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Some of history's deadliest killers have never been named.
The Fevered Past takes one medical mystery per episode - a plague, the unexplained death of a king, an epidemic that reshaped or annihilated a civilization - and works through it. What the ancient sources say. What modern science has been able to recover. Where the experts agree (or decidedly do not.) and where the honest answer is that we still simply do not know.
Some cases are famous. What killed Alexander the Great in Babylon? Some, less so: What was behind the Sweating Sickness of Tudor England, allowing the rise of Henry VIII and the Anglican Church, before suddenly vanishing?
Each episode opens with a scene placing you directly into the shoes of someone who lived through the period as an observer, lending a human perspective to events hundreds of years removed from the present - then, we begin our investigation.
The watch had ended at the second hour after dawn, and Callius walked down from the wall with the taste of bronze in his mouth. He had stood the night with three other men, none of whom he knew well, all of them straining their eyes at the dark fields beyond the gate for movement that did not come. The Spartans had not pressed the walls in some weeks. They did not need to. They had only to sit in the country and burn what they liked and wait.
Ancient Athenian:Callius had heard one of the other men give word to this thought that they all bore near the third watch. No one had argued this time. It was the heat that struck him first, coming off the stones of the street as he descended into the lower city. Three months now since the Spartans had burned the orchards at Acchani and driven the country people inside the long walls, and the city had not been built for them. The alleys between the houses of the Keramikos were full of people who had no houses, families sleeping under awnings of stretched cloth, children squatting in doorways, old men with the dust of the road still on their feet.
Ancient Athenian:The smell was something he had stopped trying to name. Smoke, bodies, and the latrines that had overflowed in the second month and being dug again and even more poorly a third time. He passed a woman sitting against the wall of a temple with her child in her lap. The child's eyes were open, and Callias did not look twice. He had learned in the last weeks not to look twice.
Ancient Athenian:At the corner of his own street, he stopped. There was a sound coming from the house of his neighbor, a man named Diocles, a potter who had taken in three cousins from the country when the walls came down at Onnoy. The sound was one he had heard now perhaps a dozen times in as many days. It was not weeping, not exactly. It was the noise a man made when he had already been weeping for a long time and had stopped being able to and started choking on the effort.
Ancient Athenian:Goliath stood in the street with his shield on his back and listened. And after a moment, he went on. His door was closed. He had left it open when he went up to the wall. He stood before it for what felt to him a long time.
Ancient Athenian:The bronze was still in his mouth, the heat was rising, and somewhere down the street, a dog was barking and barking and would not stop. He put his hand to the door and pushed it open.
Dylan:The story you heard just now was a person. A person who lived, breathed, raised a family, and witnessed firsthand the events we are going to discuss. A person reconstructed from sources, from bones, from the things that we know, and the things that we have to imagine to fill the spaces between. My name is Dylan, and this is The Fevered Past. Each episode, we take a medical mystery from somewhere in the long human record, a plague, a mysterious death, an epidemic that forever changed a culture in the future and we try to work out what actually happened.
Dylan:Now what the legend says, now what the rumors are, what the evidence read carefully and honestly will and will not let us conclude. Some are famous, there are some you will have never heard of before. Most of them have been debated for a very long time by people much more clever than myself and we'll meet a number of these people along the way, the historians, epidemiologists, and molecular biologists who have spent careers staring at the same handful of sentences and trying to figure out what disease exactly was doing the killing. A note before we begin, I'm not a physician. I am not a historian or a classicist.
Dylan:I'm a person who finds this material genuinely interesting, has done the reading, and will guide you through it as carefully as I can. I am human and I may make mistakes along the way. Where the evidence is good, I'll tell you. Where it isn't, I'll tell you that too. Where we simply do not know, which I should warn you is going to come up rather a lot, I'll say it plainly and we'll sit in that not knowing together.
Dylan:Because that, in the end, is what most of history actually is. So, let's get started. Before we dive directly into the plague itself and what ailed Athens in the fifth century BCE, I think it's important to get a little bit of geopolitical context surrounding the Hellenic world at this time. Athens at this time was a political powerhouse that had entered its golden era. It was the center of Hellenic culture alongside its rival state of Sparta.
Dylan:They had both unexpectedly expelled invasion repeatedly at Marathon, Salamis, and Plataea in the Persian Wars, spanning five decades from April to April. After the defeat of the Achaemenids in April, the period known as Pentaconatea began. Fifty years of relative peace during which the Athenians collected tribute from the Delian League, a coalition of city states that paid Athens for protections should the Persians threaten the shores of Greece once more. Using this continuous influx of wealth, Athens was able to fund art, science, and infrastructure, including the Parthenon, which was built about this time in April. This period represented a broader shift in Greek culture from myth to reason with pre Socratic philosophy and Hippocratic medicine taking root at this time.
Dylan:While not all classes of person were direct beneficiaries of this golden age following the unlikely defeat of Xerxes. For many in the Hellenic sphere, this was the moment where the future seemed at its brightest yet. Perhaps it is for this reason that the violent self destruction of the Greek world during the Peloponnesian Wars beginning in April, along with the devastating plague that would ravage seemingly only the population of Athens, seemed so crushing to those caught between the warring leagues. Before we look directly through the eyes of our primary source, Thucydides, it is important to establish an understanding of the medical methodologies that have become standard practice in this era. Though certainly lacking in the accuracy that we would recognize as modern medicine, the Hippocratic method represented a vast improvement on what had come before, a purchase far less secular and far less concerned with observable evidence.
Dylan:At its core, this method represented a fundamental shift in the epistemology of disease, away from the divine, Theos, and toward a measured empirical craft, Techni. Central to this framework was humoral theory, which held that the body was governed by four fluids, blood, phlegm, yellow, and black bile. The goal of any physician practicing in this era was to bring these four fluids into balance, a state known as eucrasia. Any imbalance, or dyscrasia, was understood as the root of disease. The practitioner's task was to examine the whole body, or soma, collecting somaiotice, or signs and symptoms, that would then inform treatment.
Dylan:A patient presenting with fever and an excess of yellow bile, for instance, might be treated with a cooling or moistening agent intended to counteract that fluid's hot and dry qualities. Primarily, however, physicians of this era believed in prognosis over intervention. The goal of treatment was not to arrest the course of disease necessarily as we treat things today, but rather to remove whatever obstacles might prevent the body from healing itself. This produced a notably conservative medical philosophy grounded in the conviction that the body tended naturally toward humoral balance. It placed heavy emphasis on dietetics, understood broadly to encompass not just food, but environment, fresh air, water quality, living quarters, and physical activity.
Dylan:All of these things tightly controlled to give the body the best possible conditions for recovery. During epidemics such as the plague that ravaged Athens and its surrounding territories between 04/30 and 04/26, Hippocratically trained physicians moved through the stricken city recording the crisis. Not seeking a cure per se, but examining the environment for causes, scrutinizing the airs and waters they suspected of producing disease within the city walls, and meticulously documenting both environmental conditions and patient symptoms. One grim consequence of this approach and one that remains painfully familiar to us today is that the intimate examination demanded by Hippocratic practice, that is smelling the breath, inspecting stool, pressing the skin to assess heat, disproportionately exposed these physicians to whatever was killing their patients. They were, as a result, often among the first to follow those patients into the mass burial pits that soon scarred the Athenian landscape.
Dylan:The Thucydides himself contracted the plague and survived, and it is his account, written as a historian in general, rather than a physician, that remains our most detailed primary source. He and his physician contemporaries, working within the constraints of humoral theory, drew conclusions we now know to be incorrect. Yet, as we will see, they came tantalizingly close to identifying the likely true cause of the Athenian Plague, despite standing nearly two millennia before even the first faint glimmers of microbiology. And so it is now, at this moment, with the population of Athens swollen somewhere between one and three hundred thousand by the refugee crisis from Attica, that the symptoms of the plague first begin to manifest Yes. Recorded by The Fevered Past Fevered Fevered Fevered Fevered Past the lifeline of the besieged city behind its own long walls.
Dylan:He writes.
Ancient Athenian:It first began, it is said, in the parts of Ethiopia and Egypt, and thence descended into Egypt and Libya into most of the king's country. Suddenly falling upon Athens, it first attacked the population in Piraeus, which was the occasion of their saying that the Peloponnesians had poisoned the reservoirs, there being as yet no wells there.
Dylan:Here, the Athenians do arrive at a plausible explanation despite an incorrect conclusion. It is entirely reasonable when faced with a situation in which so many people fall ill simultaneously to suspect the water supply. It is equally reasonable in wartime to suspect one's enemy. Thankfully, those of us studying the event today have the benefit of retrospect accumulated data and two thousand years of separation lending our objectivity a considerable advantage. Theusidades does note that similar illnesses had been observed elsewhere before, though never in Athens and never with this degree of lethality.
Ancient Athenian:It was said that it had broken out in many places previously in the neighborhood of Lemnos and elsewhere, but a pestilence of such extent and mortality was nowhere remembered.
Dylan:For all of its scholarly praise, Thucydides' description is somewhat sparse by modern standards or at least by the standards of anyone trying to suss out what disease actually befell Athens during this period. What he does offer, however, is a reasonably detailed account of symptoms and epidemiological observations which we will now examine in turn. He notes that first the disease struck the healthy and infirm alike producing violent heat in the head, redness and inflammation of the eyes, throat, tongue, sneezing, hoarseness, and a hard cough. The disease then appears to have moved to the stomach with physicians attempting to relieve patients through purging of the various vials and producing instead a profound and ineffectual retching, violent spasms, and eventually a debilitating diarrhea that sapped what remained of the patient's strength before death soon followed. Notably, the body was not hot to the touch despite the patient's internal suffering.
Dylan:Those afflicted reported burning from within and developed an extreme hypersensitivity of the skin, becoming unable to tolerate even the lightest clothing or linen. Most preferred to go entirely without. This nakedness presumably enabled Thucydides next observation, the development of reddish livid pustules and ulcers across the body, the precise Greek terminology for which has been a source of considerable debate among scholars attempting to identify the pathogen. Among the more striking details, Thucydides describes the neglected sick throwing themselves into rain tanks in the agonies of an unquenchable thirst. A grim development in a besieged city already suspicious of its water supply and struggling to contain a highly communicable illness.
Dylan:These symptoms collectively offer meaningful clues toward a potential pathogen and have been thoroughly explored by scholars and physicians throughout the twentieth and twenty first centuries. But, Thucydides account also includes several harder symptoms to reconcile, a mark left on the extremities leading to loss of fingers, toes, genitals, or eyes, and in survivors a loss of memory so complete that some knew neither themselves nor their loved ones. The first of these is most likely gangrene, a complication seen in severe infectious diseases including bubonic plague caused by the bacterium Yersinia pestis, one of the candidate pathogens proposed by scholars given the outbreaks documented across both antiquity and the medieval era, very famously the cause of the Black Plague. The second is considerably more difficult to account for, pointing to either a neurological component of the disease itself or to a comorbid process, delirium driven by severe dehydration from diarrhea for instance. The answer does matter.
Dylan:It determines whether we are searching for a disease with a neurological signature or whether we are permitted to set that symptom aside as atypical and pursue other candidates. Thucydides also provides several epidemiological observations worth noting. He records that the dying received the most compassion from those who had already survived the disease as survivors had no fear of reinfection. The same man was never attacked twice, at least not fatally. This speaks to a robust acquired immunity following infection.
Dylan:He also notes that a seemingly zoonotic dimension exists describing birds that fed upon the dead subsequently dying themselves and apparently learning to avoid the corpses thereafter. Dogs too were reportedly susceptible. Whether this reflects genuine cross species transmission or simply the chaos of a city overwhelmed by disease of every variety is difficult to say at this remote viewpoint. Perhaps most usefully, Thucydides provides enough detail to approximate a mortality rate. He describes a military detachment that contracted the illness and records that of four thousand heavy infantry under the command of Hagnon, ten fifty died, yielding a mortality rate of approximately twenty six percent.
Dylan:To summarize what our primary source gives us to work with, we have the following symptoms: fever, severe thirst, diarrhea, rash, ulceration, stomach pain, dry heaving, cough, delirium, and last but certainly not least, peripheral gangrene. From an epidemiological perspective, we have acquired immunity and survivors, a mortality rate of approximately twenty six percent, potentially zoonotic transmission, and rapid spread consistent with dense urban conditions like those in Athens at this time. From this foundation, scholars and physicians across the twentieth and twenty first centuries have attempted to identify the underlying disease with considerable disagreement and limited consensus. Though today, as we will see, the best evidence points towards what is perhaps the most compelling candidate yet proposed for what ravaged Athens for four long years and brought its dominance of the Hellenic world to an abrupt halt. And so, it is here, that the facts established, that many modern doctors and scholars have begun their research into the potential causes of the mysterious epidemic that laid low the undisputed leader of the Delian League in an effort to ascribe an explanation to such a brutal, sudden, and seemingly inexplicable turn of events in the classical world.
Dylan:There have been several proposed candidates discussed throughout the years, with contention, debate, and, it must be said, much plausibility for several of the options: Bubonic plague, pneumonic plague, influenza, smallpox, scarlet fever, measles, typhus fever, typhoid fever, ergotism or even now extinct disease that modern or even medieval medicine never categorized or some combination thereof. All of these have been proposed as serious candidates. Each of these options proves interesting in any number of ways by adding color to the story of Thucydides, depending on which of these suspects the truth lies with. So who then is the Kaiser Soze of fifth century Athens? So let's get the heavy hitter out of the way first.
Dylan:Bubonic Plague was, for lack of a more loaded word, a plague indeed on our ancestors of antiquity. The core symptoms of bubonic plague have been described at length by medieval and modern professionals and writers alike, to the point that an outbreak of the Black Death in fiction seems nearly trite at this point. Rapid onset of a high fever, chills, headaches, and extreme fatigue are hallmark symptoms of bubonic plague, all of which appear on our list of symptoms as presented by Thucydides. However, there are a few key problems with accusation against perhaps our most infamous and usual suspect of ancient mass murder. Here, things are going to get a bit ontological.
Dylan:One of the key arguments against spoofonic plague is the absence of the bubo, the hallmark swelling of the lymph nodes in the armpit, groin, and neck that comes along with an infection from Yersinia pestis. While Thucydides does indeed describe a rash, he does not describe anything quite so severe as a bubo is known to present. A nuance to this lies in the language that he wrote in Attic Greek, so many times translated and then finally extracted and rendered into modern English. He chooses a very specific word taken by some scholars, notably E. M.
Dylan:Hooker in 1978, to stand in for bubo, though it translates more closely to ulcer in English and is frequently used to denote something like swelling around a wound or some other form of ulceration on the body. Additionally, competing scholarship has pointed out that contemporary writers, Teuthusidides, used the word bubo or its Greek equivalent, meaning groin and specifically in the correct context, making it rather unlikely that Thucydides, who was a well educated general, a professional writer, and a historian of considerable thoroughness, would have reached for the wrong word had he been describing something like a bubo. Not all arguments are quite so sound. One of the more questionable arguments against bubonic plague goes as follows. The ancient Greeks, based on their recovered writings, appear to have had no word for rat.
Dylan:Therefore, there must have been no rats in Greece and consequently, no bubonic plague. As we all know, bubonic plague and its responsible bacterium Yersinia pestis is generally spread by fleas which are on infected rats which then travel via ship and lead to further infection. Now, this is a fairly asinine presumption for obvious reasons. To assume that there were no rats at all in classical Greece is absurd on its face and to deploy this as any form of scientific basis for eliminating bubonic plague as a suspect is equally so. A more substantive objection is this: bubonic plague, despite its popular representation, is not, strictly speaking, a highly communicable disease certainly not to the degree that Theusidades account would suggest.
Dylan:Transmission requires a vector, most commonly the aforementioned rat and flea two punch knockout combination. Thucydides describes a rapid transmission obviously driven by person to person contact. While one must imagine that densely packed populations such as Athens at this time would present an easier jump and go buffet for, it is probably not the level that is described here. Finally, the mortality rate presents something of a problem. Untreated bubonic plague kills somewhere between thirty to seventy percent of those infected.
Dylan:Our figure of twenty six percent sits rather comfortably below that range. And this, despite the population density of a besieged city, which one might reasonably expect to drive mortality upward rather than suppress it. While here, we'll discuss pneumonic plague. Somewhat unworthy of its own heading, it generally follows or occurs concomitantly with bubonic plague and is frequently implicated as the death knell driving the highest mortality within outbreak events. Caused by the same bacterium, its distinguishing contribution to the rather bleak proceedings is severe pneumonia and bloody sputum, the latter of which could potentially be read in a passage from Thucydides where he talks about the N word parts of the throat and tongue becoming bloody and emitting an unnatural and fetid breath, after which the pain soon reached the chest and produced a hard cough.
Dylan:It is worth noting, however, that bubonic plague does have one point in its favor. It is genuinely a zoonotic disease affecting over two hundred species across several varieties, domestic dogs included. To summarize, we match perhaps two or three of the symptoms from our list and they're pretty weak matches at that, representative of most pathological bacteria or acute viral infections. We like buboes, gastrointestinal or neurological involvement, all of which seem key to making a worthy accusation in this case. Our next suspect may be the most controversial that we discuss in the podcast today and I'm going to try to handle it gently.
Dylan:Influenza is well known to almost any person alive in the world today. It is one of the most prolific viral diseases in existence and accounts for nearly all of the pandemics in modern history to include the lethal nineteen eighteen pandemic of Spanish flu. On this basis alone, it's reasonable to examine influenza for a hand in what happened in Athens. However, on the face, some things immediately stand out as not fitting. Most people, even without the benefit of modern medicine, are not going to suffer peripheral gangrene as a result of influenza.
Dylan:Rash and ulceration are not entirely unknown as it relates to viral infections such as the flu, though it would perhaps be a bit of a stretch to consider them hallmark symptoms. However, influenza can and does cause respiratory symptoms, mortality, incredible fatigue, high fever, and certainly can cause delirium and downstream effects, though gastrointestinal involvement is somewhat rare as well. It is presumably for these reasons that Doctor. Langmuir and Doctor. Ray proposed a combination of an infection of influenza and toxic shock syndrome in 1985 to explain the events that were observed by Thucydides, going so far as to coin the term Thucydides syndrome to explain their findings.
Dylan:This hypothesis, however, does read somewhat stretched to the outside non clinical observer like myself. The doctors proposed that along with epidemic influenza, the Athenians additionally experienced concomitant infection of staphylococcus which, when emitting its endotoxins, stood to explain the remaining features and symptoms of the disease as described by Thucydides. The doctors posit that TSS combined with influenza explains the late stage emesis of every kind of bile as indicated by our primary source, along with presumable multi organ system failure as well as its hallmark as scarlatoform rash, so argued over in scholarly research. Indeed, they are correct. This combination of diseases does explain it quite well.
Dylan:However, so do several other arbitrary combinations of diseases. When we take a step back, which granted is much easier fifty years removed from this hypothesis, and realize that at the time of this paper, Streptococcal Toxic Shock Syndrome was experiencing something of a bacterial and research renaissance in the 1980s when the paper was released, rising rapidly in The United States as a result of more widespread utilization of high absorbency tampons, a somewhat different picture is painted. While we must give the doctors credit for their work and defer in the sense that we are not clinical experts, it does feel this combination is indeed plausible but it seems more likely that this is a case of diagnosis du jour with a resurgence in the 1980s causing a viewpoint that maybe doesn't necessarily reflect reality on the ground. Smallpox, the condition caused by the variola virus, is another obvious candidate given its virulence, high mortality, and its implication in several pandemics in both the classical world and in more recent times prior to its declared eradication by the World Health Organization in October 1977. Smallpox infection via a variola major does indeed fit many of the symptoms.
Dylan:It does result in high fevers, rapid mortality, and inflammation. Even respiratory distress can be a prominent feature in some of the more severe cases of smallpox infection. It also boosts mortality rates somewhere in the neighborhood of thirty percent reasonable within our margin of error at twenty six percent. Another tally in the favor of smallpox is that those who are infected and recover from the disease do indeed gain a long term immunity and are unable to be infected a second time that results in the same level of disease process as the initial infection with variola. Pustules and ulcers of the skin are also a major feature of smallpox intervention by thusavutase.
Dylan:However, this is where perhaps the theory loses a bit of traction. Smallpox ulceration is frequently extreme. Ulceration in the classical dimpled sores from smallpox can take up the entire body of a victim, leaving them as a massive bumpy pustule themselves. One would think that such a dramatic feature would be worth more than a single line in the description by The Fevered Past Fe Perhaps you might compare them to a bunch of grapes in a literary flourish, for instance. Finally, there are some things that simply do not square with what has been observed in outbreaks of smallpox in the decades leading up to the eradication of disease in the 1970s.
Dylan:Smallpox does not adequately explain bleeding and gastrointestinal distress, generally does not result in peripheral gangrene, and also somewhat fails to explain the heat factor that is while smallpox does result in fever, feeling so hot that one must jump into the city's water supply is generally not considered to be a feature of the disease. In summary, smallpox is quick and deadly, with many points in its favor, including several years of experience killing an epidemic, but its resume is not quite perfect for the listing Thucydides has posted. Now, let's talk about typhus. Typhus, like typhoid, has been a steady companion to humanity for as long as we have records of disease. The two were actually not reliably distinguished from one another until the middle of the nineteenth century.
Dylan:Both names derive from the same Greek word meaning smoke or stupor, a reference to the muttering delirium that characterizes the late stages of either disease. For the purposes of this discussion, when we say typhus, we specifically mean epidemic typhus, the louse borne disease caused by Rickettsia prauersakii. Epidemic typhus is, in many ways, the disease of the besieged city. It thrives in the conditions of crowding, poor hygiene, and the inability to change or wash clothing. Precisely the conditions one would expect to find inside the long walls of Athens during the Peloponnesian invasion, with refugees from the Attic countryside packed into a city built for a fraction of their number.
Dylan:The body louse, Petaclis Humanis Corporis, is the vector and it spreads easily between humans living in close quarters with infrequent bathing. Napoleon's grand army was famously decimated by typhus during the retreat from Moscow. It tore through the trenches of the First World War and it remains, even today, a disease that follows war and displacement wherever they occur. Clinically, typhus presents with a sudden onset of high fever, severe headache, and profound malaise, typically beginning a week or two after the bite from an infected louse. A characteristic rash develops on the trunk by the fifth or sixth day, spreading outward to the extremities and notably sparing the face, palms, and soles.
Dylan:As the disease progresses, the patient develops the muttering delirium for which the disease is named, along with photophobia and, in severe cases, multi organ involvement. Untreated epidemic typhus carries a high mortality rate of about forty percent. It is in the late stages that typhus becomes particularly interesting in the context of Thucydides' work. Among the more striking complications of severe untreated typhus is peripheral gangrene the same loss of fingers, toes, and extremities describes among the survivors of the Athenian Plague. The mechanism is rickettsial invasion of the vascular endothelium causing inflammation and thrombosis of the small vessels with predictable consequences for tissues at the end of the line.
Dylan:The fit here is frankly excellent. Where peripheral gangrene is an uncommon and notable complication of many diseases, it is a recognized and reasonably common feature of severe typhus, a disease that, as a matter of course, eats people from the extremities inward. It is for these reasons that Doctor. Robert Olson and colleagues in their 1996 paper in Emerging Infectious Diseases made a serious case for typhus as the Plague of Athens. Olsen's argument leans on the dang green fit, the crowding inside the walls, and the seven to nine day duration of acute illness described by our primary source, all of which align well with the natural history of epidemic typhus.
Dylan:The case is not new to Olsen either. Hans Zissner, in his 1935 Rat Slice and History, had already proposed typhus as a candidate, and the suggestion resurfaced more or less continuously in scholarly literature ever since. When we set the description side by side, typhus arguably fits Thucydides' work better than any of the candidates we've considered to this point. The gangrene is right. The delirium is right.
Dylan:The seven to nine day course is right. The conditions inside the walls of Athens during the siege were nearly purpose built for a louse born epidemic, and the disease itself is one that has, time and time again throughout recorded history followed armies and refugees into walled cities and produced exactly the kind of mortality that Thucydides describes. There are however the usual caveats. Thucydides describes the disease as beginning in the head and spreading downward while typhus rash classically begins on the trunk. Gastrointestinal symptoms are not a hallmark of typhus and Thucydides describes them fairly prominently.
Dylan:And as we will see shortly when we examine the molecular evidence, there is reason to believe that typhus, however well it fits in the clinical description, may not be the answer after all or at least, not all of it. And now, we talk about measles. Measles is, in some ways, the inverse of the candidates we've discussed thus far. Whereas diseases like typhus and typhoid are diseases of squalor and siege, measles is something rather different a disease that requires a relatively large and dense population simply to sustain itself. Modern epidemiological modeling suggests that measles requires a population of roughly a quarter of a million to half a million people in continuous contact to maintain endemic transmission.
Dylan:Below that, the virus burns through its susceptible hosts and dies out for want of new ones. This is a useful piece of information when we consider whether measles could have been present in the ancient Mediterranean at all. The case for measles in Athens rests largely on the work of Australian virologist Sir Frank McFarlane Burnett who in his 1962 Natural History of Infectious Disease proposed measles as a candidate for the Plague of Athens primarily on the basis of the rapid spread, the high attack rate, and the rash. Measles is among the most contagious diseases known in medicine with a basic reproduction number commonly estimated between twelve and eighteen, meaning that in a fully susceptible population, a single infected person can be expected to infect 12 to 18 others. Drop a virus like that into a walled city stuffed with refugees who have never encountered it, and the results would be catastrophic.
Dylan:Clinically, measles presents with a prodrome of fever, cough, coursera, and conjunctivitis, the so called three C's, followed several days later by the appearance of, quote, Koplix spots, end quote, inside the mouth and shortly thereafter the characteristic maculopapular rash that begins on the face and spreads downward over the body. This last point is genuinely interesting. Thustedes describes the disease as beginning in the head and progressing downward, which is one of the better fits for measles among the diseases he describes. Mortality in a virgin soil population can be devastating. The introduction of measles to the Faroe Islands in 1846 and to Fiji in 1875 produced mortality rates above twenty percent in populations that had never encountered the virus.
Dylan:The problem, however, is one of evolutionary timing. Measles is believed to have diverged from the Renderpest virus of cattle sometime between roughly 500 BCE and January CE, with the most recent molecular clock studies placing the divergence considerably later than was once believed, likely in the sixth century CE or thereabouts, well over a thousand years after the Athenian Plague. If this dating is correct and the evidence for it is reasonably strong, then measles as we understand it simply did not exist in April. There would have been no measles virus introduced to the population regardless of how fertile the conditions inside the walls of Athens might have been for it. This is, of course, not the same as saying that no Morbilla virus was present in the ancient world, only that the specific human adapted measles virus with its specific clinical presentation and its specific epidemiological behavior almost certainly was not.
Dylan:As with so many of our candidates, what fits the description well does not fit the evidence and what fits the evidence does not fit the description. We have discussed typhus, so now it is only right to discuss the disease that it was so often confused with in the ancient world. Let's examine typhoid. With typhoid, we enter what is perhaps the most interesting candidate so far proposed in our list: Typhoid fever caused by the bacteria Salmonella enterica syrvartyphae is a disease fraught with history and interlinked with centuries of human suffering and death. Typhoid fever has been with man for a very long time.
Dylan:Though it can be difficult to ascertain precise historical numbers, it can be said with absolute accuracy that it was, at the turn of the twentieth century, responsible for thirty five thousand deaths in The United States alone, and the world today still sees over one hundred thousand deaths per year sourced from this specific seraphar of salmonella. The first week of typhoid is interesting from a clinical perspective and offers some opportunity to be confused with other diseases. The patient presents with a persistent fever reaching 103 to 104 degrees Fahrenheit, extreme malaise, a dry cough, and most interestingly, typhoid tongue, a characteristic thick white coating of the tongue with bright red edges. The second week of infection is more obvious and more dangerous As salmonella typhi invades the gastrointestinal tract and increases its foothold in the body, the patient develops severe pain, bloating, and discomfort. Constipation and pea soup diarrhea are both common alternately.
Dylan:Bradycardia despite high fever is common. Patients also develop rose spots, a red rash present on the trunk that disappear when pressed. It should be noted that this does not quite fit with the description of ulceration as presented by Thucydides, at least based on the word choice, Inatic Greek. During week three of untreated and active infection, patients develop confusion and enter a state of muttering delirium. It is during this time that the intestinal hemorrhage or perforation can develop, marching the patient closer toward death.
Dylan:While considerably anomalous in the modern world, peripheral gangrene is a known feature of typhoid fever. One of the reasons this can occur is a phenomenon called typhoid arteritis an inflammation of the arteries caused by the bacteria. This leads to a decreased blood flow and inability to clear metabolic waste from the tissues of the extremities causing symptoms exactly as those described by loss of limb, usually unilateral, and frequently within the lower half of the body. This feature of typhoid was so well known in recent history that it has an entire chapter dedicated to it in the 1898 work of Doctor. William Williams Keene, The Surgical Complications and Sequels of Typhoid Fever.
Dylan:In 1994, a mass grave was discovered and excavated in the city of Athens in the ancient cemetery of Karamikos. This mass grave contained approximately 150 bodies in layers arranged somewhat randomly, with the deepest being approximately four and a half meters deep with layers of soil having settled between the bodies throughout the millennia. It was apparent that greater care had been taken during the burial of the corpses in the lower layers of the pit with decreasing care taken in the upper layers presumably as the bodies continued to stack up. Dating of the bodies and the artifacts in the pit conclusively linked it with the Peloponnesian War, the lower layers containing the majority of the corpses corresponding to approximately 04/30 BCE, the upper around 04/20 BCE with only a few dating to perhaps the last quarter of the fifth century. From these bodies, intact teeth were recovered by a team of scientists.
Dylan:Utilizing polymerase chain reaction amplification, a molecular biology technique whereby millions to billions of copies of existing DNA can be made from a relatively small sample, the DNA present in the recovered dental pulp was cultured to create testable samples for sequencing in an attempt to identify the disease that sealed the fate of the Athenians in the fifth century. Using the samplified DNA, the team carried out sequencing, looking for signatures of some of the most commonly accused pathogens: B. Praewezeckii, B. Anthracis, M. Tuberculosis, B.
Dylan:Hensley, cowpox, and S. Typhi. No attempts at sequencing were successful in finding a match except for that of Salmonella enterica. Two sequences across the recovered dentin samples revealed a ninety six percent and subsequent eighty percent match for the Serovar, which did not appear in the control cell. When we consider and compare typhoid epidemics to those in modern history while also reading the account of Thucydides, things become rather shocking and somewhat grotesque.
Dylan:There's a somewhat famous public health illustration from 1939 that shows black fingers of waste creeping toward the source of a well while children play in and near the water and a family washes its clothes using it, all oblivious to their impending slow deaths at the hands of Salmonella typhi. When we think about contaminated water and its role as a primary vector in the spread of typhoid fever in epidemics, one cannot help but cringe at Thucydides' account of the fever addled, presumably relatively unwashed and perhaps gastrointestinal challenged citizens of Athens jumping into the drinking reservoirs to cool themselves and dooming their fellow citizens as a matter of course. Unfortunately, if we are intellectually honest with ourselves, there are problems with pinning the whole crime on typhoid as there are with the other proposed diseases so far. Typhoid has never been known to be zoonotic for one. It is genetically highly adapted to higher order primates affecting humans almost exclusively.
Dylan:Typhoid was in fact readily dismissed by J. C. F. Pool and Jay Holiday in their 1979 review of material related to the outbreak merely because Athens did not draw from a central water source and as such could not possibly have accounted for the virulence of the disease as outlined by Theusidides in his seminal work. There are a few mitigating factors that may help explain this.
Dylan:Typhoid is transmitted readily by the fecal oral route, including via contaminated food, water, and exposure to infected waste products. When one takes into account that the city of Athens was an ancient city using ancient waste disposal techniques built for approximately 70,000 people and may have had as many as three times that number of humans producing waste into and around the sparse water and food supply while living elbow to elbow, it is perhaps not surprising that typhoid would have broken out and spread rapidly among the population. The DNA findings also have not gone unchallenged in literature. This is a point at which the aforementioned intellectual honesty requires us to spend some time. In a response published in the same journal in 2006, a team of scientists reanalyzed the recovered sequences against a more comprehensive database of bacterial genomes and reached a rather different conclusion.
Dylan:The matches that the first team had reported as 9680% identical to S. Typhi when compared against a wider set of soil and environmental bacteria were no longer particularly distinctive. The sequences could have plausibly come from any number of organism unrelated to the disease in question, including bacteria that one would reasonably expect to find in a 2,400 year old burial environment. Also raised was the perennial concern of ancient DNA work, contamination, which is a problem that haunts the field and has retroactively undone more than a few dramatic findings since the technology has become widely available. The original team, of course, responded to these criticisms and the exchange is preserved in the literature for any listener who wishes to follow through with it.
Dylan:But it would be inaccurate to say that the original finding has emerged from this exchange unscathed, and it would be more inaccurate to suggest that the broader ancient DNA community has come to a consensus that the Plague of Athens was indeed typhoid. It has not. There are further methodological caveats worth raising. As previously stated, the 2006 study used polymerase chain reaction with primers targeted at specific candidate pathogens. This is a perfectly reasonable scientific approach, but it is also a self limiting one.
Dylan:A targeted PCR assay can only find what it is designed to look for. The negative results of the other six candidate pathogens cannot be read as evidence of absence. They are evidence only that these particular primers on these particular samples did not amplify a product. Modern shotgun metagenomic sequencing, which captures all of the DNA in the sample regardless of source, would give a much more complete picture. To my knowledge, no such reanalysis of the teeth has been undertaken at this time.
Dylan:There's also a more fundamental point that deserves direct acknowledgment. The recovery of salmonella DNA from the dental pulp of a person buried in a mass grave is not in itself proof that salmonella killed that person. It is proof that salmonella was present in the bloodstream at or near the time of death. In a besieged ancient city with overwhelmed sanitation where typhoid was almost certainly circulating to some degree regardless of what was killing the people, the gap between this organism was present and this organism was the cause is not a small one. It is a gap that the original paper does not fully bridge.
Dylan:To the credit of the aforementioned Doctor's Pool and Holiday, they do explore an idea that is favored by the scientific team that recovered the teeth and sequenced the DNA. Whatever agent was responsible for the Plague of Athens may not be the same agent as it is today. Viruses and bacteria can evolve rapidly, and over two thousand years may change their habits entirely. It is, after all, generally in the best interests of a parasitic organism to keep the host alive for as long as possible. We have observed this behavior in syphilis, in myxoma, and arguably in the recent COVID-nineteen pandemic.
Dylan:It is reasonable to suggest that typhoid, although perfectly deadly still today, may have been more deadly two thousand years in the past. It is also possible, as these same authors propose, that typhoid was one of several concomitant illnesses being passed around Athens during the Peloponnesian siege. This is not a satisfying answer, but unsatisfying answers are sometimes the correct ones and we must remember that Thucydides was a historian in general first, not a physician, and may not have differentiated well between diseases, comorbidities, and coincidence, though he certainly would have tried. So, where then does this leave us? Typhoid remains a serious candidate.
Dylan:It is the only candidate for which any direct molecular evidence has been put forward, even if that evidence is contested, and the epidemiological and clinical case for typhoid in besieged Athens is genuinely strong. But the honest verdict, the one that survives engagement with the criticism rather than declaring victory before it, is that we just don't know. We have a finding. We have reasons to take that finding seriously, and we do have reasons to also hold it at arm's length. What we do not have, however, is a settled answer in any account of The Plague of Athens that suggests otherwise is settling its readers something that it has not earned.
Dylan:With our answer, or as close to it as we can get, it's time to turn our attention to one of the more interesting and terrifying, for those who must live through them, aspects of epidemic and pandemic disease, the social aspects and the effect which it has on societal norms. As a person who, presumably like you, lived through the COVID-nineteen pandemic beginning in 2020, I would feel that I was being done a disservice if some far flung author only looked at the scientific aspect of the disease itself and neglected to examine the profound sociological impact that it's had on the world that we lived in. To avoid dehumanizing our friends in Athens by only speaking at their symptoms abstracting ourselves from the human nature of their suffering, we should talk directly about how it affected the world in which they lived and empathize with their plight regardless of how far removed we are from it. In ancient Athens, society was built on a concept called nomos or law. However, this was comprised not only of a codified series of laws, but rather of social glue consisting of customs norms and respect for others.
Dylan:Examples of the concept of nomos are plenty. In normal times, the glory of Athens was shared amongst those who were citizens. They viewed citizenship as a duty to the city and shared in her successes. Pericles, when leading the city in his famous funeral oration just prior to the outbreak, boasted that the citizens not only followed the written laws, but the unwritten ones that brought acknowledged shame to those who broke them. During these better times, the social contract was more rigid.
Dylan:The wealthy were expected to share their wealth voluntarily or through social pressure, paying for a warship, a trireme, or sponsoring a theatrical play at the city Dionysia. Being a good citizen and having wealth meant sharing this wealth for the common good, whether that be through the arts, furthering the military goals of Athens, or through enabling religious observation. Criminally speaking, violating a neighbor's home or another sacred boundary was both a legal crime and a religious pollution or miasma. Even in war, there were strict observations about how to treat the dead and where one could walk, punishable both legally as well as from a sociological perspective, steeped in honor, expectation, and societal perception of one's peers. During the plague, this honorific observation disappeared almost wholly from Athens based on the account of Thucydides.
Dylan:During this period, he describes what he calls shamelessness. The word choice in Attic Greek itself is interesting and telling us to the extremity he felt when writing this. The word specifically had a meaning and connotation tied to the sense of duty amongst the ancient Greek peoples. It denoted a web of interwoven social obligations and contracts to each other, to the gods, and to the dead. By utilizing this word and appending the prefix to negate that word, he indicates that the exact opposite of what had been expected of the Greek world's inhabitants up to this point is now taking place.
Dylan:The social contract has been shredded in front of those seemingly unlucky enough to survive to this point in the disaster. Neighbors no longer respected their neighbors or cared for the opinions of them, once a foundational sociological pressure because they thought their neighbors would be dead in days to weeks of the mysterious and frightening plague sweeping through Athens. To quote our source directly:
Ancient Athenian:Many from want of the proper appliances, through so many of their friends having died already, had recourse to the most shameless sepulchers, sometimes getting the start of those who had raised a pile. They threw their own dead body upon the stranger's pyre and ignited it. Sometimes they tossed the corpse which they were carrying on top of another that was burning and so went off.
Dylan:Here, Thucydides describes pyre theft. A family builds a pyre for their loved one who has succumbed to the plague, and before they can light it, another group arrives, drops their corpse on it, and lights it themselves. They have not stolen just wood and labor, but the ritual itself. The pyre builders are denied the act of ignition, which in Greek practice was a charged gesture, a final duty to the dead. Even more brazen, pardon the word choice, the body goes on to a fire someone else has already lit for someone else is dead, and the carriers simply walk away.
Dylan:There is no acknowledgment, no ceremony, no witness. The anonymity is part of the shamelessness. He describes further the decay of religious observations and norms embodying the decay of normalcy in Athenian society.
Ancient Athenian:The sacred places also in which they had quartered themselves were full of corpses of persons that had died there, just as they were. For as the disaster passed all bounds, men, not knowing what was to become of them, became utterly careless of everything, whether sacred or profane.
Dylan:What is described here is shamelessness toward the gods. To leave a corpse in a sanctuary was a religious pollution or miasma of the most serious kind. In the normal Greek moral universe, it would be unthinkable. But the plague has abolished the distinction between sacred and profane. People are dying in temples and nobody has the capacity or will to remove them.
Dylan:The sacred has been profaned and nobody feels shame about it because the very category of profanation has ceased to function when the profane and sacred are equally swept away by an uncaring disease and capable of comprehension of the very concept. Finally, Thucydides describes something interesting and nuanced. As survivors recover, they are freed from the fear of death and regain a sense of morality and duty toward their peers and Athenian siblings somewhat.
Ancient Athenian:It was with those who had recovered from the disease that the sick and the dying found most compassion. These knew what it was from experience and had now no fear for themselves. For the same man was never attacked twice, never at least fatally, and such persons not only received the congratulations of others, but themselves also, in the elation of the moment, half entertained the vain hope that they were for the future safe from any disease whatsoever.
Dylan:The end of that passage reveals an inverse, however, referring to a vain hope harbored by those survivors. A hubris that in itself is incompatible with the previous Greek concepts of duty to others, is rooted in humility. Perhaps not wicked in its own right, but epistemically dangerous and perhaps indicative of a permanent or at least long term damage to that concept. It may recover, but like so many of the survivors, it will never be the same. Fevered
Ancient Athenian:It is, in my estimation, these things, as outlined by The Fevered Past
Dylan:Fevered Athens Past Fevered is not unique upon this stage. The same drama continues to play out consistently with differing actors across the span of history, as we will see as we continue to examine these cases. The demographic losses from the Plague alone were more damaging than any military conflict could have ever been for Athens. Across the entire outbreak, approximately one third to a quarter of the entire population of Athens was lost. The property holding military classes such as hoplites and cavalry were hit particularly hard given their close proximity as is known to be associated with military life, especially behind the long walls of Athens, owing to the strategy dictated by Pericles.
Dylan:Nothing harmed the Athenian chances in the Greek on Greek conflict with Sparta so much as this. The plague was a democratic catastrophe in the most literal sense. In April, the equal opportunity plague claimed the life of the leader of Athens, Pericles, who had just been reelected by the Athenians as strategos. With the death of Pericles, the fate of Athens was sealed due to the loss of something intangible. A leader of sufficient stature to hold together a burgeoning city state, fracturing demographically, socially, and militaristically.
Dylan:A generation of demagogues would follow Pericles leading Athens into catastrophe time and time again. The Peloponnesian War itself can really best be understood as a series of smaller conflicts that comprise a larger war, the first of which we have now examined as the likely epidemic of Salmonella typhi or typhus broke out within the city and was worsened by the actions of her inhabitants. This war, the Archimedean War, was finally settled in April, a series of surprising land based victories by the Athenians against Spartan hoplites punctuated by an unfortunate failure by our primary source, Thucydides. Following the victories resulting in the capture of Spartan hostages, the Peloponnesian League raised an army of allies and marched on the Athenian colony of Amphipolis in Thrace, targeting the silver mines which provided a huge portion of the Athenian war funds. To counter this enemy action, Thucydides himself was sent at the head of an army to head them off in force pitch battle protecting the source of the funds that allowed the Athenians to carry on.
Dylan:He was not able to arrive in time with his force and as a result was actually exiled by the Athenians for his failure. From here, a peace was forced for a short time before descending into war repeatedly over the next twenty years between the two competing leagues. Athens, under incompetent despotic leadership weakened by catastrophic losses to disease, failed time and time again. In the seventeenth year of the war, a poorly planned attack by Athens and Sicily led to the wholesale destruction of their entire naval fleet and primary source of their power and hegemony. Finally, in April, Athens surrendered for the last time to the Peloponnesian League.
Dylan:They were forced to demolish the longwalls that had thus far kept them safe, disarmed to only 12 trireme from a peak force of several 100, and were made a subordinate ally of Sparta, forced to follow their lead on foreign policy. The terms of this surrender were too much for Athens to take and it descended into chaos in late four zero four-four zero three BCE, leading to a period known as the Thirty Tyrants. Thucydides not only survived the plague and survived his exile from Athens, but left us with a lasting meticulous record for which we should be thankful. Athens itself was not so fortunate, fell not by Sparta in the end but rather by disease and most of all by itself. It is here where we will take our leave of the Greek city state and continue our guesswork at what it is that has ailed us over the centuries and examine the mark that it continues to leave upon us today.
Dylan:Thank you for joining me for this first ever episode of The Fevered Past. I hope you enjoyed it, and if you did, I hope you'll join us next time as we explore more mysterious diseases throughout history. Our next episode is going to be about the death of one of history's greatest conquerors, Alexander the Great, and what it was that ailed him and the horrifying implications of what it may have been. We're going to continue to release episodes on a biweekly basis, so join us again in a couple of weeks as we explore this interesting subject and dive deeper into what it was that conquered the man who could not be bested in combat. Thanks again for listening.