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Home , Bubonic plague, Plague (disease)

“The good and the bad dying indiscriminately”: The Athenian rec o n s i d e re d

Eric Michael David The author is a member of the Class This essay examines the merits of pre- Thucydides gives us a few more im- of 2002 at Columbia University viously off e red diagnoses, and con- portant clues. First, he notes that those College of Physicians and Surgeons. cludes by the suggestion of a diagnosis who visited the sick were certain to This paper won honorable mention in that has not been considered seriously contract the disease,1¶ 5 1 and that “mor- the 1999 Alpha Omega Alpha Student as the cause of the Athenian plague: tality among the doctors was the high- Essay Competition. . The manifestations of this est of all.”1¶ 4 7 This suggests that the disease conform extensively with those disease was spread through aero- As for the gods, it seemed to be the same described by Thucydides. solized particles from the or thing whether one worshipped them or t h rough contact with bodily secre t i o n s . not, when one saw the good and the bad The Thucydidean text Second, we learn that the afflicted were dying indiscriminately. often seen plunging themselves into In relating the pathogenesis of the water tanks in an effort to relieve their —Thucydides, History of the plague, Thucydides notes the follow- insatiable burning and thirst.1¶ 4 9 It fol- Peloponnesian Wa r 1¶ 5 3 ing symptoms: lows that the disease could have been 1 . burning feelings in the head i n t roduced into the city’s water supply n the second book of his History of in this manner. Finally, Thucydides the Peloponnesian Wa r, Thucydides 2 . red and inflamed eyes tells us that birds and were af- recounts a plague that stru c k I 3 . p a rched tongue and in fected as well.1¶ 5 0 Those animals seen Athens in 430 B.C. and lasted thre e the throat and mouth eating flesh died soon after do- years. Thucydides, rarely prone to ing so, and domesticated animals such histrionics in his writing, declared the 4 .m a l o d o rous bre a t h as dogs were also observed with the event a “catastrophe . . . so over- 5 . sneezing accompanied by hoarse- d i s e a s e .1 ¶ 5 0 N o w, familiarized with whelming that men, not knowing what ness of voice Thucydides’s account, we may exam- would happen next to them, became ine alternative diagnoses. i n d i ff e rent to every rule of religion or 6 . coughing and severe chest pain of law. ”1¶ 5 2 The Athenian plague is re- 7 .v o m i t i n g pestis g a rded as the most disastrous epi- demic of re c o rded ancient history, and 8 . g reat pain The clinical forms of with is viewed as one of the major factors include , 9 . i n e ffectual re t c h i n g contributing to the downfall of the an- , and pneu- cient Grecian empire .2 1 0 . reddish skin accompanied by a monic plague. All forms of the plague burning sensation exhibit an of two to Thucydides’s description of the eight days, approximately what one Athenian plague is widely viewed as 11 . small pustules and ulcers on the would expect for the Athenian plague. one of the first detailed accounts of the s k i n The bubonic form is the most common. pathogenesis and epidemiology of a 1 2 . an unquenchable thirst.1¶ 4 9 Bubonic plague and septicemic plague d i s e a s e .3 Over the past two centuries, a re improbable candidates because physicians and historians have pon- Most victims died by the seventh or they are transmitted only by , , d e red about the etiologic agent of this eighth day, and if they did not, were or contact with the tissue or dro p p i n g s epidemic. Two diagnoses have been soon afflicted with uncontrollable di- of infected or .6 T h e y most commonly accepted: and a r rhea that was followed by death.1¶ 4 9 a re not known to be transmitted by Yersinia pestis.4 M o re re c e n t l y, tu- Those who survived were marked by person-to-person contact or by the wa- l a remia, , and infection by ulcerations on the genitals, fingers, and terborne routes that are implied by influenza compounded by a staphylo- toes, sometimes leading to auto- Thucydides’s account. Indeed, al- coccal strain have been off e red as pos- . The disease was often ac- though rats are the most important sible agents.4 ,5 companied by s p a s m òn i s c u r ón, reservoir for all forms of plague,6 t h e f requently translated as “violent Pathogens can undergo dramatic mu- absence of a word for “” in classical spasms.” Since Thucydides only men- tations over the course of 2400 years. G reek has been taken as evidence that tions these spasms in conjunction with F rom our modern frame of re f e re n c e t h e re were no rats in classical A t h e n s .7 the coughing and ineffectual re t c h- and current knowledge, we can only In any case, it seems unlikely that a i n g ,1¶ 4 9 it can be assumed that these speculate about which diseases most keen observer such as Thucydides spasms were strong contractions of ab- closely resemble the Athenian plague. should fail to note the presence of rats. dominal muscles and the diaphragm Nevertheless, such an exercise enables that accompany the heavy coughing Bubonic plague is also characterized us to better understand the nature of and vomiting. There is no reason to in- by the enlargement of lymph glands. this plague, and to divine the way in t e r p ret these spasms as epileptic Thucydides, however, mentions only which , modern and classi- s e i z u res. f l u k t a i n a i s m i k r a i s k a i e l k x s i n cal, impact the course of history. “small ulcers and pustules.” It does not seem possible that either f l u k t a i n a i s

The Pharos /Spring 2000 1 or e l k x s i n would have been used to goencephalitis at the height of the ill- contact with urine, the chances describe the large buboes characteristic ness and can be severe .11 a re slim that such a mode of transmis- of bubonic plague when b o u b w n w a s sion would affect so many so quickly. T h e re are still other flaws associated the word commonly used in the fifth with typhus as a diagnosis: typhus, Wylie and Stubbs also suggested tu- century to indicate a large, swollen even under the most adverse circ u m- l a re m i a ,4 which can be dismissed be- l u m p .7 M o re o v e r, the use of the adjec- stances, is fatal in only 40 percent of all cause it carries a low mortality rate and tive m i k r a i s p rescribes that the blis- cases and cannot be transmitted p roduces skin lesions in only 20 per- ters were “small.” t h rough ingestion.9 M o re o v e r, typhus cent of all cases.1 4 These lesions are lo- In contrast to bubonic plague and sep- is not known to afflict animals other calized to the area of contact. A l t h o u g h ticemic plague, epidemic pneumonic than human beings, with the exception the disease is known to be contracted plague may be transmitted via person- of rats and the flying squirre l t h rough direct or indirect contact with to-person contact.6 Glaucomys volans of the southern a n i m a l s ,14 and affects a variety of ani- c o r responds to every symptom men- United States.9 mals, dogs are seemingly immune to it. tioned by Thucydides with the impor- Thucydides specifically mentions dogs Many of these flaws in the arg u m e n t tant exceptions of conjunctivitis, a as having been aff e c t e d .1¶ 5 0 that typhus was the Athenian plague burning sensation on the skin, and have been noted by previous authors, small ulcers and pustules.8 M o re o v e r, Influenza and staphylococcus but it has been emphasized that these within any single outbreak of Ye r s i n i a flaws do not rule out typhus as a diag- Influenza was first proposed as a cause p e s t i s, fewer than 35 percent of all cases nosis because the organism is known of the Athenian plague by L. Mercier in a re of the septicemic or pneumonic to mutate rapidly. While typhus in 1 9 7 4 .1 5 S u b s e q u e n t l y, A. D. Langmuir f o r m s .6 classical Athens would certainly have and colleagues suggested that the Typhus d i ff e red from modern typhus, such ar- “Thucydides Syndrome,” was an epi- guments based on are too demic of influenza closely followed by P e rhaps the most widely accepted speculative considering that there are staphylococcal .1 6 Both in- diagnosis of the Athenian plague has an infinite number of possible muta- fluenza and staphylococcus mutate been typhus. However, while many of tions. Why choose a disease that we r a p i d l y, and are capable of causing a the symptoms and signs of typhus are know does not fit all the symptoms, wide variety of manifestations. For this similar to those described by signs, and modes of transmission, and reason, it is impossible to argue against Thucydides (as well as having a com- then try to justify our choice by specu- the combination being the patible incubation period) it share s lating that the disease has mutated “Thucydides Syndrome” by attempt- with Yersinia pestis the lack of a drastically? Instead, we must searc h ing to cite symptoms or signs that in- generalized burning sensation and for a modern disease whose manifes- fection with one or both agents fails to ulcers or pustules of the skin.9 , 1 0 tations more closely parallel those of p roduce. Thucydides makes the point that the the Athenian plague. Influenza seems unlikely given that in- skin afflictions were common to every fluenza epidemics are known to be c a s e .1¶ 4 9 The burning and skin irrita- Leptospirosis and quite brief and do not last two to thre e tion was in fact so acute “that people A few attempts to identify the years as did the Athenian plague.1 7 could not bear the touch even of the Athenian plague as something other Indeed, the great influenza lightest linen clothing.”1¶ 4 9 In typhus, than typhus or Yersinia pestis h a v e of 1918, like other large-scale urban in- the rash, petechiae, and macu- been made in recent years. J.A.H. fluenza epidemics, lasted only six to lopapules may occur in any combina- Wylie and H. W. Stubbs have sug- ten weeks.1 8 Staphylococcal tion, but there is little discomfort gested leptospiro s i s ,5 a disease widely can be excluded because this bac- involved and these lesions appear in known for its renal and hepatic com- terium has never been known to cause fewer than 50 percent of all cases.9 ,1 0 plications. Thucydides makes no men- o u t b reaks of epidemic pro p o r t i o n .1 9 Also arguing against typhus is the fact tion of jaundice, the prominent sign Twenty to forty percent of the curre n t that Thucydides never mentions the common to fatal cases of leptospiro- world population are nasal carriers of dizziness, mental cloudiness, and con- s i s .1 2 F u r t h e r m o re, over 90 percent of staphylococcus, yet only a fraction of fusion seen in this disease. It seems un- cases of leptospirosis are mild.1 3 these carriers actually manifest infec- likely that he would have overlooked L e p t o s p i rosis is not known to pro d u c e t i o n s .1 9 these very prominent characteristics. the skin ulcers and pustules character- In the realm of mental disord e r s , istic of the Athenian plague. It may Melioidosis Thucydides makes note only of an am- p roduce a rash, but only in nine per- A rguments can be made that the nesia that occasionally appeare d cent of reported cases.1 3 Most cases are “Thucydides Syndrome” was caused among those on the path to re c o v- a c q u i red by contact with ro d e n t by tularemia, leptospirosis, typhus, or e r y.1¶ 5 1 The mental ailments of typhus, u r i n e .1 2 Though it is possible that the Yersinia pestis as long as one pre s u p- by contrast, tend to arise from menin- Athenian plague was spread thro u g h poses that extensive have

2 The Pharos /Spring 2000 o c c u r red in the organisms over the Thailand, for example, melioidosis ac- 1 7 3 5 – 3 7 . past 24 centuries. However, a far more counted for 19 percent of admissions 1 0 . Dumler JS, Walker DH. Murine ty- likely candidate for the plague at and 40 percent of deaths fro m phus. In: Mandell GL, Bennet JE, Dolin R, Athens is melioidosis, caused by the c o m m u n i t y - a c q u i red septicemia in a editors. Mandell, Douglas and Bennett’s gram-negative bacillus B u r k h o l d e r i a one-year period.2 0 With all the in- Principles and Practice of Infectious Dis- eases. Fourth edition. New York: Churc h i l l p s e u d o m a l l e i, a member of the genus vaders, prisoners, and country- Livingstone; 1995. pp. 1737–39. P s e u d o m o n a s. Patients with melioidosis dwellers descending on Athens during 11 . Duma RJ. Typhus . In: a re known to present with every symp- the early years of the Peloponnesian Hoeprich PD, Jordan MC, editors. Infec- tom mentioned: high (usually in Wars and living “during the hot season tious Diseases: A Modern Treatise of Infec- excess of 102 degrees Fahrenheit), con- in badly ventilated huts,”1¶ 5 2 it is pos- tious Processes. Philadelphia (Pa.): J. B. junctivitis, parched tongue and ex- sible that a bacterium brought in by a Lippincott; 1989. pp. 970–76. t reme thirst, bleeding in the mouth and f o reigner could spread rapidly. The 1 2 . Farrar WE. Leptospira species (Lep- tongue, pulmonary diseases ranging fact that melioidosis is uncommon in t o s p i rosis). In: Mandell GL, Bennet JE, Dolin f rom bronchitis to pneumonia, vomit- modern Greece should not blind us to R, editors. Mandell, Douglas and Bennett’s ing, and skin involvement including the striking parallels of the disease as it Principles and Practice of Infectious Dis- 2 0 eases. Fourth edition. New York: Churc h i l l ulcers, pustules, and burning. T h e now is manifest and the plague that Livingstone; 1995. pp. 2137–40. disease exhibits an incubation period s t ruck Athens in 430 B.C. 1 3 . Heath CW Jr., Alexander AD, Galton of two to four days, and, as it takes its Acknowledgement MM. Leptospirosis in the United States course, , striking muscular I am indebted to Dr. Barron Lerner, Dr. (concluded): Analysis of 483 cases in man, tenderness, and weakness may ensue. Rebecca Sinos, and Dr. David David, all of 1949–1961. N Engl J Med 1965; 273: 915–22. The fever may result in disorientation whom made valuable suggestions. 1 4 . Olsen PF. Tu l a remia. In: Hubbert WT, or amnesia, and survivors can be left McCulloch WF, Schnurre n b e rger PR, edi- with ulcers on the extremities and con- tors. Diseases Transmitted from Animals to References j u n c t i v i t i s .2 1 Transmission of melioido- Man. Sixth edition. Springfield (Ill.): Charles 1 . Thucydides. History of the Pelopon- C. Thomas Publisher; 1975. pp. 191–223. sis can be by ingestion, thro u g h nesian Wa r. Warner R, translator. New Yo r k : 1 5 . M e rcier L. Essai d’intrpré t a t i o n aspiration of aerosolized particles, and Penguin Books; 1954. “s t e r i s c óm e n o i“ de et de la “Peste” t h rough contact with bodily fluids and 2 . Longrigg J. The great plague of d’Athènes. Bull l’Assoc Guillaume Budé a n i m a l s .2 0 ,2 2 The bacterium can be iso- Athens. Hist Sci 1980; 18: 209–25. 1974; 40: 223–26. lated from soil, stagnant stre a m s , 3 . Longrigg J. Epidemic, Ideas and Clas- 1 6 . Langmuir AD, Worthen TD, Solomon ponds, pools, and market produce in sical Athenian Society. In: Ranger T, Slack P, J, et al. The Thucydides syndrome. A n e w endemic are a s ,2 0 much as one would editors. Epidemics and Ideas: Essays on the hypothesis for the cause of the plague of expect from the plague described by Historical Perception of Pestilence. Cam- Athens. N Engl J Med 1985; 313: 1027–30. Thucydides. Melioidosis affects a vari- bridge (U.K.): Cambridge University Pre s s ; 1 7 . M o rens DM, Littman RJ. “Thucy- 1992. pp. 21–44. ety of birds and other animals, both dides Syndrome” re c o n s i d e red: New 4 . Wylie JAH, Stubbs HW. The plague of Thoughts on the “.” Am J domesticated and nondomesticated, Athens: 430–428 B.C. Epidemic and epi- Epidemiol 1994; 140: 621–28. including dogs, cats, rodents, horses, zootic. Classical Quart 1983; 33: 6–11 . 1 8 . G a l i s h o ff S. Newark and the great in- 2 2 ,2 3 sheep, goats, and cows. Its onset is 5 . Langmuir AD, Worthen TD, Solomon fluenza pandemic of 1918. Bull Hist Med often very abrupt and, as with J, et al. The Thucydides Syndrome: A n e w 1969; 43: 246–58. Thucydides’ plague, it takes a rapidly hypothesis for the cause of the plague of 1 9 . Jessen O, Rosendal K, Bülow P, et al. p ro g ressive fatal course. The mortality Athens. N Engl J Med 1985; 313: 1027–30. Changing stphylococci and staphylococcal rate for untreated melioidosis is 80 to 6 . Butler T. Yersinia species (including infections: A ten-year study of and 90 perc e n t .2 0 ,2 2 A particularly viru l e n t plague). In: Mandell GL, Bennett JE, Dolin cases of bacteremia. N Engl J Med 1969; 281: R, editors. Mandell, Douglas and Bennett’s strain could overwhelm a population 6 2 7 – 3 5 . Principles and Practice of Infectious Dis- 2 0 . S a n f o rd JP. Pseudomonas species (in- without immunity. eases. Fourth edition. New York: Churc h i l l cluding melioidosis and ). In: Man- Melioidosis is the only disease that ful- Livingstone; 1995. pp. 2070–78. dell GL, Bennet JE, Dolin R, editors. fills every symptom and mode of 7 . Poole JCF, Halladay AJ. Thucydides Mandell, Douglas and Bennett’s Principles and the plague of Athens. Classical Quart transmission, and affects animal popu- and Practice of Infectious Diseases. Fourth 1979; 29: 282–300. edition. New York: Churchill Livingstone; lations as well. 8 . Poland JD. Plague. In: Hoeprich PD, 1995. pp. 2003–09. An argument against melioidosis is J o rdan MC, editors. Infectious Diseases: A 2 1 . Puthucheary SD, Lin HP, Yap PK. that the disease is fairly uncommon to- Modern Treatise of Infectious Pro c e s s e s . Acute septicaemic meliodosis: A report of day outside of Southeast Asia, A f r i c a , Philadelphia (Pa.): J. B. Lippincott; 1989. pp. seven cases. Tropical Geograph Med 1981; 1 2 9 6 – 1 3 0 6 . and northern A u s t r a l i a .2 4 Cases have, 33: 19–22. 9 . Saah AJ. (Epi- 2 2 . Leelarasamee A, Bovornkitti S. Me- h o w e v e r, been reported in Iran and demic or louse-borne typhus). In: Mandell lioidosis: Review and update. Rev Infect Dis 2 0 Tu r k e y. When melioidosis does ap- GL, Bennet JE, Dolin R, editors. Mandell, 1989; 11: 413–25. pear today, it often takes the form of an Douglas and Bennett’s Principles and Prac- 2 3 . Howe C. Melioidosis. In: Hoeprich epidemic that lasts from several tice of Infectious Diseases. Fourth edition. PD, Jordan MC, editors. Infectious Diseases: months to two years.2 2 In northern New York: Churchill Livingstone; 1995. pp. A Modern Treatise of Infectious Pro c e s s e s .

The Pharos /Spring 2000 3 Philadelphia (Pa.): J. B. Lippincott; 1989. pp. 1 3 0 6 – 0 9 . 2 4 . Handa R, Bhatia S, Wali JP. Melioido- sis: A r a re but not forgotten cause of fever of unknown origin. Brit J Clin Pract 1996; 50: 11 6 – 1 7 .

A u t h o r’s address is: 5 East 67th Street #3B New York, New York 10021 E-mail: emd11 @ c o l u m b i a . e d u

By and about the author I was born at Columbia-Pre s b y t e r i a n Hospital, where I now spend the vast ma - jority of my time. I grew up in Los Angeles, and worked as a pro f e s s i o n a l lighting designer during high school. I graduated Phi Beta Kappa from Amherst College in 1993, having double-majore d in physics and fine arts. I also became in - t e rested in classics during my college years, which is how my interest in Thucydides took root. Seduced by the con - cept of being an advocate, I entere d Columbia University School of Law, and worked for the United Nations after my graduation in 1996. During my last year of law school, I did advocacy work for c h i l d ren who were born HIV-positive and found that, while it meant a great deal to me to help them obtain housing and in - surance, I longed to help them as a physi - cian. I am a second-year student at Columbia University’s College of Physicians & Surgeons. Any free time I have is spent working as coproducer and c o d i rector of a documentary film about the effect of the Cold War on American c u l t u re. However, medicine remains the field about which I am most passionate. F rom an early age, I often accompanied my father as he made rounds each Saturday and Sunday, watching as he would pull up a chair beside a patient’s bed and speak with them for hours. I have learned much about both science and hu - manity from the time I have spent in hos - pitals, and it is an environment to which I am excited to contribute.

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