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.
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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.
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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).
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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 c
omparative 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
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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
North wrote as follows:
Chronic malaria is not infrequently associated with a species of chronic pneumonia, which in the experience of the Roman physicians, is often accompanied by the development of tubercle.⁷⁴
After considering the views expressed by more than fifty doctors and scientists on the question of the interaction of malaria and tuberculosis, Collari concluded that tuberculosis struggles to establish itself in a patient already suffering from malaria (perhaps because of the very high fever). However, a malarial infection of a person already suffering from tuberculosis rapidly exacerbates the effects of tuberculosis:
forme che assumono carattere speciale dall’influenza malarica; cionondimeno, da osservazioni raccolte, ci è permesso di argomentare ad una certa frequenza della complicazione palustre in queste manifestazioni morbose [ sc. pleuro-polmonite e bronchite]. ’
⁷² Chambers (1865); Blewitt (1843: 466).
⁷³ Hoolihan (1989: esp. 472–3, 476–7, 479–82 on malaria) discussed this nineteenth-century debate about Rome as a health resort, cf. Wrigley (2000).
⁷⁴ North (1896: 273). Sambon (1901 b: 314–15) expressed the same view: ‘in the Roman Campagna the most frequent complication is pneumonia which occurs in the winter or spring months, during relapses of the intermittent fevers’.
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When patients with chronic malaria become infected with pulmonary tuberculosis, it assumes a slow course with a tendency towards sclerosis; whereas when a patient with pulmonary tuberculosis becomes infected with malaria, the tuberculosis tends to be aggravated and to assume a course which develops rapidly.⁷⁵
A recent review of the question of the interaction between malaria and tuberculosis concluded that repeated malarial infections, even if asymptomatic, cause both quantitative and qualitative depression of the human immune system and thereby increase susceptibility to tuberculosis as well as the rate of development of tuberculosis infections, reiterating Collari’s conclusion seventy years ago. This review considered the possibility that the continuing presence of endemic malaria may be one of the reasons for the persistence of tuberculosis in tropical countries (exacerbated now by its interaction with the HIV virus), in contrast to the gradual disappearance of tuberculosis in temperate countries over the last 150
years.⁷⁶
Baccelli also observed that malaria can aggravate many other diseases.⁷⁷ Malarial interference with the T-cell component of the human immune system diminishes the immune response to other pathogens (e.g. the Epstein-Barr virus in relation to Burkitt’s lym-phoma).⁷⁸ Marchiafava and Bignami illustrated a different type of disease interaction with malaria when they described the case of a thirty-three-year-old epileptic man from outside the Porta del Popolo in Rome in whom a malarial infection brought on an epileptic fit. The interaction between malaria and epilepsy has also attracted attention in recent medical research.⁷⁹ We can hardly leave the topic of synergistic interactions between malaria and other diseases without briefly mentioning what might well become the most important interaction in tropical Africa, namely malaria’s interaction with the HIV virus, even though it is not relevant to antiquity. One study found that ‘HIV-1 infection progressively ⁷⁵ Collari (1932: 324): quando la tubercolosi polmonare si impianta nei malarici cronici assume un decorso lento con tendenza alla sclerosi; mentre quando la malaria sopravviene in un malato di tubercolosi polmonare, questa tende ad aggravarsi e ad assumere un decorso rapidamente evolutivo.
⁷⁶ Enwere et al. (1999), cf. Hovette et al. (1999) for recent research on the malaria–tuberculosis interaction.
⁷⁷ Baccelli (1881: 165–6).
⁷⁸ Whittle et al. (1984).
⁷⁹ Marchiafava and Bignami (1894: 120–1); Roy et al. (2000).
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leads to an increased prevalence and severity of malaria in semi-immune adults’.⁸⁰
Since the evidence of Galen and Asclepiades suggests that malaria was common in imperial Rome (see Ch. 8 below), the balance of probability in the light of modern medical research is that malaria dominated the mortality regime of the population in at least some districts of the city, just as it did in Grosseto, and in the surrounding countryside, even if a large majority of all deaths might have appeared to doctors in antiquity to be the result of other diseases. In the same way, when Corvisier observes that ‘fever’
(puretÎß) can only be directly connected to malaria in a small proportion of the cases in the Hippocratic Epidemics, this is only to be expected under the conditions of endemic malaria, and should not be taken to minimize its importance.⁸¹ The paradoxical yet logical conclusion of modern research is that ‘in very highly endemic centres the amount of sickness [sc. in adults] is greatly reduced in comparison with epidemic areas’, because acute illness is concentrated in infants and children.⁸² Nevertheless very highly endemic centres have higher overall mortality (including adult mortality) than areas where malaria has an epidemic character, never mind areas where it does not occur at all. Of course it is quite possible to have excess seasonal mortality patterns without the presence of malaria, but under those circumstances overall mortality for the whole population is lower, as the example of Florence shows.
5. 3 M
The effects of malaria in antiquity were probably, in their turn, exacerbated by the moderate degree of chronic malnutrition that was arguably endemi
c among the masses in most if not all ancient populations. If the recent trend towards increasing average height in the populations of modern developed countries is to be attributed to improved nutrition, as seems to be the case, then it is an inevitable conclusion that malnutrition was endemic in historical populations. Specifically in the case of ancient Rome, preliminary reports of research on the skeletal population from Vallerano near ⁸⁰ Whitworth et al. (2000).
⁸¹ Corvisier (1994: 305–8); contrast Grmek and Gourevitch (1998: 223–5), using the figurines from Smyrna in the Louvre as evidence for virulent P. falciparum malaria in the Hellenistic period.
⁸² Hackett (1937: 174).
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Rome, dating to the second century , have revealed a significant frequency of porotic hyperostosis attributed to iron-deficiency anaemia. Together with palaeodemographic evidence for low life expectancy (unreliable in detail, yet probably still reasonably accurate in respect of the overall impression given), and better-known literary evidence such as Soranus’ comments on the frequency of rickets in the city of Rome (caused by vitamin-D deficiency), it suggests a rather low standard of life in the suburbs of Rome itself with repeated infections and widespread chronic malnutrition, especially of infants and children. Such problems continued, inci-dentally, throughout the history of the city of Rome. The explanation of Soranus’ evidence was provided by Lapi in the eighteenth century. He admitted that rickets was common in Rome in his own time, even though he argued that Rome was healthier than its reputation suggested. Lapi states that rickets manifested itself in babies in Rome between the ages of nine months and two years. He attributed the prevalence of rickets in Rome to the custom of keeping infants inside rooms, with the unintended consequence that they were never exposed to ultraviolet radiation in sunlight, which converts the sterol 7-dehydrocholesterol in skin into cholecalci-ferol, vitamin D3.⁸³ We may infer that infants were kept indoors because of the widespread fear of ‘bad air’ among the Roman population. Evidently their diet did not include fish-liver oils, the most important potential dietary source of vitamin D, and was inadequate to compensate for the lack of exposure to sunlight, but an inadequate diet was not the only reason for rickets in the Roman population, both ancient and early modern.
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