107 Plague of Athens
The Greek historian Thucydides interrupts his history of the Peloponnesian War between Athens and Sparta to describe the following epidemic in 430 B.C.:
It was generally agreed that in respect of other ailments no season had ever been so healthy.
Previous diseases all turned off into the plague; and the rest of the people were attacked without exciting cause, and without warning, in perfect health. It began with violent sensations of heat in the head, and redness and burning in the eyes; internally, the throat and tongue were blood-red from the start, emitting an abnormal and malodorous breath. These symptoms developed into sneezing and hoarseness, and before long the trouble descended into the chest, attended by violent coughing. Whenever it settled in the heart, it upset that organ, and evacuations of bile ensued, of every kind for which the doctors have a name; these also together with great distress. Most patients suffered an attack of empty retching, inducing violent convulsions, in some cases soon after the abatement of the previous symptoms, in others much later. The body was neither unduly hot externally to the touch, nor yellowish in color, but flushed and livid, with an efflorescence of small blisters and sores. Internally, the heat was so intense that the victims could not endure the laying-on of even the lightest wraps and linens; indeed nothing would suffice but they must go naked, and a plunge into cold water would give the greatest relief. Many who were left unattended actually did this, jumping into wells, so unquenchable was the thirst which possessed them; but it was all the same, whether they drank much or little. The victims were attacked throughout by inability to rest and by sleeplessness. Throughout the height of the disease the body would not waste away but would hold out against the distress beyond all expectation. The majority succumbed to the internal heat before their strength was entirely exhausted, on the seventh or ninth day. Or else, if they survived, the plague would descend to the bowels, where severe lesions would form, together with an attack of uniformly fluid diarrhea which in most cases ended in death through exhaustion. Thus the malady that first settled in the head passed through the whole body, starting at the top. And if the patient recovered from the worst effects, symptoms appeared in the form of a seizure of the extremities: the private parts and the tips of the fingers and toes were attacked, and many survived with the loss of these, others with the loss of their eyes. Some rose from their beds with a total and immediate loss of memory, unable to recall their own names or to recognize their next of kin. (Text of Thucydides [book 2, chap. 49], trans. W. L. Page, 1953)Expanding rapidly in the early summer, the epidemic was far more lethal than others Thucydides had known, and he claimed that the novelty of this disease left Greek physicians powerless to deal with it. The epidemic was said to have begun in Africa, south of Ethiopia, spreading first to Egypt and Libya, then to Persia, then to Greece.
The stricken initially complained of “violent heat in the head,” coryza, swollen and inflamed eyes, throat, and tongue, proceeding to violent coughing. Then the victims usually began to vomit, the disease bringing on “all the vomits of bile to which physicians have ever given names.” Death claimed many of the sufferers in 7 to 9 days, a merciful end to wrenching convulsions, intense internal heat, and extreme thirst. Thucydides described an exanthem characterizing many cases: The skin, not hot to the touch, took on a livid color, inclining to red, and breaking out in pustules and ulcers. However, he did not offer clear comment about the distribution of the rash, thus permitting much disagreement in the literature.
Causing almost equal difficulty for medical observers today is Thucydides’ description of the behavior of sufferers, hurling themselves into wells and cisterns in order to assuage the “inner heat” and satisfy their thirst.
Thucydides does not identify any age group, sex, or socioeconomic category among those most at risk, rather emphasizing that the previously healthy were as likely to suffer and die as those previously debilitated by illness. He claims that 1,050 out of4,000 adult male soldiers perished of the Plague - a high mortality rate even if all were afflicted. Pericles, the great orator and leader of Athens, apparently perished from the sickness, but Thucydides and Socrates did not. Thucydides assumes that the disease was contagious, and no one has questioned that assumption.The epidemic lingered for 4 years in southern Greece, killing up to 25 percent of the population (if one accepts the highest mortality estimates). No subsequent epidemics in the Hellenic and Hellenistic Greek hegemony are comparable to this epidemic in magnitude. Because the epidemic, according to Thucydides and to many later historians of ancient Greece, was responsible for Athenian mili-
tary losses to Sparta, many have judged the Plague of Athens to be a “turning point” in the history of Western civilization.
Epidemiology and Etiology
Although many have speculated on causal questions surrounding the Plague of Athens and are convinced of their retrospective diagnoses, no consensus is likely to emerge. Fairly well supported arguments have advanced epidemic typhus, measles, and smallpox as candidates because all produce some of the dominant clinical and epidemiological features of Thucydides’ description. Less frequently, bubonic plague, ergotism, streptococcal diseases, and, most recently, tularemia have found scholarly proponents.
Epidemic Typhus (Rickettsial Infection)
The facts that (1) the Plague of Athens occurred during wartime, (2) the severe clinical course lasted 7 to 10 days, (3) the fever was accompanied by first respiratory, then gastrointestinal, complaints and finally delirium associated with a rash - all have led several physician-historians to a diagnosis of epidemic typhus.
Typhus is a louse-borne disease and severe cases could lead to circulatory collapse, accounting for the loss of distal extremities (fingers and toes) as well as damage to the optic nerve.Insofar as Thucydides mentions vision loss as well as loss of the use of the extremities among some survivors, William MacArthur (1954) and Harry Keil (1951) find more support for this diagnosis of the clinical symptoms than for that of smallpox. By contrast, Hans Zinsser, in his 1935 classic Rats, Lice, and History, was not persuaded that the description Thucydides offered bore any resemblance to the typhus that cost so many lives in the two world wars. Yet other clinicians, citing their clinical experiences in wartime, have been equally persuaded that the description of Thucydides does suggest typhus. J. C. F. Poole and A. J. Holladay (1982) have most recently summarized this older literature.
J. F. D. Shrewsbury (1950) argues against a diagnosis of typhus, pointing out that Thucydides made no mention of either cloudy mental state or depression, both among the symptoms most frequently reported to accompany typhus infection over the last 500 years. Shrewsbury emphasizes the generally good personal and domestic cleanliness of the ancient Greeks, in order to argue that they were not lousy and thus could not have transmitted typhus with such ease. Yet Keil has provided an extensive survey of the words for lice found in Greek texts of the fifth century B.C., which indicates that they were hardly uncommon. Even so, Shrewsbury argues that typhus is too mild a disease to have killed a quarter of those who fell ill, and consequently, he holds that some “virgin soil” epidemic of a viral nature was the more probable cause of the Plague of Athens.
Measles Virus
Indeed, Shrewsbury favored a diagnosis of measles, as did classicist D. L. Page (1953). Shrewsbury points to similar levels of mortality in the severe, virgin soil epidemics of measles in the Fiji Islands in 1876, where more than 25 percent of the native population died.
He considered the most significant passage in Thucydides to be the description of sufferers plunging themselves into cool water for relief. The Fiji Islanders displayed an identical behavior. Because even in the twentieth century, measles in adults could be malignant, causing severe diarrhea and pneumonia, he argued that the Plague of Athens may have been measles in its “pristine, virulent, early form,” not the “emasculated” modern virus. Page agrees that the Plague of Athens was measles, feeling that the clarity of Thucydides’ account was such that little support can be found in the text for other diagnoses; that is to say, Thucydides, although a layman, was not guilty of omitting crucial diagnostic details that medical contemporaries would have noted.Smallpox Virus
Robert J. Littman and M. L. Littman (1969), however, argue for smallpox as the disease called the Plague of Athens, on the basis of the specific terms used by Thucydides to describe the exanthem or rash of the infection in question. Using Page’s careful retranslation, the Littmans place emphasis on both the term φλvκταιvα( (“small blister” or “pustule”) and word ελκoς (“ulcer” or “sore”), and contend that the description could refer only to a vesicle-forming eruption. In other words, Thucydides’ description suggests a diagnosis of smallpox, because neither measles nor typhus typically forms vesicles in the exanthem. Moreover, the description hints strongly at the centrifugal spread of the rash, from face and trunk to extremities, again confirming a diagnosis of smallpox. The fact that Thucydides does not mention pockmarks among the survivors is found by the Littmans to be without import because they believed he was more concerned with the military impact of the disease than long-term effects on the survivors. In addition, the Littmans point to the absence of reference to pockmarking, even in some twentiethcentury medical accounts of smallpox.
Other Explanations
Edna Hooker (1958) has been the last scholar to incline toward a diagnosis of bubonic plague, although many scholars found this a popular diagnosis during the first third of the twentieth century. Littman and Littman, however, argue against the bubonic plague, dismissing any possibility that the terms Thucydides chose could refer to buboes (Iymphadenopathy associated with plague).
Another hypothesis, put forth by P. L. Salway and W. Dell (1955), suggests that ergotism, caused by fungal toxins in grain, explains the Plague of Athens even though Athenians rarely ate rye bread, the grain on which ergot usually grows. The occurrence of gangrene in extremities of victims who survived is, they maintain, an important symptom, which does not support the other diagnoses, but does support one of ergotism. John Wylie and Hugh Stubbs (1983) have provided a review of those infections with a wide host range that might have caused this level of human mortality 2,400 years ago, and thus they consider zoonoses other than plague and typhus. More recently, Alexander Langmuir and his colleagues (1985) have revived a pre-twentieth-century diagnosis of influenza virus, but emphasize that concurrent or subsequent staphylococcal infection could easily have created a “toxic shock” syndrome, with severe respiratory symptoms, bullous (or vesicular) skin infections, and violent gastrointestinal symptoms. As staphylococcal infection heightened the mortality from influenza in 1918, so a similar combination of viral and bacterial infection could explain the great Plague. On the other hand, Holladay (1986) takes issue with this latter explanation.
Methods of Historical Epidemiology
Study of the epidemic briefly described by Thucydides has inspired discussions of how diseases in the distant past can be identified, and thus discussions of the methods of historical epidemiology. There are three difficulties that emerge in the literature of the Plague of Athens that can and have presented themselves in other retrospective diagnostic efforts. First has to do with “virgin soil” epidemics. Although Thucydides only implies that all members of society were at risk of contracting the sickness, that no one was immune, and that immunity was conferred on the survivors of infection, he does specifically state that the disease was previously unknown to lay and medical Athenians. Some scholars hold that a new disease among a population immunologically virgin to the microorganism in question need display neither the expected seasonal onset characterizing the disease nor the case-fatality rates usually seen. Those who oppose this methodological stance hold that this principle of retrospective analysis calls into question all diagnostic precepts. Many assume that supramortality would cause a breakdown in normal nursing care and hygienic services, leading to excess mortality; therefore, they stress the need for distinguishing the socioeconomic effects of a virgin soil epidemic from discussions of the virulence of the disease or the immunologic vulnerability of the population.
The second difficulty pertains to the changing epidemiology (or even clinical presentation) of diseases over time and thus is a variation of what is called “virgin soil epidemics argument”: that infections of the past may have been caused by an organism known today but that the organism behaved quite differently in past individuals and populations. As Littman and Littman (1969) observed, “[A]s diseases adapt to new hosts under changing environments over the passage of years the symptomatology may change.” From a historical standpoint, this can be a particularly pessimistic argument, and, in fact, James Longrigg (1980) has disallowed the possibility of ever discovering the cause of the Plague on much these grounds: “Epidemic diseases inevitably become modified in the course of centuries of alternating widespread prevalence and quiescence and... symptoms can, in any case, vary considerably in accordance with diet.” Poole and Holladay (1979) go even further in denying any possible resemblance of the Plague of Athens to an infectious disease known in more recent times, whereas Langmuir and colleagues (1985) suggest that the discussion abandon altogether the hope for a one-to-one correspondence with a modern infectious disease and look instead to a physiological understanding of the processes involved.
The third difficulty focuses on the intent and fidelity of Thucydides’ account to actual events. Of the authors discussed in this essay, only Watson Williams (1957) argues that Thucydides himself might not have been terribly well informed about the epidemic, because he did not write his history until after 404 B.C., approximately 25 years after the epidemic had taken place. Williams further suggests that even if Thucydides wrote from notes or consulted one of the few physicians who survived (the account claims that most died early in the epidemic), individuals tended to believe that their own experience with an infection was characteristic of all those who suffered from it.
Most assume, however, that Thucydides’ account of the events lacks some crucial details from a modem point of view, but is otherwise accurate. Since Page’s review, which offers abundant detail that Thucydides was particularly well versed in medical terms and ideas, most have come to believe that the account was informed by contemporary medical knowledge. Longrigg (1980) argees, but skeptically considers the possibility that Thucydides “dramatically exploited [the Plague] for historiographical purposes.” On the other hand, Jody Rubin Pinault (1986), tracing an ancient legend that Hippocrates himself devised the successful remedy of building fires to combat the epidemic at Athens, argues that Thucydides’ “silence about this remarkable achievement of Hippocrates” is compelling evidence that he was not at all well versed about the Plague.
Clearly, discussions of the causes of the Plague of Athens form an important and instructive example of the study of the history of human infectious diseases. In addition, such a study reveals the many pitfalls connected with this type of integration and points to the need for still more sophisticated methods and techniques.
Ann G. Carmichael
Bibliography
Eby, Clifford H., and Harold D. Evjen. 1958. The plague at Athens: A new oar in muddied waters. Journal of the History of Medicine and the Allied Sciences 17:258—63.
Holladay, A. J. 1986. The Thucydides syndrome: Another view. New England Journal OfMedicine 315: 1170-3.
Hooker, Edna M. 1958. Buboes in Thucydides? Journal of Hellenic Studies 78: 84—8.
Keil, Harry. 1951. The louse in Greek antiquity, with comments on the diagnosis of the Athenian plague as recorded by Thucydides. Bulletin of the History of Medicine 25: 305-23.
Langmuir, Alexander D., et al. 1985. The Thucydides syndrome: A new hypothesis for the cause of the Plague of Athens. New England Journal of Medicine 313: 1027-30.
Littman, Robert J., and M. L. Littman. 1969. The Athenian plague: Smallpox. AmericanPhilosological Association, Proceedings 100: 261—73.
Longrigg, James. 1980. The great Plague of Athens. History OfScience 18: 209-25.
MacArthur, William P. 1954. The Athenian plague: A medical note. Classical Quarterly 48: 171—4.
Page, D. L. 1953. Thucydides: Description of the great plague at Athens. Classical Quarterly 47: 97-119.
Pinault, Jody Ruin. 1986. How Hippocrates cured the plague. Journal of the History of Medicine and Allied Sciences 41: 52-74.
Poole, J. C. E, and A. J. Holladay. 1979. Thucydides and the Plague of Athens. Classical Quarterly 29: 282-300.
1982. Thucydides and the plague: A footnote. Classical Quarterly 32 (new series): 235—6.
Salway, P. L., and W. Dell. 1955. Plague at Athens. Greece and Rome 2 (2nd ser.): 62-70.
Shrewsbury, J. F. D. 1950. The Plague of Athens. Bulletin of the History of Medicine 24: 1—25.
Williams, E. Watson. 1957. The sickness at Athens. Greece and Rome, 2d ser., 4: 98-103.
Wylie, John A. H., and Hugh W. Stubbs. 1983. The Plague of Athens: 430-28 B.C.: Epidemic and epizootic. Classical Quarterly 33: 6—11.