Galen and the Antonine PlagueAuthor(s): R. J. Littman and M. L. LittmanSource: The American Journal of Philology, Vol. 94, No. 3 (Autumn, 1973), pp. 243-255Published by: The Johns Hopkins University PressStable URL: http://www.jstor.org/stable/293979 .Accessed: 30/03/2011 18:26

Your use of the JSTOR archive indicates your acceptance of JSTOR's Terms and Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp. JSTOR's Terms and Conditions of Use provides, in part, that unlessyou have obtained prior permission, you may not download an entire issue of a journal or multiple copies of articles, and youmay use content in the JSTOR archive only for your personal, non-commercial use.

Please contact the publisher regarding any further use of this work. Publisher contact information may be obtained at .http://www.jstor.org/action/showPublisher?publisherCode=jhup. .

Each copy of any part of a JSTOR transmission must contain the same copyright notice that appears on the screen or printedpage of such transmission.

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact support@jstor.org.

The Johns Hopkins University Press is collaborating with JSTOR to digitize, preserve and extend access to TheAmerican Journal of Philology.

http://www.jstor.org

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