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 <j>XvxTaivai ("small blister" or "pustule") and word eXxog ("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 twentieth-century 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 (lymphadenopathy 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.

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