Galen and the Antonine Plague

Author(s): R. J. Littman and M. L. Littman

Source: The American Journal of Philology, Vol. 94, No. 3 (Autumn, 1973), pp. 243-255
Published by: The Johns Hopkins University Press
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 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 CThis 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

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244 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.

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 GALEN AND THE ANTONINE PLAGUE. 245

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

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246 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,10like 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
See Stephanus s.v. 7rvperos and 7reuTLyw8rqsand his discussion
7re/iJLyzriw&s.
of Galen's and Hippocrates' use of the word.

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 GALEN AND THE ANTONINE PLAGUE. 247

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).

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248 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).
DURATIONOF 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.

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 GALEN AND THE ANTONINE PLAGUE. 249

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.
13In 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.

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250 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'mrovf'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.

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 GALEN AND THE ANTONINE PLAGUZE. 251

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.

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252 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 has laid to rest the picture of the Antonine

25

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.
24S. 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).

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 GALEN AND THE ANTONINE PLAGUE. 253

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

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254 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.
?1Cooper (see above n. 30) pp. 86-156.

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 GALEN AND THE ANTONINE PLAGUE. 255

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.

UNIVERSITYOF 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.

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