Malaria and Rome: A History of Malaria in Ancient Italy (27 page)

Quintus Serenus expressed the opinion that quartan fevers could lead to death and should not be underestimated.⁵⁵ Nevertheless quartan fevers were often regarded in antiquity as ‘weaker’

than benign or malignant tertian fevers, even though they lasted longer on average, simply because quartan fevers only recurred every seventy-two hours.⁵⁶ Since Pliny recognized that there was ⁵¹ Celsus 3.3.1:
et quartanae quidem simpliciores sunt. Incipiunt fere ab horrore, deinde calor erumpit, finitaque febre biduum integrum est: ita quarto die revertitur
(Quartan fevers are certainly simpler.

They generally commence with shivering, then the heat erupts, and after the fever terminates there is an interval of two days; and so it returns on the fourth day.).

⁵² Dante Alighieri,
La Commedìa. Inferno. Canto
.85–8, ed. Lanza (1996):
Qual è colui che sì presso ha ‘l riprezzo
|
della quartana c’ha già l’unghie smorte,
|
e triema tutto pur guardando il rezzo,
|
tal divenn’io alle porte parole
.

⁵³ Josephus,
BJ
1.105 and
Ant. J.
13.398; Kottek (1994: 34).

⁵⁴ Pitrè (1971: 218):
frevi quartana li vecchi ammazza e li giuvini sana
.

⁵⁵ Quintus Serenus,
Liber medicinalis
48.895–8, ed. Pépin (1950):
nec tu crede levem dilato tempore febrem, quae spatium sibi dat, magis ut cessando calescat: letali quoque grassatur quartana calore, ni medicas adhibere manus discamus et herbas
(Do not believe that this delayed fever is mild, it gives itself a rest in order to return with even greater force: the quartan attacks with a deadly fever, unless we teach you to apply healing hands and herbs.).

⁵⁶ Pliny,
NH
30.30.98–9:
in quartanis medicina propemodum nihil pollet
(in cases of quartan fever medicine has virtually no effect); [Aristotle,]
Problems
1.56.866a ej g¤r m¶ Án åsqen&ß, oÛk #n tetarta∏oß ƒgvneto (for if it was not weak, it would not be a quartan fever). Galen 11.18–19K

compared the onset of quartan and of tertian fevers. See also Ch. 2 above on quartan fevers.

Horace,
Sat
. 2.3.290 also mentioned quartan fever.

134

Demography of malaria

no effective herbal remedy or any other cure for quartan fever, he decided to list a series of magical treatments for it.⁵⁷ It would not serve any useful purpose here to go through all the references in the works of Pliny and other ancient authors to remedies for malaria, except to stress that their sheer number demonstrates once again the frequency of malaria in antiquity and the difficulty of treating it. A typical example is his reference to an otherwise unknown doctor called Icatidas, who claimed that quartan fevers in men were terminated by sexual intercourse with women who were just beginning to menstruate.⁵⁸ Similar beliefs persisted in Italy until recently.

In traditional Sicilian folk medicine bathing with the urine of a pregnant woman was considered a remedy for persistent cases of quartan fever. Several early modern Italian writers recommended eating bedbugs (
Cimex lectularius
L.) as a cure for quartan fever, following a tradition stretching back to antiquity. Quintus Serenus had recommended eating bedbugs, with eggs and wine, in cases of both quartan and tertian fevers. Pliny also noted this idea, although he believed that it was useless as a remedy for malaria.⁵⁹ Another recommended method was eating the liver of a seven-year-old mouse. A different approach to the problem was the recommendation to arise on three consecutive mornings at dawn, face a window or door, and then shut it suddenly after reciting a particular prayer.⁶⁰ These ‘remedies’ merely serve to show how helpless doctors were in the face of malaria, but they continued trying. Martial wrote an epigram about a doctor who treated cases of quartan fever.⁶¹

The sophist Favorinus (
c
. 85–155) delighted in displaying his skill as a speaker by discoursing on unlikely subjects, according to ⁵⁷ Lane (1999: esp. 639–43, 650–1) discussed the role of sympathetic magic in Pliny’s remedies for malaria and also provided a list of relevant passages in the
NH
, esp.20.8.15, 26.71.115–17, 28.23.82–6 and 28.25–6.90–1, 28.28.111, 114, 30.30.98–104, and 32.38.113–16.

Quintus Serenus,
liber medicinalis
48.907, ed. Pépin (1950), suggested placing the fourth book of Homer’s
Iliad
under those who feared the return of quartan fever, another striking instance of sympathetic magic.

⁵⁸ Pliny,
NH
28.23.83:
Icatidas medicus quartanas finiri coitu, incipientibus dumtaxat menstruis, spopondit
.

⁵⁹ Quintus Serenus,
liber medicinalis
48–9,ed. Pépin (1950); Pliny,
NH
29.17.63; Dioscorides, MM
2.34.

⁶⁰ Pitrè (1971: 220–1) on Sicilian folk medicine. Similar beliefs occurred in other cultures, e.g.
in Islamic medical literature. Ullmann (1978: 109) quotes the famous doctor Ar-Razi (Rhazes) as saying that ‘quartan fever can be cured if the patient wears the unwashed and sweaty shirt of a woman in labour’ (note also pp. 1–2 on the importance of malaria in Arabia).

⁶¹ Martial 10.77.

Demography of malaria

135

Aulus Gellius. One such topic he chose was to produce a eulogy of quartan fever:

When he sought to praise Thersites and when he eulogized quartan fever, he made many observations on both topics which were charming and not obvious. He has left these comments written in his books. But in his eulogy of fever he even cited Plato as a witness, saying that he wrote that a person who got well and regained his full strength after suffering from quartan fever would afterwards be more surely and more constantly healthy.

Of course, since quartan fever was milder than tertian fevers, and since the advent of quartan fever was regarded in antiquity as a sign of the end of these more serious tertian fevers (in cases of mixed infections—see Ch. 8 below), Favorinus made life easy for himself by choosing a relatively easy subject to display his skill at rhetoric!⁶²

According to Galen’s own account of his career at Rome and the intense rivalry between doctors in the city, his fame there commenced when he correctly diagnosed quartan fever in the case of the Peripatetic philosopher Eudemus, sixty-two years old at the time. This case also shows quartan fever lasting well into the winter, just as in the case of Atticus.⁶³ Elsewhere in his works Galen observed that quartan fevers could last for as long as two years, and that they were most frequently ‘contracted’ in the autumn.⁶⁴ He also commented that quartan fevers could be dangerous in con-junction with other diseases, especially tuberculosis, and could result in dropsy:

Quartan fevers are difficult to shake off and last for up to two years, longer than the other types of fever . . . some even become dangerous in association with symptoms of other diseases, with the result that they eventually produce tuberculosis or dropsy. Quartan fever is most frequent in autumn ⁶² LiDonnici (1998: 85–7) drew attention to Aulus Gellius,
Noctes Atticae
17.12.2–5:
Cum Thersitae laudes quaesivit et cum febrim quartis diebus recurrentem laudavit, lepida sane multa et non facilia inventu in utramque causam dixit eaque scripta in libris reliquit. Sed in febris laudibus testem etiam Platonem [
Timaeus
86a]
produxit, quem scripsisse ait qui quartanam passus convaluerit viresque integras recuper-averit, fidelius constantiusque postea valiturum
.

⁶³ Galen 14.606–14, 619, 624K, with Nutton’s commentary in his edition of Galen’s work On prognosis
.

⁶⁴ Celsus 2.8.42 also regarded quartan fevers as prolonged if they appeared in the autumn (presumably new primary infections):
quartana aestiva brevis, autumnalis fere longa est maximeque quae coepit hieme adpropinquante
(Quartan fevers that start in summer are brief, while those that commence in autumn are usually long, and those which begin as winter approaches have the longest duration of all.). In 3.15–16 he gave his recommendations for treating quartan fevers.

136

Demography of malaria

and infections at that time of the year are most persistent. However infections in summer are shaken off very easily.⁶⁵

Dropsy as a late manifestation of quartan fever, in other words gross oedema appearing usually after the symptom of fever has ceased to be apparent even if the patient still has a high rate of parasitaemia, is also mentioned in the Hippocratic
Airs, waters, places
. Dropsy in these ancient texts was identified by Kibukamusoke as the nephrotic syndrome of quartan malaria, a severe kidney disease probably caused by an immunological reaction to the parasite.⁶⁶

Tuberculosis, singled out by Galen as a major complication of quartan fever, was the most dangerous of the respiratory diseases.

The respiratory diseases were the second category of disease assigned importance by Shaw to explain excess seasonal mortality in ancient Rome. These diseases are indeed very well documented as a cause of morbidity and mortality in the winter months in early modern Italy, for example in the towns of Pontedera, Cascina and Ponte di Sacco in Tuscany in 1610 as described by Cipolla from the records of the Florentine health magistrates.⁶⁷ Nevertheless detailed modern studies have demonstrated, just as in the case of the gastro-intestinal diseases, that death rates from respiratory diseases alone are much lower than they are when malaria is present as well. For example, studies in Greece in the 1930s showed that death rates from pneumonia were much higher in villages where malaria was endemic than in otherwise similar villages where malaria was not present at all. Del Panta observed that the Tuscan Maremma in the nineteenth century, in the presence of endemic malaria, had a higher death rate from respiratory diseases than the average rate for the whole of Italy (including regions where malaria did not occur at all). In Guyana following malaria eradication, mortality from both acute (tuberculosis, pneumonia) and from chronic (asthma, emphysema, bronchitis) respiratory diseases dropped significantly, accompanying a reduction in the crude ⁶⁵ Galen 7.470K: [tetarta∏oi] d»slutoi ka≥ croni*teroi par¤ p3ntaß toŸß t»pouß ¿ste ka≥ mvcri dietoıß proba≤nein . . . g≤gnontai d† ƒn≤oi ka≥ kindun*deiß di¤ t¤ peplegmvna aÛt‘

sumpt*mata, ¿ste fq≤sin tÏ teleuta∏on ∂ paregc»seiß Ëdrwpik¤ß åpotele∏n. pleon3zei d†

m3lista fqinop*r8 ka≤ ƒsti m3lista d»slutoß: Ø d† qerinÏß eÛlut*tatoß.

⁶⁶ Hippocrates,
Airs, waters, places
10 (ƒk t0n tetarta≤wn ƒß \drwpaß) (from quartan fevers to dropsy). Kibukamusoke (1973: 34) defined the nephrotic syndrome of quartan malaria as ‘a symptom complex comprised of massive proteinuria, hypoalubuminaemia, gross oedema and hypercholestrolaemia’.

⁶⁷ Cipolla (1992: 35–9).

Demography of malaria

137

death rate and elimination of the periodic variations which had previously occurred simultaneously in the overall crude death rate and in the mortality rate directly attributed to malaria.⁶⁸ The recent research on the syndrome of respiratory distress as a product of
P. falciparum
malaria raises the possibility that some deaths which were ascribed to respiratory diseases in the past might actually have been directly caused by
P. falciparum
malaria. The synergistic interactions of
P. falciparum
malaria with other diseases were observed in antiquity:

Patients with consumption, and those who suffer from other longer diseases, are very likely to be ill with semitertian fever.⁶⁹

(Likewise Asclepiades said that a persistent quotidian fever is not without danger, and many cases have progressed from it to another disease, such as dissolution of the body or dropsy or whatever occurs through the weakening of the body.)⁷⁰

In early modern Rome the interaction between
P. falciparum malaria and the respiratory diseases was observed by everyone who did research there. For example, Rey and Sormani, in an article devoted to studying statistics for causes of death in Rome in the years 1874–6, noted that Rome had a higher death rate from various respiratory diseases than other major European cities whose data were considered for comparative purposes. They attributed this excess to the complications of malaria, even at a time when malaria was on the verge of final eradication from the city of Rome, and even though the highest death rates from these respiratory diseases occurred in the months of January to March: We cannot distinguish in the cause of death statistics between simple forms and those forms with a special character owing to the influence of malaria; nevertheless the observations which have been made permit an argument for a certain frequency of malarial complications in these disease syndromes.⁷¹

⁶⁸ Balfour (1936: 119) on Greece; Giglioli (1972) on Guyana; del Panta (1989: 48–9 n. 23); Gilles and Warrell (1993: 56) described pneumonia as a familiar complication of
P. falciparum malaria.

⁶⁹ Hippocrates,
Epidemics
1.24, ed. Littré (1839–61), ii. 674–5: åt¤r ka≥ fqin*deeß, ka≥ Òsoi £lla makrÎtera nous&mata nosvousin, ƒp≥ to»t8 [sc. t‘ Ómitrita≤8] m3lista nosvousin.

⁷⁰ Caelius Aurelianus, 2.63, ed. Drabkin (1950):
Item Asclepiades ait cotidianum perseverantem non sine periculo esse, atque multos ex eo in alium morbum induci, hoc est
〈
in
〉
corporis defluxionem aut hydropem venire et quicquid potest per corporis debilitatem accedere
.

⁷¹ Rey and Sormani (1881: 131–2): ‘
Non possiamo sceverare quali siano le forme schiette e quali le 138

Demography of malaria

The increased death rate from certain respiratory diseases was a distinctive feature of mortality patterns in the city of Rome, because some other Italian cities which were not affected by malaria, particularly in the north of Italy, had significantly lower death rates from respiratory infections. For example, a comparison of Genoa with London made a few years earlier had shown that Genoa was much healthier with regard to mortality from tuberculosis and chronic respiratory diseases. Consequently the author felt able to recommend travel to certain parts of Italy as desirable for the recuperation of English patients with chronic respiratory infections, although he advised such patients to stay away in the summer from areas affected by malaria.⁷² Indeed there was even a school of thought that Rome itself was a desirable place to spend the winter for sick people from England, because of the mildness of its winter climate compared to that of London, but other nineteenth-century authors, noting that respiratory diseases were in fact widespread among the population of Rome in winter, rejected this advice. The respiratory diseases of the Roman winter were frequently attributed to the tramontane wind, just as malaria in the summer was associated with the sirocco.⁷³