A History of Scarlet Fever: Beware of Ancient Greeks Bearing Diagnoses

Regular readers may notice that I have a favourite bacterium, that I post on more than any other. This bacterium is known as Streptococcus pyogenes. My interest stems not only from the interesting ways in which it evades and bamboozles the immune system. It also comes from the weird diversity of infections that it causes. Not to mention that it once tried to kill me, and that I now study it for a living to get REVENGE.
I've decided to explore the history of the diseases caused by this bacteria, and how our understanding of them have changed over time. So let's start right to the beginning, in Ancient Greece.

The year is 430 B.C. and Athens was in the grip of war with its rival city state, Sparta. The war had reached its second year. Their leader, Pericles, had realised early on that facing Spartans on the battlefield would be suicidal. 
Instead, he goaded them into attacking the city of Attica. When the Spartans took control of the city, they found it empty of people. They had all been evacuated to Athens, and whilst the Spartans had wasted their time securing the empty city of Attica, Pericles was pillaging unprotected spartan territory. Pericles strategy was a success, but there was one factor he didn't account for in his strategy. And this factor may have changed the outcome of the war. 

An epidemic that had been proliferating in Ethiopia and Egypt had reached Greece. It probably started out as a few isolated cases in the countryside. However, when Pericles evacuated the inhabitants of cities into Athens, this changed. The city rapidly became overcrowded, and soon it was the perfect incubator for this plague.

"...people in good health were all of a sudden attacked by violent heats in the head, and redness and inflammation in the eyes, the inward parts, such as the throat or tongue, becoming bloody and emitting an unnatural and fetid breath.

"These symptoms were followed by sneezing and hoarseness, after which the pain soon reached the chest, and produced a hard cough. When it fixed in the stomach, it upset it; and discharges of bile of every kind...

Those who were ill were often abandoned, as carers would themselves be at high risk from contagion.  Pericles himself was brought low by this disease. It had killed both of his sons, his wife, until eventually the plague killed him.
As the numbers of the dead increased, hundreds were piled into mass graves, whilst more were burned on funeral pyres.
The Spartan army, seeing the smoke from these pyres of Athens, pulled back. Whilst  unassailable against any human foe, they knew better than to attack an infested city.


It is because of the writings of Thucydides that we know so much about this plague. He was one of the first writers to describe events based on facts alone, without invoking supernatural entities, or warping events to make a moral point. His detailed descriptions of the plague have lead many to speculate on the disease that caused it.
In the original first draft of this post, I was going to suggest that it may have been caused by a strain of scarlet fever, as others have in the past. Whilst this may have been the case, it is not the only suspect. Others have concluded that it was caused by some variant of the Ebola virus, whilst many believe it to have been an epidemic typhus.
The "plague of Athens" is the "Jack the ripper" case for epidemiology. This plague may have caused Athens to lose the Peloponnesian war, and the outcome of this war itself is blamed for the decline of Greece as a major power in the ancient world. This plague occupies an important place in history. Yet we can only speculate on the disease that caused it. The diversity of the diseases blamed for the plague indicates the true reason for this mystery. Thucydides descriptions of this plague are woefully insufficient to diagnose what caused it. However, had one of his contemporaries been present, it might have.

 There had been schools of medicine in Greece for around two hundred years before Hippocrates was born. They borrowed from more ancient medical traditions in Egypt and Mesopotamia. These traditions were heavily based on superstition, with prayer to a divine entity forming a keystone of their treatment paradigm.
It was Hippocrates who changed this. Like Thucydides, he did not see the hands of the gods in every day events. He described diseases as natural phenomena, divorced from the supernatural. He and his students had a disciplined approach to medicine, which involved taking detailed observations on patients and their diseases.

During his life, and for some time afterwards he and his followers created the Hippocratic corpus, a collection of works and case studies that laid the foundation for modern medicine.
At sometime between 410-400 BC, the first in a series of works known simply as "Epidemics" were written. These consisted mostly of case studies, which contemporary physicians could use as reference to determine the prognosis for their patients.
Within these records, there is a description of an outbreak of a disease that caused a severe skin rash, along with a sore throat and fever. But these symptoms in themselves do not outright indicate that this was indeed scarlet fever. During this outbreaks, some of these patients experienced complications which are somewhat unique to Scarlet fever.

"in the most of them abscessed ended in suppurations, and there were great fallings off (sloughing) of the flesh, tendons, and bones;

The symptoms described here are very similar to necrotizing fasciitis
However, he descriptions written down in "epidemics" became the main reference for later generations of physicians when they described incidences of scarlet fever as they arose.
This legacy would persist for nearly two thousand years after. That is where I'll pick up the story in the next post

References
Books
Hippocrates Epidemics Part 2 - http://classics.mit.edu/Hippocrates/epidemics.2.ii.html

Journals

Rolleston, J. (1928). THE HISTORY OF SCARLET FEVER BMJ, 2 (3542), 926-929 DOI: 10.1136/bmj.2.3542.926

Descamps V, Aitken J, &; Lee MG (1994). Hippocrates on necrotising fasciitis. Lancet, 344 (8921) PMID: 7914656