Expounded and commented upon by Gerard de Solo. Translated into Hebrew by the physician Tobiel ben Samuel de Leiria of Portugal

The Discovery of the Mass Grave

In 1994-95, whilst excavating prior to the construction of a subway station just outside Athens' ancient Kerameikos cemetery, Efi Baziotopoulou-Valavani of the Third Ephoreia (Directorate) of Antiquities, discovered a mass grave containing nearly 1,000 tombs dating from the fifth and fourth century BC.

The grave was located near the surface and inside a shaft the excavators discovered about ninety skeletons, ten of which were children. Baziotopoulou believed that a tumulus crowning the shaft might have contained one hundred and fifty people. The skeletons in the grave were placed in a haphazard fashion without any soil between them, and amongst the bones, there were various ceramic burial offerings. The low wall, which bordered the cemetery, appears to have protected it from a marsh.

Baziotopoulou-Valavani said :

'the mass grave did not have a monumental character. The offerings we found consisted of common, even cheap, burial vessels; black-finished ones, some small red-figured, as well as white lekythoi (oil flasks) of the second half of the fifth century BC. The bodies were placed in the pit within a day or two. These [factors] point to a mass burial in a state of panic, quite possibly due to a plague.'

The fifth-century BC Greek historian Thucydides detailed the panic caused by the plague, which struck Athens and Sparta in 430 and lasted two years, killing nearly a third of the population. He wrote that bodies were abandoned in temples and streets, where they were collected and buried in a hurry. The disease returned in the winter of 427 BC, and Baziotopoulou dated the grave to some time between 430 and 426 BC.

Under pressure from the state-owned subway Construction Company and its private contractors, the Greek archaeologists were forced to work quickly. The bulldozers were hard on their heels, destroying both the tombs and the mass grave. Paradoxically, the Greek government cancelled the construction of the subway station and the proposed subway tunnel underneath the cemetery.

At no time, was any apology offered for destroying the site by those responsible. It was decided that a multi-storey parking lot should be built where the huge hole remained.

The plague of Athens remains one of the great medical mysteries of antiquity. Sometimes called 'the Thucydides syndrome' for the graphic account provided by that contemporary observer, the plague of Athens has been the subject of speculation for centuries. In an unequalled, devastating 3-year appearance, the disease marked the end of the Age of Pericles in Athens and, as much as the war with Sparta, it may have hastened the end of the Golden Age of Greece.

Understood by Thucydides to have its origin 'in Ethiopia beyond Egypt, it next descended into Egypt and Libya' and then 'suddenly fell upon' Athens' walled port Piraeus and then the city itself; there it ravaged the densely packed wartime populace of citizens, allies, and refugees.

The sole contemporary source for the Athenian plague is the historian Thucydides who was born somewhere between 460 and 455 BC. He claimed that he suffered from the condition himself, but survived. He described the symptoms and the effects of this condition in detail, noting that the year had been 'especially free of disease'.

After its 'abrupt onset, persons in good health were seized first with strong fevers, redness and burning of the eyes, and the inside of the mouth, both the throat and tongue, immediately was bloody-looking and expelled an unusually foul breath. Following these came sneezing, hoarseness . . . a powerful cough . . . and every kind of bilious vomiting . . . and in most cases an empty heaving ensued that produced a strong spasm that ended quickly or lasted quite a while.'

The flesh, although neither especially hot nor pale, was 'reddish, livid, and budding out in small blisters and ulcers.'

Subject to unquenchable thirst, victims suffered such high temperatures as to reject even the lightest coverings.

Most perished 'on the ninth or seventh day . . . with some strength still left or many later died of weakness once the sickness passed down into the bowels, where the ulceration became violent and extreme diarrhoea simultaneously laid hold.'

Those who survived became immune, but those who vainly attended or even visited the sick fell victim.

By comparison, a modern case definition of Ebola virus infection notes sudden onset, fever, headache, and pharyngitis, followed by cough, vomiting, diarrhoea, maculopapular rash, and haemorrhagic diathesis, with a case-fatality rate of 50% to 90%, death usually occurring in the second week of the disease. Disease among health-care providers and caregivers has been a prominent feature. In a review of the 1995 Ebola outbreak in Zaire, the Centres for Disease Control and Prevention reports that the most frequent initial symptoms were fever (94%), diarrhoea (80%), and severe weakness (74%), with dysphagia and clinical signs of bleeding also frequently present. Symptomatic hiccups was also reported in 15% of patients.

During the plague of Athens, Thucydides may have made the same unusual clinical observation. The phrase 'lugx kene', which we have translated as 'empty heaving,' lacks an exact parallel in the ancient Greek corpus. Alone, 'lugx,' means either 'hiccups' or 'retching' and is infrequently used, even by the medical writers. Although contexts usually dictate 'retching,' we note unambiguous 'hiccups' in Plato's Symposium. In his thorough commentary on the Thucydides passage, the classicist D. L. Page remarks: 'Hiccoughs is misleading, unless it is enlarged to include retching.' Regarding 'empty, unproductive retching [he] has noted no exact parallel . . . in the [writings of the] doctors, but . . . tenesmus comes very close to it' (5). A CD-ROM search of Mandell, Bennett, and Dolin discloses no reference to either 'hiccups' or 'singultus' in the description of any disease entity.

Doubts remain about the exact nature of Thucydides' eyewitness account of the plague. No other writers who were alive at that time mention it and it is not included in Aristophanes' list of the evils of the Peloponnesion War. In Roman history there were a number of severe epidemics between 437 and 427 BC, which could fit the pattern of movement from east to west of epidemics in Mediterranean history. For Thucydides though, the plague was a significant event in Athenian history and he attributes to it the loss of over 25 per cent of Anthenian manpower, causing the decline of its military strength.

Explaining the Plague

There have been several suggestions as to the cause of the disease. Some Hippocratic medical treatises suggest that it was a result of an imbalance between the fluids of the body, caused by a mismatch between the individual – considered in terms of age, gender and constitution – his or her lifestyle and the environment. However, how could so many people of different ages and bodily types show similar symptoms at the same time? One explanation by the ancient Greeks was ‘divine anger', caused perhaps by a natural event such as an eclipse of the sun. The Hippocratic 'Nature of Man' argues that diseases usually come from one's way of life, but suggests that epidemics have a different cause. Whenever many people are struck by the same disease at the same time it is due to the air, since this is the only factor shared by the young and the old, men and women, heavy drinkers and teetotallers, those who exercise frequently and those who do not, etc. According to legend, Hippocrates and his sons cured the plague of Athens, not by treating sufferers, but by burning huge bonfires to ‘thin' the air. To quote Pliny:

'Fire, even by itself, has the power to cure. It is well known that pestilences which are due to a solar eclipse are improved in many ways by lighting fires. Empedocles and Hippocrates have demonstrated this in many places in their work.'

According to Thucydides, Athenians trying to make sense of the plague came up with different explanations. It came from the Gods, but despite visiting temples and praying, this had no apparent effect and lack of respect for the Gods became widespread. As already mentioned, another explanation for the disease was that it started in Ethiopia, eventually spreading to Athens. Then there was the possibility of poison; the Spartans had poisoned the water supply in the Piraeus, but once Athens itself was affected, this theory was discarded because the Athenian water supply came from deep wells rather than from the more easily accessible reservoirs.

Whatever the cause of the plague, Thucydides account shows an early awareness of contagion. He notes that what caused most deaths was the fact that people caught the disease while nursing others who were suffering from it, particularly vulnerable were family members, friends and doctors.

The Medical Mystery Solved?

Since 1995, the University of Maryland School of Medicine and the Veterans Affairs Maryland Health Care System have held a special historical ‘clinicopathologic conference' in which the history of an unnamed patient's illness is presented to an experienced clinician for discussion in an academic setting. These conferences were devised to teach medical students and residents how experienced clinicians would approach a difficult or challenging case. Once a year they meet to discuss the death of an historical figure. In 1999, the subject was Pericles, the military and political leader of the Golden Age of Athens, who suffered from a mild attack of the plague, which slowly wasted his body and spirit until he died in the autumn of 429 BC.

At the time of the 1999 conference, Dr. Durak a consulting professor of medicine at Duke University and Dr. Littman, Professor of Classical Languages at the University of Hawaii, Manoa, both stated that in their opinion, typhus fever was probably the cause of the death of the Greeks and Pericles. They doubted previous theories that ebola, bubonic plague, dengue fever, influenza or measles caused the Plague of Athens because the symptoms described in ancient historical records do not match those particular diseases. Despite evidence that typhus fever is spread either by lice or air, the doctors did not rule out the possibility that the plague could have been caused by something else.

Dr. Durak stated that epidemic typhus was the best explanation, because it hit hardest in times of war and privation. The Plague of Athens had all the features of this illness; 20 percent mortality, kills the victims after about seven days, sometimes causing a striking complication and gangrene of the tips of the fingers and toes.

Dr. Durak explained that the Plague of Athens is a medical and historical classic, fascinating doctors and historians for centuries. Even today we can never be absolutely sure what caused it and the mystery is still relevant today as we continue to experience the outbreak of new infectious diseases. The plague can give us insight on how to respond to AIDS, Legionnaire's Disease, drug-resistant organisms, toxic shock, hantavirus infections and other emerging diseases.

As Dr. Littman stated, plagues are a recurring phenomenon in human history, a constant fear of mankind of being struck down by an unknown disease. Certainly the Plague of Athens was very important as it changed the face of history, weakening Athens at the beginning of its 27-year war with Sparta and became the first medical outbreak so thoroughly recorded by historians.

Conclusion

Despite the investigations of many eminent physicians and historians, it would appear that there is no conclusive evidence as to the cause of the Plague of Athens. Certainly there are strong views today that it was caused by the Ebola virus, but as yet the case has not been proven. The views of Drs. Durak and Littman cannot be discounted, but once again, where is the proof?

'Theorising about the plague has been a medical parlour game for many centuries' says David Morens, a professor of tropical medicine at the University of Hawaii. 'So far it's a game nobody has won. No theory fits all the symptoms described by Thucydides, or explains the deliberate way the plague passed through the population. The latest proposal – that the plague was caused by the deadly Ebola virus – is just as full of holes as any other'.

However, its main supporter insists that his theory deserves special attention, because, unlike most other ideas, it can be put to the test. Captain Patrick Olson, an epidemiologist at the Naval Medical Centre in San Diego, has arranged for the remains of the Athenians who perished to be tested for traces of Ebola virus. Ebola claims almost all of its victims quickly, most people who get it are dead within two weeks. The virus has killed about 800 since 1976, almost all of them in Central Africa. Captain Olson and three of his colleagues point to some uncanny similarities between Thucydides' description of the plague and a report by the Centres for Disease Control and Prevention on a 1995 outbreak in Zaire. 'It just kind of triggered a resonance,' says Captain Olson.

On re-reading Thucydides he saw remarkable parallels between modern and ancient accounts. At the request of Capt. Olson, a Greek pathologist has agreed to try recovering bone marrow from the remains and testing it for genetic material produced by the Ebola virus. However, even if the tests can be done, few people who have studied the Athenian plague believe the bones will indicate Ebola. Not only will Olson have to be right, but also the evidence for Ebola would have to be intact after remaining in the ground for 2½ millennia.

Mr. Morens, who has spent as much time as anybody studying the plague of Athens certainly does not agree, he has seen many explanations for the plague, including that a combination of influenza and toxic-shock syndrome could account for the epidemic. The theory was that a flu epidemic could have made Athenians susceptible to a deadly bacterium like the one found to cause toxic-shock syndrome, but flu would have swept through Athens like wildfire, causing its damage in two months or less. According to Thucydides' account, the plague flared up over a five-year period. Mr. Morens pointed out that an Ebola epidemic wouldn't last for five years.

The newly discovered bones could prove Mr. Morens wrong, or they could even show another disease caused the Plague of Athens, possibly even a disease that no longer exists. Having worked in the dark for so long, most researchers doubt that Capt. Olson's analysis will tell them anything new and they are beginning to wonder whether studying the plague is nothing more than an academic exercise. 'I'm unwilling to endorse any theory,' said Mr. Morens, 'probably we'll never know what it really was.'

Time will tell!

Acknowledgements

Greek and Roman Medicine by Helen King
Plague Victims Found
Plague of Athens: Another medical mystery solved at University of Maryland

The Plague Of Athens