Malaria and Rome: A History of Malaria in Ancient Italy

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.
²⁹ Galen 17A.222K: oÛ per≥ pr3gmatoß, åll¤ per≥ shmainomvnou ka≥ ønÎmatÎß ƒstin Ó
z&thsiß, oÙß t0n proeirhmvnwn puret0n ønom3zein pros&kei trita≤ouß, Ómitrita≤ouß ka≥
tritaiofue∏ß.
³⁰ Jarcho (1987), contrast Sambon (1901 b, 305–10).
20
Types of malaria
endemic in London in his own time during the climatic conditions of the ‘Little Ice Age’ (see Ch. 4. 5 below), although he undoubtedly did recognize ‘ague’ or ‘marsh fever’, the indigenous English malaria caused by P. vivax (see Ch. 5. 4 below). Even as late as the nineteenth century, Littré in his great edition of the Hippocratic corpus had to insist that the diseases described in it had to be searched for among those present