Fig. 1 Alpine vista
Joint Research by Patrick Hunt, Stanford University, and Andreea Seicean, Case Western Reserve University
Epidemiology of ancient causes of death is difficult to reconstruct by descriptions of disease. Paleopathology is a growing field relative to ancient history, but as such usually depends either on material remains – generally bioarchaeological – or ancient texts. Is there a connection to be found in Hannibal’s march across the Alps in 218 BCE?
Was the huge reported loss of troops in Hannibal’s wintry montane crossing also partly caused by related sickness or disease exacerbated by the hardship of montane passage? The late Roman author Appian, circa 150 CE, states that Hannibal started with 90,000 infantry soldiers in his march. On the contrary, the more reliable Polybius states that 38,000 infantry and 8,000 cavalry actually began the alpine passage from the Rhone crossing and that Hannibal lost about half of this force (Hist. III.60.5). While Appian’s number is unverifiable and even maybe hyperbole, several sources tell us that a large portion of the army did not survive the early winter mountain passage, with possibly as few as 25,000 soldiers actually descending into Italy. Polybius also relates that the hardship was greatly exacerbated by the lack of food, loss of pack animals carrying provisions and the cold, and that the men who survived the Alps were like beasts than men due to hardship, toil and near starvation (Hist. III.60.3-4, 6).
This question of disease and related conditions of troop reduction has come up repeatedly in the last few years on the Stanford Alpine Archaeology Project’s 2006 field expedition as well as in a recent public lecture at Stanford by one of the co-authors of this brief article.
The basic likely scenario for possible infection is this: if an army column in the narrow valleys of the montane Alps is stretched out for miles, the first ranks of few soldiers side by side would be marching over fresh snow or sometimes along alpine streams. The infantry at the rear, however, would be marching behind along the same route, but now through slush and mud as the snow would have been trampled and melted by contact with hundreds of feet. Animals would also be in the train. Human and animal dung would be often unavoidable, especially at the rear of a column. Soldiers weakened by wounds, hypothermia, and fatigue would possess already lowered immune systems. Foot contact with inevitable watery fecal matter or especially drinking water downstream that had come from the gradually increasing mess upstream would have been unavoidable at times, and if even one sick or infected person spread this infection from upstream, the weakened or wounded soldiers downstream would be likely to be even more susceptible at the rear of a marching column ascending a tight and narrow alpine valley. Alpine hikers today usually know to avoid common guardia bacteria from upstream alpine bovids that can be easily transmitted to humans via drinking fecal-infected water downstream even when it looks deceptively clear and pure. This could be a recipe for a mild to severe epidemic among Hannibal’s army, especially at the weakened rear winding over miles of ascending terrain.
Epidemics are sparsely reported around the time of the Second Punic War (218-202 BCE), and source documents do not reveal any clear information that Hannibal’s troops suffered from any sort of disease or symptoms during the Alps campaign. But the dramatic reduction in troop size – Polybius states Hannibal lost about half his troops – during the sixteen day crossing from the Rhone to the Paduana in Italy have usually been attributed to the two major attacks of the Celtic tribes on the Carthaginian army, and fatalities through falls, cold, at times low levels of supplies (especially after the ambushes), as well as exhaustion from the little rest allowed to the troops. This brief article on palaeo/paleopathology assesses the possibility of the existence of unrecognized epidemics or pathogens causing some deaths within Hannibal’s troops, which may have contributed to some loss of men during the crossing of the Alps.
In the ancient primary sources, especially Polybius and Livy, there is no overt indication of disease or symptoms of illness in Hannibal’s army and no epidemic appear to contribute to the dramatic reduction in troop size until the spring of 217 BC, when the troops entered marshes somewhere west of modern day Florence, probably along the Arno river watershed. During the three days spent walking through these marshes, fatigue turned to fever within the troops and led to an infection (“a severe attack of opthalmia”) causing blindness in Hannibal’s right eye (Hist. III.79.12) somewhere in the Etrurian marshes of Central Italy around lower Tuscany .
After carefully evaluation of ancient epidemics in the context of modern microbiology and using epidemiological resources for paleopathology, the following diseases may have affected Hannibal’s troops while crossing the Alps. Any number of these potential disease reservoirs could have intensified in weakened immune systems of Hannibal’s army troops.
Fig. 2 Vibrio cholera bacteria in SEM micrograph (scale on micrograph)
CHOLERA is caused by Vibrio cholerae, and quickly brings about a severe diarrhea that can completely dehydrate and kill a human in as little as 4-6 hours (although it can linger for many more days until fatal, although depending on rehydration, it has never been 100% fatal as far as we know). Usually only associated with Asia historically, especially India where it may have reservoired in the Ganges river for centuries if not millennia, cholera is transmitted by ingestion of the bacteria in drinking fecal contaminated water, especially downstream of its contamination. Cholera toxin is an interotoxin and one of the most rapid killers known if the infected person is without rehydration of clean water, and untreated death rate is as high as 50%. While humans have long been assumed to be the major bacterial reservoir, it is now also thought to be the aquatic environment itself. Blood types are now also thought to be important, as Type O is least resistant and Type AB most resistant. If applicable to Hannibal’s multicultural, heterogeneous mercenary army of Numidians, Ibero-Celts, Gaulish Celts, Balearics, as well as Carthaginians and Libyans, among others, gene types could have been more or less susceptible to cholera, and we know that some of his ethnic groups survived the Alps crossing better than others.
Fig. 3 Salmonella enterica typhi
TYPHOID FEVER is caused by Salmonella enterica typhi and it typically has a human reservoir. It is usually transmitted by drinking (oral ingestion) or immersion in water that has been contaminated by fecal matter, especially in drinking water. Typhoid fever has a range of incubation between 5-21 days. Typical symptoms include enteric fever, abdominal pain, uncontrollable diarrhea and flushed or patches of rosy skin spots. Typhoid fever can be accompanied when infected persons have high fever by a delusional state including “Picking at bedclothes and imaginary objects” or by addressing persons not present in the the so-called “muttering” delirium. (Center for Disease Control, 2005-2006). The immediate environment and the repetitive short-term conditions within a highly-stressful state (including constant wariness over threat of loss of life) in a physically exhausting army campaign do not exclude the risk of this contamination and can in fact be highly associated with it.
Fig. 4 Mycobacterium tuberculosis
TUBERCULOSIS: There is longstanding evidence of spinal TB in human remains of early Egyptian contexts, corroborating that this disease was ancient and most likely affected humans worldwide since at least the Early Bronze Age in the Mediterranean regions (3000-2200 BCE) (Morse, Brothwell, Ucko, 1964). Tuberculosis is caused by Mycobacterium tuberculosis, and symptoms include fever, persistent cough (with blood traces), chills, increasing weight loss and hemoptysis (World Health Organization, 2006). Humans are the only known reservoir; however, as it takes years for the disease to develop and for clear symptoms to appear, therefore an intensification of weakening conditions epidemic occurring while crossing Alps may have occurred. Soldiers apparently superficially healthy, but previously infected with TB, may have been unable to survive the high altitude and the immune system crises created by the hardships of the expedition.
Fig. 5 Corynebacterium diptheriae
DIPHTHERIA has symptoms including persistent sore throat, mucous membrane swelling and is followed by death by suffocation. Diptheria is caused by Corynebacterium diphtheriae toxin. Esepcially dangerous in close proximity where people are massed together, humans are the reservoir, and the transmission is made by close contact. It has a short incubation period of 2-8 days, which makes it a potential candidate for an epidemic within the described conditions during the army campaign of Hannibal (Pilat et al., 2006). However, as the death by suffocation is not ordinary, it might be logical to expect that the primary sources would have reported these cases of suffocation, unless they were wrongfully attributed breathing difficulties due to altitude or climate.
TYPHUS is caused by Rickettsia prowazekii through a parasitic insect vector (flea or louse) (via bite, defecation, or internalized by a scratch). Infection is enhanced by the potential environmental conditions during the Alpine campaign (wintry climate, some famine, lack of bathing/adequate hygiene or sanitation). Typhus has a short incubation time (one week) and a low fatality (2.6-3.8%) when present by itself. Its typical symptoms include a high fever of intense and abrupt onset, chills, headaches, and skin rashes (Medline Plus Medical Encyclopedia, 2004). Mental status changes are noted as a state of delirium can accompany high fever.
Fig. 6 Xenopsylla cheopis flea
PALAEOPATHOLOGY AND HISTORY
Acknowledging the different spellings of the word palaeopathology (=U.K. variant spelling as opposed to U.S. spelling = “paleopathology”), such research involves, for example, the use of ancient DNA from microbial pathogens obtained from bone specimens (and other remnant tissue). Examples include proof that indigenous Americans in Andean contexts (e.g. mummies) sufered from tuberculosis, making it a pre-Columbian disease, and that sealed Jeruslaem tombs in the first century had occupants that had suffered from leprosy. This use of ancient DNA helps provide verification of traditionally labeled diseases historically diagnosed from ancient texts, however fragmentary or inconclusive such texts might be, thus answering long standing questions in disease history and providing DNA sequences that can be compared against modern isolates to track changes over time (Donoghue, Spigelman, Zian, Gernaey-Child, Minnikin, 1998). As the field has been developing only in the last few decades (especially in the 1990’s), there are not many coordinated research teams in the area of archaeologists, historians, philologists and medical specialists and only a small number of ancient disease outbreaks have been studied. Unfortunately the ancient textual sources generally use generic words in Greek and Latin for plague or pestilence, and some of the few assumptions that can be made is that they share contagiousness, are devastating on human population who can rarely fight them and are thus often fatal. Livy in his History IV.20.9 reconstructs causes of pestilence but without any clear reconstructive epidemiology long after the fact. Some historians do make the connection in Italy between malnutrition and plague but others also suggest that plague may prevent rather than be either a cause or consequence war at times (F. W. Walbank, ed., Cambridge Ancient History, vol. 7, part II, 1989, 138, 319).
Perhaps the most famous recorded ancient plague was that which spread through Athens between 439-437 BC, with two other outbreaks in 429 BC and 427 BC, during the Peloponnesian War. The only surviving first hand account of this comes from Thucydides (Peloponnesian War). The disease apparently originated in Ethiopia, spreading through Egypt and Greece (Thucydides, II, 48). The Spartan siege of the city produced overcrowding in Athens, which together with inadequate water supplies, poor hygiene, and lack of access to healthcare permitted conditions for the plague to spread rapidly (Papagrigorakis, 1998). Initial symptoms consisted of persistent and increasingly intense headaches, conjunctivitis, rash all over the body, and debilitating fever (Thucydides, II, 49). These symptoms progressed to coughing up blood, extremely violent stomach cramps and intense episodic vomiting. Unquenched thirst drove the sick to throw themselves into the wells, and most died by the seventh or eight day (Thucydides, II, 51). Infection provided some immunity in that “catching” it a second time rarely or never proved fatal (Thucydides, II, 51). One third of the Athenians, including one fourth of the army and even Pericles himself died of the plague (Demand, 2000). The Spartans invading the city were not affected (Thucydides, II, 54).
In the early 1990’s during construction work to expand a subway line through Athens, the ancient cemetery of Kerameikos, believed to contain Athens plague victims, was accidentally found (Papagrigorakis, 2006). Under the supervision of archeologist Effi Baziotopoulus-Valavani of the 4th Prehistoric and Classical Antiquities Ephorate excavations, a combined team examined skeletal material for ancient microbial DNA in an effort to identify the 439 BC Athens plague. Due to good vascularization, durability, and natural sterility, dental pulp was chosen for recovery of genetic material (Papagrigorakis, Yapijakis, Baziotopoulou-Valavani, 2006). Teeth collected from three bodies were tested using PCR DNA recovery and amplification techniques at the Athens University School of Dentistry by Dr. Manolis Papagrigorakis. A positive reaction was found for the Salmonella enterica serovar Typhi, indicating that the famous Athens plague was most likely Typhoid fever (Papagrigorakis, 2006).
Tuberculosis spondylitis is documented in Rome from the Neolithic Age (Formicola, Milanesi, Şcarsini, 1987; Canci, Minozzi, Borgognini, 2001) through the Bronze Age (Canci et al., 1996) and was also reported by Pliny the Younger (Epistolae, V, 19, 6). In 2001 AD, an Italian team (Canci, Nencioni L, Minozzi, Catalano, Caramella, Fornaciari, 2001) identified a case of healing spinal infection from Classical Rome in a 25-35 years old male through physical appearance of the spinal column as altered by the disease.
The work of Dr. Helen Donoghue et al. from UCL’s Center for Infectious Diseases and International Heath demonstrated that tuberculosis may have killed off leprosy in Europe, based on DNA evidence from human remains dating from the first century CE, including evidence from sealed tombs in Jerusalem, as mentioned. Using nestled PCR and single staged PCR to detect the Mycobacterium tuberculosis – specific DNA, the team was able to isolate and identify Mycobacterium tuberculosis complex DNA from remains dating from 600 AD.
Other field research was that conducted on the devastating 1918 Spanish influenza virus remains, done primarily in 2005. Spanish influenza killed approximately 50 million people and is believed to have jumped from birds directly to humans (Sample, 2005). This epidemic may have indirectly had much to do with ending the First World War, particularly as the ultimate futility of the horrible war was driven home by the global epidemic. At first it was impossible to study the virus as no isolates of the pathogen were made at the time, until molecular pathologist Jeffery Taubenberge was able to recreate the 1918 Spanish flu virus in a laboratory of tissue collected by pathologist Johan Hultin) from the lungs of an infected woman whose body was kept well preserved under the Alaskan permafrost (Rozell, 1998).
HANNIBAL AND DISEASE?
Neither primary source, Polybius or Livy, whose records describe Hannibal’s campaign, give any indication that Hannibal’s troops suffered from disease during the campaign prior to reaching the Italian planes. Given the detailed nature of their writing, especially that of Polybius, it is expected that should disease have been present on a notable scale, some mention of it would have been made.
One of the most famous prior records of plague in the Mediterranean region happened 209 years prior to Hannibal’s crossing of the Alps, in the form of the second outbreak of the Athenian plague, what we now know to have been typhoid fever (Papagrigorakis, 2006). Another was in 367 BCE in Italy but is not well recorded. There is no record of any other widespread disease until 161 BCE, 57 years after Hannibal crossed the Alps, and 42 years after he left Italy altogether to defend Carthage against Roman attack. The Antonine plague lasted from 161-180 CE spreading from Asia Minor through Egypt, Greece, and Italy, and killed between one fourth to one third of the population in some parts, including possibly Marcus Aurelius himself (Gilliam, 1961). Currently, no paleopathological research has been conducted to identify this disease, but it is suspected that is may have been smallpox. Another plague occurred during the reigns of Decius (249-251 CE) and Trebonianus Gallus (251-253 CE). Believed to have started in Egypt in 251 CE, this plague spread across the whole Roman Empire. Outbreaks continued until 270 CE and led to the death of the Emperor Claudius II Gothicus at Sirmium in the Balkans as reported by Zosimus, c. 500 CE (Historia Nova I.24-25), again a plague that appeared to begin in Egypt and infested ships en route to the Balkans. There is no other well documented plague until the mid-sixth century when the Justinian plague of 542 CE quickly spread throughout the Roman world and beyond as reported by Procopius, c. 550 CE (History of the Wars II.22-38), “by which plague the whole human race came near to being annhilated”, again reported by Procopius as having a source in Egypt, possibly from Nilotic connections to deeper Africa (as suggested by Prof. Steve Miller, Classics, University of California, Berkeley, May, 2000, in his Raubitschek Memorial AIA Lecture at Stanford University).
Why is there no mention of disease in Hannibal’s Alpine crossing? There might be several good reasons explaining the lack of disease, perhaps the primary one being that there was none to report! On the other hand, such pathology may be masked by the hardships, as already mentioned. After an average period of incubation of two weeks (Center for Disease Control) untreated typhoid fever can result in death within 6 to 7 days (as Thucydides recorted), even though it produces weakness from the onset. Therefore, if there indeed were incidents of typhoid fever or similar contagion within Hannibal’s troops, these men would surely have been left behind or fallen behind on their own accord due to the quick speed at which the army moved through Gaul over the Rhone and crossing over the difficult Alps all the way to Italy in a mere sixteen days total. The extreme cold, lack of supplies at times, and strenuous effort would certainly have killed off the affected quickly. While conditions were normally far from cramped, with the troops camping in open air during the entire crossing of the Alps, overcrowding in general should not have been an issue as it had been in Athens which was under siege. Furthermore, the cold climate and running water consumed by the troops directly from the running mountain streams, as opposed to foul stagnated water, would not have seemed to have provided the necessary obvious conditions for the disease to spread. It is not entirely out of the question for the troops of Hannibal to have been typhoid carriers, with those dying off fairly rapidly who had manifested the disease. It would be interesting to examine this possibility through the use of the same methodology as the Athens University team (Papagrigorakis et al., 2006), extracting DNA from any teeth remains, and perhaps even trying to enlist their help with this project. No on site testing is presently feasible for this, as the samples would have to be carefully collected and sent to a fixed lab. It would also be interesting to study the health of other armies; including those of Charlemagne in 800 CE, Charles V around 1527, Napoleon in 1800 and beyond, or any others specifically crossing the Alps that could be seen as comparanda to textual sources we have on Hannibal’s troops. If the Stanford Alpine Archaeology Project team is able over the next few years to excavate any preserved skeletal material in the Alps that can be firmly associated with Hannibal’s passage, especially under our National Geographic Society sponsorship, we hope to be able to answer this particular question of paleopathology.
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Robert Wood Johnson Foundation Archives
Part of this palaeopathology research was supported by the Robert Wood Johnson Foundation. Epidemiology scholarship recipient and medical epidemiology student Andreea Seicean utilized fieldwork opportunity in the Alps in 2006 and at Case Western Reserve University in 2005-2006.
Images courtesy of: Fig. 1: wikipedia; Figs. 2 & 6: www.medscape.com; Figs. 3 & 5: Dennis Kunkel Microscopy, Inc; Fig. 4: microbewiki.kenyon.edu
Copyright © 2007 Patrick Hunt
and Andreea Seicean