Malaria and Rome: A History of Malaria in Ancient Italy (5 page)

¹⁶ Celsus,
de medicina
3.3.2:
Tertianarum vero duo genera sunt. Alterum eodem modo, quo quartana, et incipiens et desinens, illo tantum interposito discrimine, quod unum diem praestat integrum, tertio redit.

Alterum longe perniciosius, quod tertio quidem die revertitur, ex quadraginta autem et octo horis fere triginta et Types of malaria

15

In a later passage, Celsus confirms that the pernicious semitertian fevers were frequently fatal. He ascribed that outcome to mistakes made by doctors, unintentionally suggesting that treatment may often have been worse than no treatment at all.¹⁷ This point of view was explicitly enunciated, in relation to all diseases occurring in Italy, by Latanzio Magiotti, physician to the court of the Grand Duke of Florence in the seventeenth century . Celsus himself recommended blood letting at the beginning of treatment. This is unlikely to have been beneficial to patients with the anaemias typically associated with malaria.¹⁸ Moreover tools used for bleeding could conceivably themselves have been a source of transmission of malaria via contaminated blood, if they were not cleaned thoroughly after each use. The elder Cato’s denunciation of Greek medicine as worthless was probably well founded in practice, especially in relation to malaria, however interesting the Hippocratic approach to medicine may be to modern historians of medicine, although many treatments could have worked as placebos.¹⁹

Marchiafava wrote as follows: ‘I may say, at once, on the basis of forty-three years’ experience, that pernicious symptoms arise only in connection with . . .
P. falciparum
[and not
P. vivax
].’ He later went on to differentiate
P. falciparum
from
P. vivax
malaria by ‘the long duration of the febrile access,
viz.
from 24 to 36 hours or more, with brief and poorly defined intervals.²⁰ The tertian character of the fever is recognised from the period elapsing between the onset of one access and that of the next, and in pure forms, it can clearly sex per accessionem occupat (interdum etiam vel minus vel plus), neque ex toto in remissione desistit, sed tantum levius est. Id genus plerique medici
Ómitrita∏on
appellant
. Compare the Hippocratic definition of a semitertian fever as a fever which becomes milder on one day, without completely ceas-ing, and then severe again on the following day: Hippocrates,
Epidemics
1.2, ed. Littré (1839–61), ii. 606–9: tÏ m†n Òlon oÛ diale≤ponteß: Ø d† trÎpoß Ómitrita∏oß: m≤an koufÎteroi, t∫ ‰tvr7 ƒpiparoxunÎmenoi.

¹⁷ Celsus,
de medicina
3.8.2:
plurimique sub alterutro curantis errore subito moriuntur. Ac nisi magnopere res aliqua prohibet, inter initia sanguis mitti debet, tum dari cibus
(Many patients die suddenly as a result of various errors by doctors. And unless there is a strong reason for not doing so, bleeding should take place at the beginning of the illness, and then food should be given to enable the patient to sustain a long period of fever without aggravating it).

¹⁸ Cipolla (1992: 57) for Magiotti. Thomas Sydenham regarded blood-letting as very dangerous during acute attacks of malaria in the autumn (Dewhurst (1966: 134–5); Meynell (1991: 127) ). Similarly Palmero and Vega (1988: 346) quoted the Spanish doctor Andrés Piquer as arguing in the eighteenth century that bleeding as a therapeutic method eventually led to the death of patients suffering from malaria.

¹⁹ Cato in Pliny,
NH
29.7.14.

²⁰ Marchiafava (1931: 4, 11), cf. Sambon (1901
c
: 348).

16

Types of malaria

be seen that the attacks come on alternate days’. He stressed that all the symptoms of pure infections with
P. falciparum
are more intense and more severe than the symptoms of pure infections with P. vivax
. The obvious similarity to Celsus’ description was noted by Marchiafava himself, and it does not end there. In a passage too long to be reproduced here Celsus then went on to describe quotidian fevers, emphasizing the great range of variation they displayed.²¹ The sheer length of his description of quotidian fevers relative to his description of tertian fevers indicates the great frequency and severity of quotidian fevers in ancient Rome and correlates precisely with the results of the modern research in medicine mentioned above. Celsus’ account was indeed based on an accurate assessment of the relative importance of the various classes of malarial fever. Similarly Marchiafava, on the basis of the experiences of doctors treating cases of malaria from the Roman Campagna in the Santo Spirito (for men) and San Giovanni (for women) hospitals in Rome in the late nineteenth and early twentieth centuries, went on to describe quotidian fevers, irregular intermittent fevers, and subcontinuous fevers. These were all frequently caused by
P. falciparum
, as was confirmed by microscopic examination of blood smears. He emphasized that the subcontinuous fevers were generally serious, more dangerous than cases exhibiting the classic tertian periodicity. Marchiafava also emphasized that only primary attacks or early recrudescences can become pernicious.²²

After that, survivors are developing acquired immunity. Consequently people suffering from pernicious malaria often do not yet have enlarged spleens, another classic symptom of malarial infection, noted for example in the Hippocratic treatise
Airs, Waters, Places
. What are being described in such texts are survivors with a long history of repeated infections, not those killed directly by the disease at an early stage of infection. Splenomegaly is more pro-nounced in cases of
P. malariae
than in cases of
P. falciparum
. It is least frequent in
P. vivax
malaria. A spleen may weigh as much as twenty times its normal weight as a result of malaria. The splenomegaly associated with malaria was already well known to the Romans by ²¹ Celsus 3.3.3–6.

²² Marchiafava (1931: 14–20), cf. Marchiafava and Bignami (1894: 231–2) for their views on Celsus. The San Giovanni hospital, near the church of San Giovanni in Laterano, is now Rome’s main accident and emergency hospital.

Types of malaria

17

2. Ospedale di San Giovanni, in Piazza di Porta San Giovanni, is one of Rome’s major hospitals. It formerly received patients with indigenous malaria.

the second century , and Cato prescribed cabbage as a remedy for splenomegaly.²³

There is no doubt that
P. falciparum
malaria was present and well known in all its varied manifestations in Rome at the beginning of the imperial period. It is sometimes suggested that it was a completely new disease in Roman times.²⁴ However, it must be stressed that there is no positive evidence whatsoever for this hypothesis.

There is not a ghost of a sign in the writings of Celsus, or Galen, or any other ancient Greek or Roman author, that any type of malarial fever was regarded by anyone as a new disease at any time in the period
c
.500 –
c
. 500. Both Celsus and Galen had no doubt that they could recognize all the types of intermittent fever ²³ Hippocrates,
Airs, Waters, Places
24: ej mvntoi potamo≥ m†n m¶ e÷hsan, t¤ d† \data limna∏3 te ka≥ st3sima p≤noien ka≥ ‰l*dea, ån3gkh t¤ toiaıta e÷dea progastrÎtera ka≥

splhn*dea e”nai (However if there are no rivers and it is necessary to drink stagnant water from marshes, people’s bodies inevitably have swollen bellies and enlarged spleens); Cato, RR 157.7:
et si bilis atra est et si lienes turgent
; Gilles and Warrell (1993: 54) on the weight of the spleen; H. M. Gilles in Wernsdorfer and McGregor (1988: i. 774) lists other possible causes of splenomegaly.

²⁴ Bruce-Chwatt and Zulueta (1980); Zulueta (1973), (1987), and (1994); Karlen (1996).

18

Types of malaria

existing in their own time in works in the Hippocratic corpus dating to the fifth and fourth centuries . The Hippocratic texts are basically very similar to, but less detailed than, the later Roman texts. For example:

The most acute, most serious, most difficult and deadliest diseases were continuous fevers. The safest and easiest of all, but the longest in duration, was quartan fever . . . acute disease occurs in the fever called semitertian, which is more fatal than the others . . . exact tertian fever reaches its crisis rapidly and is not fatal.²⁵

Although it would be nice to have more detail, basically this text looks very similar to Celsus, and Galen had no difficulty interpreting it in his commentary on this Hippocratic text.²⁶ It lists continuous fevers as the most dangerous of all (in agreement with Marchiafava), semitertian fevers as the most dangerous of the others (similar to Celsus), tertian fevers as not dangerous, and quartan fevers as the safest of all. Grmek has also adduced other evidence for
P. falciparum
malaria in the fifth century  with his exquisite retrospective diagnosis of the case of Philiscus in the Hippocratic
Epidemics
as blackwater fever. In blackwater fever a breakdown of erythrocytes on a massive scale causes excretion of haemoglobin in the urine. This complication of
P. falciparum malaria occurred not infrequently in adults in Mediterranean countries in the past.²⁷ The balance of the evidence,
pace
Zulueta, is that
P. falciparum
was already present in the fifth century  in Greece. Marchiafava himself had no doubt whatsoever about this and quoted the very same text of Hippocrates quoted above. The origin of the name
semitertian
was uncertain in antiquity. Galen wrote that he could fill three volumes with what had been written about it previously. This indicates both its importance and its antiquity, since the origin of the term was hopelessly lost. Galen himself interpreted semitertian fever as a combination of tertian and quotidian fevers, although other ancient medical authors may have interpreted it in terms of other combinations of fevers.

²⁵ Hippocrates,
Epidemics
1.11, ed. Littré, ii. 672–5: ejsi d† øx»tatai m†n ka≥ mvgistai ka≥

calep*tatai noısai, ka≥ qanatwdvstatai ƒn t‘ xunece∏ puret‘. åsfalvstatoß d† p3ntwn, ka≥ Â&∫stoß, ka≥ makrÎtatoß Ø tetarta∏oß . . . ƒn d† t‘ Ómitrita≤8 kaleomvn8 xump≤ptei m†n ka≥ øxva nous&mata g≤gnesqai, ka≤ ƒsti t0n loip0n o˜toß qanatwdvstatoß . . . trita∏oß åkrib¶ß, tacukr≤simoß, ka≥ oÛ qanat*dhß.

²⁶ Galen 17A.227–36K.

²⁷ Grmek (1983: 409–36); James (1920: 159–62); Stephens (1937: 530–3); Marchiafava (1931: 32–3) on blackwater fever.

Types of malaria

19

It is important to distinguish the problem of the etymology of the word
semitertian
—a linguistic and philological problem—from the problem of identifying the clinical symptoms described under that heading, a problem in retrospective medical diagnosis.²⁸ Galen rightly formulated the problem in this way:

the question is not about the reality of the disease, but about the meaning of the name, in relation to those fevers which are called tertian, semitertian, and fevers with a tertian form²⁹

He then observed correctly that in relation to periodic fevers recurring on the fifth, seventh, or ninth days, which some other ancient medical authors claimed to have observed, the right question to pose concerned not the meaning of the names, but the very existence of these diseases. The uncertainty about the origin of the word
semitertian
is not a good reason for doubting the equivalence of the symptoms described under that heading with those of a recog-nizable modern disease,
pace
Jarcho.³⁰ It simply reflects the complexity of the manifestations of the disease, which has already been noted. The testimony of Marchiafava, which has already been examined, shows that Jarcho was quite wrong to suggest that modern doctors cannot recognize the disease that Celsus and Hippocrates called semitertian fever. Celli and the other early modern Italian malariologists and numerous other modern specialists such as Grmek have all made the same identification. Furthermore, the evidence adduced by Jarcho of the failure of early modern authors to recognize semitertian fever is not pertinent, since most of the authors he considered lived in cold climates in northern Europe where
P. falciparum
malaria could not possibly have been endemic.

Consequently it would hardly be surprising, for example, if the famous English doctor Thomas Sydenham in the seventeenth century had not recognized a disease which could not have been ²⁸ Galen 17A.120K: tr≤a moi nom≤zw bibl≤a plhrwq&sesqai, cf. 17A.228K for Agathinus’

discussion of this problem; 7.363K: Ó g3r toi s»nqetoß ƒk trita≤ou ka≥ åmfhmerinoı sunecoıß, n Ómitrita∏on ønom3zomen; 7.369K; Oribasius,
Synopsis
6.23: Ø åkrib¶ß Ómitrita∏oß ƒx jsosqenoıß kr3sewß duo∏n pureto∏n ginÎmenoß, trita≤ou diale≤pontoß ka≥ åmfhmerinoı sunecoıß (A genuine semitertian fever is made up of an equal mixture of two fevers, a tertian intermittent fever and a continuous quotidian fever); Aetios of Amida 5.82, ed.

Olivieri (1950); Marchiafava and Bignami (1894: 88 n. 1). W. D. Smith (1981: 7) commented that the author of Hippocrates’
Epidemics
7.43, 94–6 simply assumed that his audience would know what a semitertian fever was.