EPIDEMICS AND PANDEMICS -...

EPIDEMICS AND

PANDEMICS

EPIDEMICS AND

PANDEMICSTheir Impacts on

Human History

J. N. Hays

Santa Barbara, California * Denver, Colorado * Oxford, England

Copyright © 2005 by J. N. Hays

All rights reserved. No part of this publication may be reproduced, stored in aretrieval system, or transmitted, in any form or by any means, electronic,mechanical, photocopying, recording, or otherwise, except for the inclusion ofbrief quotations in a review, without prior permission in writing from thepublishers.

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Epidemics and pandemics : their impacts on human history / J. N. Hays.p. cm.

Includes bibliographical references and index.ISBN 1-85109-658-2 (hardcover : alk. paper) — ISBN 1-85109-663-9 (ebook)

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CONTENTS

Preface ix

1 EPIDEMIC IN ATHENS, 430–427 B.C.E. 1

2 MALARIA IN ANCIENT ROME 9

3 PLAGUE OF THE ANTONINES 17

4 FIRST PLAGUE PANDEMIC, 541–747 23

5 SMALLPOX EPIDEMIC IN JAPAN, 735–737 31

6 LEPROSY IN MEDIEVAL EUROPE 35

7 SECOND PLAGUE PANDEMIC, 1346–1844 41

8 “FRENCH DISEASE” IN SIXTEENTH-CENTURY EUROPE 69

9 EPIDEMICS IN SIXTEENTH-CENTURY AMERICA 79

10 EPIDEMICS AND THE THIRTY YEARS’ WAR, 1618–1648 97

11 PLAGUE IN ITALIAN CITIES, 1630s 103

12 EPIDEMICS IN CHINA, 1640–1644 113

13 PLAGUE IN LONDON, 1665 119

14 SMALLPOX IN ICELAND, 1707–1709 131

v

15 PLAGUE IN MARSEILLES, 1720–1722 135

16 SMALLPOX IN BOSTON, 1721 143

17 SMALLPOX IN EIGHTEENTH-CENTURY EUROPE 151

18 PLAGUE IN MOSCOW, 1771 163

19 INFLUENZA PANDEMIC, 1781–1782 171

20 YELLOW FEVER IN HISPANIOLA, 1793–1804 177

21 YELLOW FEVER IN PHILADELPHIA, 1793 185

22 FIRST CHOLERA PANDEMIC, 1817–1824 193

23 CONSUMPTION IN THE NINETEENTH CENTURY 201

24 SECOND CHOLERA PANDEMIC, 1827–1835 211

25 THIRD CHOLERA PANDEMIC, 1839–1856 227

26 “FEVERS” AND THE GREAT FAMINE IN IRELAND, 1846–1850 239

27 TYPHOID FEVER IN CITIES, 1850–1920 249

28 YELLOW FEVER IN NEW ORLEANS, 1853 259

29 FOURTH CHOLERA PANDEMIC, 1863–1875 267

30 CARRIÓN’S DISEASE IN PERU, 1870–1871 281

31 SMALLPOX IN EUROPE, 1870–1875 287

32 MEASLES IN FIJI, 1875 297

33 FIFTH CHOLERA PANDEMIC, 1881–1896 303


Contentsvi

35 CHOLERA EPIDEMIC IN HAMBURG, 1892 321

36 THIRD PLAGUE PANDEMIC, 1894–? 331

37 SIXTH CHOLERA PANDEMIC, 1899–1923 345

38 SLEEPING SICKNESS IN EAST CENTRAL AFRICA, 1900–1905 355

39 TYPHOID MARY’S “EPIDEMICS” 363

40 CHOLERA EPIDEMIC IN NAPLES, 1910–1911 369

41 POLIOMYELITIS IN THE UNITED STATES, 1916 377


43 LUNG CANCER IN THE UNITED STATES, MID-TWENTIETH CENTURY 397

44 POLIOMYELITIS IN THE UNITED STATES, 1945–1955 411

45 SEVENTH CHOLERA PANDEMIC, 1961–PRESENT 421

46 AIDS IN THE UNITED STATES, 1980s 427

47 CONTEMPORARY AIDS PANDEMIC 439

48 THE MAD COW CRISIS AND TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHIES, 1985–PRESENT 449

49 CONTEMPORARY MALARIA 457

50 CONTEMPORARY TUBERCULOSIS 465

Epilogue 473Some General Books on Epidemics 479Glossary 481Index 485About the Author 513

Contents vii

PREFACE

This book intends to provide accurate, up-to-date historical information aboutfifty significant epidemics and pandemics. It is important for readers to under-stand that the book is a work of historical, not medical, reference—I am a histo-rian, not a physician.

It is arranged chronologically, so that the first chapter concerns an epi-demic of the fifth century B.C.E. and the last chapters discuss several contempo-rary pandemics. Each chapter presents its information in a consistent formatthat allows the reader to gain information about the time, place, and scale ofthe epidemic, its significance, the background against which it occurred, howcontemporaries understood and responded to it, and issues that remained unre-solved about it then, or have remained so since. Each chapter concludes withreferences and suggested readings, both of which are good sources for those whowish to learn more about the epidemic.

The fifty epidemics discussed in the book fall into several different cate-gories, and I have chosen them for several reasons. Some of them—the most ob-vious candidates for inclusion—were major pandemics that resulted in highdeath tolls and serious social disruption over wide areas. The three plague pan-demics (those that began in the sixth, fourteenth, and nineteenth centuries) andthe influenza pandemic of 1918–1919 illustrate that category.

But because estimates of death tolls from the past are often unreliable (ifnot entirely unknown), no accurate list of the “fifty greatest killers” could everbe compiled. The significance of epidemics has not depended solely on theirmortality rates. Some have affected particular communities in especially chal-lenging ways. The cholera pandemics of the nineteenth century, for example,often disrupted the societies they struck much more severely than their deathtolls would suggest. Some particular epidemics, such as plague in Italian citiesin the 1630s and in London in 1665, illustrate (in different ways) the evolutionof the second plague pandemic. Others have been chosen because human re-sponses to them underwent significant changes as they transpired, as was trueof the United States poliomyelitis epidemic of the 1940s and 1950s, and of thetyphoid epidemics in late nineteenth-century cities.

ix

Several other epidemics illustrate the important phenomenon of the virginsoil infection, when a disease reaches a society with no previous exposure to it.The epidemics of sixteenth-century America provide such an example on ahuge scale; the measles epidemic in 1875 Fiji, on a much smaller (and more typ-ical) one.

Still other epidemics have had literary or metaphoric importance, or refer-ences to them have entered into popular culture and everyday speech. The epi-demic in Athens in 430 B.C.E., or the Plague of Thucydides, has lived on in theworld of classical studies. References to consumption dominated literary andcultural discussions in (and about) the nineteenth century, as much because ofwho suffered from it as how many did. And also found here is Typhoid Mary,whose “epidemic” may have only resulted in three deaths, but whose name hasbecome a metaphor for a transmitter of any sort of trouble.

About half of the epidemics presented here occurred within (approximately)the past 150 years, and about half of those occurred between about 1850 andabout 1920. The generally more modern slant reflects in part the likely interestsof readers in the early twenty-first century. But it is also justified by some partic-ular historical circumstances. Documentation of more recent epidemics andpandemics is considerably more complete, partly because of the greater reliabil-ity of the statistics of population, morbidity, and mortality that (in many places)dates from the nineteenth century. And the period between the mid-nineteenthcentury and the early twentieth has particular interest as the time both whenWestern conceptions of disease and responses to epidemics underwent dramaticchanges, and when the West was in a position to impose those conceptions andresponses on other civilizations. The result has been some unusually well docu-mented historical accounts of significant epidemics in that period.

The book includes some current epidemics and pandemics. I have chosenthose largely on the basis of their worldwide scope and high mortality (AIDS,malaria, tuberculosis) or their effects on human behavior (mad cow diseaseand—again—AIDS). But with the partial exception of mad cow, those currentexamples have already proven devastating; their effects have been real, not po-tential. This book is a work of historical reference. For that reason I have not in-cluded other current (or recent) epidemic scares, such as severe acute respira-tory syndrome (SARS) in 2003, whose historical significance is still unknown.Today’s shock disease may in a few years be relatively forgotten, as is the Le-gionnaires’ disease of the 1970s; it may prove to have been a false alarm, as didthe swine flu of the same decade. Of course, avian flu (or some other futurethreat) may also become a major pandemic; some reasons that may or may nothappen are discussed in the Epilogue, which considers some present and futureprospects for confronting epidemics.

Prefacex

The epidemics chosen for this book have been drawn from many parts ofthe world, for diseases have paid little attention to national frontiers. But it isalso true that the majority of the diseases found here have affected the Westernworlds of Europe and North America. In part that reflects my interests andknowledge, in part it reflects the density of available scholarship and informa-tion, and in part it recognizes that many of the users of this book will seek in-formation about the Western (and especially the American) past. I recognizethat ultimately the choices of epidemics and pandemics to include have beenpersonal ones, and I would like readers to understand that. Certainly manyother epidemics might have been chosen, in addition to or instead of, the onesfound here.

The words “epidemics” and “pandemics,” found in the book’s title, havemeanings that are imprecise. An epidemic, according to the New Shorter OxfordEnglish Dictionary, is a disease “normally absent or infrequent in a populationbut liable to outbreaks of greatly increased frequency and severity,” or a “tempo-rary but widespread outbreak of a particular disease.” No agreement exists, how-ever, on how widespread or frequent qualifies a disease as an epidemic. Anotherstandard dictionary, Webster’s New Collegiate, gives another and somewhatbroader definition: “excessively prevalent.” Following that view, this book in-cludes such examples as consumption in the nineteenth century. Consumptionhad long been a serious disease in the Western world, year in and year out; con-temporaries judged it “excessively prevalent” in the nineteenth century, and itprobably was. Most of the epidemics treated here, however, were sudden spikesin mortality and morbidity, “of greatly increased frequency and severity.”

A pandemic is simply an epidemic on a very wide geographical scale, per-haps worldwide, or at least affecting a large area of the world. But again, no quan-titative measure exists that establishes when an epidemic becomes a pandemic.

Readers of this book should be aware that the identification of the causes ofpast epidemics is often unsure, and that point should emerge from a number ofthe chapters in the book. Modern disease understandings and categories differsignificantly from those of past ages and places. When people of the sixteenthcentury spoke of a “great pox” they may have meant what we now call syphilis,but they likely included in their term other (by more recent standards) ailmentsas well. Some older descriptions of symptoms may suggest several possibilitiesto a modern student; some might even describe diseases now not known.

This book is a work of synthesis. In writing it I have necessarily leaned onthe work of many other authors, and my debt to those authors is immense.Some chapters in the book have relied particularly on one author or another,without whose works the chapters would not have taken the form they take, orindeed would not have been possible at all. I hesitate to name some, for fear of

Preface xi

omitting others. But the following chapters did rely to a great extent on one au-thor: smallpox in eighth-century Japan, on William Wayne Farris; epidemics inseventeenth-century China, on Helen Dunstan; smallpox in 1707 Iceland, onJón Steffensen; plague in 1771 Moscow, on John T. Alexander; yellow fever in1853 New Orleans, on John Duffy; cholera in 1892 Hamburg, on Richard Evans;cholera in 1911 Naples, on Frank Snowden; Typhoid Mary, on Judith WalzerLeavitt; and poliomyelitis in the United States in 1916, on Naomi Rogers.

Those debts, and many others, may be found in the suggestions for furtherreading found at the end of each essay. I hope that the readers of this book willbe inspired to consult other readings, and will gain pleasure and informationfrom doing so.

Prefacexii

1

1EPIDEMIC IN ATHENS,

430–427 B.C.E.

WHEN AND WHERE

In the summer of 430 B.C.E., a very violent epidemic struck the Greek city ofAthens. According to the contemporary Athenian historian Thucydides (whohimself suffered from the disease and is the most important source of informa-tion about it), the epidemic first affected the adjacent port area (Piraeus) andthen moved into the central upper city. The epidemic occurred early in thePeloponnesian War, a major conflict between the city-states of Athens andSparta and their respective allies, which began in 431. The disease accompaniedAthenian military forces in their campaigns of 430 and 429, both at sea andagainst the Chalcidians of Thrace. The epidemic returned strongly in 427, afterapparently easing in 428. It then disappeared, at least from written records, al-though it may have spread as far west as Rome in later decades.

Between 25 and 35 percent of the Athenian population may have died inthis catastrophic epidemic, which struck all segments and age groups of thepopulation. Thucydides at one point, for example, refers to 1,050 deaths in a de-tachment of 4,000 heavy infantry (hoplites).

This epidemic has traditionally been called the “Plague of Athens,” but itwas almost certainly not an epidemic of bubonic or pneumonic plague. Theidentification of its cause (in modern biomedical terms) remains uncertain, al-though smallpox (or perhaps measles) seems most likely. (See “Unresolved His-torical Issues.”)

SIGNIFICANCE

Some of the Athenian epidemic’s significance stems from its time and place, forAthens in its classical age has been a focus of Western study for centuries. The

Peloponnesian War has long symbolized a clash of value systems thought cen-tral to the traditions of Western civilization. Thucydides, who told its story, be-came one of the prime exemplars of Western historical writing. The traditionsof classical education that dominated Western elites for several centuries (atleast before the mid-twentieth) assured that those elites may have been more fa-miliar with Athens in the fifth century B.C.E. than they were with much of theircontemporary world. Abraham Lincoln’s Gettysburg Address (1863) echoedthemes from Thucydides. For many generations of well-educated Europeans andAmericans, therefore, the Plague of Athens was a familiar point of reference.

Epidemics and Pandemics2

Thucydides, c. 465–c. 395 B.C. (Library of Congress)

In its time this epidemic was evidently an exceptional event, noticed in away that other epidemics were not. At least in the short run it weakenedAthens while the city-state was engaged in a very serious war with a powerfulenemy. That weakness led to rising criticism of the policies of the long-timeAthenian democratic leader Pericles. His opponents noticed that Pericles’ warpolicies included moving people into Athens from the surrounding countrysideof Attica, apparently worsening the epidemic situation.

Thucydides also recounted a serious breakdown in respect for laws and so-cial norms in the wake of the epidemic, and that may in turn have played alonger-range role in what many scholars have since seen as a “collapse of Athe-nian morality” during and after the Peloponnesian War (Fine 1983, 464).

The short-term effects on the demography of Athens were likely serious.Robert Sallares has suggested that pregnant women may have suffered particu-larly high mortality rates in 430–427, with the result that in the crucial waryears of 412–409 Athens had trouble maintaining military manpower. Largerclaims that the epidemic began the decline of the Athenian empire (“a blow onAthenian society from which it never entirely recovered,” from McNeill 1976,105) seem less likely and certainly harder to prove. (See also “Unresolved His-torical Issues.”)

BACKGROUND

The disease described by Thucydides probably found Athens to be virgin-soilterritory; a place whose population had no previous exposure to it. The highrate of mortality the disease exacted, and the fact that Thucydides said that itssymptoms were new to the people and their medical knowledge, are both char-acteristics of a virgin soil epidemic. In addition, its appearance in the midst of amajor war meant that people were moving around, both with military forcesand because Athenian policy concentrated rural populations within the city.Opportunities for contagion were thus magnified.

HOW IT WAS UNDERSTOOD AT THE TIME

This disease baffled the Athenian people. They saw no clear cause for it. Thedisease arrived during a year that had otherwise seemed healthy, and it attackedthe strong as readily as the weak. Some sought a sinister cause, believing thatthe Spartan enemies had poisoned reservoirs. Many more believed in the dis-pleasure of the gods, but the performance of rites to appease them had no effect.

Epidemic in Athens, 430–427 B.C.E. 3

Contemporaries noticed some phenomena associated with the disease. Itwas evidently contagious; doctors who attended the sick were at particular riskas a result. In the same vein, Thucydides noted that the most densely settledarea, the upper city, suffered heavily. He also observed that people once strickenby the disease apparently gained immunity from further attacks. And he thor-oughly described the disease’s symptoms, although he did so as an intelligentlayman, not a physician (see “Source Reading 1”).

SOURCE READING 1

The contemporary Athenian historian Thucydides, an eyewitness of the epi-demic, describes its effects:

That year then is admitted to have been otherwise unprecedentedly free from

sickness; and such few cases as occurred, all determined in this. As a rule,

however, there was no ostensible cause; but people in good health were all of a

sudden attacked by violent heats in the head, and redness and inflammation in

the eyes, the inward parts, such as the throat or tongue, becoming bloody and

emitting an unnatural and fetid breath. These symptoms were followed by

sneezing and hoarseness, after which the pain soon reached the chest, and pro-

duced a hard cough. When it fixed in the stomach, it upset it; and discharges of

bile of every kind named by physicians ensued, accompanied by very great dis-

tress. In most cases also an ineffectual retching followed, producing violent

spasms, which in some cases ceased soon after, in others much later. Exter-

nally the body was not very hot to the touch, nor pale in its appearance, but

reddish, livid, and breaking out into small pustules and ulcers. But internally it

burned so that the patient could not bear to have on him clothing or linen even

of the very lightest description, or indeed to be otherwise than stark naked.

What they would have liked best would have been to throw themselves into

cold water, as indeed was done by some of the neglected sick, who plunged

into the rain-tanks in their agonies of unquenchable thirst, though it made no

difference whether they drank little or much. Besides this, the miserable feel-

ing of not being able to rest or sleep never ceased to torment them. The body

meanwhile did not waste away so long as the distemper was at its height, but

held out to a marvel against its ravages; thus when they succumbed, as in most

cases, on the seventh or eighth day to the internal inflammation, they still had

some strength in them. But if they passed this stage, and the disease descended

further into the bowels, inducing a violent ulceration there accompanied by se-

vere diarrhea, this brought on a weakness which was generally fatal. For the

disorder first settled in the head, ran its course from thence through the whole

of the body, and even where it did not prove mortal, it still left its mark on the


extremities; for it settled in the privy parts, the fingers and the toes, and many

escaped with the loss of these, some too with that of their eyes. Others again

were seized with an entire loss of memory on their first recovery, and did not

know either themselves or their friends. (Thucydides 1982, 115–116)

It was understood (Thucydides reported) that the disease had its origins in“Ethiopia,” meaning Africa below Egypt, another example of determination tolocate disease somewhere apart from home; it then, he said, came to infectEgypt, Libya, and the Persian Empire before it appeared in Athens. Some Atheni-ans remembered an old saying that death would accompany a war with the Spar-tan Dorians. (Dorians were one of several different ethnic branches of the an-cient Greeks. Spartans were Dorians; Athenians were Ionians, and so regardedSpartans as a bit different.) Others recalled an oracle consulted by the Spartans inwhich a god promised to be with them—the Spartans—in the war. That Spartawas apparently little affected by this epidemic lent credence to that belief.

RESPONSES

For the Athenians of the fifth century no clear distinction existed betweenmedicine and religion, and so the responses of the city and its physicians com-bined elements of each. Medical arts seemed helpless, and no remedies appliedconsistently worked for more than a few victims. The rituals and rites per-formed for such gods of healing as Asklepios did not help. In their desperation,people (especially the poorer from the countryside without adequate housing inthe city) gathered around public fountains seeking the relief of water and theirbodies lay in the streets.

In such a time of high mortality, disposing of the bodies of the deceased be-came a problem, owing both to their numbers and to labor shortages created bythe war and the epidemic. Burial customs were disregarded. “Shameless” people(as Thucydides called them) placed bodies on the pyres erected for others, andThucydides also reported a general weakening of morality and respect for law.

SOURCE READING 2

Thucydides reflects on the epidemic’s effects on public behavior:

Nor was this [the illegal disposal of bodies] the only form of lawless extrava-

gance which owed its origin to the plague. Men now coolly ventured on what


they had formerly done in a corner and not just as they pleased, seeing the rapid

transitions produced by persons in prosperity suddenly dying and those who be-

fore had nothing succeeding to their property. So they resolved to spend quickly

and enjoy themselves, regarding their lives and riches as alike things of a day.

Perseverance in what men call honor was popular with none, it was so uncer-

tain whether they would be spared to attain the object; but it was settled that

present enjoyment, and all that contributed to it, was both honorable and use-

ful. Fear of gods or law of man there was none to restrain them. As for the first,

they judged it to be just the same whether they worshipped them or not, as they

saw all alike perishing; and as for the last, no one expected to live to be brought

to trial for his offences, but each felt that a far severer sentence had already been

passed upon them all and hung ever over their heads, and before this fell it was

only reasonable to enjoy life a little. (Thucydides 1982,118; readers might want

to compare this account with “Black Death” by Boccaccio, written during the

fourteenth century; see the chapter “Second Plague Pandemic, 1346–1844”)


“The Athenian Plague,” a painting by Nicolas Poussin (1594–1665). (Bettmann/Corbis)

UNRESOLVED HISTORICAL ISSUES

The Plague of Athens was almost certainly not plague, but the positive identifi-cation of the disease responsible remains elusive. The description by Thucy-dides makes no mention of the buboes typical of bubonic plague, while the du-ration of individual cases makes the rapidly fatal pneumonic plague equallyunlikely. Another candidate, typhus, is not contagious person-to-person, de-pending for its spread on an insect vector (the louse), while the Athenian epi-demic seemed to have moved too rapidly (especially if it jumped to Athens fromPersian territory) to be anything but airborne. Robert Sallares, in a careful re-view of the broad ecology of the situation, argues convincingly that smallpoxwas the most likely culprit. Reported mortalities from more recent smallpoxepidemics in virgin soil are consistent with those reported by Thucydides;smallpox is an airborne virus that moves more rapidly in densely settled places(and in fact needs a certain level of human population density to sustain itself);and while Thucydides’ description doesn’t specifically mention pockmarks,other parts of that account seem consistent with smallpox. Measles, anotherpossibility, shares many of the same causal arguments as smallpox, but Thucy-dides makes no reference to its characteristic rash. Some modern writers havesuggested two diseases acting in concert, but Thucydides did not think so. Ex-tensive modern historical and medical literature has also put forward manyother suggestions, among them tularemia (rabbit fever), glanders (primarily adisease of horses), and ergotism (from eating grain infected by a fungus). But un-til more information appears, smallpox seems the most likely candidate.

The long-term effects of this epidemic remain conjectural. Population lev-els in Athens may have been lowered at a crucial time as a result of the epi-demic, which may have contributed to Athens’ ultimate defeat in the long Pelo-ponnesian War against Sparta. But it is more difficult to argue a longdemographic decline, for human populations usually have recovered fairlyquickly from single great epidemics; only repeated epidemic shocks may de-press population levels for a long period. (See, for example, “Smallpox Epidemicin Japan, 735–737,” and “Second Plague Pandemic, 1346–1844.”) So while theepidemic of 430–427 may have had serious immediate effects on Athens duringthe Peloponnesian War, arguments that relate it to a longer-run decline of Athe-nian power in the fourth century B.C.E. are less clear.

Also difficult to judge are the epidemic’s long-term effects on popularmorale (and morality) in Athens. Donald Kagan (2003, 78) makes the point thatthe abandonment of burial customs illustrated the “panic, fear, and collapse ofthe most sacred bonds of civilization,” and John Fine (1983, 464) argues that


such “horrors” had “far-reaching” effects on Athenian morality. At the least,the experiences of the epidemic of 430–427 should be considered when suchlarge speculative issues are raised.

REFERENCES

Fine, John V. A. 1983. The Ancient Greeks: A Critical History. Cambridge, MA: HarvardUniversity Press.

Kagan, Donald. 2003. The Peloponnesian War. New York: Viking.

McNeill, William H. 1976. Plagues and Peoples. New York: Doubleday/Anchor.

Sallares, Robert. 1991. The Ecology of the Ancient Greek World. Ithaca, NY: CornellUniversity Press.

Thucydides. 1982. The Peloponnesian War, book II. “Crawley” trans., rev. ed. T. E. Wick.New York: Modern Library.

SUGGESTED ADDITIONAL READING

A sample of the extensive literature that offers different explanations of the disease re-sponsible for the epidemic follows:

Eby, Clifford H., and Harold D. Evjen. 1962. “The Plague at Athens: A New Oar in Mud-died Waters.” Journal of the History of Medicine and Allied Sciences 17: 258–263.

Littman, R. J., and M. L. Littman. 1969. “The Athenian Plague: Smallpox.” Transactionsof the American Philological Association 100: 261–275.

Poole, J. C. F., and A. J. Holladay. 1979. “Thucydides and the Plague of Athens.” Classi-cal Quarterly, n. s., 29: 282–300.

Scarborough, John. 1970. “Thucydides, Greek Medicine, and the Plague at Athens: ASummary of Possibilities.” Episteme 4: 77–90.

Wylie, J. A. H., and H. W. Stubbs. 1983. “The Plague of Athens, 430–428 B.C.: Epidemicand Epizoötic.” Classical Quarterly, n. s., 33: 6–11.

For those who read German, the following article reviews the extensive literature on theproblem:

Leven, Karl-Heinz. 1991. “Thukydides und die ‘Pest’ in Athen.” Medizin historischesJournal 26: 128–160.


9

2MALARIA IN

ANCIENT ROME

WHEN AND WHERE

Malaria was a frequent malady in the ancient Roman world. In many ways itwas more an endemic disease than an epidemic one (see the Preface and theGlossary), but its likely significance for Roman society, its dramatically sea-sonal character, and the wide geographical variations in its incidence, all sug-gest epidemic may be appropriate. Many points about its history in the ancientMediterranean, however, remain controversial or uncertain, and so this discus-sion concludes with a number of unresolved issues. A strong case can be madethat malaria affected the demography of the Roman world, perhaps stuntingeconomic productivity, contributing to agricultural change, depopulating someregions and changing the social system of others, and occasionally diverting thecourse of political and military history.

Malaria in at least some forms was apparently found across the Mediter-ranean area from an early period of ancient Roman history, certainly by the fifthcentury B.C.E. Its outbreaks were highly seasonal, beginning in July, with thenumber of cases peaking in September; subsequent deaths rose through the fallmonths, before subsiding by December.

Its incidence varied widely from one region to another. In general, malariaconcentrated in low-lying areas, below about 500 meters above sea level. InItaly some regions were thought by the Romans to be especially dangerous, andprobably were. Such regions included much of southern Italy, the island of Sar-dinia, the Pontine Marshes to the south of Rome, and the low-lying regions ofcoastal Etruria to the northwest. In the city of Rome itself, the low valleys thatlay between the hills, and the lands along the river Tiber, were fever-ridden.

SIGNIFICANCE

A modern historian has put the case for the importance of malaria in the an-cient Roman world thus:

Malaria enormously increased mortality levels, sharply reduced life expectancy

at all ages, and significantly altered the age-structures of human populations in

Europe in the past, wherever it became endemic. However, occurrences of

malaria tended to be highly localized . . . Consequently malaria generated enor-

mous regional variations in demographic patterns in early modern Europe. In

view of the compelling evidence from ancient sources for the endemicity [of

malaria] in large areas of central and southern Italy . . . the comparative evi-

dence from early modern Europe suggests that such major regional variations

in demographic patterns should have occurred in Roman Italy. There is no

doubt whatsoever that that is exactly what happened. (Sallares 2002, 269)

If Sallares is correct, malaria played a major role in the depopulations ofimportant regions during the long period of Roman rule. The populations ofsouthern and coastal Etruscan lands fell off after about 300 B.C.E.; by the firstcentury C.E. the population of the once-fertile Pontine Marshes had collapsed.Malaria also contributed to elevated death rates in indirect ways; it interactedwith both gastrointestinal troubles (such as dysentery) and respiratory ones(such as tuberculosis). Pregnant women were particularly vulnerable to it, aswere their babies, many of whom suffered from low birth weight. The city ofRome itself was especially malarial, for reasons discussed in the “Background”section.

The ravages of malaria altered the way some Italian lands were used. Insome cases lands became so malarial that laborers could not be employed onthem in summer; as a result they were given over to pasture of animals. In otherplaces the farming population fled as environmental conditions made their landsmore disease-ridden; if those lands stayed in cultivation they may have beenworked by slave labor instead, the slaves having less choice in the matter.

The Roman historian Tacitus suggests some ways in which malaria mighthave interfered with military affairs. The soldiers of Vitellius (one of four em-perors in the chaotic year C.E. 69) were thus weakened as they occupied Rome:

Amidst the allurements of the city and all shameful excesses, they wasted

their strength in idleness, and their energies in riot. At last, reckless even of

health, a large portion of them quartered themselves in the notoriously pesti-

lential neighbourhood of the Vatican; hence ensued a great mortality in the

ranks. The Tiber was close at hand, and their extreme eagerness for the water

and their impatience of the heat weakened the constitutions of the Germans

and Gauls, always liable to disease. (Tacitus 1942, 532)


Speculations have been made about larger political consequences ofmalaria. To choose one example: did its presence discourage the complete con-quest of Italy by Attila, the king of the Huns, in the fifth century?

Malaria was undoubtedly a presence in Roman life and death, but its over-all significance remains in doubt. (See “Unresolved Historical Issues.”)

BACKGROUND

Some understanding of the modern beliefs about malaria will clarify both therole the disease played in ancient Rome, and the relevance of the environmentalbackground that characterized ancient Rome. Malaria is caused by one of sev-eral related parasitic microorganisms. In ancient Rome three of these were ap-parently present, those now called Plasmodium falciparum, Plasmodium vi-vax, and Plasmodium malariae. All cause intense fevers that strike periodicallywith debilitating effects on the body. The fevers from the first two microorgan-isms are called tertian fevers (meaning they appear every third day, counting in-clusively; if fever day one is a Monday, fever will reappear on day three,Wednesday), while Plasmodium malariae leads to a quartan fever pattern (ev-ery fourth day). Of these three versions of malaria, that from Plasmodium falci-parum, sometimes called malignant tertian fever, is the most serious; infectionwith it may last upwards of a year, and is often fatal. Malaria from Plasmodiumvivax (benign tertian) is less serious but can persist for several years. Quartanfever may become utterly chronic, lasting one’s whole life. Multiple infectionsby more than one type are possible; it is also possible that a previous Plasmod-ium malariae infection may lessen the effects of Plasmodium falciparum.

These microorganisms are found in mosquitoes that belong to the largegenus called Anopheles, which includes hundreds of species, only some ofwhich carry the parasites. Those different species may inhabit different envi-ronments, and that fact contributes to the wide regional variations in malariaincidence. But most often Anopheles mosquitoes are found around bodies ofstagnant fresh water: pools, fish ponds, puddles, drainage ditches, and swamps.In Italy the mosquitoes generally are not (and presumably were not) foundhigher than about 500 meters above sea level.

The ancient city of Rome offered a number of such environments. Thebanks of the Tiber frequently flooded; much of the city lay in valleys betweenits famous seven hills, and mosquitoes favored those low lands; and the denselysettled city’s population favored irrigated gardens. And Rome adjoined other ar-eas of Italy that had an ancient reputation as feverish, the lands of Latium andEtruria with many low-lying and swampy grounds.

Malaria in Ancient Rome 11

The Romans undertook active projects in the landscape that contributed tocreating malarial environments. Their intensive development of croplands inEtruria and Latium involved widespread deforestation. That in turn diminishedthe absorption of rainwater by foliage, which meant higher underground watertables and greater likelihood of flooded lowlands and marshes. The Romanswere especially famous for their road building, and many of those projects dis-rupted drainage patterns and created new wetlands.

And the expansion of the great city of Rome represented further opportuni-ties for both mosquitoes and Plasmodium parasites. Ancient Rome’s populationwas perhaps one million, and its people lived in very crowded conditions, greatnumbers of them in the valleys between hills; mosquitoes had many (and easy)choices of people to infect. Rome was furthermore a huge magnet for in-migration, and people perhaps native to regions where malaria was not endemicflocked into the city where it certainly was. And people left Rome as well, per-haps carrying malaria infections with them to other places. Sallares refers to thecity as a “population sink” in which malaria collected, and from which it mightdrain elsewhere (Sallares 2002, 277).


Aqueducts were among the most dramatic examples of Roman manipulation of the landscape,

although other projects contributed more directly to the creation of malarial environments.

Undated painting by Zeus Diemer. (Bettmann/Corbis)

HOW IT WAS UNDERSTOOD AT THE TIME

The Romans—and the Greeks from whom they adopted many of their beliefsabout disease—were familiar with fevers, which had been clinically described(with some precision) both by the authors of the Hippocratic Corpus (fifth cen-tury B.C.E.) and by later writers. Some of those fevers are clearly tertian and quar-tan malaria. About the causes of those fevers less agreement existed. Some fol-lowed the Hippocratic writings and blamed an imbalance of the body’s humors:

Continued fever is produced by large quantities of the most concentrated

bile . . . Quotidian fever is caused by a large quantity of bile, but less than that

which causes continued fever . . . Tertian fever lasts longer than quotidian

fever and is caused by less bile . . . Quartans behave similarly to the tertians

but last longer, as they arise from still less of the heat-producing bile and be-

cause they give the body longer respites in which to cool down. (Hippocratic

Writings 1978, 270–271)

The Roman understanding of fevers also might include a conviction thatsuch ailments had divine (or perhaps demonic) origin. Roman (and Greek)thought about diseases included both natural explanations (such as the hu-moral theory quoted above) and supernatural ones; no clear distinction wasmade between the two modes, and they often flowed seamlessly together inmedical explanations.

Some Romans believed that a quartan fever in the late summer or autumnwas a good omen for future health. And since (according to modern beliefs) aPlasmodium malariae infection may protect against later Plasmodium falci-parum, such Roman thinking may have been wise.

On an indirect level, the Romans understood that some environments wereunhealthy, and urged that they be avoided if possible. Such thinking went backat least to the fifth-century B.C.E. Hippocratic text Airs, Waters and Places,which associated diseases with environments. Following its counsel, such laterauthors as the Roman engineer Vitruvius (of the first century B.C.E.) and theslightly later Greco-Roman geographer Strabo feared swamps and marshes asfeverish territory.

RESPONSES

Direct medical or therapeutic responses to malarial fever were few, and gener-ally limited to bed rest. The possibly divine origin of fevers led to people wear-ing amulets that might ward off an attack.


The environmental beliefs of the Romans led to a number of indirect re-sponses to malaria that actually had some effect. Roman home owners wereurged to avoid swampy lands and river banks, and to place homes on higherground where winds might blow. In some cases such advice was rooted in aes-thetics more than in fear for health; marshes might contain unpleasant smells.For much the same reason, Romans regarded mosquitoes as pests and used fu-migants and skin repellants against them. But no evidence exists that the Ro-mans associated mosquitoes with disease transmission.

UNRESOLVED HISTORICAL ISSUES

Historical arguments about the significance of malaria in ancient Rome persist.At the heart of the debates may be unresolvable questions about demography:did depopulation occur in some parts of the Roman world at all? If it did, howmuch did malaria contribute to that? Were the places that the Romans identi-fied as “pestilential,” such as the Pontine Marshes, really depopulated, or atleast abandoned by Roman citizens? Convincing population figures for Romanhistory remain elusive.

Other questions about the significance of malaria stem from some factsabout the disease itself. If malaria was very prevalent, should not the generalhealth and vigor of the Italian population have been impaired by such a chronicand weakening disease? Or did the Roman population continue to provide hardysoldiers for the state’s armies? If so, did less malarial regions contribute morevigorous men?

If malaria really had been endemic in the Roman population for centuries,would not the members of the population have adjusted to it? Would Romanbodies have acquired some immunities or inherited resistance? How much, inshort, can an endemic disease affect demographic change?

How widespread was Plasmodium falciparum in the Roman world, and if itwas widespread when did it become so? For historians who argue the impor-tance of the disease to Roman demography, the long-term and widespread pres-ence of that type of malaria is a crucial part of their case, for it is “malignanttertian” fever that it is most often and most quickly fatal. But the presence ofwidespread Plasmodium falciparum remains in doubt.

Studies that argue the importance of malaria in ancient Rome have reliedheavily on the documented effects of the disease in later periods of history, es-pecially in Italy itself. While many such backward projections are convincing,those who wish to downplay malaria’s role have argued that such a method can-not replace more direct evidence.


Malaria was certainly present in the Roman world, and the Romans werevery conscious of it. What remains uncertain is its quantitative, demographiceffect on the Roman population, and thus on Roman social structure, economicproductivity, and political and military power. For those reasons, the potentialsignificance of malaria on the whole course of ancient Mediterranean history,including what in earlier historical writing was called the “decline and fall ofthe Roman Empire,” is enormous. But the case remains unproven. Brunt (1971)summarizes doubts about malaria’s importance; Sallares (2002), the most recentthorough discussion, makes the case for its significance.

REFERENCES

Brunt, P. A. 1971. Italian Manpower, 225 B.C.–A.D. 14. Oxford: Clarendon.

Hippocratic Writings. 1978. Edited by G. E. R. Lloyd. Translated by J. Chadwick et al.London: Penguin.

Sallares, Robert. 2002. Malaria and Rome: A History of Malaria in Ancient Italy. Ox-ford: Oxford University Press.

Tacitus. 1942. The Complete Works of Tacitus. Translated by Alfred J. Church andWilliam J. Brodribb. New York: Modern Library.

SUGGESTED ADDITIONAL READING

Jackson, Ralph. 1988. Doctors and Diseases in the Roman Empire. Norman: Universityof Oklahoma Press.

Lo Cascio, Elio. 1994. “The Size of the Roman Population: Beloch and the Meaning ofthe Augustan Census Figures.” Journal of Roman Studies 84: 23–40.

Shaw, Brent D. 1996. “Seasons of Death: Aspects of Mortality in Imperial Rome.” Jour-nal of Roman Studies 86: 100–138.


17

3PLAGUE OF THE ANTONINES

WHEN AND WHERE

A major epidemic began in 165 C.E., reportedly among Roman troops in Parthia,a Mesopotamian area on the fringe of the Roman Empire. From there it spreadwidely over the Roman world, reaching Rome in 166. It lasted for at least fif-teen years, and an epidemic outbreak in Rome in 189 may have been a continu-ation of it. No certain knowledge of mortality is possible, but on the basis ofparallels with more recent disease episodes, some modern authorities have esti-mated that perhaps 10 percent of the Roman Empire’s population, or as many asfive million people, perished in the epidemic. Specifically heavy losses mayhave been suffered by Roman armies and in the densely settled cities of the em-pire, especially Rome itself. Other evidence has been used to argue high levelsof mortality in the Nile delta during the epidemic, but that conclusion is at besttentative.

Galen, the famous Greco-Roman physician, lived at the time of the epi-demic and left some clinical descriptions of cases. Those descriptions stronglysuggest that the epidemic was smallpox. Although sometimes called a plague,no evidence suggests that bubonic plague was responsible, or even present. Inaddition to smallpox, other simultaneous infections may have been involved.

SIGNIFICANCE

The Plague of the Antonines was one of a series of powerful epidemics thatshook the Roman Empire. One modern scholar has concluded that “the [earlier]historians’ indications of a major widespread catastrophe are largely correct”(Duncan-Jones 1996, 136). Another historian, more cautious about claims forthe importance of this epidemic, admitted that it “caused more deaths than any

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