Malaria and Rome: A History of Malaria in Ancient Italy (43 page)

He made these remarks repeatedly, emphasizing the importance of the phenomena under discussion. Similarly, Marchiafava and Bignami noted that ‘lethargic and comatose “complicated” fevers’

with cerebral symptoms were the forms of
P. falciparum
malaria most frequently encountered by doctors in hospitals in Rome in the nineteenth century. Baccelli also noted that lethargy was a dangerous condition in some forms of the disease.⁴³ Francesco Torti, the author of an important treatise on (the use of quinine in) cinchona bark, described lethargy as one of the seven symptoms of pernicious periodic fevers that were particularly liable to lead to death, and noted that it did not occur in tertian fever (caused by
P. vivax
).

Finally the seventh lethal symptom of any intermittent pernicious fever, not characteristic of a simple tertian fever, is an extremely sleepy state of mind, or deep lethargy, which very frequently tends to accompany the febrile paroxysms . . . if it is neglected, and its progress is not inhibited, I would almost say that lethargy, if not conquered by any medical art, will be fatal, like a major stroke, during one or other of the periodic episodes of fever. When this state of mind commences, the patient first falls into a deep sleep. If he is awoken, he immediately goes back to sleep. Shortly afterwards he cannot remember what had happened immediately before.

Consequently he frequently asks for a pot, then forgets to pass urine, and ⁴¹ Rawson (1982) and the speculative arguments of Polito (1999); Nutton (1983: 10–11).

⁴² Caelius Aurelianus,
On acute diseases
2.63–4, ed. Drabkin (1950):
Item Asclepiades ait cotidianum perseverantem non sine periculo esse . . . apud Romam vero, inquit, frequentare advertimus has febres cum corporis atque mentis oppressione in similitudine lethargiae . . . item similia de his scribit, et non semel sed frequenter, dicens certa ratione mentis apprehensionem typorum in accessionibus fieri, atque hoc apud Romam frequentare
.

⁴³ Marchiafava and Bignami (1894: 93, 123–6, 150–1); Baccelli (1881: 180). Caelius Aurelianus II.65–6 described catalepsy as a condition predominantly occurring in the autumn.

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is drowsy in the meantime. Sometimes he answers a question, but is unable to express himself coherently. It may be the case that he understands his own error, but nevertheless cannot correct himself, or continue, but babbling instead, he either cuts short his words, or uses the wrong word, just as if he were affected by a slight stroke causing paralysis of the tongue. Eventually, as his drowsiness intensifies, he is completely immobile, and snores through his nostrils. He cannot be awakened by any sound, physical force or contact, ligatures or tourniquets, affixing of cupping-glasses or of vesicants, or even fire at any time whatsoever, and if he does become conscious for a time, he immediately relapses into the same sleep, or falls into an even deeper coma, and does not begin to awaken until the periodic attack of fever is coming to an end. Even if he begins to awaken after the first or second period of fever, it is always with a little more difficulty, and if spasmodic gasping is added to the lethargy, he succumbs to his inevitable fate during the third or fourth periodic attack of fever at the latest.⁴⁴

The fact that lethargy was frequently a term applied in antiquity to cerebral malaria caused by
P. falciparum
is demonstrated by a text of Aetios of Amida, quoting Archigenes and Poseidonius.⁴⁵ Aetios states that lethargy could arise in various ways, but goes on to say that it was a common effect of quotidian and semitertian fevers. It was also possible in quartan fevers, according to Aetios. However, it is significant that he does not mention tertian fever (caused by P. vivax
) here.
P. vivax
does not cause cerebral malaria because it does not (unlike
P. falciparum
) induce cytoadherence of parasitized erythrocytes to the endothelium of capillaries in the brain.⁴⁶

⁴⁴ Torti (1755: 195–6):
Septimum denique lethale symptoma Perniciosae cuilibet Intermittenti, non uni Tertianae familiare, est gravis affectus soporosius, seu profundus Lethargus, qui paroxysmos febriles saepe-saepius comitari consuevit . . . si negligatur, nec inhibeatur progressus, Lethargum una, vel altera accessione mortiferum, ac omni arte invincibilem, fortis Apoplexiae instar, fere dixerim certo portendit. Cum huiusmodi affectus incipit, aeger primo est in soporem pronus, a quo excitatus, statim in sommum relabitur; paulo post fit immemor rerum immediate ante gestarum, unde non raro matulam poscit, deinde mingere obliviscitur, atque interim dormitat; nonnumquam obloquitur, nec suos conceptus valet exprimere; & licet sui erroris sit compos, se tamen nequit corrigere, aut continere: immo quandoque balbutiens, vel verba mutilat, vel unum pro alio pro-fert, non secus ac si levi Apoplexia in linguae paralysim degenerante foret detentus. Ingravescente tandem sopore omnino iacet, ac stertit naribus, neque ulla voce, ulla vi, frictione, ligatura, cucurbitularum, aut vesicantium appositione, immo nec igne quandoque actuali valet excuti; & siquidem excutiatur aliquantisper, statim in eumdem soporem, immo in profundiorem recidit, nec nisi declinante accessione incipit expergisci. Quod si una, vel altera vice resipiscat quidem, sed semper paulo difficilius, aut si soporosae affectioni adjungatur singultus, tertia ad summum, vel quarta accessione, inevitabili fato succumbit
. Marchiafava and Bignami (1894: 13–18, 96 n.1) discussed Torti’s classification of intermittent fevers.

⁴⁵ Aetios of Amida 6.3: [Ø l&qargoß] ƒn≤ote d† ka≥ ƒp≥ t0n cron≤wn puret0n sumba≤nei kat¤ per≤odon bapt≤zesqai aÛtoŸß t‘ \pn8, oÍon poll3kiß g≤netai ƒp≥ åmfhmerin0n puret0n ka≥ Ómitrita≤wn, πsti d’ Òte ka≥ ƒp≥ tetarta≤wn.

⁴⁶ This is the conventional explanation of the pathology of severe
P. falciparum
malaria. An 222

City of Rome

The situation described by Asclepiades lasted throughout the Principate (and most probably throughout late antiquity as well), since Galen made very similar comments in the second century .

Galen wrote pages and pages on forms of ‘fever’ (puretÎß) that can now be identified as malarial fevers. Since it would take a very long time to scrutinize all his writings on the subject in detail, it is only possible to mention a few of the most important points here.

Galen described semitertian fevers as very common in Rome, more familiar to men in the capital of the Roman Empire than anywhere else.⁴⁷ This passage also shows clearly that Galen recognized that different places had different pathocoenoses, and this implies a diversity of mortality patterns in different parts of the Roman Empire.

That there is such a fever, as I have stated, does not require the evidence of Hippocrates or anyone else as a witness, since we observe it every day, especially at Rome. For just as other diseases are common in other places, so this evil is frequent in this city.⁴⁸

The fever arising from yellow bile on its own is called tertian, but the fever which requires an equally strong share of the raw humour is strictly called semitertian. It is most frequent at Rome, being very familiar to men in the city.⁴⁹

He explicitly states that semitertian fevers were extremely dangerous, much more dangerous than tertian fevers: ‘this type of fever [semitertian] is malignant and extremely dangerous’;⁵⁰ ‘Semitertian fever . . . is . . . much worse than tertian fever.’⁵¹ Galen also discussed mixed infections, which are only to be expected where malaria is endemic, as noted above. His comments on the various alternative view, expounded most recently by Clark and Schofield (2000), is that the severe pathological effects are the result of an inflammatory state caused by a toxin released by the malaria parasite.

⁴⁷ Martial 2.40 and 4.80 also mentioned semitertian fevers, cf. 2.16 and possibly 3.93 for less specific references to fevers. Rodrígues (1985/6) and Wittern (1989) discussed Galen on fevers.

⁴⁸ Galen 7.435K: Òti g¤r ka≥ toioutÎß tiß g≤netai puretÏß, Øpo∏on e”pon, oÛkvt’ ƒn t‘de m3rturoß oÇq’

⁴⁹ Galen 17A.121–2K: Ø m†n oˆn ƒp≥ mÎn7 t∫ toia»t7 [sc. xanq∫ col∫] sunist3menoß ønom3zetai trita∏oß, Ø d† ka≥ tÏn ∑mÏn cumÏn jsosqen[ proslab*n, åkrib¶ß Ómitrita∏oß g≤netai, ple∏ston ƒn

⁵⁰ Galen 7.467–8K: [Ø Ómitrita∏oß] . . . £griÎß tv ƒsti ka≥ kindunodvstatoß o˜toß Ø t»poß.

⁵¹ Galen 17A.235K: Ø d’ Ómitrita∏oß . . . πstin . . . polŸ ce≤rwn toı trita≤ou.

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age-groups, which were characteristically targeted by different types of malarial fevers, are of great significance for establishing the epidemiology of malaria in the second century . Galen says that semitertian fevers struck men in the prime of life in autumn, when it was very dangerous, while tertian fevers attacked young men, and quotidian fevers, the most dangerous of all, attacked young children in particular.⁵²

Tertian fever, caused by
P. vivax
, becomes a disease of childhood when
P. vivax
is hyperendemic, as it was on Sardinia, for example, in the nineteenth century. However, to interpret all these texts it is necessary to remember that ancient Rome (like early modern Rome) was constantly receiving large numbers of adult immigrants who would have been vulnerable (see Ch. 11 below). All the literature on malaria in early modern Rome states that adult immigrants or visitors were more vulnerable than people who had been born and had lived all their lives in Rome.⁵³ This was because the indigenous inhabitants knew what had to be done in the way of avoidance behaviour, as will be seen later (Ch. 11 below). They might also have had acquired immunity following childhood infection, or even inherited innate immunity. Galen’s observation on the epidemiology of quotidian fevers is extremely important because it shows that
primary
attacks of
P. falciparum
malaria frequently occurred in infancy or early childhood in the second century .⁵⁴

⁵² Galen 7.468K: [Ø Ómitrita∏oß] . . . pleon3zei d† ƒp≥ m†n t[ß f»sewß t[ß kat¤ toŸß £ndraß, Ólik≤aß d† t[ß kat¤ toŸß åkm3zontaß, ¿raß d† m$llon t[ß fqinopwrin[ß, Òte ka≥

l≤an kindun*dhß tugc3nei ([semitertian fever] . . . is common in men, particularly those in the prime of life, most frequently in autumn, when it is exceedingly dangerous); 17B.642

[trita≤oi] . . . o˜toi g¤r colwdvstato≤ te puret0n Åp3ntwn ejs≥ ka≥ ple∏stoi to∏ß nean≤skoiß g≤nontai . . . oÈ presbıtai t0n nvwn t¤ m†n ple∏sta nosvousin ¬tton ([tertian fevers] . . . are the most bilious of all fevers and most frequently occur in young men . . . in most cases old men are less affected than young men); 11.23K: pa∏deß d† ka≥ m3lista oÈ mikrÎteroi ka≥ Òsoi t0n tele≤wn flegmatik*tero≤ tv ejsi ka≥ t¶n 1xin toı s*matoß pace∏ß ka≥ årgÏn tÏn b≤on πconteß ƒn plhsmona∏ß ka≥ mvqaiß ka≥ loutro∏ß sunecvsi ka≥ m3lista to∏ß ƒp≥ trof∫

åmfhmerino∏ß eÛ3lwtoi (children, especially younger children, and adults who have more phlegm and are fat and lead an idle lifestyle with excessive eating and drinking and continuous bathing, and most of all those who are being cared for by a nurse, are easily affected by quotidian fevers).

⁵³
e.g.
Aitken (1873); Baccelli (1881); Rey and Sormani (1881); North (1896); Bercé (1989).

Similarly Dobson (1994: 47) and (1997: 318) ) noted that
P. vivax
malaria was more dangerous to immigrants than to the indigenous inhabitants of the English marshlands.

⁵⁴ M. Greenwood (1921) considered Galen as an epidemiologist. In many other instances, for example in relation to the Antonine plague, Galen’s epidemiology turns out to be very disappointing. Grmek (1994: 4) accepted Galen’s epidemiological evidence, speaking of
une expansion hyperendémique aux temps de Galien
. However, the idea of an
expansion
in Galen’s time does not take account of the earlier evidence of Asclepiades.

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City of Rome

The inference is that the transmission rate of
P. falciparum
malaria was very high; high enough to create a situation in which acute clinical illness and direct mortality as a result of malaria was concentrated among children. In relation to the fact that the Romans continued to use the Greek word
semitertian
and had not coined a specific Latin word for the disease, Quintus Serenus stated that mothers did not want to use a specific word for it for fear that by speaking of it it would be attracted to their own children. This fascinating observation confirms that
P. falciparum
malaria was regarded as typically a disease of childhood during the time of the Roman Empire. It also illustrates the importance of sympathetic magic in Roman popular thought:

more deadly is the fever which is called semitertian in Greek; no one, I think, could have named it in our language and mothers would not have wanted to⁵⁵

Acquired immunity to the strains present in such a locality is gradually built up by survivors of primary attacks, in response to repeated infections. The result is that episodes of acute clinical illness become less frequent with increasing age. Under such circumstances the bulk of severe illness is concentrated among children.

Severe illness among adults is only observed among immigrants, who do not have any acquired immunity. After the city of Rome became the centre of Christianity during the period of the Roman Empire, Christians migrating to or visiting Rome were particularly susceptible to the scourge of ‘Roman fever’. The cases of St.

Augustine and Alcuin have already been mentioned, as well as the English monks mentioned by Gervase in  1188. Hyperendemic malaria was the pattern over much of the Campagna Romana throughout the medieval and early modern periods. Under such circumstances
acute
infections of indigenous adults were less frequent. Epidemics of malaria among adults were only observed when large groups of people who were not native to the area appeared on the scene, for example French and German armies.

Many historians have observed that malaria acted as a protection for Rome from foreign invaders. This viewpoint had already been explicitly articulated by Godfrey of Viterbo as early as  1167, when he recorded in verse the destruction of the army of Frederick ⁵⁵ Quintus Serenus,
liber medicinalis
51.932–4, ed. Pépin (1950):
mortiferum magis est quod Graecis hemitritaeos
|
vulgatur verbis; hoc nostra dicere lingua
|
non potuere ulli, puto, nec voluere parentes
.