were the America, Africa and Central Asia. In epidemics sewer rats.3,4 plague is transmitted to humans by the bite of the Oriental or Indian rat flea and the human flea. The The germ, the rats, and the fleas primary hosts of the fleas are the black urban rat and Yersinia pestis is most likely a clone that evolved the brown sewer rat. Plague is also transmissible some 1,500 to 20,000 years ago from a common person to person when in its pneumonic form. ancestor with Yersinia pseudotuberculosis, an animal Yersinia pestis is a very pathogenic organism to both enteropathogen which does not cause blood infection humans and animals and before antibiotics had a or plague. The bacillus probably arose in Asia, very high mortality rate. Bubonic plague also has although it had been present in east-central Africa for military significance and is listed by the Centers the past two millennia and probably longer.2, 5 There for Disease Control and Prevention as a Category A are three biovars of the bacillus based on phenotypic 1 bioterrorism agent. differences, Antiqua, Medievalis, and Orientalis, and There have been three great world pandemics of it has been postulated that they were responsible for plague recorded, in 541, 1347, and 1894 CE, each the first, second and third pandemics respectively. time causing devastating mortality of people and A paleomicrobiological analysis by Drancourt et al animals across nations and continents. On more in 2004 however indicated that all three pandemics than one occasion plague irrevocably changed the were most likely caused by the Orientalis biovar.6, 7 social and economic fabric of society. There had also been debate for some time whether the In most human plague epidemics, infection initially Justinian and the Black Death plagues were actually took the form of large purulent abscesses of lymph due to Yersinia pestis and were not instead epidemic nodes, the bubo (L. bubo = ‘groin’, Gr. boubon = haemorrhagic fevers3,8. Analyses by Drancourt and ‘swelling in the groin’), this was bubonic plague. When others have found evidence of the plague bacillus bacteraemia followed, it caused haemorrhaging and in specimens of persons known to have died in necrosis of the skin rapidly followed by septicaemic the first two pandemics. It is also very difficult to shock and death, septicaemic plague. If the disease discount the vivid and accurate descriptions of the spread to the lung through the blood, it caused an bubonic plague that were given by historians such invariably fatal pneumonia, pneumonic plague, and as Procopius of Caesarea, Gabriel de Mussis and in that form plague was directly transmissible from Giovanni Boccaccio. person to person. The vector host in the Black Death pandemic was The three great plague pandemics had different Rattus rattus - the ‘old English’ or black rat. The geographic origins and paths of spread. The Justinian black rat originated in India and migrated along Plague of 541 started in central Africa and spread to the Silk Road from Asia to the Middle East, and Egypt and the Mediterranean. The Black Death of then travelled in ships on the sea trade routes, 1347 originated in Asia and spread to the Crimea settling in most areas of the world and cohabitating then Europe and Russia. The third pandemic, that comfortably with humans in their houses, factories, of 1894, originated in Yunnan, China, and spread to and dockyards. The black rat had probably acquired Hong Kong and India, then to the rest of the world.2 the disease from contact with infected wild rodents from the steppes of Central Asia and Russia, and The causative organism, Yersinia pestis, was not in fact the disease may have been transported in discovered until the 1894 pandemic and was infested marmot hides taken by Tartar hunters discovered in Hong Kong by a French Pastorien from Manchuria. The brown or sewer rat, Rattus bacteriologist, Alexandre Yersin. Four years later norvegicus, didn’t become prevalent in the Western in 1898 his successor, Paul-Louis Simond, a fellow world until the 18th century. It originated in Central Volume 20 Number 2; April 2012 Page 11 History Asia and migrated westward on the sea routes from regard to what they were doing. And China and India. The brown rat flourished in Europe the body showed no change from its where there were open sewers and ample breeding previous colour, nor was it hot as grounds and food and in the 18th and 19th centuries might be expected when attacked by a replaced the black rat as the main disease host.4, 9 fever, nor indeed did any inflammation set in, but the fever was of such a The primary vectors for transmission of the disease languid sort from its commencement from rats to humans were the Oriental or Indian and up till evening that neither to the rat flea, Xenopsylla cheopis, and the Northern sick themselves nor to a physician or European rat flea, Nosopsyllus fasciatus. The who touched them would it afford any human flea, Pulex irritans, and the dog and cat fleas, suspicion of danger. It was natural, Ctenocephalides canis and felis, were secondary therefore, that not one of those who had vectors. In the pandemics, the infected fleas were contracted the disease expected to die able to spread the plague over long distances as from it. But on the same day in some they were carried by rats and by humans travelling cases, in others on the following day, along trade routes at sea and overland, and also by and in the rest not many days later, a infesting rice and wheat grain, clothing, and trade bubonic swelling developed; and this merchandise. When infected, the proventriculus took place not only in the particular of the flea becomes blocked by a mass of bacteria. part of the body which is called boubon, The flea continues to feed, biting with increasing that is, “below the abdomen,” but also frequency and agitation, and in an attempt to relieve inside the armpit, and in some cases the obstruction the flea regurgitates the accumulated also beside the ears, and at different blood together with a mass of Yersinia pestis bacilli points on the thighs.”14 directly into the bloodstream of the host. The fleas multiply prolifically on their host and when the host The focus of the Justinian pandemic was dies they leave immediately, infesting new hosts and Constantinople, reaching a peak in the spring of 542 thus creating the foundations for an epidemic.10, 11 with 5,000 deaths per day in the city, although some estimates vary to 10,000 per day, and it went on The Justinian Plague of 541-544 to kill over a third of the city’s population. Victims The first great pandemic of bubonic plague were too numerous to be buried and were stacked where people were recorded as suffering from the high in the city’s churches and city wall towers, characteristic buboes and septicaemia was the their Christian doctrine preventing their disposal by Justinian Plague of 541 CE, named after Justinian cremation. Over the next three years plague raged I, the Roman emperor of the Byzantine Empire at through Italy, southern France, the Rhine valley and the time. The epidemic originated in Ethiopia in Iberia. The disease spread as far north as Denmark Africa and spread to Pelusium in Egypt in 540. It and west to Ireland, then further to Africa, the then spread west to Alexandria and east to Gaza, Middle East and Asia Minor. Between the years 542 Jerusalem and Antioch, then was carried on ships and 546 epidemics in Asia, Africa and Europe killed 15, 16 on the sea trading routes to both sides of the nearly 100 million people. Mediterranean, arriving in Constantinople (now The pandemic had a drastic effect and permanently Istanbul) in the autumn of 541.12, 13 changed the social fabric of the Western world. It The Byzantine court historian, Procopius of contributed to the demise of Justinian’s reign. Food Caesarea, in his work History of the Wars, described production was severely disrupted and an eight year people with fever, delirium and buboes He wrote that famine followed. The agrarian system of the empire the epidemic was one ‘by which the whole human was restructured to eventually become the three field race came near to be annihilated’. Procopius wrote feudal system. The social and economic disruption of the symptoms of the disease : caused by the pandemic marked the end of Roman rule and led to the birth of culturally distinctive “ ... with the majority it came about societal groups that later formed the nations of that they were seized by the disease medieval Europe.12 without becoming aware of what was coming either through a waking vision Further major outbreaks occurred throughout or a dream. ... They had a sudden fever, Europe and the Middle East over the next 200 some when just roused from sleep, years - in Constantinople in the years 573, 600, 698 others while walking about, and others and 747, in Iraq, Egypt and Syria in the years 669, while otherwise engaged, without any 683, 698, 713, 732 and 750 and Mesopotamia in 686 and 704. In 664 plague laid waste to Ireland, Page 12 Journal of Military and Veterans’ Health History and in England it came to be known as the Plague ensued from the septicaemia.