Malaria
In the opinion of most scholars, malaria was common in classical antiquity. Moreover, it seemed to be widespread geographically, as references to both local malarious and malaria-free regions indicate.
Malaria, in fact, may have been endemic in some regions; if so, it undoubtedly colored the clinical findings of some chronically ill patients and may have been responsible for infant deaths not otherwise indicated. Less certain are the socioeconomic consequences of endemic malaria, although work efficiency must certainly have been impaired in malarious regions and among those who suffered from chronic malaria.Despite the large literature on the history of ma- Iaria and the innumerable surveys undertaken in conjunction with malaria eradication programs (in which patients were examined before or in the absence of chemotherapy, and hence were clinically analogous to patients of classical times), it is not easy to document the early history of malaria.
There are many reasons for our lack of certainty regarding malaria in classical antiquity, and since they are so intimately bound up with our interpretations of classical sources, it is worth listing some of them. This will help us to do what the ancient physicians tried to do, namely to distinguish malaria from a host of other diseases and pathological conditions.
First, until the late nineteenth century, there was no knowledge of the pathogenic organisms (the Plasmodia) involved. Thus, any diagnosis of malaria (or of one of the diseases with which it was often confused) depended, to a great extent, on the accurate recording of the signs and symptoms exhibited by a patient. Second, and perhaps as a function of its widespread distribution, malaria was often confused with other febrile conditions (e.g., phrenitis). On this matter, we have the explicit testimony of Galen’s works, as well as smaller texts such as that of Alexander of Aphrodisias.
Diodes and Crasistratus both wrote books entitled On Fevers, which have been lost. Third, and as a consequence of the first two points, the nomenclature was confused and inconsistent. Until the postclassical term, literally meaning “shivering fever,” came into use, other terms were commonly employed. None of them were completely satisfactory because they had other conflicting definitions such as “nightmare” or the shivers that accompanied the disease. The term febris was too broad, and hence although the root meanings of fire, heat, and burning were applicable to malaria fever, they could and did apply to other febrile conditions; καυσoς, or febris ardens, also signified intense, burning heat, though, of course, there was no way of translating the subjective sensations of a feverish patient into thermometric terms. Other, more restricted terms existed, but they will be examined later. Fourth, the different types of Plasmodium infection, best exemplified by the well-known terms tertian and quartan malaria, were so well recognized that they were regarded as separate diseases; moreover, other diseases (e.g., phrenitis and lethargy), which may have had a malarial basis, were regarded as capable of passing or changing into other febrile conditions and hence confounded diagnosis, prognosis, and therapy alike.These difficulties notwithstanding, a close reading of the chapters devoted to “fever” and so forth in the classical medical texts and a comparison of those texts with the numerous but scattered references to “fever” in the nonmedical texts leaves little doubt that malaria was indeed common and well known. The best evidence for this claim is provided by the conjunction of signs and symptoms that would be recognized as malarial today, in the absence of any chemotherapy. Principally, three signs, when associated with other data (e.g., cachexia or habitation in an area known to be “unhealthful,” especially when situated near a marsh or estuary), established diagnoses until the advent of blood smears.
First was splenomegaly. In routine physical examinations of the sort that Hippocrates advocated, palpation of the hypochondrium would often reveal an enlarged, tender spleen according to Celsus and Hippocrates. Second was the invariable sequence of chills, fever, and sweats, which was noted in many texts, among them those of Celsus, Pliny, and Hesychius. Third was the periodic nature of the disease, usually indicated in Latin by accessia. This is a more complex issue because of the nosological tendencies of medical writers who divided and classified fever into various forms: cottidian (daily); tertian (every third day; counting day of onset and day of crisis = every 48 hours); quartan (every fourth day; counting day of onset and day of crisis = every 72 hours). To these may be added the more puzzling quintans, septans, nonans, semitertians, and other mathematical, though not necessarily clinical, entities.It was presumably through a long period of noting and recording the constellation of such signs, and patients’ symptoms, that a “malarial constitution” was defined, according to Hippocrates. This, in turn, led to the establishment of the typical malaria cachexia and its common occurrence in classical Rome, as indicated by Martialis, Juvenal, Horace, and Livy.
The same wide range of opinion covering the differential diagnosis of malaria applies equally well to its etiology. There are hints of a very ancient belief in a supernatural origin. Sophocles, when describing an epidemic (of unknown origin) at Thebes, refers to a “fever-bringing god.” This does not prove that malaria was the cause of the epidemic any more than the presence of a temple dedicated to the goddess or numen Febris in Rome (according to Cicero and Pliny) proves that malarial fevers could always be distinguished from other fevers.
In Hippocrates, the etiology of four types of fever was explained in humoralistic terms. Three of the fevers are clearly malarial: cottidian, tertian, and quartan. The first two of these were caused by various amounts of surplus yellow bile; quartan was caused by a mixture of yellow and black bile. It was the “mixed humoral state” that was responsible for the longer cycle, which explained why quartan was more recalcitrant to therapy.
In addition to a humoralistic etiology, Galen wrote of a “feverish constitution” being due to a pestilential air, which could also be described as a “pestilential constitution.” It was also observed, for example by Celsus, that fatigue and hot weather led to fever; elsewhere he states, however, that therapy is difficult because fever can have both evident and hidden causes.
Both medical and nonmedical writers (e.g., Hippocrates, Horace, and Juvenal) agreed that late summer and autumn were the most likely seasons to be characterized by fever - a vestige of which survived until recently in the phrase estiυoautumnal fever for falciparum malaria.
Jerry Stannard