EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Objectives: In this study, we aimed to investigate the effects of malaria on the lives of Roman pontiffs.
Materials and Methods: The histories of all 264 popes from Saint Peter to John Paul II were extensively studied.
Results: Malaria affected the lives of Roman pontiffs. Between 999 AD and 1644 AD, 21 of 99 popes were affected by malaria (21.4%). The first affected was Gregory V and the last was Urban VII, the 138th and the 235th pope, respectively. There were 15 deaths (15.2%). Six pontiffs (6.1%) were infected but survived. Many cardinals and their assistants, especially those coming from northern countries, contracted malaria during conclaves, and many died.
Conclusions: By about 450 BC, malaria had arrived in Rome. By the second century BC, malaria was endemic. It affected the lives of Roman people. To prevent infection, the popes adopted the custom of ancient affluent Romans who used to spend summer months in high plains far from Rome. The first to adopt the custom was Paul I in 767, who just moved his residence to Saint Paul, out of the walls. Sixtus V started the Congregation of Waters and Streets, which was routinely reinforced by his successors until 1860, when the Kingdom of Italy was born.

Malaria is an ancient disease that has accompanied humankind since its beginnings¹ and described for the first time in a Chinese document from 2700 BC. It is caused by a protozoan parasite of the genus Plasmodium and is transmitted by female mosquitoes of the Anopheles species. The parasite was described by Alphonse Laveran (1880) who did not convince his colleagues at the Academy of Medical Science² but received the Nobel Prize for Medicine/Physiology in 1907. Ronald Ross (1857-1832) elucidated the modality of transmission in culicine mosquitoes and birds infected with Plasmodium relictum. For this, he was awarded the Nobel Prize in 1902.³ The whole cycle of the parasite was elucidated by the Italian marialogists Giovanni Battista Grassi, Amico Bignami, Giuseppe Bastianelli, Camillo Golgi, and Ettore Marchiafava in 1898. Angelo Celli gave a fine description of malaria as early as 1933.⁴ Other relevant scientists who contributed to unraveling the mysteries surrounding malaria were Henry Shortt and Cyril Garnham.⁵ The existence of dormant stages of the parasite in the liver was finally shown in 1982 by Wojciech Krotoski.⁶

The term malaria was coined in the 14th century in Venice, Italy. Marco Cornaro (1412-1465), a “savio delle acque”/wise of water (plumbing expert), was the first to speak of “mal aere” and of “mal aria.”⁷ Rome has been a malarial site since about 450 BC, where it arrived through travels and shipping either directly from Africa or from Sardinia or from Greek colonies in Southern Italy.^8-13 Malaria was a problem of public health in Rome where “Dea Febris” (the goddess of fever) was worshipped¹⁴ in February (the month dedicated to her). Romans would seek the divine intervention to be healed from malaria rather than for its prevention.

Aqueducts, channels for irrigation, and drainage ditches have been part of the administration of the city from the third century BC onward. Even when emperors abandoned the city, pontiffs took great care of waters from rivers, lakes, and marshes.

We also know that the upper echelons of Roman society would spend their summers in the foothills outside of the city, where Horace (65-8 BC) in Satires wrote on his highland estate that he did not need to fear an unhealthy autumn.

Indeed, in Rome, those who could afford it left the city during the unhealthy season. Roman pontiffs continued this practice; thus, merchants came to Rome to trade during the winter months.^15,16 Although malaria has been reported as a cause of death of Roman pontiffs, no systematic paper to our knowledge has addressed this topic.

A careful study by Retieff and Cilliers, who investigated the lives of popes reigning from 1492 to 2005, reported malaria to be the likely cause of death for Gregory V, Damasius II, Leo X, Sixtus V, and Urban VII.¹⁷ Previously, Gualino18 reported other cases of papal malaria; however, some doubts have been cast on many of the fevers he attributed to malaria ending in papal deaths.

Therefore, we conducted this study to ascertain the prevalence of popes who died from malaria and the popes who survived the infection. We suggest that the findings will indicate a high prevalence of malaria in Roman pontiffs.

Materials and Methods

We examined the following: (1) histories of papacy, archiaters, and personal physicians^19-23 of Bartolomeo Sacchi, known as Platina (1421-1481), Luigi Gaetano Marini (1782-1815), Giuseppe de Novaes (1736-1821), Mathieu-Richard A. Henrion (1805-1862), and Ludwig Von Pastor (1850-1928); (2) the papal medical histories^18,24-26 of Luciano Gualino, A. Paravicini Bagliani (2000), Giovanni Ceccarelli (2001), and Giorgio Cosmacini (2018); (3) the recent monographs on popes^27-30 of Claudio Rendina, Peter G. Maxwell-Stewart, and Wendy J. Reardon; and (4). online encyclopedias Treccani and Britannica.^31,32

Malaria affected the lives of Roman Pontiffs. Between 999 AD and 1644, a total of 21 of 99 popes (Table 1 and Table 2) were affected by malaria (21.4%), that is, nearly 1 of 4. The first was Gregory V, the last Urban VII, the 138th pope and the 235th pope, respectively. There were 15 deaths (15.2%) (Table 1); 6 popes (6.1%) survived (Table 2).

After the death of Gregory IX in 1241 from malaria, the conclave elected Celestine IV, who died of malaria 17 days after and was not enthroned. In that conclave, the English Cardinal, Robert of Somercotes, succumbed to malaria, while Cardinal Fieschi (Innocent IV) and Cardinal Riccardo Annibaldi were infected but recuperated. In the Conclave of 1276, when Adrian V was elected pope, he moved the court to Viterbo to protect himself; however, he died of malaria within 40 days.

In the Conclave of 1287 to 1288, 6 cardinals perished from malaria and 4 fled Rome.

In agreement with Jones,¹⁴ the high percentage that we found of Roman ecclesiastics who contracted malaria is an indication that the disease presented a public health hazard that had consequences on all of Rome’s inhabitants.

Malaria arrived in Rome⁸ either from the Greek colonies in Southern Italy or from Sardinia and/or directly from Africa. It became endemic in the second century BC also because of Tiber River flooding and the presence of small cisterns under houses (impluvium, compluvium) collecting the rain¹⁴ as well as because of famine and invasions (for example, Alaric and Attila).

Roman writers, poets, and scientists wrote extensively on malaria (Table 3). The first description was authored by Plautus (about 250-255 to 184 BC) in the Curculio: “Did a fever leave you yesterday or the day before.” The fact that a playwright referred to the periodicity of the disease in a comedy means that the spectators could understand the topic to which he alluded.

The next was by Publius Terentius (190-185 to 159 BC) in Hecyra12: “What kind of disease is it?” “Fever.” “Quotidian?” “They say so.”

Cicero (106-43 BC) frequently mentioned tertians and quartans and turned these words, defining them as divine fevers “ne tertianas quoque febres et quartanas divinas esse dicendum sit” (De natura deorum 3, 24). In Satires, Horace (65-8 BC) wrote that, on his highland estate, he did not need to fear an unhealthy autumn, whereas in Odes, he wrote that all parents fear for their children in autumn. Marcus Terentius Varro (116-27 BC), in De re rustica (1,12) wrote, “Advertendum etiam, siqua erunt loca palustria, et propter easdem causas, et quod crescunt animalia quaedam minuta, quae non possunt oculi consequi, et per aera intus in corpus per os ac nares perveniunt atque efficiunt difficilis morbos.” This is translated to mean “Precautions must also be taken in the around swamps, for the above reasons and because there are bred certain minute creatures, smaller than the eyes can see, which float in the air and enter the body through the mouth and nose and there cause serious diseases.”

Celsus (floruit about 50 AD) dedicated writing about fevers in book 3 of De Medicina³³:

“These then are the things to be done by those, who, being in health, have cause merely to be apprehensive. Now there follows the treatment of fevers, a class of disease which both affects the body as a whole, and is exceedingly common. Of fevers, one is quotidian, another tertian, a third quartan. At times certain fevers recur in even longer cycles, but that is seldom. In the former varieties both the diseases and their medicines are of various kinds.

Now quartan fevers have somewhat simpler characteristics. They nearly always begin with shivering, then heat breaks out, and the fever ends. This is followed by two feverless days; then on the fourth day it recurs.

The tertian fevers belong to two classes. The one, beginning and presenting in the same way as a quartan, has merely this distinction, that it affords one feverless, and recurs on the third day. The other is far more pernicious; and it does indeed recur on the third day, yet out of forty-eight hours, about thirty-six, sometimes less, sometimes more, are in fact occupied by the paroxysm, nor does the fever entirely cease in the remission, but it only becomes less violent. This class most practitioners term hemitritaion. Quotidian fevers, however, vary and have many [forms].”

In ancient Rome, the wealthier classes left the city during the unhealthy season and returned in winter. Roman pontiffs were at daily risk of Roman fever. Cardinals and their assistants participating in the conclaves were also at risk of infection. At the greatest risk were those coming from Northern countries and less those living on the shore of the Mediterranean Sea because of acquired resistance.^15,16

Popes were well aware of the impending risk to contracting malaria, so much so that, in summer, they moved their residences (Table 4), sometimes within the city limits traditionally thought to be healthier, although more frequently to distant hills. This custom was adopted for the first time by Paul I in 767 AD who moved to St. Paul just outside of the walls.

The number of deaths caused by malaria was a reason why the pontiffs began to recover wetlands. Volunteers for such campaigns received one-third of the land recovered. A specific Congregation for Waters was instituted by Sixtus V with the constitution “Immensa Aeterni Dei” on January 22, 1588. It had jurisdictional powers on rivers, lakes, roads, and bridges. It worked in collaboration with the Congregation “super viis, pontibus et fontibus” and was presided by a cardinal. It benefitted from the skills of a “chamber cleric,” who presided Roman aqueducts. Congregation’s decisional powers extended to mills, sewers, channels, ports, waters, rivers, and bridges. The president was also a member of the Congregation of the Plains and of the Congregation of Pontine Marshes, which shared the secretary of the Congregation of Waters and Streets. Thus, a strong service, with internal unity, was created and empowered.³⁴

In 1612, the congregation reformed by Paul V with the Bulla In sede beati Petrui. It was divided into 2 sections, one supervising the sources of waters and the streets in Rome the other maintaining rivers, bridges, ditches, streams, and drains.

In 1712, all waters were united under the super-vision of the Congregation (decree of Clement XI, November 26, 1701). The power of the congregation included mills, sewers, channels, ports, remediations, water, rivers, and bridges. Furthermore, its president was a member of the Congregation of Plains and of Congregation of Pontine Marshes, which shared the secretary of the Congregation of Waters and Streets.³⁴

At the start of Christian era, malaria was endemic in Rome. Popes were at such high risk of being infected that, in summer months, they relocated to the hills around Rome and beyond. They also planned for malaria prevention by starting the Congregation of Waters and Streets.

Volume: 21 Issue: 6 June 2023 - Supplement - 2

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