1. The Plague of Athens Hans House, MD, FACEP Vice Chair for Education Department of Emergency Medicine University of Iowa

5. Objectives Discuss a historical case presentation and explore the differential diagnosis of an unknown infectious disease Understand the impact infectious diseases may play in the course of human history Try to learn almost as much ancient Greek culture as my 6 year old daughter

6. Marathon: 490 BC

9. Thermopylae 479 BC

10. 300 “Come back with your shield or on it”

11. Themistocles and the Battle of Salamis

12. Themistoclian walls

13. No longer united by the threat of Persia, alliance between Sparta and Athens deteriorates

14. Pericles c495 – 429 BC Dominated Athenian politics for 30 years Athens had great navy No match for Sparta in open battle Utilize walled port to resupply and stage raids Intended to fight war of attrition

16. Summer of 430 BC: plague begins Thucydides Plague in an Ancient City, Michael Sweerts, 1652

17. ‘‘It first began, so it is said, in Ethiopia above Egypt, and then descended into Egypt and Libya and into most of the King’s land. Suddenly falling upon Athens, and first attacked the population at Piraeus, so that they themselves said that the Peloponnesians had thrown poison into their wells: for there were, as yet, no cisterns there. But afterwards it came to the upper city as well, and from that time the deaths became much greater.”

19. “But suddenly, healthy men were seized first with mighty heats in the head, and redness, and inflamed eyes, and the inside, both the throat and tongue, immediately became blood-red and emitted an atypical, foul breath.’’ ‘‘After which came sneezing and hoarseness, and in not much time the pain descended into the chest, and produced a severe cough; and when it fixed in the stomach, it upset it, and vomiting of bile of every kind named by physicians ensued, accompanied by great suffering; and in most cases nonproductive retching followed, giving way to violent spasms, which sometimes abated soon after, in others, long after.’’

20. “But suddenly, healthy men were seized first with mighty heats in the head, and redness, and inflamed eyes, and the inside, both the throat and tongue, immediately became blood-red and emitted an atypical, foul breath.’’ ‘‘After which came sneezing and hoarseness, and in not much time the pain descended into the chest, and produced a severe cough; and when it fixed in the stomach, it upset it, and vomiting of bile of every kind named by physicians ensued, accompanied by great suffering; and in most cases nonproductive retching followed, giving way to violent spasms, which sometimes abated soon after, in others, long after.’’

21. “But suddenly, healthy men were seized first with mighty heats in the head, and redness, and inflamed eyes, and the inside, both the throat and tongue, immediately became blood-red and emitted an atypical, foul breath.’’ ‘‘After which came sneezing and hoarseness, and in not much time the pain descended into the chest, and produced a severe cough; and when it fixed in the stomach, it upset it, and vomiting of bile of every kind named by physicians ensued, accompanied by great suffering; and in most cases nonproductive retching followed, giving way to violent spasms, which sometimes abated soon after, in others, long after.’’

22. ‘‘Externally, the body was not very hot to the touch, and was not pale, but reddish, livid, and flowering with small blisters and wounds. But internally was it such a heat that the patients could not bare garments or fine cloths being laid on them, nor be anything but naked, and would have liked best to hurl themselves into cold water, as in fact, many of those neglected did, throwing themselves into cisterns, tormented by unquenchable thirst. And it was the same whether they drank much or little.’’

24. ‘‘Also, they were ceaselessly tormented by the inability to rest or sleep. And the body, while the disease flourished, did not whither, but withstood the ravages of the disease; so that when they died, as most did, on the seventh or ninth day from the burning heat, they still had some strength. But if they escaped this, the disease descended into the bowels, creating a great ulceration, and at the same time, accompanied by acute diarrhea, and many later died from exhaustion because of this... it left its mark on the extremities. For it fell upon the genitals, and the tips of the hands and the feet, and many escaped, being deprived of these, some also lost their eyes. Others again were taken with a complete loss of memory after recovery, and they failed to know either themselves or friends’’

26. Durack DT,.. Am J Med 2000;109:391 Cunha. Infect Dis Clin N Am 2006; 20: 253–272

29. I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant: To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art - if they desire to learn it - without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else. I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art. I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work. Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief and in particular of sexual relations with both female and male persons, be they free or slaves. What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about. If I fulfil this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot. Translation from the Greek by Ludwig Edelstein. From The Hippocratic Oath: Text, Translation, and Interpretation, by Ludwig Edelstein. Baltimore: Johns Hopkins Press, 1943.

31. Asclepius, son of Apollo Chiron, the great tutor

34. 1998

36. Typhoid Fever Insidious onset over weeks Abd pain, Rose Spots follows Progressive sepsis Ulceration and perforation at site of Peyer’s Patches Neurological sx possible Diarrhea in about half Pulse- fever dissociation Pneumonia seen in children 15% mortality w/o Abx

38. Impact of the Plague Killed Pericles and 25% of the population Athens rebuffed peace offer by Sparta in 425 BC Sicilian expedition Sparta victorious 404 BC, Socrates executed 399 BC Ended Athens’ golden age, replaced with anarchic, live for the moment existence Ended ancient world’s experiment w/ democracy

40. Summary Marathon 300 Spartans Pericles and Thucydides Staff of Asclepius vs Caduceus Hippocratic Oath Greatest medical mystery in history lives on…maybe…

42. Raining 300 Men STOP PODCAST