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Abstract
At an annual meeting in Maryland, physicians and historians try to solve long-standing medical mysteries. This year: what killed Pericles and 100,000 other Greeks during the Plague of Athens (430-429 B.C.)?
For the past five years, physicians and researchers have convened for a sort of Quincy-meets-The-History-Channel conference, a special session of the University of Maryland School of Medicine's Clinico-Pathologic Conference (CPC). Normally, physicians at the weekly meeting present unusual modern cases and, through analysis and discussion, make a diagnosis. At a "Historical CPC," speakers discuss a historical figure whose death is cloaked in mystery. They review clinical evidence in its historical context, outline past theories, and "solve" the case.
Past subjects have included Edgar Allen Poe (they decided he died of rabies), Alexander the Great (typhoid fever), and Ludwig von Beethoven (syphilis). The group has also debated the sanity of General George Custer. This year, researchers tackled the puzzle of Pericles, who died in 429 B.C., eleven days after coming down with a fever, headache, and sore throat. Later symptoms included sneezing, coughing, chest pain, projectile vomiting, insatiable thirst, halitosis, diarrhea, and a generalized rash.
There is little question Pericles died of the Plague of Athens. David Durack, vice president of medical affairs at Becton Dickinson Microbiology Systems and consulting professor of medicine at Duke University, outlined the plague's symptoms as written by Thucydides, a historian and plague survivor.
"He described a heat in the head, redness and burning in the eyes, inflamed throat, fetid breath, sneezing, coughing, retching, vomiting, flushed and livid skin, an unquenchable thirst, an intolerance for clothing, and fluid diarrhea, with death on the seventh to ninth day," said Durack. Complications of survivors included gangrene of the extremities and private parts, blindness, and amnesia.
The plague originated in Africa and spread to Athens via Piraeus, a port city, in 430 B.C. After a year of the epidemic, the disease subsided to endemic proportions over the next three years. The plague so debilitated Athens that Robert Littman believes it helped lead to Sparta's victory in the Peloponnesian War (431-404 B.C.).
"Wars in fifth-century Greece were dependent on the size of armies and numbers of ships," said Littman, a professor of classical languages at the University of Hawaii, where his main areas of research are ancient medicine and the social and political history of Athens.
"Athens lost 25 percent of its population during the plague; this severely curtailed the power of its army. Furthermore, the loss of Pericles, the leading statesman and commander in chief of the Athenian forces, contributed to the defeat," said Littman.
According to Durack, at the time of the plague, Athens covered about three square miles and held as many as 400,000 people. "That's greater crowding than New York City, and without the high-rises," he said.
Thucydides' account indicates that Athenians knew the disease was contagious. However, they believed a miasmus - an unknown but harmful element in the air - was causing the disease, and they lit fires within the city to purify the air. (Miasmatic theory dominated Western thought for nearly 2,000 years, and was the basis of the name "malaria" - literally, "bad air" - a disease the Greeks associated with air from foul-smelling swamps.)
What killed nearly 100,000 Athenians? The illness behind the plague has never been identified. More than 30 diseases and conditions have been proposed, including dengue, Ebola, ergotism, Lassa fever, bubonic or pneumonic plague, influenza, measles, Rift Valley fever, scarlet fever, smallpox, toxic shock syndrome, tularemia, typhoid fever, and typhus fever.
Durack dismissed influenza - which would have run through the city in weeks rather than years - as well as toxic conditions, because Thucydides' account suggests that survivors acquire immunity.
Durack's "shortlist" included Lassa fever, smallpox, and typhus.
The winner? Typhus.
"Typhus is associated with times of war," said Durack. "It's an obligate intracellular parasite, a bacterium that affects endothelial cells. That would explain the rash."
Damage to the central nervous system could lead to amnesia, and similar damage to the optic nerve could lead to blindness - both complications in survivors. Sufferers of typhus and Rocky Mountain spotted fever, a related condition, have lost fingers and toes due to gangrene. In addition, said Durack, typhus' fatality rate and the time from onset to death fit with Thucydides' description.
Epidemic typhus is transmitted by body lice; other forms of the disease are carried by ticks, mites, and fleas. The genome of the epidemic typhus pathogen, Rickettsia prowazekii, was recently sequenced. So it's possible, said Durack, to find DNA evidence left from the Plague of Athens that could confirm his diagnosis.
Evidence may be at hand. During recent subway construction in Athens, workers discovered 160 corpses. According to Littman, the bodies have been dated to 430 B.C. Because the Greeks normally did not bury their dead en masse, he believes the corpses are casualties of the plague. Though chances are slim that DNA will be recovered, said Littman, this paleobiological evidence is the only hope of validating that typhus swept through Athens nearly 2,500 years ago.
And if typhus was the Plague of Athens? In a word . . . so?
"This is not an idle academic exercise," said Littman. "It helps us to understand our present world and our present practice and theory of medicine."
Added Durack, "This exercise can help us think about and respond to similar diseases as best we can, such as AIDS, and to other emerging diseases in the future." Thucydides himself presaged the mystery and the historical significance of the plague when he wrote: "All speculation as to its origin and its causes . . . I leave to other writers, whether lay or professional; for myself, I shall simply set down its nature, and explain the symptoms by which perhaps it may be recognized . . . if it should ever break out again."
Nancy Volkers is a Baltimore-based freelance science writer and editor.
Caleb Brown is an illustrator and biologist living in Montana. By day he drives a delivery van, and by night he draws pictures with his computer.
Historical Clinico-Pathological Conference - provides online information on this year's event, as well as synopses from previous years. The conference was broadcast live January 29, 1999.
The Peloponnesian War - a course outline by Ellis Knox of Boise State University.
Internet Classics: The History of the Peloponnesian War - full text of Thucydides' book, translated by Richard Crawley. The plague shows up in the second book, seventh chapter. (An interesting point: Thucydides mentions both the plague and Pericles in great detail, but omits the fact that Pericles died from the plague.)
The Asclepion - focuses on the ancient medicine of Greece, Mesopotamia, and Egypt.
The Thucydides Syndrome: Ebola Déjà Vu? (Or Ebola Reemergent?) - suggests that Ebola was the source of the Plague of Athens. A letter published in the April-June 1996 issue of Emerging Infectious Diseases; includes references.