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Get Well Soon

History's Worst Plagues and the Heroes Who Fought Them

Henry Holt and Company

Antonine Plague

When you arise in the morning, think of what a precious privilege it is to be alive — to breathe, to think, to enjoy, to love.

— MARCUS AURELIUS

Every so often — frequently when consenting adults are reported to be having sex in some manner that would have been banned in the Victorian age — a TV commentator will shake his head and discuss how this behavior led to Rome's final days. Often it seems those pundits have a poor understanding of kindness, compassion for one's fellow man, and the progressive flow of social mores. And we can absolutely say they always have a poor grasp of "Rome's final days."

To be clear, the Roman Empire didn't end because everybody was having sex. No civilization was ever toppled by "too much sexy time" — except for Bavaria in 1848, but that is an unrelated (if delightful) story.

The beginning of the final days of Rome wasn't caused by heartwarming weddings between gay people. It began with a plague that erupted in the 160s. At that very time Romans were at the height of their power and their massive empire stretched from Scotland to Syria.

They were able to conquer and defend such a huge empire because the Roman army was a massive force. During the period around 160, the army consisted of twenty-eight legions composed of 5,120 men each. The legionnaires volunteered to serve for twenty-five years, after which time they could retire with a generous pension of about fourteen years' pay. And in case 143,360 men in the army seems a little light — for comparison there are currently approximately 520,000 active duty soldiers in the United States — there were additional auxiliary armies that made up about another 60 percent of the force. Those were often composed of noncitizens who, if they survived their years of service, were granted Roman citizenship.

Now, you may wonder, Yes, but who would survive twenty-five years in the military? If you were a Roman soldier, your chances of staying alive during the period 135 to 160 were actually comparatively reasonable. While the exact statistics are unknown, it was a time of relatively few battles. You might not even have to fight. Walter Scheidel, a professor at Stanford University, writes: "For all we can tell, the 239 veterans (representing two years' worth of releases) who were discharged from legio[n] VII Claudia around AD 160 had not experienced substantial combat operations during their twenty-five or twenty-six years of service."

Those troops didn't see action in twenty-five years. I bet they were laughingstocks. But that's a good thing! They did not have to fight, ever!

If they did see battle, the Roman troops were stunningly, perhaps even unnecessarily, well equipped. The legionnaires were outfitted with lorica segmentata, an extremely flexible armor made of metal strips. The first-century historian Josephus described the impressively arrayed Roman army: "They march forward, everyone silent and in correct order, each man maintaining his particular position in the ranks, just as he would in battle. The infantry are equipped with breastplates and helmets and carry a sword on both sides. The infantry chosen to guard the general carry a javelin and an oblong sword. However, they also carry a saw, a basket, a shovel, and an ax, as well as a leather strap, a scythe, a chain, and three days' food rations." They were like the Swiss army knives of soldiers.

So the Roman army had great armor, great numbers, great training, and in some cases at least three days of food on them at all times. Shortly after this, they'd begin losing battles and cities to the Germanic tribes.

I initially thought that the Germanic tribes must have had some fairly cool equipment to successfully combat the Imperial Roman army. Fortunately, Tacitus was there to set me straight. The Germanic tribes fighting them were pretty much naked. The historian wrote of at least one Germanic tribe: "They are either naked, or lightly covered with a small mantle; and have no pride in equipage: their shields only are ornamented with the choicest colors. Few are provided with a coat of mail and scarcely here and there one with a casque or helmet." I especially like that Tacitus took time to scoff that the German shields were artistically weak. The Encyclopedia Britannica, in an instance of unusually helpful specificity, backs up Tacitus, explaining that the Germanic tribes would all be horribly ill equipped until the sixth century:

Their chief weapon was a long lance, and few carried swords. Helmets and breastplates were almost unknown. A light wooden or wicker shield, sometimes fitted with an iron rim and sometimes strengthened with leather, was the only defensive weapon. This lack of adequate equipment explains the swift, fierce rush with which the Germans would charge the ranks of the heavily armed Romans. If they became entangled in a prolonged, hand-to-hand grapple, where their light shields and thrusting spears were confronted with Roman swords and armour, they had little hope of success.

In spite of their inferior equipment the tribes were incredibly courageous. Women fought alongside men, sometimes with their children. For many, their greatest wish was to die a glorious death in battle. The nineteenth-century historian John George Sheppard describes the German tribes: "Though often defeated, they were never conquered; a wave might roll back, but the tide advanced; they held firmly to their purpose till it was attained; they wrested the ball and sceptre from Roman hands, and have kept them until now." The Germanic tribes were willing to continually attack the Roman Empire despite being outnumbered and possessing inferior armor and weaponry. They were ready. They lived for battle. They had been threatening, though failing to penetrate, the empire's borders since being defeated by the Roman general Gaius Marius in 101 BC. I'm not saying that it was surprising that they attacked. I am saying they never should have won. The best army in the world still, logically, shouldn't have been defeated by a bunch of nearly naked people with presumably taupe-colored shields.

But the tribes had the strongest ally in the world on their side. It wasn't human. It was the Antonine plague.

The expanse of territory the Roman troops covered would prove to be their undoing This plague came to Rome from Mesopotamia around AD 165–66. It was carried home by Roman troops who had been fighting in that region. And when it arrived in Rome it was a nightmare. A nightmare even by the standards of people who were used to disease.

Although we may rave about how technologically advanced Rome seemed compared to the Dark Ages following Roman civilization's collapse, it was imperfect. There were public latrines, but few private houses were connected to public sewers; many people dumped their waste directly onto the streets. The Tiber River was also prone to flooding, which meant (forgive this description but there's no other clear way to say it) that a river of shit would occasionally flow through the streets. And though people used bathhouses, the water they bathed in wasn't disinfected and frequently contained bacteria. As you might expect, malaria, typhoid, dysentery, hepatitis, and cholera all thrived during the period, yet the historian Edward Gibbon claimed this was the age during which, "the human race was most happy and prosperous." I should cut Gibbon a little slack here — he published his Decline and Fall of the Roman Empire beginning in 1776 — but pretending any historical age before proper indoor plumbing was a glorious epoch is a ludicrous delusion. Frank McLynn, a modern-day historian, writes in Marcus Aurelius, A Life: "Horrific as malaria and all the other deadly diseases were, Romans absorbed them as part of daily existence; slaves and other wretched of the Earth were already living a death-in-life, so they may not have been unduly perturbed by the approach of the Reaper. But the 'plague' that hit Rome under Marcus Aurelius was entirely different, both in degree and kind, from anything Romans had experienced before."

Much of what we know about the nature of this plague is taken from the writings of Marcus Aurelius's physician, Galen. In fact, the Antonine plague is even sometimes called the Plague of Galen.

Although Galen was a great physician, he was not a terribly courageous man. Galen was a self-promoter above anything else. According to McLynn, he consistently claimed to be a self-made man, casually downplaying the fact that he came from an extremely wealthy family and had inherited numerous estates as well as a stellar list of contacts. He employed underhanded tactics to win debates, and he constantly aggrandized his own achievements. Personality-wise, you could think of him as the Donald Trump of ancient Rome. He was also something of a coward when it came to disease. Now, I don't think cowardice is an abnormal reaction in life-or-death situations; it can be very similar to intelligent self-preservation. I fully expect that I would be weak and spineless in a plague. However, it's not a great trait in a physician.

Galen came very close to not recording this plague at all. When the disease began breaking out in 166, he fled Rome for the less disease-ridden countryside. He claimed he was leaving Rome not because he was understandably scared, but because all the other physicians were so jealous of him and his awesome skills that Rome just wasn't a cool place to be anymore. We don't know exactly where he was from 166 to 168, only that he was summoned back to join Marcus Aurelius in Aquileia (today northern Adriatic Italy) in 168. One year later, when the outbreak worsened in that region, Galen told Marcus Aurelius that the Greco-Roman god of medicine Asclepius had come to him in a dream and said that Galen should go home to Rome for sure. Galen claimed the god regularly chatted with him in his dreams and gave him advice on a number of medical matters. I don't put it past Galen to use an "a god told me to do it" excuse to remove himself from danger, but it's also possible that he did believe these messages. Marcus Aurelius mercifully allowed Galen to return to Rome, where he spent the rest of his life as the private physician to the future emperor Commodus. He lived, seemingly very happily, into his eighties — a major accomplishment considering the generally shortened life spans of his era.

Fortunately for us, despite his best efforts, Galen didn't succeed in avoiding the pestilence entirely. Instead, he studied and wrote extensively about the Antonine plague. From his records we know specifics about the symptoms and progression of the disease. We know that the plague caused victims to break out, very suddenly, in small red spots all over their bodies, and after one or two days, the spots would turn into a rash. Fever blisters would then swell for the next two weeks, before scabbing over and breaking off, leaving an ashy appearance all over the body. We also know that victims would develop a fever, though perhaps not one that was immediately obvious. Galen wrote: "Those afflicted with the plague appear neither warm nor burning to those who touch them, although they are raging with fever inside, just as Thucydides describes."

Galen's remarks upon Thucydides's description are most likely in reference to the latter's devastating account of the Plague of Athens in 430 BC, which wiped out around two-thirds of Athens's population. Galen might have understandably thought the two afflictions were one and the same. I love that Galen was just casually familiar with a text written six hundred years before his time! Reading history books is great! However, the two plagues don't have much in common other than victims developing a high fever and then dying. Today, the Plague of Athens is usually thought to have been bubonic plague or possibly the ebola virus, whereas modern physicians suspect the Antonine plague was smallpox.

Still, it is interesting that Thucydides is referenced, because the Plague of Athens was regarded as an apocalyptic event. Thucydides writes:

Mortality raged without restraint. The bodies of dying men lay one upon another, and half-dead creatures reeled about the streets and gathered round all the fountains in their longing for water. 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.

By comparing the two, Galen gives a sense of the magnitude of the Antonine plague — unless he is wildly hyperbolic. Given his personality, I can see how that might give one pause. But although Galen was a showboater, he wasn't deliberately inaccurate about anything except the greatness of his own skills.

Galen is less interested in the historical and societal impact of "his" plague than Thucydides was. His writings focus instead on how certain ailments progressed and what factors might indicate a patient's potential survival. Galen writes: "Black excrement was a symptom of those who had the disease, whether they survived or perished of it ... if the stool was not black, the exanthem always appeared. All those who excreted black stool died of it." This kind of writing is great. This is one of the first times in the historical record that a figure writes about a disease as a physician rather than as a historian. Doubtless that information was of great interest to anyone who was tending to a loved one, insofar as if their feces turned black, you would know to start making funeral arrangements.

Today, experts turn to Galen's writings to determine the precise nature of the plague. Through the precision of his descriptions, we know that about two weeks after the first symptoms of the Antonine plague (the blisters), a rash would begin to coat the tongue and throat of the afflicted. Galen also noted that many victims coughed up blood. He describes one man as vomiting up scabs, which is maybe the foulest image I can give you.

As horrible as the disease sounds, not everyone died from it. If you had what Galen called "black exanthema" (which means a "breaking out" or a widespread rash), you had a good likelihood of surviving. Galen even tells, happily, of a man rising from his bed on the twelfth day of the disease. He claims:

On those who would survive who had diarrhea, a black exanthema appeared on the whole body. Due to a remnant of blood, which had putrefied in the fever blisters, like some ash that nature had deposited on the body. Of some of those who became ulcerated, the part of the surface called the scab fell away and then the remaining part nearby was healthy and after one or two days became scarred over. In those places where it was not ulcerated the exanthema was rough and scabby and fell away like some husk and hence all became healthy.

There's debate today over whether the plague that led to Rome's fall was typhus or measles or smallpox. I am on Team Smallpox!

However, no matter which disease it was, the debate would have made no difference to anyone at the time. There was no medicine that would come close to treating any of them. Before 1600, people would have difficulty differentiating any type of disease from another; any quickly spreading epidemic would simply be referred to as a plague.

Scholars also continue to debate over the total death toll from the Antonine plague. Frank McLynn notes, "Even if we split the difference between the most impressive scholarly studies, we can't get lower than a total mortality of 10 million." It was probably higher! McLynn himself estimates the total death toll as around 18 million. At the height of the outbreak, slightly later in 189, Cassius Dio claimed it caused around two thousand deaths a day in Rome. There's certainly no estimate that makes the death toll from this plague anything short of overwhelming.

I'd love to tell you about how the disease was treated, cured, or even prevented with any degree of effectiveness. But I can't! It was the year 166, and that optimism is reserved for future chapters in history. The Roman people may have prayed for a cure, but the best they could hope for was someone who was able to keep society minimally functional. Because if you are a citizen of any time, you really don't want a repeat of the Plague of Athens, where corpses were piling up in the temples. In almost every plague throughout history, it takes a remarkably strong leader just to keep the bodies out of the streets.

Rome was fortunate. That leader was Marcus Aurelius, the last of those described by Machiavelli as the Five Good Emperors. Beyond being the emperor who employed Galen, Marcus Aurelius practiced a philosophy you're probably familiar with: Stoicism. If not, some freshman taking Philosophy 101 is going to tell you about it with great excitement one of these days. I will preempt that student by saying that the basic tenet of Stoicism is to exercise reason and employ restraint over emotions, especially the negative ones like anger and greed. One should attempt to behave in accordance with nature, accepting and being prepared for the unchangeable aspects of existence, such as death. The philosophy is beautifully summarized by Marcus Aurelius in his Meditations: "Say to yourself in the early morning: I shall meet today inquisitive, ungrateful, violent, treacherous, envious, uncharitable men. All of these things have come upon them through ignorance of real good and ill. But, because I have seen the nature of what is good and right, I can neither be harmed by any of them, for no man will involve me in wrong, nor can I be angry with my kinsman or hate him; for we have come into the world to work together."

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Excerpted from Get Well Soon by Jennifer Wright. Copyright © 2017 Jennifer Wright. Excerpted by permission of Henry Holt and Company.
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