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Galen and the Antonine Plague

Authors:
Galen and the Antonine Plague
Author(s): R. J. Littman and M. L. Littman
Source:
The American Journal of Philology,
Vol. 94, No. 3 (Autumn, 1973), pp. 243-255
Published by: The Johns Hopkins University Press
Stable URL: http://www.jstor.org/stable/293979 .
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GALEN AND
THE ANTONINE
PLAGUE.
During
the
reign
of
Marcus
Aurelius the Roman
Empire
was
struck
by
a
prolonged
and destructive
epidemic.
It
began
at
the
end of
165,
or
beginning
of 166
A.D.,
in
Mesopotamia
during
Verus'
Parthian
campaign
and
quickly
spread
to
Rome
within
the
year.1
The
epidemic
lasted
at
least until
the
death
of
Marcus
Aurelius
in
180
A.D. and
more
likely
into
the
early
part
of
Commodus'
reign,2
probably
with another
outbreak in 189
A.D.3
The Antonine
plague
was
once
viewed
as a decisive event
in
Roman
history.
According
to Niebuhr
4
C
This
pestilence
must
For the evidence see S.H.A.
Verus
8.1-2;
W. Schur RE
36,
3rd
ed.
(1949)
2025
s.v.
Parthia;
J. F.
Gilliam,
"The
Plague
under
Marcus
Aurelius,"
AJP 82
(1961)
228-29
(hereafter
Gilliam).
Lucian
(Hist.
Conscr.,
15)
tells
of the work
of
Crepereius Calpurnianus,
who
in
his
history
of
Verus' Parthian
War,
wrote
of a
plague
in
Nisibis
after
the
style
of
Thucydides.
The
siege
of
Nisibis
was
probably
in
165,
but
the
date is uncertain
(see
Gilliam
229).
As
Gilliam
says,
there
is
no
way
of
knowing
whether
this is the
same which
struck
the Romans
at
Seleucia
in
winter
165/66
A.D.,
but there
is
no
reason to
doubt that
it
was
the
same
disease.
2
This is
based
on
Galen's comments.
See
Gilliam
228
n.
12.
8
According
to
Dio
Cassius
72.14.3-4
about
189
A.D. under
Commodus'
reign
a
pestilence
occurred,
the
greatest
of
any
of
which he had
knowl-
edge,
in
which
2,000
persons
often
died
in
Rome
in
a
single
day.
What
other
plagues
Dio
has
in
mind
when he
says
this one was
the
greatest
is
not
clear.
Dio
may
not consider
this
as
part
of the
plague
under
M.
Aurelius,
or
this
outbreak
might
have
been more
virulent
than
those under
Marcus. Herodian
1.12.1
refers to this
outbreak. He
says
a
plague
struck
Italy.
This
does
not
preclude
the
possibility
that it
also
attacked other
parts
of
the
Empire.
His account does
not
seem
very
reliable. He
says
the
plague
killed
all
the
animals that came
into
contact
with men
and also
that there
was
a
famine.
Although
it
is
possible
that
the
outbreak of 189
was another
disease,
most
likely
it
was the
same
one
as struck
under
M.
Aurelius.
In their
routes
of
contagion
plagues
lie
dormant,
wait for a
more
susceptible generation
and
double
back
along
the
routes
which
they
have taken. For
example,
Mexico
City
suffered
major
outbreaks
of
smallpox
in
1737,
1761,
1779
and
1797/98.
A
second
flareup
of
the
epidemic
in
189
A.D.
would
be
perfectly
consistent with
the
pattern
of
epidemic
diseases.
4
Lectures on
the
History
of
Rome,
2nd
ed.,
III
(London,
1849)
251.
243
R. J.
LITTMAN
AND
M.
L.
LITTMAN.
have
raged
with
incredible
fury;
and
it
carried
off
innumerable
victims.
As
the
reign
of
M. Aurelius forms
a
turning
point
in
so
many
things,
and
above
all in
literature
and
art,
I
have
no
doubt
that
this crisis
was
brought
about
by
that
plague
.
. .
The ancient world
never recovered
from
the
blow
inflicted
upon
it
by
the
plague
which
visited it
in
the
reign
of M. Aurelius."
Otto Seeck
5
maintained that over
half
the
population
of the
Empire
perished.
Recently
a
more
realistic
picture
of
the
effects
of
the
plague
has been
reached.
Freely admitting
that
the
Antonine
plague
probably
caused
more
deaths than
any
other
epidemic
during
the
Empire
before
the
mid third
century,
J.
F. Gilliam
6
demonstrates that the
significance
of
the
epidemic
as
a
factor
in
Rome's
decline,
as well
as its
general
importance,
has been
vastly
overstated,
in
the
exaggerated
accounts
of his-
torical
writers
of
late
antiquity,
such
as the iHistoria
Augusta,
and in
modern works.
Gilliam
suggests
a
mortality
of
about 2
percent
or
one
million
deaths,
as
a
more
plausible
estimate
of
the
catastrophe.
The
Antonine
plague
holds
an
important place
in the
history
of
medicine
because
of
its association
with Galen.
Galen
had
first
hand
knowledge
of the
disease.
He
was
in Rome when the
plague
reached
there
in
166
A.D.,
although
he
soon left
(Kiihn
19.15).
Galen
was also
present
in the
winter of
168/9
A.D.
during
an
outbreak
among
troops
stationed
at
Aquileia
(Kiihn
19.18).
He
had
considerable
experience
with
the
epidemic
since
he
refers to
it
as
very
long lasting
and
speaks
with
assurance
on
its
symptoms
and
his
treatment
of
it.
Although
Galen describes other diseases
and methods of treat-
ment
at
times in
very great
detail,
unfortunately
his references
to
the
plague
are
scattered and
brief,
with
no
attempt
at
a
com-
plete description.
Unlike
Thucydides
in
his account
of
the
Athenian
plague,
Galen
was
not
trying
to
present
a
description
of the
disease
so
that it
could be
recognized
by
future
genera-
tions,
should it
break
out
again;
nor was he
writing
for the
layman.
He was more
interested
in
the
treatment
and
physical
effects
of
the disease.
For
example,
in
his
discussion
of
the case
5
Geschichte
des
Untergangs
der antiken
Welt,
3rd
ed.,
I
(Stuttgart,
1910)
398-405.
6
Gilliam
225-51.
244
GALEN
AND
THE
ANTONINE PLAGUE.
of
a
young
man
afflicted with
the
plague,
he concentrates
on
the
treatment of
internal
and
external ulcerations
(Kiihn
10.360ff.).
The few
other
contemporary
writers
whose works
survive
give
no additional useful
information
on the nature
of
the
disease.
Because of
the
paucity
of
detail
in
Galen,
writers
have
been
wary
of
making
a
firm
diagnosis
of
the
Antonine
plague.
Tenta-
tively
the
epidemic
has been identified
as one
of
smallpox,
exanthematous
typhus
or
perhaps
bubonic
plague,
with
smallpox
most
preferred.7
Firstly,
it
is
the
purpose
of this
paper
to show
that
the case for
smallpox
is
very strong,
and
that
the
evidence
points
to a
high
incidence of
hemorrhagic
smallpox
in
the
out-
break.
Secondly, through
the
identification
of
the
disease,
we
hope
to arrive
at a more accurate
estimate
of
the
mortality
rate.
I
IDENTIFICATION OF
THE
DISEASE.
Although
Galen's
description
of
the
symptomatology
of
the
Antonine
plague
is
sketchy,8
we
believe that
enough
informa-
tion
is
present
to
make a firm
diagnosis
of
smallpox.9
Since
7
H.
Haeser,
Lehrbuch der
Geschichte
der
Medicin und
der
epi-
demischen
Krankheiten,
3rd
ed.,
III
(Jena,
1882)
24-33,
smallpox.
H.
Zinsser,
Rats,
Lice
and
History
(Boston,
1935)
pp.
135-37 concurs.
A
Castiglioni,
A
History
of
Medicine
(New
York,
1941)
p.
244,
exanthema-
tous
typhus
or
perhaps
bubonic
plague.
In the tenth
century
Rhazes
felt
Galen's
plague
was
smallpox.
See
A
treatise
on
the
smallpox
and
measles
by
Abu
Beer
Mohammed
ibn
Zacariya
ar
Razi
(commonly
called
Rhazes),
trans.
W.
A.
Greenhill
(London,
1848).
As
diseases
adapt
to
new
hosts under
changing
environments
over the
passage
of
years,
the
symptomatology
may change.
However,
basic
symptomatology
of
a
disease
remains
the
same.
For
example,
typhus
and
typhus
related
diseases,
while
they
have
a
tendency
to
mutate,
have
always
exhibited
a
flat
centrifugal
rash.
Smallpox
seems
to have
undergone
the
least
change
in
the
course of
history.
This is
particularly
evident when
we
see
the
close
argreement
between
Rhazes'
tenth
century
description
of
smallpox
and
modern
accounts of
the
disease.
8
The
passages
are
collected
by
J.
F.
K.
Heeker,
De
peste
Antoniniana
commentatio
(Berlin,
1835)
and
Haeser
(see
above
n.
7).
For
the
medical
aspects
of
smallpox
see T. F.
Ricketts
and
J. B.
Byles,
The
Diagnosis
of
Smallpox
(London,
1908)
(hereafter
Ricketts
and
Byles);
for
the
history
of
typhus
see Zinsser
(see
n.
7
above);
for
245
R.
J.
LITTMAN
AND M. L. LITTMAN.
the account
is
incomplete,
one cannot
argue
out
of
hand
that
a
sign
or
symptom
was not
present,
simply
because
Galen
does
not
describe
it,
unless
that
symptom
would
be
an
integral
part
of
the
specific
item
Galen
is
describing.
Below is a
summary
of the
signs
and
symptoms
of
the disease
as
Galen
presents
them.
SUMMARY
OF SIGNS
AND
SYMPTOMS.
EXANTHEM.
1.
On
the
ninth
day
a
certain
young
man
was covered
over
his
whole
body by
an
exanthem,
as
was the case with
nearly
all who survived.
Drying
drugs
were
applied
to
his
body.
On
the twelfth
day
he
was able
to
get
out
of
bed.
(Methodus
medendi 5.12=Kiihn
10.360ff.).
2. In
those who were
going
to
survive who
had
diarrhea,
a
black
exanthem
appeared
over the
whole
body.
It
(the
exanthem)
was
ulcerated
in most cases
and
dry (no liquid
oozing
out)
in
all.
The
blackness was
due
to
a
remnant
of
blood
which had
putrified
in
the
fever
blisters,10
like
some
ash
which nature
had
deposited
on
the
skin.
"
Of
some
of
these which
had
become
ulcerated,
that
part
of
the
surface
called
the
scab fell
away
and
then the
re-
maining
part
nearby
was
healthy
and after
one
or
two
days
be-
came
scarred
over.
In
those
places
where
it
was not
ulcerated,
the exanthem was
rough
and
scabby
and fell
away
like
some
husk and
hence
all became
healthy." (Methodus
medendi
5.12=
Kiihn
10.367).
3.
In
many
cases
where
there
were
no
bloody colliquescences
(diarrhea),
the entire
body
was covered
by
a
black
exanthem.
"And sometimes
a
sort
of scale
fell
off,
when
the
exanthem
had
typhus
see
R. P.
Strong,
Typhus
Fever
with Particular
Reference
to
the
Serbian
Epidemic
(Cambridge,
Mass., 1920)
and
S. B.
Wolbach,
et
al.,
The
Etiology
and
Pathology of Typhus
(Cambridge,
Mass.,
1922);
for
bubonic
plague
W.
E.
Jennings,
A
Manual
of
Plague
(London, 1903)
and
J.
Cantlie,
Plague
(New
York,
1900).
An
excellent introduction
to
the medical
aspects
of viral and rickettsial diseases is T. M.
Rivers
and F.
L.
Horsfall
(eds.),
Viral
and Rickettsial
Infections
of
Man,
3rd
ed.
(Philadelphia,
1959).
10
Galen
uses
the
word
,rvper6s.
This
seems to be
equivalent
to
7re/iJLyzriw&s.
See
Stephanus
s.v.
7rvperos
and
7reuTLyw8rqs
and his
discussion
of
Galen's
and
Hippocrates'
use
of
the
word.
246
GALEN
AND
THE
ANTONINE PLAGUE.
dried and
dissipated,
little
by
little,
over
a
period
of
many
days
after the crisis."
(De
atra
bile
4==Kiihn
5.115).
FEVER.
1. Those
afflicted
with
plague
appear
neither
warm,
nor
burn-
ing
to those
who touch
them,
although
they
are
raging
with
fever
inside,
just
as
Thucydides
describes
(in
the Athenian
plague).
(Comment.
1
in
Hippocratis
Libr.
6
Epidemiorum.
Aph.
29=Kiihn
17.1.885).
2.
Galen
calls
the
plague
a
fever
plague.
(Comment.
S
in
Hippocratis
Libr.
3
Epidemiorum. Aph.
57-Kiihn
17.1.709).
BOWELS.
1.Black excrement
was
a
symptom
of
those
who
had
the
disease,
whether
they
survived or
perished
of
it.
Colliquescence
(diarrhea)
was
first
auburn,
then
yellowish
red,
later
black,
like fecal
matter of blood.
(Comment.
4
in
Hippocratis
Aphorismos.
Aph.
31=Kiihn
17.2.683).
2.
Colliquescence
of
evacuation
was
an
inseparable
symptom
of
the
plague.
(Comment.
S
in
Hippocratis
Libr.
S
Epidemiorum.
Aph.
57=-Kiihn
17.1.709).
3.
In
many
who
survived,
black
stools
appeared, mostly
on
the
ninth
day
or
even
the seventh
or
eleventh
day. Many
dif-
ferences occurred.
Some
had
stools
that were
nearly
black;
some
had
neither
pains
in their
excretions,
nor
were their
excretions
foul
smelling. Very
many
stood
in
the
middle. If the
stool
was
not
black,
the exanthem
always
appeared.
All
those who
excreted
very
black
stools
died.
(De
atra
bile
4=-Kiihn 5.115).
VOMITING.
Occurred
in some
cases.
(Methodus
medendi
5.12=Kiihn
10.367).
STOMACH UPSET.
Occurred
in all
cases.
(Methodus
medendi
5.12=Kiihn
10.367).
FETID BREATH.
Occurred.
(De
praesagitione
ex
pulsibus
3.4=Kiihn
9.357).
247
R.
J.
LITTMAN
AND
M.
L.
LITTMAN.
COUGH-CATARRH.
1.
On the
ninth
day
a
young
man had
a
slight cough.
On
the tenth
day
the
cough
became
stronger
and
with
it
he
brought
up
scabs.
(Methodus
medendi
5.12=Kiihn
10.360).
2.
After
having
catarrh
for
many
days,
first
with
a
cough
he
brought
up
a little bright fresh
blood,
and
afterwards
even
part
of
the membrane
which
lines
the
artery
and
rises
through
the
larynx
to the
pharynx
and mouth.
(Methodus
medendi
5.12=Kiihn
10.367).
INTERNAL
ULCERATIONS AND
INFLAMMATION.
On
the tenth
day
a
young
man
coughed
and
brought
up
a
scab,
which was an
indication
of an
ulcerated
area
in
the
windpipe
in
the
region
of
the
trachea
near
the
jugular
vein. No
ulcers
were
present
in
the
mouth
or throat
(there
was no
problem
of
ingesting
food).
(Methodus
medendi
5.12=Kiihn
10.360).
The
larynx
was
infected,
and
the
man's
voice
was
damaged.
(Methodus
medendi
5.12==Kiihn
10.367).
DURATION
OF THE
DISEAiSE.
1. The
crisis
appeared
on the
ninth to
twelfth
day.
On
the
third
day
after the ninth
the
young
man
was
able
to
rise
from
his bed.
(Methodus
medendi 5.12=Kiihn 10.360. Cf. De
atra
bile
4=Kiihn
5.115).
DIFFERENTIAL
DIAGNOSIS.
The
distinguishing
feature
and the differential
symptoms
for
most
exanthematous
diseases
(where
a
skin
eruption occurs)
is
the
rash.
Dr.
J.
C.
Snyder
states
11
(italics ours):
Before
the
appearance
of
the
characteristic
rash,
and
on
clinical
grounds
alone,
it
is
impossible
to assert with ac-
curacy
that
a
patient
is
suffering
from
typhus.
The
clinical
picture
of the
early stages
of
several
acute
infectious
diseases
closely
resembles
that
of
epidemic
typhus.
Those
which
are
likely
to
be confused
with
it are
murine
typhus,
small-
pox,
relapsing
fever
malaria,
typhoid
fever,
meningococcic
meningitis,
measles
and
yellow
fever. The
appearance
and
the evolution
of
the
typhus
rash
serve
to
distinguish
it
from
eruptions
which are
features
of certain
other acute
infectious
diseases.
"Rivers
and
Horsfall
(see
above n.
9)
811.
248
GALEN
AND
THE
ANTONINE
PLAGUE.
Dr.
Snyder
told
us in
conversation
of
his
experience
with
typhus
and
smallpox
while he
was
a
young
physician
in
Cairo. Simul-
taneous
outbreaks
of
the two diseases
occurred,
and
it
was
often
impossible
to
distinguish
between the
two
in
their
early stages.
Fortunately
one of
the
symptoms
with which Galen
deals
in
great
detail is the
skin rash.
The
first
point
which
he
emphasizes
each
time
he
speaks
of
the exanthem is that it
covered the
entire
body.
This is
consistent
with
the
topical
distribution
of
small-
pox
and
typhus
rashes,
but not with bubonic
plague.12
Another
salient
feature
of
the
rash
was
that
it
was
generally
black,
al-
though
in
one
case
presumably
it
was not.13
According
to
Galen
the
blackness
was
due to
a
remnant
of blood
putrified
in-the
fever
blister
(hemorrhagic).
In
smallpox
the
rash
usually
be-
comes
vesicular and
there
are
pronounced
hemorrhagic
extra-
vasations
into
the
lesions.
This
phase
of
smallpox
is
identified
as
hemorrhagic
smallpox
and was
attributed
by
Ricketts
and
Byles
to
the
circulation
of a
specific
poison
or
toxin.14 Another
phase
of
smallpox
which
could be
described as
having
a
black
exanthem is
the
purpuric,
in
which
the skin is
densely
packed
with
small
petechiae
which
spread
out
with
larger
extravasa-
tions.15
However,
we believe
that
Galen refers
primarily
to
the
classical
hemorrhagic
exanthem.
Hemorrhagic
extravasa-
tions
into
the
skin
also
occur in
typhus.l6
A differential feature
of
the
smallpox
and
typhus
rashes
is
that
smallpox
produces
raised
vesicular and
pustular
lesions,
while
the
lesions
of
typhus
are
flat
and
never
pustular.
While Galen is
not
specific
on
1"
In
bubonic
plague,
plague
boils
may
be
present
(Jennings
[see
above n.
9]
87),
but
they
do not
occur
in
every
case.
In
addition,
the
distribution
is
not over
the
whole
body,
but tends to
be near
the buboes
in
the
groin
and
axilla.
In
his
description
of the
bubonic
plague
at
the
time
of
Justinian,
Procopius
(2.22.30)
reports
"
in
some
cases
the
body
broke
out
with
black
pustules."
Procopius
does
not
say
these
pustules
covered
the whole
body.
Also
there
is
no
mention of
buboes in
Galen.
As
part
of
his
remarks
about the
exanthem,
we
would
expect
references
to
the
buboes if
the
disease
were indeed
bubonic
plague.
13
In
Methodus
medendi
5.12=Kuhn
10.360
Galen
describes
a
case
with a
rash,
but he
does
not
say
the
rash
was black.
Since
in
other
cases
he
says
it is
black,
presumably
here
the rash
was
not so.
"Ricketts
and
Byles
109.
Hemorrhage
from
smallpox
is
not neces-
sarily synonymous
with
hemorrhagic
smallpox.
5
Ricketts and
Byles
97.
"
Ricketts and
Byles
109.
249
R.
J.
LITTMAN AND M.
L.
LITTMAN.
whether
the
exanthem
in the
Antonine
plague
was raised or
flat,'7
he
suggests
that
it
was
pustular.
In
his
discussion
of
raised
blisters
(Kiihn 17.1.882)
(7reqA7&yW8es),
which he
defines
as
pustules
and
ulcers,
Galen
implies
that
these
were
present
in
the Antonine
plague.
He further
implies
the Antonine
plague
had
a
blistery
rash
when
he
says
the
plague
was similar
to the
Thucydidean
plague
and
quotes
a
passage
which includes
Thucydides'
words
about
the rash
being
blistery
(AXvKrcatvatF
r/LKPpats
Kal
XK'mrov
f'rev6KOsK),
although
he
was
more interested
in
comparing
the fevers
in the two
plagues.
In
another
passage
Galen
again says
the
plague
was
very
close
in form
to
the
one
described
by Thucydides
(Kiihn 12.191).
Galen
also
says
the
exanthem
became
ulcerated
in
most
cases
(EXAKWsr
).
This
would
correspond
to
the
pustular
stage
of the
smallpox
rash.
Accord-
ing
to
Galen
the
blackness
was like some
ash
which nature
had
deposited
on
the
skin
(Kiihn 10.367).
This
suggests
a raised
hemorrhagic
lesion
and/or
desquamating
lesion,
which
favors
the
identification of the disease
as
smallpox.
Galen describes
the
exanthem
as
becoming rough
and
scabby
(escharotic)
where
there was
no
ulceration,
and he mentions
a
scabbing
around
the ulcerated areas
(Kiihn
10.367).
This
cor-
responds
to
the
desquamation
process
in
smallpox
lesions.
Ac-
cording
to
Ricketts
and
Byles,
the
cuticle around the
mark
left
by
the
fallen
eschar becomes
partly
detached
and
ragged.18
The
typhus
desquamation
on
the
other
hand is
branny
(fine
powder)
and
is
usually
not
rough
and
never
escharotic.
Galen
implies
the exanthem
might
not
appear
in
fatal
cases.19
This is not
an uncommon occurence
in
hemorrhagic
smallpox.
According
to
Ricketts
and
Byles,20
"
Cases
in which
death
wholly
anticipates
the efflorescence
are,
in
reality, very
exceptional.
More
often,
when
cases of
that
repute
occur,
it
is
possible
to
de-
tect
a few
papules
if
they
are
sought,
not
on
the
face,
but
on
some
part
of
the
body
where
the
circulation
is
less
impaired."
17
Galen uses the
word
'XKOS
(Methodus
medendi
5.12=Kiihn
10.360)
and
edPOv0A.a
(Methodus
medendi
5.12=Kuhn
10.362)
with
refers
to
undifferentiated
exanthem.
18
Ricketts
and
Byles
55.
19
Galen
says
(Kuhn
10.360
and
10.367)
that the exanthem
appeared
on
the
whole
body,
"as was the case
with
nearly
all who survived."
2o
Ricketts and
Byles
96.
250
GALEN
AND THE ANTONINE
PLAGUZE.
In
referring
to blood
in
the
pustules
and
other
bleeding
in
hemorrhagic
smallpox,
Ricketts
and
Byles
add
"Yet
all
these
tardy
evidences
of
the
tendency
to
bleed
are
wholly
devoid
of
significance. They
are
but
the
foot-prints
of an illness
which
has
passed."
21
This
is
consistent
with
Galen's
statement
that
those who
were
going
to survive
developed
a
black
exanthem.
Galen's
description
of
the
exanthem
provides
a
fairly typical
picture
of
the
smallpox
rash,
particularly
of
the
hemorrhagic
phase
of
the disease. The rash
was
unlike
that
of
typhus,
par-
ticularly
in
its vesicular nature and in
its
desquamation.
No
plague
disease
other than
smallpox
is known to
produce
an
exanthem
such
as
Galen
describes.22
The
other
symptoms
and
signs
which
Galen
dwells
on
are
those
of
the
alimentary
tract,
particularly
diarrhea and
black
stools.
Galen said
that if
the stool
was
very
black,
the
patient
died
(Kuhn 5.115).
Gastrointestinal
symptoms
are not
very
important
in
the differential
diagnosis
of
most
exanthematous
diseases,
though
they may
assist
in
identifying
the
disease.
They
happen
to coincide well
with the
symptoms
of
hemorrhagic
small-
pox,
where
black
stools
would
indicate
gastrointestinal
bleeding.
Diarrhea
is
a
frequent
sign
of
smallpox.
In
hemorrhagic
small-
pox
intestinal
ulcerations
and
bleeding
occur
frequently.
In
some
cases
the
entire
circumference
of the
bowel
may
be
black
for
several
inches
from
extensive
extravasations
of
blood
be-
neath
the
mucous
membrane.
Galen remarks
that the
amount
of
black
stools varied. This
variation
would
depend
on
the
severity
of
the
intestinal
lesions.
Galen also
observes
that
in
cases
where
the
stool was
not
black,
the black
exanthem
appeared
21
Ricketts
and
Byles
75.
22
Galen
makes
no
reference to
the residual
scarring
so
characteristic
of
smallpox.
Given
his
only
partial
description
of
the disease and his
primary
interest
in
treatment and
diagnosis
of
the
disease,
the
omission
of
the
scarring,
which
is
a
result of
the disease
that
may
not
appear
until
several
weeks
after
the
disease
has
run
its
course,
is
not
startling,
though
regrettable.
However,
his
description
of the
exanthem
is
suf-
ficiently
complete
to
allow
identification
of the
disease
as
smallpox.
There
are
modern
near
parallels:
in
the
account of
smallpox
in
C.
E.
van
Rooyen
and A.
J.
Rhodes,
Virus
Diseases
of
Man
(New
York, 1948)
pp.
286-98,
there
is
no
mention
at
all
of
the
characteristic
pockmarks.
In
the
description
of
smallpox by
Ricketts
and
Byles
only
one
para-
graph
in
the
entire
book
deals
with
the
pockmarks.
251
R. J.
LITTMAN
AND
M.
L.
LITTMAN.
(Kiihn
5.115).
This
is consistent with
hemorrhagic smallpox,
for
if
the
patient
is
severely
ill,
death
may
occur
before the
appearance
of
the
exanthem.
In
less
severe
cases,
where the
stool is
not
black
and
intestinal
bleeding
is
not
present,
there
is time for
the exanthem
to manifest itself
before death ensues.
Although
diarrhea also
occurs
in
bubonic
plague
and
typhus,
constipation
is the
more
usual
symptom.
In
bubonic
plague
only,
the stool
may
occasionally
contain
blood.23
In
the
Antonine
epidemic
the
duration of the
disease
and
other
symptoms
and
signs
which
Galen
describes,
such as
fever,
vomiting,
fetid
breath,
catarrh,
cough
and ulceration
of
the
larynx
and
trachea
are
consistent with
smallpox.
Although
Galen's
description
of
the
plague
is
incomplete,
it
is
adequate
enough
to enable firm identification
of
the
disease
as
smallpox
because of
the excellent
description
of
the most
important
diagnostic sign,
the
exanthem.
The
hemorrhagic
nature of
the
exanthem and
the intestinal
bleeding
strongly
suggest
that
there
was
a
very
high
incidence
of
the
hemorrhagic
phase
of
smallpox,
as
well
as
the
purpuric phase,
which are the
disease's most
virulent
forms. In
the
Minneapolis
outbreak
of
1924-25,
164
deaths occurred
out of 196
cases of
hemorrhagic
and
purpuric
smallpox,
while
there were
only
165
deaths out of
386 cases of
unclassified,
discrete
and
confluent
smallpox.24
Bubonic
plague
and
typhus
are
unlikely
causes
of
the
Antonine
plague
since
neither exhibit the features
of the
disease
which
Galen
describes,
particularly
in
regard
to the
exanthem.
II
MORTALITY
RATE.
J. F. Gilliam
25
has
laid
to rest
the
picture
of
the
Antonine
plague
as
devastating
the
entire
Roman
Empire
and
killing
half
the
population.
However,
we
believe
he
has
gone
too
far
to the
other extreme in
estimating
a
mortality
of
only
1
to
2
percent
due
to
the
plague.
A
mortality
rate
of
7
to
10
percent
would
be
a
more reasonable
figure.
23
Jennings
83.
24
S.
E.
Sweitzer
and K.
Ikeda,
"Variola: a
clinical
study
of the
Minneapolis
epidemic
of
1924-1925,"
Arch.
Dermat.
Syph.
15
(1927)
19-29.
2
Gilliam
(see
above n.
1).
252
GALEN
AND THE
ANTONINE
PLAGUE.
Many
factors make
it
difficult
to
assess the
mortality
of
the
Antonine
plague.
The ancient
sources
are
vague
and
may
exag-
gerate.
More
important,
they may
be
generalizing
from
an
out-
break in a
single
city,
such
as
Rome.
Even
along
routes
of
contagion
and centers
of
infections,
the same
pandemic
will
have
varying
effects.
The
mortality
rate
in a
particular
city
would
be
affected
by
such
factors
as
crowding,
sanitary
conditions,
season of
the
year, severity
of
secondary
infections which ac-
company
the
plague
in a
particular
place,
the
methods
with
which
the
city may
deal
with
the
plague
and
also
pure
chmnce.
Compare
the effects of
smallpox
which
struck Greece
in
430-427
B.C.26 Athens
was
very
hard
hit because
the
city
was
under
siege
and crowded
with
people,
while
the
Peloponnese escaped
almost unscathed.
Even
where
conditions in
various cities
appear
to
be
comparable,
such as
in
the
smallpox
outbreak
in West
Prussia in
1874,
considerable
variation
often exists
in
mortality
rates.27
Even if
we were
to
have
accurate
statistics
for
the
deaths
occurring
in
one
city during
the
Antonine
epidemic
we
would
be
unable
to
generalize
about
the
whole
Empire.
In
the case
of
the Black Death
(bubonic
plague)
which
struck
Europe
in
the fourteenth
century,
we
can
arrive
at
more
accurate estimates
because of the existence of
many
records,
such
as
poll
tax,
parish
and
hearth
tax
records,
which
provide
information
over
a wide
geographical
area
and
time.
It is
equally
impossible
to
approxi-
mate
with
certainty
the death rate of a
plague
disease at
any
specific
outbreak,
solely
from
the
nature of
the
disease,
because
of
such
factors
as
the
resistance
of
the
populace
to
the
disease.28
26
For
the identification
of
the
Athenian
plague
as
smallpox,
see
R.
J.
Littman
and
M.
L.
Littman,
"The Athenian
Plague:
Smallpox,"
TAPA 100
(1969)
261-75.
27
F.
Prinzing,
Epidemics
Resulting
from
Wars
(Oxford,
1916)
p.
222.
During
the outbreak
in
West Prussia
the
death
rate
ranged
from
a
low of
4.8
percent
of
the
population
in
Berent,
to
11.9
percent,
over
twice
the
death
rate,
in
Schwetz.
28
If
a
disease strikes a
virgin
population,
where
resistance
is
low,
the
mortality
rate
will
be
extremely
high.
For
example,
the outbreak
of
measles in
Fiji
in
1875
killed a
great
number of
the
inhabitants,
though
measles
is
usually
a
very
mild
disease.
In
1801
General
Leclerc
landed
in
Haiti with
25,000
men
to
put
down the
revolt
led
by
Toussaint
L'Ouverture.
An
epidemic
of
yellow
fever
then
almost
annihilated the
253
R.
J.
LITTMAN
AND M.
L. LITTMAN.
An individual
outbreak
of
smallpox
could
have a
mortality
rate
of
nearly
80
percent
if
the
more virulent
forms of the
disease were
prevalent,
and
as
low as 1
percent
if
the
less
virulent
forms
of
the
disease
predominated.
However,
if
we
study
out-
breaks over
a
long
period
of
time
and broad
geographical
area,
a clear
pattern
of the
mortality
rate
emerges
for
the
disease.
During
a
pandemic,
smallpox
tends
to be fatal
to an
average
of 25
percent
of
those
infected.
In
any
single
epidemic,
however,
usually
only
60 to
80
percent
of
the
population
might
contract
the
disease. It has
been
estimated that
during
the
eighteenth
century
60
percent
of
the
population
of
Europe
were attacked
by
smallpox
and
10
percent
of the total
population
died
of
the disease.29
During
a
smallpox
outbreak in
Mexico
City
in
1779/80
approximately
16 to 18
percent
of
the
population
died
of
the
disease.30
In a
later
outbreak
in
1797/98
the
mortality
rate
was
about 7
percent.31
In
the
previously
mentioned
outbreak
of
smallpox
in
West
Prussia about
7
to
8
percent
of the
populace
died.
Thus,
when
a
severe
epidemic
of
smallpox
strikes,
it
seems
to
produce
a
mean
fatality
of
about 10
percent
of
the
popula-
tion.
As
we
have
shown,
the
Antonine
plague
was most
likely
smallpox.
Since
this
plague
was distributed over a
wide
geo-
graphical
area,
lasted
for 23
years
with
sporadic
flareups,
and
was
not
attacking
a
virgin
population,
we can
presume
that
this
smallpox
pandemic
followed
a
median
mortality
rate
for
the
disease,
or
a
death
rate of
7
to
10
percent.
On
this
basis,
the outbreak
in
165/6-168
A.D.
would have
caused
approxi-
mately
3
1/2
to
5 million
deaths,
at
a
conservative
estimate.
French
troops.
By
1803
only
3,000
were left
alive to evacuate
the
island,
most
deaths
being
due to
yellow
fever,
while the
native
popula-
tion
was
barely
affected.
Nearly
50
percent
of the
population
of
New
Spain
died
of
smallpox
in 1520
when
an infected sailor
from
Cortez's
ships
spread
the
disease to
the
populace.
2,
See
E.
E.
Duvillard,
Analyse
et Tableaux de
l'Influence
de
la
Petite Verole
(Paris,
1806)
pp.
105-106.
For
example,
in
Edinburgh
during
the
years
1744-1753
the
death rate
from
smallpox
was
9.6
per-
cent
and from
1754
to
1763
9.8
percent.
[C.
Creighton,
A
History
of
Epidemics
in
Britain
(New
York,
1965)
2.523].
80
D.
B.
Cooper,
Epidemic
Disease
In Mexico
City
1761-1813
(Austin,
Texas,
1965)
p.
68.
?1
Cooper
(see
above
n.
30)
pp.
86-156.
254
GALEN
AND THE
ANTONINE
PLAGUE.
Over the
twenty-three
year period,
assuming
that
the
initial
flareup
and
the
one in 189
A.D.
were the most
severe,
a
total
number of
deaths
of
7
to
10
million over the
normal
mortality
rate would
be
again
a
conservative estimate.
Although
pandemics
may
affect an
entire
area,
centers of
population,
such
as
cities and
armies
are
usually
hardest
hit.
Plagues
are
highly contagious
and
tend to
occur
when
many
people
are crowded
together,
as
in a
city
or
army
encampment.
Once
an infectious
plague
strikes,
its effects
are
compounded
by
the
great difficulty
in
maintaining
sanitary
conditions in
a
city.
"The
degree
of
infection is in
direct
proportion
to the
progress
of
communications.
Geographical
isolation is
in itself
a
form
of
defense: islands
lying
outside
customary
sea
lanes and
self-
supporting
mountainous
regions
constitute
fortresses
of
passive
resistence."
32
Thus
we can
expect
the
greatest
mortality
among
armies and
cities,
which indeed
seems
to be
the
case
with
the
Antonine
pandemic.33
The fourth
and fifth
century
sources
consistently
refer
to
depopulation
in
the
army,
and
Rome
itself
seems
to have
been
hard
hit.34 If
the death
rate
in
the
Empire
was
7 to 10
percent
on
average,
the
rate in
the
cities
and
among
the
army
would be
considerably
higher,
perhaps
13
to
15
percent.
Thus
we
can see
that
the
Antonine
plague
significantly
in-
creased
the
mortality
rate,
with a
concomitant
disruptive
effect
on
the
Empire.
However,
even with
this
revised
mortality
rate,
Gilliam's
conclusions
remain:
the
plague
was
not
a
decisive
event
in
Roman
history.35
R.
J.
LITTnMA
AND
M.
L.
LITTMArN,
M.D.
UNIVERSITY
OF
HAWAII
AND
SUNY,
DOWNISTATE
MEDICAL
CENTER.
82A.
Siegfried,
Routes
of Contagion
(New
York,
1965)
p.
17.
88See
Prinzing
(above
n.
27).
84
Gilliam
236-39
deals with
some
figures
on
recruits.
His
results
are
inconclusive.
For the
few
inscriptions
he
produces,
there
was a
decline
in
the
army,
but
there
is no
way
to
judge
if
this
plague
had
a
role
in
it,
and other
explanations
are
possible.
Eutropius
8.12,
Orosius
7.15.5-6,
S.H.A.
Marcus
17.2 refer
to
losses
in
the
army.
The
fact that
the
plague began
on
Verus'
Parthian
campaign
and
was
brought
back
by
the
army
means
that it
must have
been
raging
in
Verus'
forces.
85
We
are
indebted
to
Professors
Glen
Bowersock
and J. F.
Gilliam.
255
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Will COVID-19 end the urban renaissance that many cities have experienced since the 1980s? This essay selectively reviews the copious literature that now exists on the long-term impact of natural disasters. At this point, the long-run resilience of cities to many forms of physical destruction, including bombing, earthquakes and fires, has been well-documented. The destruction of human capital may leave a longer imprint, but cities have persisted through many plagues over the past millennia. By contrast, economic and political shocks, including deindustrialisation or the loss of capital city status, can enormously harm an urban area. These facts suggest that the COVID-19 pandemic will only significantly alter urban fortunes if it is accompanied by a major economic shift, such as widespread adoption of remote work, or political shifts that could lead businesses and the wealthy to leave urban areas. The combination of an increased ability to relocate with increased local redistribution or deterioration of local amenity levels, or both, could recreate some of the key attributes of the urban crisis of the 1970s.
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Did climatic events help give rise to the Antonine Plague? This chapter examines the climate of Eurasia and Northeast Africa in the latter half of the second century CE, possible connections between observed climatic changes and the second-century pandemic (165–190 CE), and societal downturn that followed the pestilence. By exploring potential explanations for apparent connections between a changing climate and the Antonine Plague, a link between climatic events and the pandemic’s arrival to the Empire emerges. The chapter then considers the ongoing debates concerning the impact of the Antonine Plague. Both exaggerated and understated interpretations of the pandemic’s effects dominate the histories, in spite of the evidence. This chapter approaches the question of impact with caution by avoiding Empire-wide generalisations and focusing on the effects of the “plague” from a regional perspective.
Epidemic Disease In Mexico City 1761-1813 (Austin, Texas, 1965) p. 68. ?1 Cooper (see above n. 30) pp
  • B Cooper
B. Cooper, Epidemic Disease In Mexico City 1761-1813 (Austin, Texas, 1965) p. 68. ?1 Cooper (see above n. 30) pp. 86-156.