The Plague of AthensHans House, MD, FACEPVice Chair for EducationDepartment of Emergency MedicineUniversity of Iowa

Objectives

• Discuss a historical case presentation and explore the differential diagnosis of an unknown infectious disease

• Understand the impact infectious diseases may play in the course of human history

• Try to learn almost as much ancient Greek culture as my 6 year old daughter

Marathon: 490 BC

Thermopylae479 BC

300

“Come back with your shield or on it”

Themistocles and the Battle of Salamis

Themistoclian walls

No longer united by the threat of Persia, alliance between Sparta and Athens deteriorates

Pericles

• c495 – 429 BC• Dominated Athenian

politics for 30 years• Athens had great navy• No match for Sparta in

open battle• Utilize walled port to

resupply and stage raids• Intended to fight war of

attrition

Summer of 430 BC: plague begins

Thucydides

Plague in an Ancient City, Michael Sweerts, 1652

‘‘It first began, so it is said, in Ethiopia above Egypt, and then descended into Egypt and Libya and into most of the King’s land. Suddenly falling upon Athens, and first attacked the population at Piraeus, so that they themselves said that the Peloponnesians had thrown poison into their wells: for there were, as yet, no cisterns there. But afterwards it came to the upper city as well, and from that time the deaths became much greater.”

‘‘It first began, so it is said, in Ethiopia above Egypt, and then descended into Egypt and Libya and into most of the King’s land. Suddenly falling upon Athens, and first attacked the population at Piraeus, so that they themselves said that the Peloponnesians had thrown poison into their wells: for there were, as yet, no cisterns there. But afterwards it came to the upper city as well, and from that time the deaths became much greater.”

“But suddenly, healthy men were seized first with mighty heats in the head, and redness, and inflamed eyes, and the inside, both the throat and tongue, immediately became blood-red and emitted an atypical, foul breath.’’

‘‘After which came sneezing and hoarseness, and in not much time the pain descended into the chest, and produced a severe cough; and when it fixed in the stomach, it upset it, and vomiting of bile of every kind named by physicians ensued, accompanied by great suffering; and in most cases nonproductive retching followed, giving way to violent spasms, which sometimes abated soon after, in others, long after.’’

“But suddenly, healthy men were seized first with mighty heats in the head, and redness, and inflamed eyes, and the inside, both the throat and tongue, immediately became blood-red and emitted an atypical, foul breath.’’

‘‘After which came sneezing and hoarseness, and in not much time the pain descended into the chest, and produced a severe cough; and when it fixed in the stomach, it upset it, and vomiting of bile of every kind named by physicians ensued, accompanied by great suffering; and in most cases nonproductive retching followed, giving way to violent spasms, which sometimes abated soon after, in others, long after.’’

“But suddenly, healthy men were seized first with mighty heats in the head, and redness, and inflamed eyes, and the inside, both the throat and tongue, immediately became blood-red and emitted an atypical, foul breath.’’

‘‘After which came sneezing and hoarseness, and in not much time the pain descended into the chest, and produced a severe cough; and when it fixed in the stomach, it upset it, and vomiting of bile of every kind named by physicians ensued, accompanied by great suffering; and in most cases nonproductive retching followed, giving way to violent spasms, which sometimes abated soon after, in others, long after.’’

‘‘Externally, the body was not very hot to the touch, and was not pale, but reddish, livid, and flowering with small blisters and wounds. But internally was it such a heat that the patients could not bare garments or fine cloths being laid on them, nor be anything but naked, and would have liked best to hurl themselves into cold water, as in fact, many of those neglected did, throwing themselves into cisterns, tormented by unquenchable thirst. And it was the same whether they drank much or little.’’

‘‘Externally, the body was not very hot to the touch, and was not pale, but reddish, livid, and flowering with small blisters and wounds. But internally was it such a heat that the patients could not bare garments or fine cloths being laid on them, nor be anything but naked, and would have liked best to hurl themselves into cold water, as in fact, many of those neglected did, throwing themselves into cisterns, tormented by unquenchable thirst. And it was the same whether they drank much or little.’’

‘‘Also, they were ceaselessly tormented by the inability to rest or sleep. And the body, while the disease flourished, did not whither, but withstood the ravages of the disease; so that when they died, as most did, on the seventh or ninth day from the burning heat, they still had some strength. But if they escaped this, the disease descended into the bowels, creating a great ulceration, and at the same time, accompanied by acute diarrhea, and many later died from exhaustion because of this. . . it left its mark on the extremities. For it fell upon the genitals, and the tips of the hands and the feet, and many escaped, being deprived of these, some also lost their eyes. Others again were taken with a complete loss of memory after recovery, and they failed to know either themselves or friends’’

‘‘Also, they were ceaselessly tormented by the inability to rest or sleep. And the body, while the disease flourished, did not whither, but withstood the ravages of the disease; so that when they died, as most did, on the seventh or ninth day from the burning heat, they still had some strength. But if they escaped this, the disease descended into the bowels, creating a great ulceration, and at the same time, accompanied by acute diarrhea, and many later died from exhaustion because of this. . . it left its mark on the extremities. For it fell upon the genitals, and the tips of the hands and the feet, and many escaped, being deprived of these, some also lost their eyes. Others again were taken with a complete loss of memory after recovery, and they failed to know either themselves or friends’’

Durack DT,.. Am J Med 2000;109:391Cunha. Infect Dis Clin N Am 2006; 20: 253–272

Asclepius, son of Apollo Chiron, the great tutor

1998

Typhoid Fever•Insidious onset over weeks•Abd pain, Rose Spots follows•Progressive sepsis•Ulceration and perforation at site of Peyer’s Patches•Neurological sx possible•Diarrhea in about half•Pulse- fever dissociation•Pneumonia seen in children•15% mortality w/o Abx

Impact of the Plague

• Killed Pericles and 25% of the population• Athens rebuffed peace offer by Sparta in 425 BC• Sicilian expedition• Sparta victorious 404 BC, Socrates executed 399

BC• Ended Athens’ golden age, replaced with

anarchic, live for the moment existence• Ended ancient world’s experiment w/ democracy

Summary

• Marathon• 300 Spartans• Pericles and Thucydides• Staff of Asclepius vs Caduceus • Hippocratic Oath• Greatest medical mystery in

history lives on…maybe…

Raining 300 Men

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