Age of Hypochondriacs

Sometime​ in the late 160s CE, the Roman doctor Galen suffered a great misfortune: the loss of almost all his slaves to a disease he called (in Greek) ‘the protracted plague’ – a term used for any major epidemic. In a treatise discovered in a Thessaloniki monastery in 2005, Galen boasts that he was not at all moved by this tragedy, nor indeed by one far worse in 192, when a fire destroyed his library. But he did take a great interest in the sickness itself, which assailed the Roman Empire in waves for a decade or so after the first cases were reported in 165 CE. He provides our only detailed account of the symptoms: first fever, then a few days later diarrhoea or the coughing up of blood, and in the second week a pustular dry rash with black sores which would crust over and fall off. It ‘spreads over entire cities and destroys them horribly’. It was seasonal, striking in the colder parts of the year. Efficacious treatments included soil from Armenia or the island of Lemnos, Stabian milk and ‘theriac’, a paste made up of opium and ingredients such as saffron, myrrh, cinnamon and vipers. Galen championed theriac, becoming the sole supplier to the emperor, but he also recommended the administration of young boys’ urine to the sores. The immunity conferred on survivors presumably made it worth it.

Galen doesn’t provide enough information for modern doctors to diagnose the illness now known as the Antonine Plague, named for the emperor at the time, Marcus Aurelius Antoninus. As Colin Elliott explains in his lively account of the outbreak, the fact that sores appeared all over the body seems to rule out the disease that we call plague, where the buboes are concentrated at the groin, neck and armpits (boubon is Greek for ‘groin’). Suspects include measles and scarlet fever, but most specialists now think it was a form of smallpox, so called since the 16th century to distinguish it from the ‘great pox’, or syphilis, and a member of the same virus family as horsepox, cowpox and camelpox.

This supposition is based above all on Galen’s descriptions of his patients’ rashes, but no ancient source mentions the permanent scarring traditionally associated with smallpox, and sequencing of smallpox DNA found in the mummified remains of a Lithuanian child buried around 1650 has shown that Variola major, the vicious form of the disease that devastated much of the world in modern times, only emerged after 1500. But a genetically related orthopoxvirus, an ancestral cousin of smallpox, has been found in Viking-era burials in northern Europe, and it may have been this or something like it that affected the Romans.

As Elliott notes, the smallpox theory is largely responsible for the scholarly consensus that the Antonine Plague was a very big deal: modern smallpox killed a third of its victims – between 300 and 500 million in the 20th century alone – and blinded a quarter. (In 1980 it became the first human disease certified as eradicated by the World Health Organisation.) Elliott himself is a minimalist, at least by recent standards: he is prepared to contemplate total mortality in the region of between one and two million across the Roman Empire rather than the twenty million some have suggested. But he still agrees that it was ‘the worst disease event in human history up to that time’.

The outbreak as described by later Roman writers was certainly pretty bad. Eutropius reported that it had affected most of the empire’s inhabitants and almost all Rome’s military forces. Other commentators tell of thousands of deaths, the devastation of Italy and difficulties in recruiting soldiers for the Marcomannic wars that inconveniently broke out on the German border in 166. But these authors were writing two centuries or more after the event, and some were given to sensation. References in contemporary sources are hazier. There are vague reports of sudden flight from illness, and of excess death. Sickness became a metaphor: a senator in the 170s described rising gladiator prices as ‘a great disease’. But Galen is the only eyewitness to discuss the epidemic in any detail.

Galen may himself be responsible for the later fame of this particular plague. He had every reason to exaggerate the sickness that helped to make his name and it wouldn’t be his only piece of showmanship. He began his career tending to the wounds of gladiators (excellent medical training in a society where human dissection was frowned on), spent most of it as official physician to the emperor, and courted notoriety with public vivisections. His voluminous writings make up an estimated 10 per cent of surviving literature in ancient Greek, much of it memoir, pop philosophy or self-help.

This means we can’t be sure how dangerous the Antonine sickness really was, how many lives it claimed or whether it affected rural areas as well as cities. We don’t even know when it ended. Galen mentions further waves after the initial crisis, and the hyperbolic theologian Jerome later claimed that an outbreak in 172 almost wiped out the Roman army, but nothing more is heard of the disease after the mid-170s. Nor do we know where it came from. Ancient sources insist that Roman soldiers brought it home after sacking the Parthian city of Seleucia in the autumn of 165. This sounds like the medieval theory that linked the arrival of the Black Death in Europe with the return of Genoese traders from the Black Sea city of Kaffa. A Mongol army had besieged Kaffa, supposedly catapulting their infected dead over the city walls. But the story about Seleucia is different: the Romans were said to be infected not by enemy soldiers, but by the anger of the god Apollo. When they ransacked his temple in Seleucia and stole the cult statue, they inadvertently broke open a bound casket and unleashed a deadly cloud of infected air.

This story, again told by much later writers, fits contemporary notions of contagion: Romans may not have known about bacteria, but the popular concept of ‘miasma’ blamed bad air for the transmission of disease, handily explaining why so many people in the same place became infected and having the right effect in encouraging caution around the sick and dead. A Roman amulet protecting against plague, found in the Thames in 1989, warns against kissing.

Elliott doesn’t dismiss the Seleucia story altogether: there is no doubt that both disease and famine tormented the Roman troops on their ill-fated excursions across the eastern frontier in 165-66. Those soldiers then returned from the front lines during the summer of 166, when the warm weather would have kept a new disease ‘at a low simmer’, spreading too slowly to attract notice at first. But he makes a more plausible case for multiple sites of transmission across the Roman borders as populations came into closer contact than ever before.

Commerce is part of this story, with Rome’s (temporary) defeat of Parthia enabling trade to pass across the Euphrates towards the Mediterranean as well as along the more traditional Red Sea routes. Armies probably played the largest role, however. Soldiers regularly made long journeys in large groups, rotating through camps and operating in close contact with local communities. Elliott gives a sense of the distances involved with the story of Marcus Statius Priscus, a Roman senator who was sent from a posting in Britain to govern Cappadocia in 161 and took command there of legions from modern Germany and Romania.

Elliott suggests that the Antonine Plague may have been ‘the world’s first pandemic’ – that is, effectively global. There are reports of an unusual sickness in China going back to 151 CE: one major outbreak, in 162, was said to have killed a third of the Chinese army. It kept returning to Chinese cities and regions until the mid-180s, usually during the colder part of the year. It isn’t impossible that a Chinese disease reached Rome in this period, or vice versa. ‘Roman’ (really Alexandrian) merchants first arrived in the Eastern Han dynasty’s capital, Luoyang, in 166, but there were already many indirect connections.

As Elliott notes, however, ‘what is plausible is still never quite provable.’ And in the absence of air travel we might expect to hear of disease-afflicted areas in the lands between China and Rome’s eastern borderlands. An inscription from 156 does describe a widespread and long-lasting sickness in Yemen, a landing point for spice ships crossing the Indian Ocean. This was serious enough to be mentioned by a later Roman historian, but there is no evidence to suggest it lasted into the 160s. Nor are there reports of contemporary epidemics in India, the Gulf or anywhere else on the usual shipping routes. The less popular overland routes across Central Asia do not seem to have been affected either, though Elliott does note a suggestive outbreak of sculptures of the goddess Hariti in the lands of Kushan, between China and Parthia, in the mid-second century. Five hundred years later, at least, she is associated with ‘pox-like diseases’. There is a bigger question that he tacitly avoids: why should we assume that Roman authors were right in their conviction – really just a guess – that plagues came from outside the empire at all?

Perhaps it is simply the notion of a pandemic originating in China that is attractive. It wouldn’t be the only contemporary resonance to creep into Elliott’s account: we also hear a surprising amount about the inefficacy of ‘irrational’ public health measures, while ‘punishing and persecuting the non-compliant’ is ‘sadly familiar’ and the ‘uncomfortable truth’ is that ‘uncontained pandemics will run their course.’ Covid certainly provides parallels for the Antonine Plague. It’s hard not to smile at the mention of the orator Aelius Aristides, who swore he caught the plague months before anyone else despite having none of the symptoms. And Elliott nicely describes the triumph at Rome in October 166 celebrating victory over the Parthians – with tens of thousands of soldiers and spectators present – as a ‘super-spreader event on the grandest scale’.

But, in the absence of more informative genetic studies, new inscriptions or forgotten manuscripts, the search for novel perspectives on the disease is a bit hopeless. And by demonstrating how little evidence there is to support existing scholarly models, Elliott undermines his own chances of building a satisfactory alternative account. That isn’t a criticism: judicious ambivalence is an underrated virtue, and the Antonine Plague provides the kind of fresh lens on society that can justify yet another book about the Romans.

Elliott’s evocation of the ancient cities in which disease found such congenial quarters is particularly edifying. Demographic studies suggest that the city of Rome would have produced 45,000 kilos of faeces and 1.3 million litres of urine a day. Going by the frequency of signs daubed on Pompeian walls forbidding their use as a toilet, plenty of it was produced in public. And that wasn’t the only distasteful form of fly-tipping: archaeologists have found pits full of infant remains in cities throughout the empire. These appear to confirm ancient reports that Romans regularly abandoned unwanted babies in the streets, as well as elderly slaves – which may explain why the emperor Vespasian’s breakfast was once interrupted by a dog carrying a human hand. Rome’s famous sewers only made things worse, backing up during the frequent floods. Add fluorine and lead poisoning as well as mosquitos, and it’s no surprise that osteology reveals average heights across the Roman Empire in the first four centuries CE were on average ten centimetres shorter than those of people living the same lands before or after. Ancient DNA studies show that many people continued to choose Rome and other cities over their rural origins, and Elliott points out that these new arrivals would have lacked immunity to diseases spread most easily in densely packed urban environments.

Did​ the Antonine Plague matter for Roman history? There’s no doubt that the outbreak coincided with an economic downturn across much of the empire. The closure of silver mines in Western Europe in the mid-160s was significant enough to cause a dramatic decline in the amount of lead that can be measured in ice cores extracted in Greenland. (When silver was smelted, lead particles travelled up into the atmosphere and settled at the poles.) Quarries went out of action too, and the social effects of recession included violence in the cities and on the field. Warlords fought for power, the winners punished their new subjects indiscriminately and impoverished peasants raided towns. Marcus Aurelius’ successor, Commodus, praised the townspeople of Bubon in southern Turkey for putting a stop to local brigands, arresting some and killing others. Meanwhile rebellion against Roman forces gathered pace from Sparta to Egypt.

The plague is often seen as central in explaining these developments, but Elliott describes new statistical modelling that suggests Rome’s economic problems began in the 140s, two decades before the disease arrived. Environmental factors played an important role. There is considerable evidence of drought and colder temperatures in the period, from the Rio Grande to the Rhine. Roman grain production had long been centred on Egypt, where the annual inundation of the Nile watered the crop, which was then transported by flotilla from Alexandria to the mouth of the Tiber. From the 150s, however, the Nile floods regularly failed. The composition of sand grains in sediment cores from southern France suggests that the mid-second century ce als0 saw the most extreme storm activity in the Mediterranean in the last ten thousand years. Even the grain that could be harvested risked not making it to Rome.

Then there was the empire itself. Elliott argues that the epidemic exposed ‘the underlying fragility of the Roman system’ and the weakness of its institutions. This may come as a surprise: the second century CE is often described as a golden age for Rome, the final gasp of what Seneca, a century earlier, had called the Pax Romana. But the Latin pax means ‘pacification’ rather than ‘peace’ and, as Elliott puts it, the ‘defining characteristic of the period was hardly an absence of violence, but rather an absence of any meaningful limit on Rome’s ability to make violence’. A small elite jealously guarded the benefits of empire while many – even most – of its subjects lived under the threat of poverty and hunger. In addition to a short-sighted focus on feeding the city of Rome and the Roman army at the expense of other citizens, and the concentration of imperial grain production in a single territory, corruption, mismanagement and provincial resistance compromised both the food supply and the Roman administration as a whole: Galen describes people watering the wheat they paid in tax to the state to add to its weight, and so inviting fungus, rot and vermin.

Elliott must be right that the long-term effects of exogenous shocks such as epidemics depend on the health of endogenous institutions. And given the overall state of the Roman economy and society at the time, even a low mortality rate would have had a serious impact. But his claim is still that the consequences of the Antonine Plague were largely indirect. He considers the possibility, for instance, that it caused a ‘crisis of faith’, in which the refusal of Christians to engage with the old gods produced unprecedented moral panic. A new interest in enforcing the worship of Roman divinities took hold in some local communities in the late 170s and continued into the next century. Elliott describes a mandate of 250 as a ‘collective inoculation’ with ‘no religious exemptions’, though it was enforced in particular on Christians, still a small if widely spread group of ‘radical mystery cultists’.

It makes sense to consider the connections between religious persecution and epidemic disease: when the Black Death arrived in Catalonia, Jews in a number of towns were slaughtered by their Christian neighbours. All the same, no ancient source associates Christian persecution with the Antonine Plague, which had faded by the time serious persecutions began. A more plausible precipitating factor, Elliott argues, was the law Marcus Aurelius passed in 177 introducing ceilings for gladiator fees while permitting showrunners to buy condemned criminals for execution. This reduced the supply of gladiators, but local entrepreneurs could now source entertainment for their games by accusing their neighbours of Christianity; if they refused to perform sacrifices to the Roman gods, they made themselves available for sale and public slaughter. But state-sponsored persecution of Christians only really took off in the mid-third century. By this time there was a new ‘Cyprianic’ plague on the block, if anything even more mysterious than its Antonine predecessor.

In the end, the biggest threat posed by the Antonine Plague, as Elliott sees it, was the ‘spirit of pandemic’: ‘the disease’s lingering presence as a threat both real and perceived’. This was an ‘age of hypochondriacs’. But might the lingering threat of disease sometimes be a good thing, encouraging survivors to question the institutions – and leaders – that had failed to contain the threat? When a capricious and exploitative imperial government has revealed its deficiencies, alternatives suddenly become imaginable.