¹⁵ Krogstad (1996); Marsh (1998) on the recent upsurge of mortality directly caused by P.
falciparum malaria in Africa following the development of resistance to the drug chloroquine.
¹⁶ Coluzzi (1999).
¹⁷ Baldari et al. (1998), cf. Castelli et al. (1993); Sabatinelli et al. (1994); Romi et al. (1997).
¹⁸ Aristotle, Politics 1280a35–7.
8
The city of Rome
The city of Rome itself is obviously of particular interest. It requires discussion on its own, since it constituted a distinctive environment, as far as malaria is concerned, which must be considered separately from the Campagna Romana, the Pontine Marshes, and the Tuscan Maremma. Cicero gave credit to the legendary Romulus for choosing a healthy spot in a pestilential region for the site of the city:
He chose a site which both has abundant sources of water and is healthy, in a pestilential region, for there are hills¹
Similarly Livy spoke of the ‘very healthy hills’ of Rome.² He put these words into the mouth of Furius Camillus in a speech supposedly delivered c.386 , following the siege of Rome by the Gauls, in the context of a proposal to move the entire population of Rome to the healthier site of Veii. The statements of Cicero and Livy are admissions that the areas surrounding the hills of Rome were unhealthy in their own time. (Whether Livy’s statements actually tell us anything about the fourth century is a separate question.) During his description of the Gallic siege Livy had earlier described an outbreak of disease among the Gauls (exacerbated by food shortage). This epidemic was attributed to the unhealthy location of their camp on low ground between hills.³ Such localities were evidently regarded as unhealthy in Livy’s own time. Malaria is the only major disease that has this precise ecological requirement in Mediterranean environments, because the low ground is where mosquitoes breed. The Gallic siege may be the earliest attested example of the devastating malaria epidemics destroying foreign armies attacking Rome that occurred in so many later ¹ Cicero, de republica 2.6.11: locumque delegit et fontibus abundantem et in regione pestilenti salubrem; colles enim sunt.
² Livy 5.53.4: saluberrimos colles.
³ Livy 5.48.1–3: urgebat, Gallos pestilentia etiam, cum loco iacente inter tumulos castra habentes, (Pestilence was also affecting the Gauls, since their camp was situated in a place between hills.).
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historical episodes, and this could be the reason why the Gallic sack of Rome apparently did little damage to the city, according to the results of recent archaeological research. Unfortunately no description of the symptoms is provided by Livy.⁴
Livy’s comments illustrate the close juxtaposition of healthy and unhealthy areas that was characteristic of malaria in Italy in the past. In the early modern period the incidence of malaria in the most densely populated districts of the city of Rome itself on the hills was also often described as relatively light. For example, Bonelli described ‘light malaria’ in the city of Rome in 1782. Bercé, writing about the sixteenth and seventeenth centuries , stated that ‘the city of Rome was not regarded as really dangerous, except for the hot months in some districts exposed to Tiber floods’.⁵
Nevertheless the description of how the cardinals, who assembled in the Vatican following the death of the pope on 8 July 1623 to elect a new one, were decimated by malaria by 6 August suggests that it was essential (especially for non-immune visitors) to be very careful indeed which districts of Rome they entered. Eight cardinals and thirty other officials died and numerous others became ill.
The new pope Urban VIII fled for his life from the Vatican to the Quirinal (61 metres above sea level), which was thought to be safer.
Subsequent papal elections were less lethal because of the increasing use of quinine, which was brought back to Rome in 1632 from South America in the bark of the cinchona tree by the Spanish priest Alonso Messias Venegas. It became popular after a successful trial in the Santo Spirito hospital in Rome organized by Cardinal Juan de Lugo in 1643.⁶
The artificial infection experiments at Horton Hospital in England demonstrated that by the twentieth century infections with Italian strains of P. falciparum required much larger doses of quinine for treatment than infections with African or Indian strains. This may be evidence for the evolution of a degree of resistance to quinine by P. falciparum strains in Italy between the seventeenth and the ⁴ About four years earlier, according to the annalistic tradition (Livy 5.31.5), a very hot and dry summer had caused disease and famine in the vicinity of Rome, preventing the Romans from sending out an army against Volsinii. This might be an even earlier malaria epidemic, but there is no description of the symptoms.
⁵ Bonelli (1966: map on pp. 678–9); Bercé (1989: 241): la ville de Rome n’était d’ailleurs pas réputée vraiment dangereuse, avec l’exception des mois chauds dans les quelques quartiers accessibles aux débordements du Tibre.
⁶ Celli (1933: 130); P. F. Russell (1955: 93).
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28. Cardinal Juan de Lugo (1583–1660) orders the use of cinchona bark to treat patients with intermittent fevers. Reproduction of an oil painting by a Roman painter in the Ospedale di Santo Spirito in Rome. The Wellcome Library, London.
twentieth centuries.⁷ However, there were no effective remedies for malaria in Europe in antiquity. The papal election in 1623 demonstrates how devastating P. falciparum malaria sometimes was in Rome before the increasing use of quinine moderated its effects both in Rome in particular and more generally in Europe as a whole. The records of the Listae status animarum almae urbis Romae indicate a crude death rate for Rome of 43.1 per 1,000 in 1623, a bad year for malaria. This figure may be compared to the normal crude death rate of slightly over 30 per 1,000 estimated for Florence, a city unaffected by P. falciparum malaria, during the early seventeenth century by Cipolla, as an indication of the excess mortality that might be produced in Rome by an epidemic of malaria.⁸
⁷ Covel and Nicol (1951).
⁸ Schiavoni and Sonnino (1982: 107) record that the crude death rate in Rome in the pre-204
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To understand the demographic evidence from the periods studied by Bercé and Bonelli for the purposes of comparison with the evidence of the ancient medical authors which will be considered shortly, it has to be remembered that the population of the city of Rome during those periods was very approximately an order of magnitude smaller than it was during the time of the Roman Empire. The Listae status animarum almae urbis Romae recorded a population of slightly more than 90,000 people at the end of the sixteenth century, perhaps very roughly a tenth of the population of imperial Rome.⁹ Consequently the lowlying, frequently flooded areas along the Tiber, in the valleys between the various hills, as well as the lower slopes of the hills, the most dangerous areas in terms of the risk of malaria and densely occupied during the time of the Roman Empire, had a much smaller human population during the periods studied by Bercé and Bonelli. The popes from Sixtus V
in the late sixteenth century onwards had instigated a deliberate policy of shifting settlement from the lowlying areas to the vious year, 1622 (an even worse year for malaria), was 54.1 per 1,000. They note (p. 105) that the pontifical statisticians kept these demographic records precisely so as to be able to make les nombreuses observations que l’on peut faire sur la qualité de l’air. Cipolla (1992: 78) on Florence; del Panta and Rettaroli (1994: 35–7). Spigelio (quoted by Corradi (1865: ii. 39) ) described the disease of 1622 as febbre semiterzana maligna. Corradi also quoted Doni on this year: A. MDCXXII aestas atque autumnus magnum proventum malignarum febrium attulerunt, quae paucis mensibus multa hominum milia, ad vicena, vel tricena ferme atque ex his plurimos nobiles atque illustriores oppresserunt (In the year 1622 the summer heat and the autumn brought a great crop of malignant fevers, which in a few months killed many thousands of men, up to twenty or nearly thirty thousand, including many of the nobles and
more illustrious men.). Compare Cagnati’s (1599) description of the year 1593 in Rome (discussed by Corradi (1865: ii. 684–6): abortis tertianis praesertim, quas duplices vocant, quartanis, dysenteriis, fluoribus ventris, et acutis febribus, quae aliquos interficere (Particularly common were failed tertian fevers, which they call double tertians, also quartan fevers, dysenteries, diarrhoea, and acute fevers, which caused some fatalities.). Cagnati then went on to give a detailed description of the symptoms of the intermittent fevers of that year.
Corradi (1865: i. 640) summarized 1581 as follows, a mixture of different diseases: Mali assai perniciosi furono nell’estate in Roma, dove pure, siccome in altre parti d’Italia, caddero strabocchevoli pioggie.
Erano febbri terzane, quartane, continue con esanthemi, cioè petecchie e dissenteria.
⁹ Schiavoni and Sonnino (1982: 97–100) record a population for the city of Rome of 90,455 in 1598. By 1699 it had climbed to 135,099. By 1797 the city’s population had increased to about 160,000, although it dropped to 112,000 by 1814, as a result of the two periods of French occupation. J. C. Russell (1985: 1–25) and Storey (1997) attempted to revise the population of the city of Rome during the period of the Roman Empire downwards to about 450,000, on the basis of the density of houses in Ostia and Pompeii. Such arguments do not take account of the evidence of ancient authors indicating that ancient Rome had large numbers of multi-storey dwellings (e.g. Aelius Aristides, Orat. 14 p. 324, ed. Dindorf; Aulus Gellius NA 15.1.2; Dionysius Hal. AR 10.32.5; Vitruvius 2.8.17; Strabo 5.3.7.235C; Herodian 7.12.5–7; Cicero, de lege agraria, 2.96), and so a higher population density.
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healthier hills.¹⁰ (Human settlement was perforce concentrated in lowlying areas for much of the medieval period because of the need for drinking water, following the breakdown of most of the aqueducts, which had brought water to the city of Rome during the time of the Roman Empire.¹¹) As Delumeau put it in his monumental study of the city of Rome in the sixteenth century: It is for reasons of health that the popes now took an interest in the zone of the hills: in the summer they fled the heat and the pestilential air of the lower town.¹²
The danger of malaria was mitigated in medieval and early modern Rome by extreme avoidance behaviour (see also Ch. 11
below). For example, a substantial proportion of the population went away from the city during the dangerous period of late summer and early autumn. In the seventeenth century those who left Rome for the mountains during the summer would not return to the city before the Ides of October at the earliest.¹³ Such customs would be expected to reduce both morbidity and mortality from malaria. Presumably the very considerable extent of temporary migration during the summer away from dangerous areas, such as Rome and Grosseto, explains why the recorded crude death rates from such areas in early modern Italy often seem to have been, if anything, lower than the crude death rates in the English marshlands (see Ch. 5. 4 above), even though the combination of P. falciparum and P. vivax in Italy was more dangerous than P. vivax alone in the marshlands of England. In Italy in antiquity, members of the élite had the option of moving to villas in healthier areas during the summer and autumn, as the Younger Pliny did when he went to Tifernum in Umbria. However, it is not obvious that the bulk of the mass of the urban plebeians in antiquity had anywhere to go during the dangerous season, and slaves had no say in the matter.
More detailed accounts of the medical geography of the city ¹⁰ Finding safe locations for the pope and his court during the dangerous season was indeed a constant preoccupation long before the period studied by Delumeau. Toubert (1973: i. 363–4, ii. 1051–3) wrote about the eleventh and twelfth centuries as follows: les sources narratives et les pérégrinations anciennes de la cour pontificale à travers le Latium illustrent, en tout cas, cette recherche constante de l’ ‘aria buona’ dont les malariologues ont confirmé le bien-fondé.
¹¹ Procopius BG 1.19.28 noted that the Romans relied on wells for their drinking water during the siege by the Goths in the sixth century .
¹² Delumeau (1957: i. 311): C’est pour des raisons de salubrité que les Papes s’intéressent désormais à la zone des ‘monts’: l’été ils fuient la chaleur et ‘l’air pestiféré de la ville basse’.
¹³ Doni (1667: 114).
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of Rome show that the distribution of malaria within Rome was as complicated as the topography of the city, with its numerous hills and valleys. Some districts were quite safe, while others were dangerous in the summer and autumn. Baccelli provided interesting information in a very useful but propagandistic article about malaria in the city of Rome, which was published by the Ministry of Agriculture in 1878, as part of a massive book (a goldmine of information) intended to help to justify the choice of Rome as the capital of the recently unified Italian state. Baccelli had the task of arguing that Rome was healthier than its reputation for bad air, especially among English writers and travellers, suggested. His task was in fact fairly easy by then. Extensive drainage schemes, filling in and paving over of lowlying areas, and substantial construction work all over the city, leading to the conquest of the lower land from the hills (the inverse of the movement in the sixteenth century described by Delumeau), were indeed well on the way by then to eliminating malaria from the city of Rome. Indeed the situation improved so drastically that Mendini was able to describe Rome as now the healthiest of the large Italian cities, in his hygienic guide to Rome to which Baccelli contributed a preface.¹⁴ Nevertheless Baccelli still had extensive information available about the situation before the modernization of Rome commenced: We find that on the right bank of the Tiber the centre of the Leonine city can be said to be immune to fevers; on the other hand more or less unhealthy are the side streets, Porta Angelica, the Vatican hill; the Janiculum and the entire area from the Janiculum to Porta Portese is unhealthy. On the left bank of the Tiber the unhealthiness of the vicinity of Monte Testaccio, of Porta and Via Ostiense and of Porta San Sebastiano is well known; the same may be said of the lowlying plain between the Caelian and Palatine hills, of the Aurelian wall, of Porta Metronia, of Via Ferratella until the Lateran hill and of the surroundings of Santa Croce in Jerusalem. Other more elevated localities, even if they cannot be regarded as completely immune to fevers, are sufficiently more healthy.¹⁵
¹⁴ Pesci (1971: 596–7); Mendini (1897: 83–100).
¹⁵ Baccelli (1881: 156): Troviamo che sulla destra del Tevere la città Leonina, nel suo centro, può dirsi immune dalle febbri; più o meno malsane sono invece le vie laterali, Porta Angelica, il Monte Vaticano; malsani sono il Gianicolo e tutto quel tratto che si estende dal Gianicolo fino a Porta Portese. Sulla sinistra del Tevere è nota l’insalubrità delle adiacenze di Monte Testaccio, di Porta e via Ostiense e di Porta San Sebastiano; così pure dicasi del basso piano compreso tra il Celio e il Palatino, del recinto Aureliano, di Porta Metronia, di via Ferratella fino al colle Laterano e dei dintorni di Santa Croce in Gerusalemme. Altri punti più elevati, se non possono dirsi immuni, sono assai più salubri.
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VIA CASSIA
Riv
River Tiber
er Aniene
Villa
Borghese
TIBURTINA
Vatican
VIA
City
Quirinal
Ospedale
Viminal
Santo Spirito
Ghetto
Capitoline
Esquiline
Janiculum
Forum
Colosseum
VIA
Isola
Palatine
P
OSPEDALE DI
R
Tiberina
E
SAN GIOVANNI
NES
VIA AURELIA
Circus
T
CAELIAN
IN
TRASTE
VERE
Maximus
A
HILL
Aventine
Baths of
MONTE
Caracalla
TESTACCIO
Riv
er Tiber
VIA
TUSCOLAN
A
VIA APPIA
VIA OSTIENSE
Map 6. The city of Rome
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29. The vicinity of Monte Testaccio was one district of the city of Rome that was dangerous with regard to malaria in the past. The hill is about 45
metres above sea level and is composed entirely of broken pots, which had been thrown away from the port facilities of ancient Rome on the River Tiber nearby. It is now overgrown with vegetation.
Information is also given on districts that had been afflicted by malaria before the construction work mentioned above, for example Piazza Barberini, Via Quattro Fontane, San Nicola da Tolentino, Via Urbana, and the vicinity of the Baths of Diocletian.
The drainage of the lake at the entrance of the Villa Borghese eliminated malaria from that particular district. Celli wrote that ‘it was sufficient in those days only to ride in the evening through the Villa Borghese in order to catch the fever’.¹⁶ Other writers also gave detailed accounts of the medical geography of the city of Rome with reference to malaria. One of the earliest such works was the pioneering book on the medical geography of malaria in the Roman Campagna written by Giovanni Baptista Doni, who has already been mentioned several times in passing, de restituenda salubritate Agri Romani, published in Florence in 1667. Doni began by observing that various countries were noted for particular diseases.
He gave as one example the ‘sweating sickness’ in England, a ¹⁶ Celli (1933: 131), referring to the first half of the nineteenth century.
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phenomenon of that period which has puzzled medical historians ever since. The causative pathogen might have been a hantavirus, according to the most recent research. Doni explicitly compared the Ager Romanus as a whole to southern Sardinia, and then concentrated on malaria in the city of Rome. He reckoned that the most heavily built-up areas of the city were healthier, also buildings facing north and east, and the districts further away from the Tiber, while areas close to the Tiber, and buildings facing south and west, and buildings in lowlying locations, particularly in the valleys, were more dangerous.¹⁷
Malaria and Rome: A History of Malaria in Ancient Italy Page 29
