THE MIRACULOUS FEVER-TREE

Malaria, medicine and the cure that changed the world

Fiammetta Rocco

DEDICATION

For Dan, for the best of gifts and so much else besidesAnd for my father who, without quinine,would have died as a boy

CONTENTS

Cover

Title Page

Dedication

Maps

Early-Eighteenth-Century South America

Central Africa

World Distribution of Malaria

Introduction: The Tree of Fevers

1 Sickness Prevails – Africa

2 The Tree Required – Rome

3 The Tree Discovered – Peru

4 The Quarrel – England

5 The Quest – South America

6 To War and to Explore – From Holland to West Africa

7 To Explore and to War – From America to Panama

8 The Seed – South America

9 The Science – India, England and Italy

10 The Last Forest – Congo

Notes on Sources

Further Reading

Index

Acknowledgements

About the Author

Praise

Copyright

About the Publisher

MAPS
Early-Eighteenth-Century South America

Central Africa

World Distribution of Malaria

INTRODUCTION The Tree of Fevers

‘Cinchona revolutionised the art of medicine as profoundly as gunpowder had the art of war.’

BERNARDO RAMAZZINI, physician to the Duke of Modena, Opera omnia, medica et physica (1717)

Francesco Torti’s ‘Tree of Fevers’ may be nearly three hundred years old, but it swells on the page as though it rose from the ground this very spring. At the crown, its trunk branches like an earthly anemone, and its arms grow thick and dark. On the left side of the engraving, the tree bark hums with sap and leaves grow at intervals in thick bunches of green. The branches on the right, by contrast, are denuded and leafless. Tissue-white, they curl upwards as if in supplication to the Almighty.

Torti, who once saved his own life by taking a dose of powdered Peruvian quinine bark to cure an intermittent fever, as malaria was once called, believed that there were two kinds of fever: those, represented by the leafy branches on the left side of his tree, that respond to treatment with the bark; and those, like the dead willowy kind, that do not.

But Torti took his inspiration from another tree, one that he had never seen, and one that for centuries would remain an enigma. The magnificent Cinchona calisaya, the red-barked Andean tree that produces quinine, is one of ninety varieties of cinchona, a relative of the madder family, which also includes coffee and gardenias. Some cinchonas have large leaves, some small; some smooth, some roughly corrugated. But the leaves on the older trees of the true red bark – the cascarilla roja that grows eighty feet high – are fiery red. The colour offsets the lilac-like flowers that grow in delicate white clusters, and which are followed by a dry fruit that splits, at the onset of winter, to release narrow winged seeds so tiny and fine that they run to as many as 100,000 to the ounce. Joseph de Jussieu, the first European to set eyes on the cinchona, thirty years after Torti’s engraving of 1712, believed that Cinchona calisaya was the most beautiful tree he had ever seen.

For Torti and de Jussieu, intermittent fever or malaria was a disease of the Old World. No one knew for certain where it came from or what caused it. But everywhere the Old World expanded its boundaries – pushed ever on by commerce, religion and war – malaria followed. And the price it exacted was beyond imagining. ‘Malarial fever,’ wrote Sir Ronald Ross, the Englishman who in 1902 was awarded the Nobel Prize for Medicine for proving that malaria is transmitted by mosquitoes, ‘is important not only because of the misery it inflicts upon mankind, but also because of the serious opposition it has always given to the march of civilisation … No wild deserts, no savage races, no geographical difficulties have proved so inimical to civilisation as this disease.’

Within the foul-tasting, bitter red bark of the cinchona tree is an alkaloid that prevents and treats malaria. The Peruvian bark, which was first brought to Europe in 1631 or thereabouts, was looked upon as a miracle. But its discovery was also a riddle. Cinchona was a tree of the New World. It grew where the rain was plentiful in the foothills of the high Andes, where malaria had never existed. How did anyone guess that among all the trees in South America, it was the bark of the cinchona that would cure malaria? How was it that a seed so small it is almost invisible could grow into a tree, one eighteenth-century source wrote, that was as crucial to the art of medicine as gunpowder had been to the art of war?

This book is the story of the riddle of quinine, the miraculous fever-tree which transformed medicine – and history.

1 Sickness Prevails – Africa

‘Malaria treatment. This is comprised in three words: quinine, quinine, quinine.’

SIR WILLIAM OSLER, Regius Professor of Medicine, Oxford, 1909–17

‘If you ever thought that one man was too small to make a difference, try being shut up in a room with a mosquito.’

THE DALAI LAMA, 1977

My grandparents had been married for many years when they left Europe for Africa in 1928, though not to each other.

My Parisian grandmother, Giselle Bunau-Varilla, had had at least two husbands, if not three. My Neapolitan grandfather, Mario Rocco, was being sought by Interpol for trying to kidnap his only child. His first wife, a tall, thin Norwegian with wide cheekbones and a finely arched brow, had been labouring for years to expunge him from her life. She wanted, above all, to change their daughter’s identity from Rosetta Rocco, a Catholic, to Susanna Ibsen, a Protestant – and to be rid of her husband forever.

The Neapolitan solution was to remove the child by force and go into hiding, a plan that ultimately failed, though not before it had annoyed the authorities and landed my grandfather in a great deal of trouble.

As an antidote, a year-long safari in the Congo seemed a welcome distraction to all concerned. Yet as the moment of departure drew near, both my grandparents were filled with the excitement of the unknown. Their journey turned from being an all-too welcome respite from their domestic travails to a grand, passionate tropical adventure.

A few hours before New Year 1929, they boarded the sleeper train in Paris that was bound for Marseilles. My grandmother, as always, could be counted on to remain calm even while eloping to Africa with someone else’s husband. My grandfather, who had jet-black hair with a deep white streak that swept back from his forehead, only felt his fine sense of the dramatic swell as he put Paris behind him. ‘Don’t even tell my in-laws what continent I shall be in,’ he wrote to his family from the train.

In Marseilles they boarded the SS Usambara, a passenger ship of the Deutsch Öst Afrika line that would bear them across the Mediterranean to Port Said, through the Suez Canal, and down the East African coast to Mombasa. From there, the plan was to travel by train and on foot across Africa’s thick equatorial waistline to the heart of the continent. They thought they would be away for at least a year. Longer, perhaps.

My grandparents were accompanied by a sizeable quantity of luggage. To equip themselves for a hunting trip that would take them as far west as the Ituri forest on the banks of the Congo river, they had paid a visit to Brussels, to the emporium of Monsieur Gaston Bennet, a specialist colonial outfitter who sold ready-prepared safari kits with everything a traveller might need for a journey of three, six or even nine months.

Monsieur Bennet’s inventory sounds much like the necessities that H. Rider Haggard’s hero Alan Quartermain packed when he set off in search of King Solomon’s Mines. For their extra-long hunting trip, he sold my grandparents four heavy-calibre rifles, including a double-barrelled Gibbs .500 which my grandfather Mario, with manly Neapolitan excitement, described in his diary as ‘una vera arma’ – a real weapon – and a .408 Winchester for my grandmother Giselle, who hoped to shoot an elephant. Eight months later she killed a lone male; its tusks soared high above her head when it lay dead on its side. She allowed herself to be photographed alongside the beast, leaning heavily on the barrel of her rifle as if it were a staff. But the truth is that she felt a little sick at what she had done. Killing the elephant unnerved her. She was five months pregnant at the time, which may have made her especially sensitive. She never shot an animal again.

As well as the rifles, my grandparents were outfitted with two pairs of shotguns, a twelve-bore and a lady’s twenty-bore; five hundred kilos of ammunition in watertight boxes; six trunks of tropical clothing; twelve cases of brandy; eight of books; a typewriter; a gramophone with my grandfather’s favourite record, ‘My Cutie’s Due at Two-to-Two Today’; coloured beads for gifts; and enough sketchpads, pastels and modelling clay to last them a whole year—my grandfather was a painter and my grandmother a sculptress. Their effects were packed into tin trunks weighing not more than twenty-five kilos each, the maximum that would be carried by an African porter. Giselle stood barely an inch over five feet and always wore a turban, which had the effect of both hiding her incipient baldness and making her seem taller than she really was. When my grandparents reached the Ituri forest she unpacked her clay and set about modelling a local Tutsi chief who towered nearly two feet above her. He watched her as she worked, his face impassive. He said nothing, but his children danced around and called her ‘Potipot’, she who works with clay.

In addition to the safety precautions of heavy Damascus-barrelled guns and several changes of boots, Monsieur Bennet packed my grandparents a sizeable medicine chest that was manufactured from black metal and lined with marbled endpapers to absorb any moisture and keep its contents safe from ants. In it he placed gauze bandages and sutures, several bottles of Dr Collis Brown’s Elixir, a concoction made of morphine, cannabis and treacle that had been invented in 1856 and was recommended for treating diarrhoea, boric acid for the eyes, carbolic acid against lion and leopard scratches, Epsom salts and castor oil for constipation, and a brown goo called Castellani’s Paint to fight skin fungi. There were also twenty-four sets of steel syringes and needles, each packed in a small metal box with a tight lid for easy boiling, the best method of sterilisation in the bush. No medicine chest bound for Africa was complete without a supply of purple crystals of permanganate of potash, for washing raw vegetables and cleaning out snakebite wounds. With it came a snakebite pencil which you used to cut a Y-shaped incision, so you could lift the skin immediately surrounding the bite and pack it with permanganate.

Snakes are highly sensitive to vibration, and most of them will slither away when they detect you approaching. Mosquitoes, on the other hand, do not. Among the most important items in Monsieur Bennet’s medicine chest was packet after packet of powdered sulphate of quinine, to guard against malaria. Alan Quartermain packed an ounce of quinine and one or two small surgical instruments into his bag for the final assault on King Solomon’s Mines. He would not have left home without it. ‘This was our total equipment, a small one indeed for such a venture,’ he wrote. ‘Try as we would we could not see our way to reducing it. There was nothing but what was absolutely necessary.’

From Mombasa Mario and Giselle headed west towards their first stop, Voi, a railway junction halfway between Mombasa and Nairobi. The land was flat and scrubby, with occasionally a mound of hills rising in a greeny-purple haze in the far distance. They saw Masai herders with thin, high-boned cattle that were oblivious to the sun’s heat. Dried-out umbrella thorns provided the only shade, and a patchy shade at that. Shortly after Voi they made a detour south across the border with Tanganyika to try to get a better view of Mount Kilimanjaro, Africa’s highest peak. They passed the spot where General von Lettow-Vorbeck, the German soldier-adventurer, had routed a British regiment fourteen years previously. By 1917 the British had begun to fight back, and von Lettow was in trouble. Supplies were running short. Recurring bouts of malaria had reduced many of the soldiers, von Lettow among them, to yellow, shrunken skeletons. Unable to obtain any imported quinine tablets, von Lettow’s officers began making it themselves from the powdered bark of cinchona trees that they found growing locally. The cinchona had been planted in the early 1900s, by Tanganyika’s German colonial masters. Von Lettow’s soldiers couldn’t make tablets, though, so they stirred the ground-up bark into their coffee. It was a horrible brew which the troops called ‘Lettow-schnaps’, but it worked.

Although they had lived in Europe their whole lives, both my grandparents already had some experience of malaria before they left for Africa. In 1886 my great-grandfather, Philippe Bunau-Varilla, became the Chief Engineer of the Panama Canal, a scheme that had been dreamed up by Ferdinand de Lesseps shortly after he had finished his canal at Suez. By the time France’s Panama project collapsed in 1889, twenty-two thousand men had died of yellow fever and malaria.

No one made it a requirement that those who went to Panama should take regular doses of quinine. This is astonishing, for quinine was already well known by then – Jules Verne wrote about it in his novel L’Île mystérieuse in 1874; later Chekhov would call his favourite dog Quinine (being a doctor, he called his other dog Bromide). The problem was that quinine was difficult to obtain, as supplies from the 1860s on were intermittent. Worse still for the project’s managers, it was expensive: while the American Civil War was at its height, much of what was available was shipped north to protect the Union soldiers who were taking over more and more of the Confederate land where malaria had long been a scourge, and that trade still ran strong after the war ended. The officials of the French Compagnie Universelle du Canal Interocéanique calculated that it was cheaper to let its workers die than to spend a lot of money trying to cure them with costly medicines. Even a prophylactic dose, which would surely have saved them much money over the long run, was, they calculated, beyond their budget. The Americans, who took over the canal’s building works in 1903, were of the opposite view, and forced their workers to take a regular prophylactic dose of quinine or face mandatory punishment. In less than a year, the US Army’s soldier-engineers managed to stamp out virtually every trace of malaria. But that is getting ahead of the story.

My grandfather, for his part, was born in Naples but spent much of his childhood staying with an aunt who lived in the hills of Maremma. To many, this part of Tuscany was known as ‘la Maremmamara’ – bitter Maremma – because of how malaria had forced people to abandon the land in the eighteenth and nineteenth centuries. Another aunt lived in the Roman Campagna, where malaria had existed since Roman times, and from which it was not wholly stamped out until the 1930s, when Mussolini embarked on draining the Pontine marshes at the mouth of the Tiber, thus ridding western Italy of the pools of stagnant water in which the malaria-carrying mosquitoes bred.

In truth, the whole of southern Italy in summer was a hellhole of malaria. Travelling through the region in 1847 on his way to Sicily, Edward Lear, the artist and poet whose children’s verse usually speaks lovingly of the oddities across the seas, noted in an unusually serious vein that malaria turned the population yellow and shrivelled many to living skeletons. ‘After May,’ he wrote in a letter to his brother in the spring of that year, ‘the whole of this wide and fertile tract … is not habitable, and in July and August to sleep [i.e. to die] there is almost certainly the consequence of fever.’

George Gissing, who made the same journey nearly sixty years later, wrote in his Calabrian classic By the Ionian Sea of the amiable Dr Sculco, who advised him to ‘get to bed and take my quinine in dosi forti. [Was I not] aware that the country is in great part pestilential [because of] la febbre?’ Of course, Gissing, Lear and the other foreign writers who journeyed to the south of Italy could always leave if things got too bad. For the innkeeper in Giovanni Verga’s nineteenth-century short story ‘Malaria’ there was no such option. First came the railway, which took away the brisk business he’d enjoyed from the carriage trade. Then it was the malaria that struck, bearing away each of his four wives in turn, earning him the nickname ‘Wifekiller’. When none of the village girls would consent to become his fifth bride, he said to himself, ‘Next time I’ll be taking a wife who’s immune to the malaria. I won’t go through all this again.’ But it was not to be.

‘The fact is,’ wrote Verga, ‘that malaria enters your bones with the bread that you eat and whenever you open your mouth to speak … The malaria fells the townspeople in the deserted streets, it pins them down in the doorway of houses whose plaster is peeling in the sun, as they shudder from the fever, wrapped up in their overcoats, and with all the blankets from their beds round their shoulders.’

Massimo Taparelli, the writer and statesman who, as Marchese d’Azeglio, served as Prime Minister of Italy under King Victor-Emmanuel II, often mentioned the disease in his diaries. ‘While we were staying at Castel Gandolfo [the Pope’s summer home],’ he wrote on one occasion in 1860, ‘I used to go down to the plain to shoot. But instead of birds I got the terrible marsh fever, the ancient scourge of Latium …

‘No one can have any idea of the iciness of the cold phase or the burning heat of the hot attack of these painful fevers. Quinine is certainly the most beneficent discovery for the Roman Campagna. There may be no steam there, no newspapers, no other modern inventions but at least they have quinine, and that’s worth all the rest put together.’

When my grandfather was growing up, everyone in southern Italy regularly took quinine in the summer, when the danger of catching malaria was at its worst.

My grandfather saw his African safari as just the start of a grand adventure that would take him and my grandmother around the world. ‘From here, we shall travel on, to Dar es Salaam, to Beira and then around the Cape to Rio de Janeiro,’ he wrote to his mother as they arrived in Africa in February 1929. They never left. Later that year my grandmother, who had already lost her first baby in childbirth, became pregnant again. Already thirty-seven, she wanted to take no risks a second time. The couple returned to Nairobi to await her confinement.

While she was in hospital, Mario took off in a small plane to look for a friend they had made during their months in the Congo. Before the end of the day he ran out of fuel and crash-landed by the shores of Lake Naivasha, about seventy-five miles from Nairobi on the shady floor of the Rift Valley. A grizzled Englishman, who introduced himself as Harvey, hailed him when he climbed, unhurt, from the wreckage. Mr Harvey took him back to his house, a bungalow with a mottled thatch roof, where after several stiff drinks and a lot of talk he offered to sell Mario his property. Hurrying back to Nairobi to tell Giselle, Mario stopped at the telegraph office to send a cable to his father-in-law, who would be putting up the purchase price.

That telegram was sent more than seventy years ago, and I have it here before me as I write. Its blue folds are as soft as a baby’s cheek, and the pages quite floppy with being taken out and put away so many times. It is addressed, in brief telegraph-speak, to ‘Bunovarila, 1 Grande Chaumiere, Paris’. And it says: ‘Purchased shamba Naivasha 3000 acress [sic] three miles lake front. 5000 pounds. 2000 cash, balance three years. Best bargain. Cable if you want me home to fix everything or cable approval.’

By the time Mario and Giselle decided to stay in Africa on the farm by the shores of Lake Naivasha, the supply of little packets of quinine sulphate they had brought with them in 1929 had long since been used up. Neither of them had caught malaria in the Congo; only heatstroke. But in 1936 Mario came down with a bad attack as he returned from a trip to Lake Victoria, a notorious malarial spot even today. In 1940, just after the start of the Second World War, he had another attack while he was in a British internment camp in Nairobi.

As an Italian, Mario had been arrested as soon as war broke out in September 1939. Giselle, a French national, was allowed to remain on the farm, where she turned her attention from sculpture to raising pigs, as well as to my father and his two sisters. She stayed in touch with her family in Paris, and though the seaborne post was slow, it did its work. Once a month, sometimes more often, a postal vessel docked at Mombasa and a few days later my grandmother received a delivery of letters, newspapers and parcels from Europe, which contained among other things regular supplies of quinine for all the family. And, if she was lucky, there might also be a letter from my grandfather.

I found those letters in an old shoebox the morning after Mario died in 1976. For more than a quarter of a century he had kept them under his bed. Lonely, frustrated and often sick in the internment camp, he longed for home. His letters were restricted by the camp authorities to a single sheet of paper, and over time he perfected the tiniest, neatest handwriting you ever saw, so that he could write first in one direction and then at right angles over the page, stretching out for as long as he could the connection with his family. ‘I dreamed last night that you were sitting by my bed,’ he wrote to Giselle in the winter of 1943 after a bad attack of malaria. By then he had been interned for nearly four years. ‘Nothing would heal me more quickly than to feel your hand upon my cheek.’

Through the war years Mario fell ill several times with malaria. ‘I don’t know what is worse; the fever or the shivering,’ he wrote. ‘There is no quinine. Cold water is the best we can hope for.’ Beyond the heartache and the loneliness there was a cold reality about malaria in Africa that is as relevant now as it was then. With access to efficient anti-malarial drugs, Giselle and her children remained healthy. Mario, who like so many Africans today did not have the medicines he needed, did not.

Back in Kenya in the early 1950s he had a third bad attack, and in 1958 a fourth while on a long winter visit to Europe. After that, it would often strike when the rainy season was under way. Our farm, with its warm climate and its clumps of thick papyrus that stretched out for yards into Lake Naivasha, was the perfect habitat for the Anopheles mosquito that spreads the disease. In the rainy season, when the mosquito larvae hatch in their thousands, it can be especially bad, and even today we always sleep under mosquito nets.

I have had malaria only once, when I was eighteen. I had been on holiday at the mosquito-ridden Kenyan coast, and cared little about remembering my pills. That was enough. Soon after I returned, I began feeling unwell. I took my temperature. 101°F. By nightfall it was up to 104° and I was beginning to hallucinate. With any other illness, I have always felt that I was still myself. I might be in pain or feel nauseous, but I was me – only sicker. Sick with malaria, however, my body felt it was no longer my own. It had been invaded, as if it had been subjected to a military coup. I remember walking into my father’s bedroom; I watched myself, as if I were another person completely. The fever was just beginning to shoot up. The parasites in my blood that had invaded the red corpuscles were splitting them open and destroying them in a rampant urge to reproduce. I lay down on the bed, and passed out. After that everything is blank. My blood had been hijacked. That is how the delirium begins. ‘I have lain on my cot for forty days,’ the explorer David Livingstone wrote to his wife from Luanda, in present-day Angola, in 1854. ‘So fierce was the delirium that I remember almost nothing of it.’ The fever would kill him nearly twenty years later. Clearly, I was lucky.

My father gets it more often than any of us, and worse. Just a few days before I wrote this, he called to say he was ill again. ‘I began to feel colder and colder and colder,’ he told me, his voice thin with fever. ‘I got into bed with a hot water bottle and kept piling on blankets. For two or three hours I just shivered and shuddered as if I was in an icy blast. Then, suddenly, it stopped. And I started getting hotter and hotter and hotter, and throwing all my covers off. Forty-eight hours later it started all over again. And every forty-eight hours it’s been the same for about a week.’

As always, my father went to his Italian doctor in Nairobi, Mauro Saio, one of the world’s leading specialists in treating malaria. Dr Saio has worked so long with the disease that he named his speedboat Anopheles after the mosquito that spreads the disease. ‘You have headache, vomiting, diarrhoea,’ he explained, ‘and if it’s not caught in time and the parasites keep reproducing, you can have respiratory distress and systemic organ failure.’

For Dr Saio, combatting malaria is a campaign. As he told me the first time we met, ‘It’s a battle. A hard battle. I know this disease. I fight this disease every day of my life. It is my personal enemy.’

My grandparents tried to protect themselves and us, my sister and my four cousins. As far back as I can remember, the daily ritual of breakfast on the farm was broken on Sundays by the distribution of the quinine, or its modern chloroquine-based equivalent, Nivaquine: two tablets for the grown-ups, and for the children a spoonful of Nivaquine syrup, which was increased to two spoonfuls when we were about twelve years old. Oh, it tasted awful. It wasn’t like today, when pharmaceutical companies try to make their medicines palatable to children; in the 1960s they had other priorities—all a medicine was required to do was to work, and you just had to take it. Quinine is marked by its particularly bitter taste. Over the centuries, many people have refused to swallow it for fear that they were being poisoned.

Nivaquine is also bitter, and the vile taste of the syrup clings to your teeth and gums long after you have swallowed it down. Just writing about it makes me wince at the memory. It tasted so ghastly that my grandfather had to devise his own method for persuading us children to take it. He bribed us. If we swallowed down the Nivaquine, we were allowed to choose what we would have for Sunday lunch.

This was no mean bribe, for my grandfather was a tremendous cook. By his place at the head of the table lay a book covered in well-loved, shiny dark red leather. Il Talismano della Felicità was written nearly a hundred years ago, and it contains instructions for making every manner of Neapolitan delicacy. Once we had all swallowed our Nivaquine, my grandfather would pour himself another cup of black coffee, drop into it a lump of sugar, light a cigarette and then reach for his Talismano. Slowly he would turn the pages, stretching out the agony of anticipation. And then he would begin, in a deep, sonorous voice. ‘So, bambine, what will it be today? Pizze fritte? Sartù di riso? Maccheroni al ragù? Melanzane alla parmigiana?’ We would vie to be the one who made the final choice, completely forgetting the filthy taste of the Nivaquine in our anticipation of the meal to come. In our house, the danger of malaria was vanquished by greed.

When I was fourteen, I was sent to boarding school in England. I arrived at my new convent school in Sussex on a bleak January afternoon. Snow-filled clouds hung over the landscape like a laundry bag waiting to burst. One of the Irish nuns showed me into a dormitory with seven beds covered with old rose-coloured candlewick bedspreads. Her manner was brisk, and she didn’t stay long. I had arrived in the middle of the day in the middle of the school year, and she had things to be getting on with. The other girls were in class, and every bed in the dormitory had been taken except one, that stood alone in the middle of the floor. Slowly I unpacked my trunk, and stowed away the clothes my aunt had ordered off a long list from a department store in central London: thick white underpants (inner, changed daily), huge navy-blue serge underpants (outer, changed weekly). I thought of running barefoot in the soft African dust and splashing in the ditches by the side of the farm roads, and felt a bit sick with the longing to be back home. None of my roommates, it turned out, had ever been to Africa. They giggled among themselves and argued endlessly about the merits of rival pop stars. At night, they tossed and mumbled and farted in their sleep. There was not a moment of privacy. We even had to share baths. By the end of term the seven of us had been living so closely together for so long that our menstrual periods all began and ended on the same day. But that did not bring us closer. The loneliness of living in a foreign crowd so far from home was with me always. I felt that I had landed on another planet. There was something about the fact that my family, my entire tribe, had packed up everything it owned and turned its back on Europe that set me apart. It was as if I had lived my entire life in another language.

As the winter wore on through February and the windy weeks of March, I felt as if it would never end. I missed my sisters and the mental shorthand we assumed together because we had always lived in the same house. I missed the tropical rituals: barbecues at Christmas, snow that came in tins for spraying on the Christmas tree, and the way the sun went down every day at the same hour, whatever the season. I even missed the beastly Nivaquine, for the danger that forced us to take it was something familiar to me. I missed my grandfather’s sweet tomato sauce, and the smell of the land after it had rained. I missed everything so much that I would lie awake at night trying to conjure up the smells of home. It was as hard as sewing raindrops.

Then one day, on one of the rare weekends we were allowed out, a friend of my father’s took me on a long Tube journey to St Joseph’s Foreign Missionary Society in Mill Hill, in the very outer suburbs of north London, where he had to pick up a package. St Joseph’s was the male equivalent of the convent school I attended. But while my Irish nuns had devised a whole book of rules for keeping us from talking to boys or fraternising in any way with the outside world, St Joseph’s positively encouraged a spirit of independence in its young men.

During the time that my father’s friend concluded his business, I wandered down a long corridor, the walls of which were covered in small photographs of all the priests who had ever served St Joseph’s abroad. The early ones were sepiatinted. Gradually they became black-and-white. It was there that I realised for the first time that pulling up your roots and embarking on a new beginning was something people had always done. Though they knew they might never return, like my grandparents those priests had rolled the dice and boarded ship.

St Joseph’s Foreign Missionary Society, or the Mill Hill Fathers as they are commonly known, now has missions in nineteen different countries, stretching from Brazil to St Helena and from Brunei to Sudan, which is impressive in our secular age.

At the end of the corridor was a large wooden door which led to the Society’s chapel. On a stand to the left of the altar I found a red leather-bound Roman missal. It was open at the page of prayers for persecuted Christians: ‘Father, in your mysterious providence, your Church must share in the sufferings of Christ your son, give the spirit of patience and love to those who are remembered for their faith in You, that they may always be true and faithful witnesses to your promise of eternal life.’

Faith was what had inspired the Mill Hill Fathers to go across the seas. Yet when I sat in the pew of their little chapel and looked around the walls, I realised that it was not a weakening of belief, nor persecution, that killed their priests so often and so young – but disease: overwhelmingly malaria. Running along the top of the wall, just under the eaves, was a stone course carved with the words: ‘Pray for the Souls of our Dear Brethren, the Diseased Missionaries of St Joseph’s Society.’ Beneath it, covering all four walls, were stone slabs listing the names of the hundreds of missionaries who had died in the course of doing God’s work. The first slab covered 1872 to 1905, the years of the Society’s earliest ventures abroad. On it were the names of thirty-two men, starting with the Reverend Cornelius Dowling, a doctor as well as a priest, who died of malaria in Baltimore on 9 August 1872, at the age of thirty-one.

Like the Reverend Dowling, two-thirds of those commemorated in the chapel had died before they reached the age of forty. They succumbed, far from home, in India, Kashmir, Borneo, Italy, France, Uganda and Singapore. As the years progressed, the ever-expanding array of places where the Mill Hill Fathers passed away is proof that sickness and death did nothing to quench their Christian fire. By 1917 the missionaries were dying in the Congo, Borneo, Uganda, the Philippines, the Punjab and on the Isle of Wight. By 1925 it was Sarawak, Madras, Kisumu in western Kenya, and in the dry north of the country, the bleak and lonely Kavirondo Gulf. The dangers they faced were multiple, yet according to the records, fully three-quarters of them died of the same thing: Roman or intermittent fever, tertian ague, or as it later came to be known, malaria.

It took a special kind of courage to leave home and travel to Africa in the nineteenth and early twentieth centuries. Not only were the distances enormous and the prospects of return uncertain, but Europeans thought of Africa as a kind of wild and unpredictable beast that had to be beaten into submission physically, morally and politically.

There were dangerous animals, savage tribesmen and, always, the threat of disease: sleeping sickness, river blindness, yaws, leprosy, trachoma, typhoid, tick fever, filariasis, beriberi, bilharzia, kwashiorkor, rinderpest and East Coast Fever were just a few of the ailments waiting in Africa. Of the many illnesses threatening both man and beast, though, none seems to have preyed on travellers’ minds as much as that which became known in many parts as the ‘pioneer shakes’ – malaria.

Some diseases were terrifying simply because they were deadly. Yellow fever and malaria’s cousin, blackwater fever, which turns your urine the colour of dark Burgundy and your kidneys into fragile sacs that can burst at the slightest movement, are like poisonous snakes: they kill in a matter of hours. But there is something particularly insidious about the way malaria stalks its victims, the way its parasites lurk within the body, hiding from its immune system and lying silent for years until you think you have finally shaken it off, only to find that it always returns, driving you mad with fever, shivering, delirium and pain, weakening you more with every bout before, often, it eventually kills you. As the malaria parasite reproduces in your blood, it swells and bursts out of your red blood cells, leaving in its wake a sludge of wrecked haemoglobin. Some of this material ends up in the liver and the spleen, causing them to swell and turn black. In the unlucky few the parasite accumulates in the capillaries of the brain, causing the cerebral malaria that kills so fast.

Of the thirty-six girls in my primary school class in Kenya, eleven were dead before the age of forty. Five were killed in car accidents, most of them by hit-and-run taxi drivers, who are paid by the journey and drive as fast as they can. One died in childbirth. But four died of cerebral malaria, caused by the deadly Plasmodium falciparum parasite, which kills so many people in Africa. Perhaps, as I had done when I was eighteen, they had become cavalier about the dangers, and didn’t take their anti-malaria tablets; perhaps they were just unlucky, and failed to get adequate medical treatment in time. Between them they left nine orphaned children.

Daily life in Africa is so harsh that there is often little time to dwell on the nuances and inequities of history. Uppermost in the minds of Europeans who travelled there, from the earliest years, was how to overcome disease before it overcame you. Many who live there today still think of malaria as a ghostly presence in their lives; something that visits and revisits with the advent of the rainy season, and from which you never quite escape. In the nineteenth century Henry Morton Stanley, who reckoned he caught malaria more than two hundred times during his exploring years, carried his own cure, which he called a ‘Zambesi Rouser’, made of powdered jalop, calomel, crushed rhubarb and quinine, ‘to be taken with a little water whenever an attack of malaria threatens’. My father is more circumspect. He takes his weekly pills in silence, and only ever talks of having a ‘touch’ of malaria, or even a ‘go’ of it, as if loudly to invoke a more severe diagnosis might in some way be calling down the fury of the fates.

Fourteen miles from my grandparents’ farm, on the other side of Lake Naivasha, is the small district hospital. Thirty beds are divided between three wards, but in the rainy season, when malaria can reach epidemic proportions, patients have to queue up to be admitted. Even in the dry months a steady stream of people, most of them women with small children, line up at what passes for an outpatients department round the side of the hospital. Most of them will have travelled in a hot bus or walked many miles to get there, and they sit, uncomplaining and undemanding, beneath the sprawling pepper trees while they wait, sometimes for hours, to be seen by a doctor.

‘No wonder they’re called patients,’ laughs a nurse holding a blood sample. She appears cheerier than she ought to be, considering the long hours of work that still lie before her. She and three doctors will see about 180 patients in a morning, spending enough time with each to give a quick diagnosis, offer a prescription or decide if further examination is needed. There is none of the smart whiteness of Dr Saio’s office at the main hospital in Nairobi, though the work that is done here is very similar.

The hospital in Naivasha is run by local community doctors. The consultation rooms are spotless and the walls are papered with educational posters about AIDS, safe sex and the importance of using clean water for mixing infant formula. Everyone pays fifty US cents to see the doctor, the same again for a blood test, and between ten cents and a dollar for medicine. A limited range of drugs is supplied cheaply by the Anglican Church which, despite its charity, is Protestant enough to have concluded early on that people value something more if they have to pay for it, no matter how small the sum.

Outside the door is a hand-painted sign with a message from the first Book of Peter, a reminder that so much in Africa is still a matter of faith. ‘Cast all your cares unto Him, for He cares for you,’ it says. Cheap and simple to run, the clinic is more effective than one might think, given its simple furnishings and tiny annual budget. For many Africans, this is the very best medical knowledge they will encounter.

A woman in a red patterned skirt and a white headscarf enters the consulting room. Asked what her name is, she mumbles ‘Grace’ in a barely audible voice. She complains of a swollen stomach. A nurse palpates her abdomen, and concludes that she is about twenty weeks pregnant. Although this would be her third child, Grace seems not to have noticed that her menstrual periods had stopped, or had any idea that she might be expecting. Perhaps another child was too much of a burden for a poor family, and she did not want to admit the truth. The nurse signs her up for admission to the hospital five months hence, and arranges, meanwhile, for fortnightly antenatal visits.

The next patient, Joseph, complains of chest pains. He has chronic oedema. His lower legs look like tree trunks and he suffers from high blood pressure. He pulls his thick jacket around him as the doctor prescribes a new medication for his angina, and shuffles out.

A heavyset young woman in red flipflops and a blue headscarf comes in next. She speaks softly to the doctor in Kikuyu. She is called Sandra. Both her children are running a temperature and she has a bad chesty cough. She wants them all to be tested for malaria. The doctor examines them. ‘Say “ah”,’ he commands, peering down the throat of each child.

The thick white ulcers of oral Candida indicate that they are probably both HIV positive. Without proper medication, it will only be a matter of time before they have AIDS. On the wall is a poster of a strip cartoon showing how AIDS is transmitted. It says nothing about foetal transfer of the virus. Beside it another chart outlines how to prescribe Amodiaquin, the standard treatment for malaria now that chloroquine, a synthetic anti-malarial compound developed during the Second World War, is so ineffective that many African countries, including Kenya, have discarded it. For a baby of less than seven kilos, you give a quarter of the daily dose. For a child weighing more than fifty kilos, the daily dose is three tablets.

The nurse asks each child to put out a hand. Gently she swabs a finger, pricks it and smears the gentle swell of blood onto a glass slide. Moments later a lab technician dips the slides into staining fluid, dabs the end with a piece of kitchen towel to clear the excess moisture, and puts the slide to dry on the warm back of a paraffin picnic fridge beside his desk. In a few moments the slides are ready and he slips them under the microscope, the only piece of machinery in the clinic that runs on electricity.

The circular-shaped parasite, with its dot-like red eye at one edge that is so characteristic of malaria, is clearly visible. Sandra and her two children all have malaria, though they are lucky they do not harbour the deadly falciparum parasite. A pharmacist counts out a tiny handful of white pills and slips them into a small square envelope. They are quinine sulphate, which is made from the bark of the cinchona tree grown in the last cinchona forest, in the eastern Congo.

My grandparents may have been unusually adventurous in the way they happily traded in a comfortable life in Paris for an unknown future in Africa, but their caution in insisting that we all regularly dosed ourselves with quinine was proved right. To many Western travellers today, malaria is something that exists over the horizon. It does not carry the slow promise of death that is embedded in AIDS; in this part of Africa, AIDS has seeped into so many villages that small children and old grandparents are often the only people still to inhabit the silent thatched huts. Nor does malaria conjure up an explosive, primitive fear, like being attacked by a lion or bitten by a poisonous snake. Most travellers know that malaria exists, but they buy an ordinary over-the-counter dose of prophylactics and go on holiday regardless, often ignorant of whether the prophylactics work or not. In Britain there are more articles in medical journals devoted to the depressive side effects of mefloquine, or Larium as it is usually known, one of the strongest anti-malarial prophylactic drugs on the market, than on the disease itself.

Malaria stalks Africa, where it is a real cause of fear and grief. The United Nations World Health Organisation estimates that as many as five hundred million people are infected by the disease every year. That is eight times the population of France or Great Britain, or twice as many people as live in the United States.

Of those who fall sick, as many as three million die every year. The very large majority of these are small children for whom clean water, decent food, antibiotics and quinine-based drugs to fight the onset of the disease, let alone a decent prophylactic, are no more than a dream, perhaps heard of, but unattainable. Malaria is so common, and so deadly, that the WHO estimates one person dies of it every fifteen seconds. In the last decade it has killed at least ten times as many children as have died in all the wars that have been fought over the same period. Yet the mosquito that carries it is little larger than an eyelash.

Out of just under five hundred different varieties of Anopheles mosquito that are recognised today, only about twenty are thought to be seriously responsible for spreading the disease to humans. The malaria parasite packs the salivary gland of the female mosquito, of no danger to anyone including its host until it bites a human being. Only when it injects some of its saliva containing the malaria parasite into the bloodstream does the mosquito transfer this dread disease. In the course of the bite it also withdraws blood. Its victim may already be infected with the parasite. If the mosquito moves on to other people and bites them, the endless cycle of infection and reinfection will simply repeat itself. The Anopheles mosquito needs blood to lay its eggs, but the damage it inflicts on humans is completely incidental to the insect. ‘A man thinks he’s quite something,’ the American writer and cartoonist Don Marquis had his cockroach hero Archy say in archy and mehitabel. ‘But to a mosquito a man is only a meal.’

The mosquito breeds in pools of stagnant water – overflows from rivers that have flash-flooded and then subsided, roadside ditches, forgotten furrows in uncultivated fields, water butts in towns and rain-filled puddles in the middle of country roads. In the Naples of my grandfather’s youth, the mosquito found a comfortable home in the well-watered window boxes of the city tenement buildings. When my great-grandfather was in Panama, it was customary for the nurses in the little French clinic on the hill above the engineering works to stand the hospital beds in huge flat bowls of water to stop the black spiders from climbing up the bed legs and biting the patients. No one could have devised a better breeding ground for mosquitoes had they tried. Among the canal workers of the mid-nineteenth century it was customary to warn newcomers that if you didn’t have malaria when you went into hospital, you would undoubtedly catch it while you were there.

Today malaria is chiefly a danger to people in the tropics, particularly the poor, who live in bad housing with inadequate drainage and no mosquito nets, insecticide sprays or fancy prophylactics. But once upon a time it was common all over Europe. Even so, no one knew exactly what it was. Nor did they know how to treat it. When a cure finally was discovered, it revolutionised theories of medicine and the way physicians thought about treating illness.

Nowhere in Europe was the scourge more deadly, and the need for a cure more acute, than around the Basilica of St Peter’s in the centre of Rome, where every summer for centuries it killed hundreds of people, making no distinction between peasant, priest or pope.

2 The Tree Required – Rome

‘When unable to defend herself by the sword,Rome could defend herself by means of the fever.’

GODFREY OF VITERBO, poet, 1167

Giacinto Gigli lived for sixty-five years in an alleyway by the Via delle Botteghe Oscure. His small townhouse was one of several built close together. They clung, like a gaggle of shy children, to the end of one of the crooked passageways that cluttered the centre of Rome, seeming almost to lean into one another when the wind whipped around them during the early days of winter. Gigli was not born there, but from the time when he was twelve years old until just before Christmas 1671, when he died at the age of seventy-seven, he returned every night from his work in the papal palace at the Vatican and climbed the stairs to the study, his favourite room, at the top of the house, where his desk was placed between two tall windows.

One of them looked westwards, over the bend in the Tiber where tradesmen, prelates and visitors would cross the bridge that led towards the Santo Spirito hospital and beyond it to St Peter’s and the palace of the Vatican. From that window Gigli could just see the golden dome of St Peter’s, though often it seemed almost to fade away in the summer haze, when the city became too hot to bear and the Pope’s court moved to the palaces and villas in the coolness of the hills that surround the city. The other window, on the far side of the room, looked north-east towards the Quirinale, the highest of Rome’s seven hills, where the Pope’s own summer palace had been built so that he could escape the unhealthy summer air, and where a gentle breeze blew all day through the shady trees.

The Gigli family was part of Rome’s petite bourgeoisie, though by his death Giacinto’s father had been able to leave his son the property near the Via delle Botteghe Oscure, two other smaller houses in the centre of the city, and a vineyard on the road to Frascati, a considerable inheritance for a modest man. When he was twelve Gigli entered the Collegio Romano, the Jesuit school where he studied grammar, humanities and rhetoric. For a while he studied law in the studio of Angelo Luciano, a well-known Roman advocate, and graduated as a specialist in papal law. By that time his father was dying, and as Giacinto prepared to take his place as the head of the Gigli family, the young man’s thoughts turned to marriage. He had known Virginia Lucci all his life. She was his neighbour’s daughter, and the time had come to ask for her hand.

As he grew older, Gigli began to acquire the status of a man of respect. He was made a rione, representing his parish of Pigna in the committees and on ceremonial occasions that would occasionally bring together the city and the Holy City. Dressed in velvet and bedecked with feathers, he would walk in line before the horsemen that accompanied the papal processions. Later he was made a caporione, before eventually serving twice as the priore, the head of all the caporioni, responsible to the Pope for helping collect taxes and keeping order within the Holy City. These duties gave Gigli an intimate insight into Rome, and particularly the clerical administration that ran it. He became something of an expert on Vatican politics – who was in favour and more importantly who was not, how different cardinals behaved and how they were discussed. ‘All this and more is the lifeblood of the Holy City,’ he would write.

We don’t know what Gigli looked like, for no contemporary likeness of him survives. But we know a great deal else about him: how he lived, how he filled his day, what he did when he fell ill, whom he saw and what he ate. Gigli was meticulous about recording the details of his life in his diary, which survives in the Vatican library, writing something every day, even if only a brief phrase or two. He wrote in Latin, in an elegant slanting hand, taking care to reach the very edge of the page before starting on the next line.

Gigli had acquired the habit of chronicling his daily life before his marriage. In 1614, when he was only nineteen, he even began an autobiography, entitled Vita. He kept this up assiduously for about five years, making minute notes of everything that went on in his household, recording the names of the servants who came and went, what they were paid and what they earned in tips or small gifts, like the woollen socks that were given to the nurse who came to care for his only son. While this might seem unnecessarily fussy to some, these were not bad habits for a diarist to acquire. In addition, he also wrote poetry, long verses about his native city and eulogies of the Popes in rhyming octets.

The papal court was the centre of Gigli’s life. From the first entry in the diary, on 29 May 1608, to the last, when he was almost too blind to write any more, yet fretted about missing the baptism of the Pope’s new baby niece, he specialised in the comings and goings of the Vatican. The Pope’s court was newly returned to Rome after the alternative papacy, set up the previous century in Avignon with the support of the King of France, had threatened to rob Rome of much of its wealth and influence. Restored once more to its traditional home, the leadership of the Roman Catholic Church was doing all it could to spread the counter-Reformation in Europe and impose its spirit, burning heretics and attempting to suppress Protestantism whenever it could.

In the first decades of the seventeenth century, though, when Gigli was making his daily observations of the Holy City, papal Rome still hadn’t really found its feet. The memory of the schism lived on, making the city fathers nervous, hidebound, inward-looking; too fearful of the Turkish forces that threatened Venice, or the Spaniards who lay siege to Naples, ever to be easy. Naturally conservative, papal Rome then was more fearful of change than it had ever been. In 1633 Galileo Galilei, after publishing his arguments for a Copernican cosmology, with the earth and the planets revolving around the sun, rather than with the earth at the centre of the universe as had long been the prevailing view, would be tried for heresy and his works banned.

Like his masters in the Church, Gigli was a conservative man. Over the years we get a good idea of what he approved of and what he didn’t. Gigli was something of a prig, and there was much that went on in Rome that made his lip curl in distaste. Despite that, he had a fine eye for daily life in the city – the storms, the fires, the earthquakes, the fate of the jailed heretics who were often hung, drawn and quartered, their various portions exposed to the populace as an example to those who might be tempted to question the Pope’s authority. He wrote about the availability of bread, about miracles, comets and eclipses of the sun. Although he was a rational, educated man, there was a medieval part of Gigli that could not help but believe that God sent signs to his people below, good signs if he was pleased with them and punishments when he was enraged.

On a more down-to-earth level, Gigli wrote about people’s anger at the rising taxes, their irritation at the inflexibility of the authorities and their fear of the Tiber’s floods, which he always described as the river getting ‘out of its bed’. In 1630 he wrote of the arrival in Rome of an elephant, ‘which no one had seen for a hundred years’, since the King of Portugal sent one as a gift to Pope Leo X in 1514. This particular beast, by contrast, had been brought to the city by a private citizen, and anyone who wanted to see it had to pay him one giulio for the pleasure.

In turn observant, witty and fastidious to the point of pernicketiness, Gigli became Rome’s most wonderful portraitist. At the start of the seventeenth century, the city had a population of about 115,000. It was a tenth of the size of its imperial predecessor, smaller by far than Paris or London—smaller even than Naples – but it was growing after the ravages of the previous century, when it had been sacked and later flooded, before being visited by the plague and then cast into ruin during the papal schism. With the return of the papacy, diplomats, bankers, doctors, artisans, traders, horsemen and financiers jostled in the capital for any part of the papal chancery’s swelling business.

Most of these people lived and worked, as Gigli himself did, in the occupato, the dense gathering of taverns and tenement houses separated by narrow cobbled streets that nestled in the crook of the arm of the Tiber where it curved in an ‘S’ shape, first west and then south-east. Inevitably they were almost all connected, one way or another, with the Church establishment. The three most important routes into the city converged on the Ponte Sant’ Angelo, just south of the Vatican, bringing travellers who were always hungry for news and for business directly into the heart of the city. Over it rose the bell towers of nearly 350 churches. The tallest among them were the great basilicas that kept watch over the tombs of the apostles. Then there were the churches that guarded the sacred reliquaries of the saints, and occasionally, some believed, even fragments of the True Cross. Lower still were the chapels of the patrician families and the oratories of the guilds. From every sacred spire and belfry the city trumpeted its patronage of the holy. In brick and stone, every street, every façade, every arch and roof and alleyway proclaimed its thousand years as a Christian symbol.

All that lay within the occupato.

Beyond the occupato, though, lay the disoccupato. And that was another story altogether.

To the east of the city, starting at the Capitol, to the south and to the north ranged a barely inhabited wasteland ‘set with ruins, where green snakes, black toads and winged dragons hid, whose breath poisoned the air as did the stench of rotting bodies’, as an eyewitness to the epidemic that killed half of the newly crowned Holy Roman Emperor Frederick Barbarossa’s army had described it in July 1155.

Encircling the town proper and extending out to the Aurelian walls, the disoccupato had barely changed in five hundred years. The loose patchwork of fields and vineyards was set with small houses, sheds and straw huts, tiny churches, gardens, groves and ancient ruins such as the Baths of Constantine and the Temple of Serapis. Much of it was only ever used for a few weeks each year. Dry in midwinter or at the height of a rainless summer, the disoccupato needed just the first downpour of spring to transform it into a swampy marsh, its muddy roads and ditches becoming pools of stagnant water that turned first green and then brown in the summer heat.

Rome at that time may have been an exciting city in which to live, but it was hardly a healthy place, though it was not until 1631 that it suffered the beginnings of the plague epidemic that would eventually kill nearly half its citizens. In an entry written at the end of December 1624, Gigli was full of apologies. ‘I, Giacinto, have not been able to make daily descriptions of life as I would have liked, for I have been sick for a long time, with grave and lingering maladies, as a result of which there are many things I have not seen and others I have not noted. But, with God’s pleasure, I am now well and healthy, and I hope in the Holy Year of 1625 that I will be able to make diligent note of things as they occur unlike those I have missed this year.’

Medicine had barely advanced over the centuries, and it is easy to forget how small a proportion of Europe’s adult population would have been healthy at any one time. Stomach disorders of one kind or another were chronic, both among the rich, whose diet was poorly balanced, and among the poor, who found it hard to find sufficient food for themselves and their children. When they did, it was often rotten. Recurring outbursts of bacterial stomach infections resulted in dysentery, which often killed the old and the very young. Tuberculosis was rife, and for women childbirth was always very dangerous. Both sexes suffered from rotting teeth, while suppurating ulcers, eczema, scabs, running sores and other skin diseases were very common and sometimes lasted for years.

Gigli was constantly preoccupied with matters of health, his own and that of his family. And the malady he wrote about most often was the Roman or marsh fever, which we now know as malaria. ‘It returns every year in the summertime,’ he says, ‘and no one can feel himself to be safe from it.’

Rome then was the most malarious city on earth. Hundreds of people died of the disease every summer, while hundreds more were left so weak they were unable to walk, and became prey instead to the slightest infection. The rise and fall of the Tiber, which often broke its banks and flooded the plain of the Campagna, left pools of stagnant water through the countryside which provided the ideal breeding ground for the Anopheles mosquito that spread the disease. The views of those observers, such as the first-century BC Roman writer Marcus Terrentius Varro, who thought the miasma might be alive, full of what he called animaletti, ‘minute animals [that are] invisible to the eye, breed there [in swamps] and, borne by the air, reach inside of the body by way of the mouth and nose, and cause disease’, were regarded as extremely bizarre. Most Romans in Varro’s time knew only enough to recognise the intermittent fever and shivering that visited them every year.

Giacinto Gigli had a particular reason to know about the fever. His only grandchild, Maria Cecilia Hortenzia Gigli, died of it at the age of fifteen. One day she complained of an aching head and stiff limbs. Rivulets of sweat ran down her forehead, dampening the sheets. Yet just a few hours later her mother was piling on the covers in an effort to keep the child warm. At seven o’clock in the evening, just three days after falling ill, she passed away.

Gigli was deeply affected by his granddaughter’s death, and he must have fretted greatly at her decline, against which he would have had no cure other than the herbs and amulets left over from medieval times. His diary entry that day is unusually terse, and comes suddenly after a description of a great fire that destroyed the Santa Caterina de’Funari monastery. Numb with grief, he writes only that: ‘She was fifteen years, five months and three days, and her beauty, her virtue and her goodness will be eternally remembered.’

The most important hospital in Rome at the time was the Santo Spirito, which had been built between the Tiber and the walls of the Vatican and which Gigli could see from his study windows. The Santo Spirito trained many of Europe’s finest doctors, but for most of the city’s population the cost of visiting a professional doctor was beyond their means. They preferred, in any case, to consult the herbalists and sellers of secret potions whom they had known all their lives. Many medieval cures had involved patients and physicians trying to expel their diseases by transferring them to other objects. Peasants in a number of European countries would bring a sheep into the bedroom of a fever patient, in the hope of displacing the ailment from human to beast. One cure that was still popular in the seventeenth century involved a sweet apple and an incantation to the three kings who followed the star to Bethlehem. ‘Cut the apple into three parts,’ advised the prescription. ‘In the first part, write the words Ave Gaspari. In the second write Ave Balthasar and in the third write Ave Melchior. Then eat each segment early on three consecutive mornings, accompanied by three “Our Fathers” and three “Hail Marys” as an offering to the Holy Trinity.’

Another prescription, from a well-known sixteenth-century Roman healer named Tralliano, was supposed to be especially good against the most common fevers, called tertian and quartan because they resurged with worrying regularity, either every three days or every four. Tertian and quartan fevers were almost certainly malaria, and Tralliano’s cure was the same for both: ‘Take a ripe peach and remove the pip. Put the pip into an orange and tie it around the neck of the patient. He will be healed expertum et verum.’

Another was more complicated. ‘Write the following words on a piece of paper,’ it advised.

Abracolam …

Abracolai …

Abracola …

Abracol …

Abraco …

Abraco …

Abraco …

Abra …

Abr …

Ab …

A …

At the end, add the phrase, ‘Consumatum est.’ Then have the paper tied to the neck of the patient by a young virgin using a long piece of string and reciting at the same time three ‘Our Fathers’ and three ‘Hail Marys’ in honour of the Holy Trinity.

Gigli and his fellow Romans thought they knew only too well whence spread the fever that killed his granddaughter and was as permanent a feature of the city as the smell of incense or the gentle scent of summer apricots. From the swamps and stagnating ponds of the disoccupato, it was believed, rose dark mists laden with fever. In Rome, went a saying, if you did not catch the fever from the aria, you caught it from the mal’aria. Bad air.

The word malaria, or mal’aria as it was always written until recently, was unknown in English until the writer Horace Walpole introduced it. In July 1740, while on a visit to the Holy City, he wrote to his friend H.S. Conway, ‘There is a horrid thing called the mal’aria that comes to Rome every summer and kills one.’ For more than a century afterwards, though, mal’aria was not taken to mean a disease so much as a noxious gas which rose from swamps or rotting carcases and vegetation, and which caused a group of ailments variously known as intermittent fever, bilious fever, congestive fever, swamp fever or ague.

Whichever of these was really malaria, the Romans had known for centuries about the miasma. From the disoccupato it invaded the city and forced the citizens to take to the hills every year during the worst of the summer heat, leaving the city abandoned; abandoned, that is, by those who could afford to leave. The rest stayed behind, entrusting their health to the Almighty and to the concoctions of the healers whose numbers always grew larger in summer.

Malaria had probably existed in Rome since late antiquity. Chronicles of the imperial Roman army talk of soldiers suffering from constantly recurring fever, chills, sweating and weakness, and many historians believe that one of the main causes of the collapse of the Roman Empire may well have been the prevalence of malaria around the shores of the Mediterranean Sea. In 2001, British and American scientists found malarial DNA in the bones of an infant skeleton that had been unearthed in a fifth-century villa at Lugano, near Rome.

No one is quite certain why, but malaria seems to have receded during the early Middle Ages, only to reappear with even greater severity in the years when Giacinto Gigli lived in Rome at the beginning of the seventeenth century, continuing into the eighteenth century, when it was an annual occurrence in Kent and the fenlands of England, eventually reaching as far afield as Scandinavia, Poland and Russia.

Within the Vatican, many of whose buildings were erected on Rome’s lowland, by the banks of the Tiber, malaria was especially prevalent, striking with little heed for the age, rank or title of its victims. In July 1492 Bartolomeo da Bracciano, one of the senior courtiers at the palace of the Vatican, wrote to his friend Virgilio Orsini: ‘The Pope, last night, had a great fever of the quartan variety, alternating between hot and cold. The Pope is confined to his bed, and it is said that perhaps he will never rise from it.’ Indeed, he didn’t. Four days later, on 25 July 1492, Pope Innocent VIII was dead.

Eleven years later Pope Alexander VI died, again most probably of malaria, after dining in the palatial garden of his friend Cardinal Adriano Castellesi da Corneto in August 1503. Adrian VI died of malaria in the summer of 1523, and in August 1590 Sixtus V too died of malaria at the age of sixty-nine, after a brief and very active pontificate. He had caught it a year earlier while sleeping in a hastily erected cabin during a tour of work being undertaken in the marshes around Castello Caetani, not far from Rome. Even the Borgias, who tried valiantly over the years to murder one another, could not kill each other or their enemies so regularly or so reliably as would malaria.

In the summer of 1623, shortly before Gigli, to his immense pride, was made a caporione for the first time, the Pope, Gregory XV, fell gravely ill. In his diary, the twenty-eight-year-old Gigli reported: ‘His Holiness is not well. We must pray to the Lord.’ It was said that the Pope had caught the fever the previous year, and now it had returned with a vengeance. From his study overlooking the city Gigli could see the palace of the Quirinale, nicknamed Monte Cavallo, where the Pope lay on his sickbed. An earlier Pope, also called Gregory, had chosen this superb site, less than a century before, to build his summer residence in an effort to escape the malaria that always plagued Rome during the hot summer months. In the courtyard in front of the palace, another Pope had had statues of four prancing horses installed. Nearly twenty feet high, they were Roman copies of Greek symbols of Castor and Pollux, the patrons of horsemanship who were known as the ‘horse tamers’, and it was they that gave the hill its nickname.

At the centre of the palace itself, dark heavy drapes shut out the light and the world beyond. For some days the Pope had been lying unmoving in his bed, covered only by a light blanket of fine wool. His head ached, his spleen was swollen and his body tormented in turn by fever and sweating, then by shivering and chills. A small troupe of Penitentiaries, the Jesuits who heard confessions in St Peter’s basilica, prayed at his feet. Occasionally one would rise from his knees and another would step forward to take his place. With their gentle voices and indistinguishable cassocks of rough grey wool, they represented an unceasing rosary of care for the souls of the dying.

As a caporione, Gigli was often called upon to make the short journey from his home near the Via delle Botteghe Oscure to Monte Cavallo. During that long summer of 1623 he made the journey more as a way of obtaining news of the Pope’s health than because there was a great deal of work to be done. For while no one knew whether the pontiff would live or die, the papal courtiers lived in an atmosphere of suspended animation, talking only in whispers. ‘We are all weary,’ Gigli wrote at the end of the first week of Pope Gregory’s illness.

Among those who attended the Pope’s sickroom was his nephew Ludovico Ludovisi. Though not yet thirty, Ludovisi had been made a cardinal by his uncle, which had enabled him to amass a considerable fortune in cash and works of art in just two years. Was his life as a man of influence about to come to an end? Should the Pope die, Ludovisi was too young to be elected pontiff himself. His only future lay in seeking to influence the choice of his uncle’s successor. If a candidate with his backing should attain the throne of St Peter, Ludovisi’s eminence would continue. But he had made many enemies, and would have little time to build the alliances that were essential if he were to sway the complicated negotiations that would follow Gregory’s death.

As soon as the Pope died, the seal on the fisherman’s ring that was the emblem of his pontificate would be broken. The new Pope would be given a new seal with his own name. Predictions of Pope Gregory’s death had been made so often that he had often lamented, in the days when he felt better, that his fellow cardinals had scarcely elected him when they began planning the conclave that would select his successor. Now, it seemed, the end really had come. Gone were the badges of his office, the high, pointed, cone-shaped hat, the silken gloves. Gone too were the papal vestments with their strange names handed down through the ages – the flabellum, the falda and the fanon. On his deathbed Christ’s vicar on earth wore a simple cotton shift with a wrap about his shoulders. Beneath it his pale body was only a man’s, and a rotting one at that.

As Ludovisi and the other senior cardinals looked on, together with the Penitentiaries, Giacinto Gigli and the rest of the city waited outside for news. Pope Gregory’s confessor began the sacrament of extreme unction. With holy oil he anointed the pontiff’s eyes, his nose, his mouth, his ears. The palms of the Pope’s hands had been anointed when he became a priest, so the confessor made only the sign of the cross in oil upon the backs of his hands. ‘By this holy unction,’ he prayed, ‘and by His most tender mercy, may the Lord forgive thee whatsoever sin thou hast committed by touch.’ As death drew closer, the priest began the commendation of the soul, calling: ‘Subvenite’.

In a few moments the secretary of state of the curia would knock at the door with a silver mallet, and call out for the Pope by name. Obtaining no response, he would enter the chamber and approach the bed. With another, smaller, mallet he would touch the Pope upon the forehead. Three times he would call the Pope’s name and tap his cold forehead with his silver mallet. Only then would he pronounce him truly dead.

‘Subvenite,’ prayed the papal confessor once more.

‘Come to his help all ye saints of God. Meet him all ye angels of God. Go forth, O Christian soul.’

It was shortly before ten o’clock at night on 8 July 1623. Pope Gregory’s confessor raised his hand and with the tips of his fingers touched his head, his heart, his left side and his right. In his diary that night, Gigli wrote: ‘In Nomine Patris, et Filii, et Spiritus Sancti.’

On the night Pope Gregory died, only thirty-four members of the Sacred College of Cardinals that would elect his successor were in Rome. The other twenty or so were scattered all over the continent, some as far away as Madrid or the Baltic Sea. For a new Pope to be elected, the cardinals had no choice but to go to Rome. But the decision to travel there was not to be taken lightly. Crossing the continent, whether by sea or coach, or even on foot, was difficult and often dangerous. And Rome in the heat of summer, with the incidence of malaria rising virtually every day, was no place to be. Yet if a cardinal did not go, his vote would not be counted. He would not be able to influence the election, and as a result a Pope from a rival faction might take the throne. Knowing that Pope Gregory himself had died of the marsh fever, the cardinals who made their way towards the Holy City in the summer of 1623 did so with great trepidation. Drawing close, most of them would have elected to spend their last night well beyond the disoccupato, where the country air was still clear and there was little danger of breathing in the noxious gases that were believed to cause the fever. On the final day of the journey, each man made sure to rise early. The coach windows were clamped shut, and the cardinals were careful to wrap scarves about their faces, while high above the coachman would whip his horses through the approaches to the city.

That year there was trouble even before the conclave began. The interval between the death of the Pope and the election of his successor – the sede vacante, the vacant throne – had long been a time of release, a civic exhalation after a period of fierce papal control. By tradition, the jails were emptied. When he was caporione, it was Gigli’s job to carry the key to the jails and oversee the prisoners’ liberation. During the sede vacante the populace could say whatever it wanted, and the people did, many of them writing what they thought of the authorities on little pieces of paper which they then stuck on a statue of the limbless Pasquino, which is why he later came to be known as the ‘talking statue’.

The papal interregnum was never so tumultuous as it was following Pope Gregory’s death in 1623, when Rome erupted in an orgy of violence. It was such, Gigli recorded, as no one could remember ever having witnessed.

Not a day passed without many brawls, murders and waylayings. Men and women were often found killed in various places, many being without heads, while not a few were picked up in their plight, who had been thrown into the Tiber. Many were the houses broken into at night and sadly rifled. Doors were thrown down, women violated – some were murdered and others ravished; so also many young girls were dishonoured and carried off.

As for the sbirri [the papal guards], who tried to make arrests, some were killed outright, and others grievously maimed and wounded. The chief of the Trastevere region was stabbed as he went at night on the rounds of his beat, and other chiefs of the regions were many times in danger of their lives. Many of these outrages and acts of insolence were done by the soldiers who were in Rome as guards of the various lords and princes; as happened especially with those whom the Cardinal of Savoy had brought for his guard, at whose hands were killed several sbirri who had taken into custody a comrade of theirs. In short, from day to day, did the evil grow so much, that had the making of a new Pope been deferred as long as it once seemed likely, through the dissensions of the cardinals, there was ground to apprehend many other strange and most grievous inconveniences.

Eleven days after Pope Gregory’s death, when the novena of funeral services was finally ended, fifty-five cardinals entered into the conclave to elect his successor. Three of them – Campori, a veteran of earlier conclaves, Galamina and Serra – arrived on the very evening the conclave doors were closed. Not one of them wanted to stay in the city longer than was absolutely necessary, and as it turned out they were right. None of the French cardinals had managed to reach Rome at all, though that did not stop the envoys of the French King, Louis XIII, from seeking to influence the outcome of the election both from within and, when the papal palace doors were sealed, from without.

From the moment the doors of the Vatican were bricked up until a new Pope was elected, the cardinals lived in the papal palace, voting twice a day, morning and evening, in an effort to reach a nearly unanimous agreement on a candidate. The rest of the time, in between the obligatory attendances at mass, the cardinals lobbied and intrigued against each other, the older generation trying to hold their own against the younger men, the Spanish fighting to gain the upper hand against those supported by France or by Germany. ‘We know nothing of their sacred procedures,’ wrote Gigli primly. ‘Nor should we.’

Of course, this wasn’t strictly true. Gigli could not help but be overcome with curiosity about what was actually happening behind those sealed-up doors. By the main stove in the Sistine Chapel, he tells us, a stack of grass mixed with crushed charcoal lay ready. If, when the ballots were counted at the end of the day, no agreement had been reached, a small fire was lit. The scrutineers bound up the slips of voting paper, wet them and then burned them in the stove. The charcoal and the damp paper turned the smoke from the burning grass a dark grey, a sign to the people of Rome who stood watching that the throne of St Peter was not yet filled. Only when a new Pope was finally elected was the fire lit with grass alone, save for the last bundle of voting slips, this time dry. The smoke that curled up the chimney would be almost completely white.

With no prospect of an early agreement, the cardinals retired at night to a series of small square cubicles, cells almost, that stretched down the corridors of the Belvedere at the centre of the palace. Each room contained a narrow cot of dark wood. Hanging above it on the wall was a crucifix. There was a jug of cold water for washing, and a prie-Dieu. The fare was hardly luxurious. Tradition had it that if no Pope were chosen within three days, the cardinals would be restricted for five days to one dish only at supper. If after that the chair of St Peter was still vacant, they would be fed for the remainder of their stay in the conclave on nothing but dry bread, wine and water.

The tensions in Rome in the last days of July 1623 reflected those all over Europe. With the counter-Reformation, the Catholic Church was once again flexing its muscles after having been temporarily cowed by the rise of Protestantism across the continent. While it had yet to reach the extremes of the Inquisition, the Catholic power of the counter-Reformation was already a force to be reckoned with. Rome would not be so easily swept aside by the new order. In Germany, the Bohemian revolution would soon spread. France and Spain, always natural enemies, were circling each other once again. Each wanted to extend its influence over the small princeling states of northern Italy and beyond, and saw the election of a new Pope as a heaven-sent opportunity to gain the upper hand.

As always at the start of a conclave there were many interests, many candidates. There was Cardinal Sauli, who at the age of eighty-five had been a major contender in at least two earlier conclaves, and would have been so again had it not been for the fact that he was known to be completely under the influence of his valet and his wife. There was Cardinal Ginnasio, an inveterate gambler who had won 200,000 crowns in one night while he was Papal Nuncio in Madrid. There was Cardinal Campori, who had arrived at the last minute in the hope that he might this time wear the tiara that had been denied him at the previous conclave. And there was Cardinal Ascoli, a monk who regarded uncleanliness as a sign of godliness, and was generally shunned by his more urbane colleagues. There was also the dead Pope’s young nephew, Ludovico Ludovisi, greedy for power and influence. Known as ‘il Nipote’, it was he who introduced the word nepotism to Italian and the other Romance languages.

No clear victor emerged from the first scrutiny on the morning of 20 July. The votes of the fifty-five cardinals were distributed among several of their number, but it was already obvious that the final battle would be between two factions.

Ludovisi, despite his youth, was the leader of one group. He was hampered, however, by the fact that his uncle’s short pontificate meant he had been able to create only a small number of new cardinals. The recently appointed Cardinal Richelieu, who within months would become Chief Minister to the French King Louis XIII, mentions that Ludovisi begged the Pope on his deathbed to strengthen his party with fresh nominations. This the Pope refused to do, adding somewhat unexpectedly, ‘that he would already have to account to God for having made so many unworthy ones’.

The second group, which was made up largely of the cardinals who had been named by Pope Gregory’s predecessor, the Borghese Pope Paul V, was more powerful. Ten months earlier, in September 1622, its leader, Scipione Borghese, Pope Paul’s nephew, had given his fellow Cardinal Ludovisi a copper pendant painted by Guido Reni of the ‘Virgin Sewing’, but this did little to hide the fact that the two men hated one another. During Pope Gregory’s pontificate, Borghese had managed to keep his faction more or less intact, even though some of the cardinals supported him with more enthusiasm than others. Yet, big as it was, this group was not strong enough to carry the day without making strategic alliances with some of the other cardinals who were supported by an array of different interests.

The French, for one, were keen to play their part in the proceedings, and Richelieu regarded the election of a francophile Pope as essential to tilting matters France’s way in northern Italy, where politics were less than stable. Moreover, Richelieu knew that within the College of Cardinals was one who would be devoted to his interests.

Maffeo Barberini came from a Florentine family that had made a fortune in trade. Orphaned as a young boy, he was sent to his uncle, who was a member of the curia. When the lad showed promise, his uncle steered him into an ecclesiastical career, and before long he was appointed Papal Nuncio in France, where he made the acquaintance of Richelieu and the French King. This last was something of a stroke of luck. When the Nuncio in Spain, Cardinal Mellini, had been elevated to the purple, France immediately requested that as a matter of etiquette the same honour should be conferred on Barberini. Cornered, Pope Paul V, Scipione Borghese’s uncle, felt he had no alternative but to comply, which he did, though with little grace. So although technically Barberini was a cardinal of Borghese’s generation, he was not bound to him by any feelings of gratitude or loyalty. Richelieu, who was aware of these undercurrents, made secret arrangements with Ludovisi and the Grand Duke of Tuscany to support Barberini once their own candidates failed, as they were bound to do.

After the first day the scrutinies continued, with the voting swinging between Ludovisi’s first candidate, Cardinal Bandini, and Borghese’s Cardinal Mellini, a Florentine whom everyone knew would never be elected – not least because he had eighty-three nephews to provide for, which might risk carrying papal nepotism a little too far. Several days went by. The enmity between the two camps was almost physical, and Borghese and Ludovisi refused even to speak to one another. Matters were not helped by the heat, which was growing daily more oppressive. The cardinals were appalled at the idea of a protracted conclave under such unhygienic conditions.

Then, the calamity they had all feared happened. One by one, the cardinals began to fall ill with the fever. Still worse for some, more than two dozen of their attendants also became indisposed, and were incapable of attending to their duties. The cardinals’ underclothes remained unwashed. Their cubicles and the passages of the Belvedere where they were housed quickly fell into a condition of nauseating neglect, ‘the atmosphere being laden,’ one of them wrote in his diary, ‘with putrid miasmas and sickening smells of decaying victuals that the potent perfumes of the young cardinals could not manage to disguise.’ As Gigli added, ‘It was lacking in all dignity.’

By 3 August, after the college had been in conclave for fifteen days, at least ten of the fifty-five cardinals were ill with malaria. The next day, Borghese too succumbed. The physicians suggested potions, blistering, bleeding. Nothing worked. Borghese began thinking of leaving the conclave. All of a sudden, the francophile Cardinal Maffeo Barberini began canvassing support within his own party, supported by some of the other senior cardinals, including Ludovisi. On 5 August Cardinal Borghese had another and more severe attack of the fever. In a panic, he wrote to the Dean of the conclave asking for permission to quit the proceedings. Apprised of the fact, Ludovisi and his supporters began lobbying the Dean to refuse Borghese’s request. His absence, they argued, would create a deadlock, and the entire assembly would be forced to risk their health, even their lives, for the convenience of one man.

The Cardinal Prince of Savoia was entrusted with the task of telling Borghese that the Dean refused to grant him his request. Borghese fell into a rage, and when it was suggested to him that the election of Barberini might be the quickest and simplest solution to the problem, he realised that he had been outmanoeuvred by his enemies. Judging that anything was better than running the risk of remaining in the fetid atmosphere of the Holy City, he grudgingly gave his consent.

Immediately, Ludovisi ordered the bell of the Sistine Chapel to be rung. Borghese was carried there wrapped in blankets, and Barberini’s election took place at once. When the votes were counted, he fell on his knees to pray. Rising, he announced that he accepted the conclave’s choice, and would take the name Urban VIII. The fire in the stove of the Sistine Chapel was lit with grass only. From its chimney rose a plume of white smoke. ‘Habemus papam,’ Gigli wrote in his diary.

The name Urban, many believed, was for Urbi et Orbi – ‘For the city and for the world’ – the motto of the city of Rome over which Barberini, as Pope, would soon preside as both temporal and spiritual leader.

But the Holy City was about to demonstrate that it had powers of its own. ‘As soon as they left the conclave,’ wrote Giacinto Gigli, ‘nearly all the cardinals fell ill and many were on the point of death. Even Pope Urban himself was among the sick.’

By the beginning of August, less than a month after Pope Gregory’s death, the summer epidemic of malaria was spreading all over the city. Hundreds of people lay sick in the Santo Spirito hospital, by the Vatican. On 16 August a papal avviso reported that forty of the cardinals’ attendants had died of the fever. One of the cardinals had already succumbed. On 19 August it was the turn of Cardinal Serra, one of those who had arrived just as the conclave doors were closing. Four days later Cardinal Sauli, who had been a possible candidate for the papacy, also died of the fever. By mid-September four more cardinals were dead, making a total of six, more than a tenth of those who had assembled for the conclave.

Outside the Vatican, the priests who said mass in the small churches on the lower reaches of the Tiber, and the lay members of the city’s many confraternities who worked so diligently among the poor, died in even greater numbers.

The new Pope too could not throw off his illness. Racked with fever, alternately hot and then shivering with cold, he could feel his spleen hard and swollen by the malaria. His coronation was delayed by nearly eight weeks. Even then, he had barely recovered. At the end of his coronation day Urban’s head ached. His neck was stiff, and for many weeks afterwards, one of his courtiers wrote, he could not bear the weight of the coveted papal tiara upon his head. Giulio Mancini, the senior doctor at the Santo Spirito hospital, was summoned to attend him. The new pontiff took to his bed. For nearly two months he did not leave it. Not until early in November, when the temperature had fallen and the summer fever died down, would Pope Urban be strong enough to undertake the ceremony of the possesso, when he would ride across Rome in a procession that saw him symbolically take possession of the Holy City. There were many who had feared that the new Pope would never be well enough to rise from his bed at all. But Urban would confound them all.

The newly-elected Pope was an educated man; yet although the early days of his pontificate were distinguished by a flourishing of the arts and the sciences, he was also deeply conservative, and in time that aspect of his character would prevail. Despite his championing of artists like Bernini and Boromini, his rule over the Roman Catholic Church would be known more for how it shackled its subjects than for how it liberated them through progress. Urban VIII imprisoned Galileo. He waged war across Europe for years at a time, financing his soldiering by imposing such high taxes on the city that he became known as Papa Gabella, the Tax Pope. Yet, having been educated by the Jesuits at the Collegio Romano, he also supported the quest for scientific knowledge and education that they were promoting; indeed, on the very day of his election, 6 August 1623, he issued the bulls of canonisation that made saints of Ignatius Loyola and Francis Xavier, the two men who had founded the Society of Jesus a century earlier. The Jesuits believed in educating first, converting later. Pope Urban became a great patron of Catholic missions abroad, and well before the middle of the seventeenth century there were Jesuit missions as far afield as China and South America.

A year after his coronation, Urban paid an official visit to the Santo Spirito hospital to confer a papal blessing upon Giulio Mancini and the other doctors who had helped save his life when he was sick with malaria.

From its earliest history, the order of the Confraternity of Santo Spirito had a special link with the Vatican. It was the conduit through which the Pope directed nearly all his charitable giving, and Giulio Mancini would remain Urban’s personal physician throughout his reign. One of its surgeons became a specialist at dissecting and embalming. It was he who would be assigned the delicate task of embalming the Pope when he died in 1642.

The Ospedale Santo Spirito in Sassia, to give it its proper name, had the official task of caring for poor pilgrims who flocked to the city in Holy Years. An earlier Pope had built a hospice there for sick paupers after he had a dream in which an angel showed him the bodies of Rome’s unwanted babies dredged up from the Tiber in fishing nets. As many as fifty wetnurses were employed in the hospital at any one time, each being able to suckle two or three babies.

The hospital Pope Urban visited could accommodate the wounded and the fevered in 150 beds, and as many as four hundred during the summer epidemics of malaria. Twice a day each doctor, accompanied by his assistant and the assistant apothecarist, would visit one of the four wards, each of which normally held about forty patients. He inspected and palpated the patients and questioned them about their symptoms. He would scrutinise their blood, which after every bloodletting was kept in a special niche by the bed, and he would prescribe treatments.

Although a special ward was reserved for the nobility, and some of the hospital’s doctors also treated the cardinals and bishops who resided within the Vatican – as well as the Pope – the Santo Spirito was primarily intended to serve the poor. Most of the patients would have been artisans – blacksmiths, tailors, horsemen, bakers and butchers – but there were also many beggars who were cared for by lay nurses. Johannes Faber, a German physician who studied at the hospital, recalled that in 1600, when he began his five-year training, more than twelve thousand people received shelter, food and treatment from the Santo Spirito, as well as medication from the apothecary which had been established on the ground floor.

Under Pope Urban, the apothecary of Santo Spirito would become one of the greatest centres for dispensing medicine in Europe. It was here that quinine, in the form of dried cinchona bark, would be given to the malaria patients in the city for the first time. In 1630 the Pope named a Spanish archbishop, Juan de Lugo, a Jesuit lawyer and university professor, as director of the apothecary. Elevated to the purple in 1642, Cardinal de Lugo would become responsible for turning the pharmacy from an artisanal studio to something approaching an industrial production line.

Like an apothecary that was being built at the same time by another Jesuit across the seas in Lima, Peru, de Lugo’s Roman medicine house resembled nothing that had gone before it, either in scale or in vision. By the time Archbishop de Lugo took charge of the apothecary of the Santo Spirito hospital, its shelves were filled with recipes for preparations of medicines, prescriptions for their use and descriptions of illnesses and symptoms treated by different physicians. Spread on long tables were all the instruments of preparation: pestles, mortars, presses, beakers, alembics, boilers, distillating tubes, glass containers and ceramic jars. Neatly labelled in thousands of jars and bottles were botanical and chemical ingredients. Camillo Fanucci, one of the hospital’s Jesuit apothecaries, wrote in his Treatise on all the Pious Works of the Holy City of Rome: ‘I resolve to tell Monsignor Teseao Aldobrando, commendatore of this hospital, that after looking over the hospital accounts, every year we distribute more than fifty thousand syrups, ten thousand medicines and twenty-five thousand other medicines. And thus, it is obvious to anyone that no expense is spared in this hospital in the care of the sick.’

Travellers from abroad would bring small quantities of new cures to Rome. One Jesuit, travelling back from China, brought rhubarb, which would become widely used for stomach disorders. Another, from South America, came with bezoar stone, calcium phosphate that is formed in the stomach of the llama, which would become highly prized for treating all manner of ailments, from dysentery to infertility.

Yet another priest, also a Jesuit, carried back a small bundle of dried bark, the bitter-tasting outer skin of the cinchona tree, that was used by some Andean Indians of northern Peru as a cure for shivering. The priest, who knew about the marsh fever that was so prevalent in Europe, thought the powdered Peruvian bark might be worth trying against the marsh fever that struck the people of Rome during the summer, causing them repeated attacks of the sweats followed by shivering.

Thus it was that, in a prescription for curing fever noted down in the early 1630s, a Jesuit priest, Father Domenico Anda, the chief apothecarist at the Ospedale Santo Spirito, made the first passing mention of quinine – or to give it its botanical name, cinchona, which was then known as Corticus peruvianus, the ‘Peruvian bark’.

Acc. Flor. Samb. iii |
Sal.c.s. | Cortic. Peruvian. i
S.diapol.a | Stib.diapol.
Sir.giov.ii | Sal. Tart.a a g.XV
Spir. Theria.cum p |

Fac pulverem et irrora oleo Matth. Et cum diascord. Fraest.pul.et ita per triduum.

If you go today to the Santo Spirito hospital and look around the rooms where Father Domenico had his apothecary, you see immediately how important the cinchona bark was to the development of medicine and to the reputation that the Roman apothecary would gain throughout Europe. Around the walls is a series of ceramic tablets. They show Pope Urban’s Spanish priest, Cardinal de Lugo, visiting a feverish patient. At the bottom of one of the tablets is written the words: ‘Purpureus Pater his solatur in aedibus aegros deluges Limae cortice febrifugio’ (In this abode, Cardinal de Lugo offered comfort to the sick with the febrifuge bark from Lima). With one hand the Cardinal crosses the patient gently on the forehead; with the other he offers him the Jesuit cure that will help drive away the Roman fever, stay the chills and ease his aching bones.

Father Domenico’s prescription was referred to in a pamphlet written by Pietro De Angelis, the director of the Santo Spirito in the 1950s, who gave himself the task of educating the public about the varied work of the hospital. The original, however, no longer exists. It had been held for many years in the library of the hospital’s most famous director, the seventeenth-century physician Giovanni Battista Lancisi. The library was closed to the public in the early years of the twentieth century because the building was considered unsafe. Repairing it fell foul of Italian bureaucracy and inefficiency, and it would remain closed for more than sixty years. When finally it was reopened in the mid-1990s, Father Domenico’s prescription and three other of the rarest documents in Lancisi’s collection had simply vanished. But a record of the text survives in Pietro De Angelis’s pamphlet.

The medical world in Europe, which had barely progressed since medieval times, would take a spectacular leap forward from the 1630s with the adoption and distribution of cinchona bark in Rome. Not only was quinine the first real treatment for the Roman marsh fever, but the way it worked ran counter to the prevailing orthodoxy about fever as a disease and what was at the root of it. As a result, quinine can be described as the modern world’s first real pharmaceutical drug. In time, it would change medicine forever.

That Europeans learned about it at all can be attributed to the work of a lay monk by the name of Agustino Salumbrino. A determined and energetic man with a quick, restless mind who stood not five feet high in his sandals, Brother Salumbrino had worked as an infirmarian on the wards of the Santo Spirito hospital. Unmarried, and with nothing to tie him to Rome, he set sail in 1604 for Peru, where he was determined to serve the Society of Jesus and heal the sick, and where eventually he founded the most famous pharmacy in Latin America.

The medicine he sent back to Rome came too late to treat Giacinto Gigli’s young granddaughter. But for nearly a century, all the quinine that was dispensed in Europe would come from Brother Salumbrino’s apothecary in Lima.

3 The Tree Discovered – Peru

‘Aquí tenían los Jesuitas un local donde expedían al público una corteza febrífuga de la quina o cascarilla.’ (From this place the Jesuits provided the public with a febrifuge made from quinine or bark)

Street plaque on the Jesuit church of San Pedro, Lima

A vicuna, a cinchona tree and the horn of plenty.

The Peruvian national emblem, as seen on every Peruvian coin

In 1663, Sebastiano Bado, a doctor from Genoa, published an account of a story he had heard from an Italian merchant who lived for many years in Lima, the capital of the viceroyalty of Peru.

The Countess of Chinchón, the wife of the Viceroy, fell ill with a tertian fever, which, Bado wrote, ‘in that region is not only frequent but severe and dangerous’. Rumours of the Countess’s impending death spread through the city of Lima and beyond, even reaching the Andean hill town of Loxa, in what is now southern Ecuador. On being told of the Countess’s illness the Prefect of Loxa immediately wrote to her husband recommending a secret remedy he knew of, a concoction made from the bark of a local tree, which he said would cure her of all her ills. The Viceroy sent for the Prefect, who brought with him the remedy. Eagerly the Countess took it, and ‘to the amazement of all’, wrote Bado, ‘she was cured’.

As soon as the people of Lima learned of the Countess’s miraculous recovery they begged her to help them, for they had often suffered from the same fever themselves. The Countess at once agreed. Not only did she tell them what the remedy was, she ordered a large quantity of it to be sent to her so that it could be dispensed to the poor and the sick. In their gratitude the people named the cure ‘the Countess’s Powder’.

For more than three hundred years this sugary story was accepted as the true version of the discovery of quinine, the world’s first pharmaceutical drug, that was carried back to Europe by the grateful Countess. It led to all sorts of literary fancies, most of them mercifully now forgotten. In its day the best-known was Zuma, written in 1817 by the Countess de Genlis, in which an Indian maid in the service of the Viceroy’s household discloses the virtues of the Peruvian bark when her mistress, the Countess of Chinchón, falls ill with malaria. Other variants of this tale include Hualma, the Peruvian, a German novel about the discovery of quinine by a pseudonymous author, W.O. von Horn, and The Saintly Vicereine, a play by a Spanish poet, José María Pemán, the composer of General Franco’s preferred national anthem. Written in 1939, The Saintly Vicereine played for a while to enthusiastic European audiences in search of an evening’s distraction from the impending war, then faded quickly away.

The problem with the story of the Countess’s miraculous discovery, however, is that it is completely untrue.

The Countess of Chinchón died suddenly in Cartagena on 14 January 1641, on her way back from Peru to Madrid, though her husband’s diaries show she was rarely ill before that, and never with anything resembling malaria. Malaria may well have struck the Count, the Viceroy of Peru, on more than one occasion; he even seems to have suffered from it after he returned to Spain. In time he recovered, but the detailed diaries left by his secretary, Antonio Suardo, make no mention of tree barks or miraculous remedies of any description.

That the fable of the Countess’s miraculous cure continued to be retold may have much to do with the fact that cinchona bark, in the early seventeenth century, really was a miracle cure. Here was an incomprehensible disease – malaria, marsh fever or the ague, as it was then called – that had been the scourge of Europe for centuries, while the cure for it was to be found high in the dense forests of a mountain range halfway across the world. The word ‘malaria’ did not then exist, and no one knew what really constituted agues – whether quotidian, tertian or quartan – or how people caught them, let alone how they might be cured of them. Nor, when they came eventually to learn about cinchona bark, did the doctors and apothecarists who prescribed the cure really understand how it worked either.

So how did anyone ever make the connection? How was it possible that a Jesuit priest, with little knowledge of doctoring, came to understand enough about the medicinal properties of the bitter bark to know that it might prove useful in treating malaria, a disease that would not be fully understood for another two centuries?

Some nationalistic South American historians have insisted, with little evidence, that the Spanish conquistadors must have learned about cinchona’s fever-curing qualities from the Incas. While it is certainly true that the local Indians were renowned for their knowledge of plants, poisons and cures, there is scant evidence to support the argument that they knew cinchona bark cured malaria. The conquistadors wrote home about many things in the century after they first arrived in Peru in 1532, but cinchona is not mentioned by any of them. Other historians insist that the Incas kept back the secret of the miraculous fever-tree to show their displeasure at the Spanish occupation. While theoretically possible, this is unlikely, given the extent and complex nature of the contacts between the conquistadors and the local populations they encountered in South America.

The reality is that many Peruvians may not have known that the bark existed at all, at least not as a cure for malaria. The cinchona tree grew in small isolated clumps in the foothills of the high Andes. And although malaria has existed in Peru since the days of Christopher Columbus, it is found in areas of low altitude, as it is in Africa, and not at the heights where the cinchona tree grows most happily.

According to contemporary written accounts, the Indians who lived in the Andes sometimes drank infusions of cinchona bark to stop them shivering. But the observation that it might also cure marsh fever, or tertian ague, came only a century after the first conquistadors arrived in the New World, and it was made not by the local Indians, but by the European visitors.

Two Spanish writers living in Peru were the first to make any detailed description of the effects of cinchona bark on patients suffering from the ague. In 1638 an Augustinian friar and herbalist, Antonio de la Calancha, wrote: ‘A tree grows in the country of Loxa which they call of fevers, whose bark, of cinnamon colour, made into powder given to the weight of two reals of silver in a drink, cures the ague and tertians; it has produced in Lima miraculous results.’

Calancha had been born in Chiquisaca (now Sucre), in the highlands of Bolivia, in 1584. He grew up among the Andean Indians, and was intimately aware of their customs and folk medicine. He entered the Augustinian Order in 1598, and was appointed the Rector of St Idelfonso College in Lima nearly twenty-five years later. Calancha spent much of his adult life writing his nine-hundred-page Corónica moralizada de la orden de N.S.P.S. Agustín en el Peru, and his account of the properties of the cinchona bark was probably written around 1630, the year that the Viceroy, the Count of Chinchón, first fell ill with the ague, as noted in the diary of his secretary, Antonio Suardo.

Another priest, Bernabé Cobó, a Jesuit who arrived in Lima from Spain in 1599, wrote an account of cinchona as a short chapter entitled ‘A Tree for the Ague’ in his magnificent multi-volume Historia del Nuevo Mundo, which was written in 1639 but not widely disseminated for another two centuries. In it he says: ‘In the district of the city of Loxa, diocese of Quito, grow certain kind of large trees, which have bark like cinnamon, a bit coarse and very bitter; which, ground to powder, is given to those who have the ague and with only this remedy it is gone. These powders must be taken to the weight of two reals of silver in wine or any other liquor just before the chill starts. These powders are by now so well known and esteemed, not only in all the Indies, but in Europe, that with insistence they are sent for from Rome.’

The writings of Calancha and Cobó were well known to virtually everyone who has written about cinchona or quinine over the past hundred years. Four other Spanish writers, all of them far more obscure, bear out Calancha and Cobó’s observations that cinchona came to the attention of the Jesuits in Peru in or around 1630.

Gaspar Caldera de la Heredia was born in Seville of Portuguese extraction in 1591 or thereabouts. He studied medicine at the University of Salamanca, practising first in Carmona before settling in Seville, then already the centre of Spanish imports from the Indies. Caldera’s interest in remedies from the New World is easily understood; his father had lived in Mexico, and three of his children went to Lima in 1641, precisely at the time when the use of cinchona in Spain and other parts of Europe was gaining momentum. His writings on cinchona are preceded by a series of letters that he exchanged in 1661 with Girolamo Bardo, the pharmacist at the Jesuit College in Rome and a close collaborator of the doctors from the Santo Spirito hospital who cured Pope Urban VIII of the malaria he caught during the papal conclave that elected him.

Caldera’s Tribunalis Illustrationes et Observationes Practicae, in which he writes about cinchona, was published in 1663, the same year that the Genovese doctor, Sebastiano Bado, published his celebrated book on cinchona, Anastasis Corticis Peruviae Sen Chinae Chinae Defensio. Caldera’s writing shows him to be a learned man, a cautious scientist, a sound clinical practitioner and a faithful witness. Cinchona, he wrote, came from a tree like a large pear tree called quarango by the Indians, who used it as timber. Jesuits at missions in the foothills of the Andes noticed that the Indians drank its powdered bark in hot water when shivering after being exposed to dampness and cold. Quinine has many side effects, some of them quite unpleasant, such as tinnitus, but one of its more beneficial properties is that it can act as a muscle relaxant, which is why it calms the nervous impulse that causes shivering, and why today it is sometimes prescribed for people with pacemakers, or more commonly for those who suffer from leg cramps.

The Jesuits, Caldera noted, believed that cinchona might be effective in checking the shivering that is associated with ague, and they tested the powdered bark on a few patients suffering from quartan and tertian fever. Shortly afterwards, some Jesuits of the missions in Quito took the bark to Gabriel de España, an energetic pharmacist who had his botíca in Lima near the bridge over the Río Rimac, and who was renowned throughout the young city for his knowledge of local medicinal plants. De España began to pass samples of cinchona to a number of physicians as well as other apothecaries in the city, who used the bark in the treatment of intermittent fevers with great success.

Gaspar Bravo de Sobremonte, who studied medicine at the University of Valladolid, where he held several chairs including Surgery, Method and Medicine, also wrote about cinchona. Bravo was considered one of the best physicians of his day, and many of his works were published in Spain and France. In the second edition of his Disputatio Apologetica pro Dogmatica Medicine Praestantia, which was published in 1639, he describes how the Spaniards – ‘us’, he calls them – used Peruvian bark to treat intermittent fevers after observing Indians in Peru drinking the powdered bark in hot water when they were shivering with cold.

In the 1670s, two other Spanish doctors also wrote about the curative effects of cinchona. Pedro Miguel de Heredia (no relation of Gaspar Caldera de la Heredia) studied medicine at one of the greatest of the Spanish faculties, Alcalá de Henares. There he held the chair of Prima of medicine, retaining it several times after the compulsory contests that took place every four years. Miguel left Alcalá de Henares in 1643. More than forty years later, the second edition of his four-volume Operum Medicinalium recounted how the Jesuits in Peru had tested cinchona.

Similarly, Miguel Salado Garcés, who held the chair of Method at the University of Seville and was committed to discovering every new drug that came from America, wrote in 1655 in his Estaciones medicas that ‘the missionaries of the Society of Jesus [in the province of Quito] used the powders of Quarango following the second transit of Galen with great ingenuity, after observing that the Indians took them when shivering from cold after swimming in iced water or from the coldness of the snow, and stop trembling within a short time; [the Jesuits] used them to control the shivering in tertian and quartan fevers: and as they noticed that the repetition of the fever stops, they advised them as a great febrifuge (and they still continue to do so) to cure them …’

Caldera, Bravo, Miguel and Salado Garcés all put the Jesuits at the centre of the story of the early discovery of cinchona in Peru. But who was responsible for gaining it such wide renown in Europe?

In the spring of 1605 a small group of Jesuit priests disembarked at Callao, at the mouth of the Rio Rimac downstream from Lima. For nearly three hundred days they had been tossed about, never knowing a moment’s quiet as they rode the swells of the vast Atlantic Ocean on their journey towards the southern tip of South America. The final part of the voyage, hugging the continent’s west coast, was if anything worse than the open sea. Gigantic waves hurled themselves across the vessel, throwing up thick columns of spray that then collapsed upon the deck, drenching everything in a foamy swirl and threatening to drive the ship onto the jagged rocks.

Now that they had reached dry land, their leader Father Diego de Torres Bollo urged them ashore. As he called for yet more donkeys to carry the supplies that the priests had brought with them from the Holy City, one of their number, a small man in sandals and the rough brown tunic of a lay brother, broke away to look around him.

Agustino Salumbrino was then about twenty-five years old, but his beard was thick and he looked older, for he had started work when he was still very young, and had never taken a single day of rest since. While Salumbrino had already studied and travelled more than most men would have done in a lifetime, he knew that Peru was the place where he would spend the rest of his days. More than that, he knew exactly what he would do with his time there.

Francisco Pizarro’s conquest of Peru in the 1530s was well known to Europeans by the beginning of the seventeenth century, for at least two of the conquistadors who had travelled with him to South America had written widely-read accounts of the magnificent Inca civilisation. Pizarro’s conquest was driven entirely by greed for Inca gold and treasure, but he painted it with a religious sheen to give legitimacy to his actions. Accompanying him on his first journey to the New World was a troop of Dominican priests. Four decades later, on 1 April 1568, the first Jesuit priests, eight of them in all, arrived in Lima.

The city was then only thirty-three years old, and still known by the name Pizarro had given it, La Ciudad de los Reyes. Despite its strange microclimate, which casts a thick fog over the coast for nearly ten months of the year, the City of Kings deeply impressed the small party of Jesuits. They admired the formal chequer pattern of the streets, so characteristic of sixteenth-century Spanish towns, that extended in a straight line right down to the Rio Rimac, which now runs through the centre of the city. They thought highly of the beautiful public square in front of the viceregal palace, the monasteries of the religious communities and the buildings of the civil and ecclesiastical administrators. Father Diego de Bracamonte, one of the newly arrived Jesuits, paid Lima a handsome compliment when he wrote home describing the city as ‘another Seville’.

Among the first tasks to which the young Jesuits set their minds was finding a suitable location for housing the fledgling mission. Before paying a call on the acting Governor, Lope Garcia de Castro, they explored the city. They soon chose a square, three blocks to the east of what is now the Plaza Mayor, which then housed the Viceroy’s palace, and three blocks from the Franciscans, in a rather densely populated area of the city. After a brief public hearing, the Jesuits were granted the expropriated property, for which they were obliged to pay twelve thousand pesos in compensation to its former owners. The transaction, which was completed in just over two weeks, makes it sound as if the Jesuits had arrived in Lima with plenty of money. If anything, the reverse was true: for thirteen years after they moved in to San Pablo the Jesuits had to assign one of their most capable lay brothers to be the limosnero, the man in charge of begging alms on a daily basis from the well-to-do families of the city.

In the early years, the Jesuit College of San Pablo depended for its existence on these donations from the citizens of Lima, and a series of small and sporadic royal grants. In 1581, though, San Pablo took over a property outside the city, and over nearly two centuries, until the Jesuits’ expulsion from the Spanish Empire in 1767, those holdings steadily increased in size until the Society of Jesus became one of the country’s biggest landholders. Its haciendas produced wheat, which was ground into flour in a mill that was also owned by the college. The Society planted new vines and an olive grove, which provided the Jesuit fathers with as much wine and oil as they needed. They raised cattle and goats, and grew sugar cane. A trapiche, or sugar mill, produced sugar and cane syrup. By 1600 San Pablo owned about ten rural properties, of which some were put under intense cultivation while others were used for grazing.

The haciendas fed and clothed all the 160 or so priests who lived at the college in Lima. By the first half of the seventeenth century they also supported two thousand workers whom the Jesuits employed to run their properties, and three hundred slaves who were engaged in the vineyards of San Xavier, picking and pressing the grapes and producing the well-known Jesuit wines, as well as pisco, the traditional Peruvian liquor that is distilled from white grapes. As the haciendas grew bigger and more efficient, they turned from being simple agricultural properties into agro-industrial plants—a fusion of farms with mills, sugar refineries and distilleries – which delivered to Peruvian markets some of the best wines, flowers, sugar, oil and honey available in the viceroyalty.

Over the years many Jesuits sailed across the Atlantic to join the missions that were being set up in Chile and Argentina, as well as Peru, but there was always room for more. In order to expand throughout the viceroyalty, the Jesuit mission in Lima had to have more resources. And that meant more people.

Thus it was that in 1601 Diego de Torres Bollo, one of the senior Jesuit priests at the mission of San Pablo in Lima, left for Rome to petition the Vicar-General of the Order of the Society of Jesus to send more young Jesuits to South America. To reach the Holy City he had had to sail around the north-west coast of South America to Panama, then travel by mule over the isthmus to Puertobelo before resuming his journey once again by ship. The voyage took many months, and was fraught with danger. Not long after he arrived, Torres Bollo fell ill and was admitted to the Jesuit infirmary in Rome. The man who took care of him was Agustino Salumbrino.

Salumbrino had joined the Jesuits in 1588. After taking his vows in Rome in 1590, he was sent to the Jesuit college in Milan to become an infirmarian. There he made a special study of pharmacy, and when, after a few years, he returned to Rome, he resolved to put his medical knowledge at the service of the many Jesuits who lived in the Holy City. In the course of his convalescence, Torres Bollo, who would later found the Jesuit mission in Paraguay, told Salumbrino all about St Ignatius’ missions in the New World, and the great college of San Pablo which was being built in the young city of Lima. He described the plans the Peruvian Jesuits had for setting up new missions over the whole continent.

Each time he came to see his patient, Salumbrino, like the Mill Hill fathers whom I had visited in north London, felt the call of the mysterious world across the seas. As he listened to Torres Bollo, the lay brother began to recognise what his life’s work would be. He would go to Peru and live in the college of San Pablo in Lima, putting his knowledge of pharmacy to good use as he built up the botíca into the best pharmacy in the New World, which for nearly forty years, until his death in 1642, is exactly what he did.

Today, the soaring Baroque church of San Pedro, next to the Biblioteca Nacional in the centre of Lima, is all that is left of the great Jesuit College of San Pablo, which rapidly fell into disrepair after the Jesuits were expelled from the Viceroyalty of Peru and the rest of the Spanish Empire in 1767.

The church is dark, though well cared for. The remnants of its first crucifix are housed in a glass cabinet in a corner. The dark wood gleams in the shadows. In another corner, a vast reliquary rises. When you look at it more closely, you see that it is made of hundreds of boxes of dusty human bones, said to come from the many local priests who have been canonised and then forgotten.

The priest who says mass there today, under the fifty-two crystal chandeliers strung along the ceiling, urges his congregation, as Catholic priests do everywhere, to ‘go in peace, and to love and serve the Lord’. Despite the medieval, talismanic quality of the church’s interior, its enormous congregations reflect the power that the Catholic Church still commands in Peru, and the extent to which it has permeated every level of political and intellectual life. Alejandro Toledo, who won the presidential election in 2001, considered including two Jesuits in his cabinet. One was a well-known figure, Father Juan Julio Witch, an economist and academic who became a household name in 1997 after the Japanese embassy in Lima was taken over by terrorists during a reception to celebrate the Emperor’s birthday. Given the opportunity to leave the embassy compound, Father Juan elected instead to stay behind with the other hostages. For four months he said mass there every day, urging his small and frightened congregation to keep their spirits up and pray for salvation, while outside television cameras and frustrated army marksmen waited for the terrorists to give way. Today his name is known throughout Peru.

It has long been accepted that the Jesuits were responsible for introducing cinchona into Europe. As I read more about the role of the Society of Jesus in Peru’s long history, I kept wondering if, after all the wars and insurrections, burning and looting, any written material still survived from their earliest time there. Eventually, I learned that the bulk of a large private collection of Peruvian Jesuitica, built up by an obsessive hoarder, Father Rubén Vargas Ugarte, who came from a wealthy family and was himself a Jesuit priest, a historian of the Church and a Peruvian nationalist, had been placed in the state archives in Lima. No one could tell me over the telephone what the collection contained. And so I travelled to Peru, not knowing what I might find, or indeed whether I would find anything at all.

For a long time after I got there, I was little the wiser.

The state archive occupies a dark corner at the back of the building that is better known as the Peruvian national bank. It has its own entrance, but there is no sign on the door; nor, once you are inside, are there any directions to tell you where to go. At least Father Rubén’s material was there, though what it contained no one could tell me. It hadn’t been opened, and although some of its papers had been looked over by scholars past, the collection had come with no inventory and there was no catalogue. But I was welcome, the librarian said, to look through it if I wanted. A long pile of boxes was stacked down the hallway, though quite how far it extended and how many boxes it contained I couldn’t really tell.

The librarian gave me a key to the archive, and said I could work there for as long as I wanted each day. Outside, Peruvians were preparing to go to the polls. The atmosphere was tense, and there was a sporadic curfew. Occasionally I would emerge from the archive at the end of the day and find that I could not return to my hotel. I went back inside and slept on the floor, shielded from the draught by Father Rubén’s mountains of paper.

I began methodically going through each box. I picked out details of property transactions, plantings and harvests on the Society’s haciendas, chronicles of boundary disputes, baptismal records, the sale and purchase of slaves, shopping lists, inventories. I had come across Agustino Salumbrino’s name in the Jesuit archive in Rome, but I still knew very little about him. Would I ever find out more?

Then one day I found two old books dating back to 1624. They were inventories. Page after page in the volumes of El Libro de Viáticos y Almacén are filled with inky lines that once were black but now are faded to a rusty brown. The quills the writers used were so sharp they have ripped through the paper. That these documents survived at all was a miracle. No one has ever tried to conserve them, and some of the paper crumbled in my hand. Yet it was still possible to read what the Jesuit administrator of San Pablo had written there nearly four hundred years earlier. In addition to listing everything that came into and went out of the college, from the cases of books that were sent from Europe to supplies of medicines, clothing and tableware that were despatched to other Jesuit missions, he also provided a complete inventory of Brother Salumbrino’s pharmacy.

By the time Agustino Salumbrino arrived in Lima in 1605, the mission at San Pablo was firmly established, with several classrooms, a small library, a chapel, private rooms and even an infirmary, which, although basic, was clean and well run. Salumbrino quickly realised, however, that the infirmary was not sufficient to take proper care of all the sick in Lima. What he needed was a proper pharmacy, and a steady supply of medicines. These were hard to obtain in colonial Peru, but Salumbrino was a tireless worker, and he had made up his mind not merely to build a pharmacy, a botíca, as it was called, at San Pablo, but to do it in the grand manner, not only to serve the college’s local needs, but to supply all the Jesuit colleges throughout the viceroyalty.

Agustino Salumbrino’s ambition to set up a pharmacy to help treat the poor of Lima had its roots not just in the rich medical lore that he encountered as soon as he arrived in Lima, but also in the Jesuits’ earliest philosophy. The instructions left by the founder of the order, St Ignatius Loyola, forbade his followers to become doctors. The task that lay before them, he emphasised, should focus upon men’s souls. This did not mean that Jesuits were ignorant of the importance of maintaining good health; indeed, every Jesuit mission was enjoined to appoint one of their number as a ‘prefect of health’ to ensure that the priests’ diet was adequate and that they were well cared for. The most capable lay brothers would be chosen to run the college’s infirmary and have immediate care of the sick. Most important, the Society’s founder insisted, each college would ensure that it had an adequate supply of medicines, either by setting up a pharmacy of its own, or by finding a reliable source of supply. Despite being expressly forbidden to practise medicine, Jesuit priests often turned their attention to the study of herbs and plants, and a number of them, especially in the foreign missions, became apothecaries.

San Pablo’s infirmary was in a clean and quiet courtyard in the south-eastern corner of the college. By the time it was properly established it had about fifteen private rooms, all facing the fountain in the centre of the courtyard. Brother Salumbrino built his pharmacy close by the infirmary. Knowing that he needed to be as self-sufficient as possible, he began by planting a small herbarium in a corner of the garden at San Pablo. He chose plants that were well known for their medicinal properties: camphor, rue, nicotiana, saffron and caña fistula, a Peruvian wild cane that was often used for stomach disorders in place of rhubarb. These Brother Salumbrino and his two assistants made up into medicinal compounds, which were dried, powdered and mixed in the laboratory according to strict pharmaceutical rules. To help him, Salumbrino ordered two of the most important pharmacopoeias then available in Europe: Luis de Olviedo’s Methodo de la Colección y Reposición de las Medicinas Simples y de su Corrección y Preparación (printed in Madrid in 1581), which he had used in Rome; eventually, he also ordered Juan del Castillo’s Pharmacopoea Universa Medicamenta in Officinis Pharmaceuticis Usitata Complectens et Explicans (printed in Cadiz in 1622).

Pharmacopoeias were works that described chemicals, drugs and medicinal preparations. They were issued regularly with the approval of different medical authorities, and were considered standard manuals in every pharmacy in Europe. Besides these two classics, Brother Salumbrino could also consult and follow the prescriptions of Girolamo Mercuriale, physician to the Medicis and Professor at the universities of Padua, Bologna and Pisa, who exercised a profound influence on medical circles all over Europe.

Over the next century and a half the botíca at San Pablo would order at least ten other pharmacopoeias that specialised in local drugs and chemicals, including its vade mecum, Felix Palacios’ Palestra Farmaceutica, which was printed in Madrid in 1713, the year after Francesco Torti had his ‘Tree of Fevers’ published. The botíca put in regular orders for extra copies of Palacios’ work to be sent out to the other Jesuit colleges in the viceroyalty. The book was so highly regarded, and was so frequently referred to, that the pharmacists at San Pablo would eventually write inside the cover of their own copy: para el uso diario de esta botíca (‘for the daily use of this pharmacy’).

By 1767, when the Jesuits were forced to leave Peru and the final inventory of the pharmacy was compiled, the San Pablo medical library contained about a hundred books. The full list, given in another set of books that I found among Father Rubén’s boxes, Cuenta de la Botíca 1757–1767, included the ancient classics by Galen and Hippocrates as well as voluminous Latin commentaries on the two masters by several medieval doctors. The library also had books on several other branches of medicine, including anatomy and osteology, treatises on different kinds of fevers and their remedies, descriptions of contagious diseases and their infections, and the methods of combating them.

Surgery was also a favourite subject at San Pablo, and one could find on the shelves of the college’s library Bartolomé Hidalgo de Agüero’s Thesoro de la Verdadera Cirugía y Via Particular contra la Común (printed in Seville in 1624), and Juan Calvo’s Primera y Segunda Parte de la Cirugía Universal y Particular del Cuerpo Humano, which was published in Madrid in 1626 and reprinted many times in the seventeenth century, and was still in use more than a hundred years later – though one shudders to think of operations being carried out without the benefit of any anaesthetic or antibiotics in the humid atmosphere of seventeenth-century South America.

The Jesuits who came to Peru just after Pizarro’s conquest of the Incas were the first order with a clear mission to educate and then, by doing so, to convert the Indians to Catholicism.

There was a clear division, though, over exactly how this should be done. The ascetic, intellectual Jesuits who ran the order from Rome were of one view, while the energetic activists who left their homes to promote its interests overseas were of quite another. The young Jesuits in Lima were pioneers of the soul. They believed strongly in catechism. Each day, a group of priests would leave San Pablo, walking in procession through the streets of Lima, holding a crucifix and ringing a bell to attract groups of Indians and blacks to whom they would preach. Not everyone liked this. One early Provincial Superior of the Jesuits in Peru, José de Acosta, was dismayed by this helter-skelter missionary activity, and was bitterly critical of having so many men tramp around as ‘holy vagabonds’. His own bias tended towards the old Jesuit ideal of learned men influencing councils and kings.

What he failed to realise was that most of the Jesuits, such as Brother Agustino Salumbrino, who went to Peru early on were not driven to write books or meditate. They were zealous, educated men, full of drive and courage, who wanted to make a difference, whether it was by saving souls or promoting good health.

The early Jesuits soon expanded their missionary activity to Cuzco, the old Inca capital that Pizarro seized in 1534. They bought a fine palace that had been taken over by one of Pizarro’s lieutenants on the main square, only to tear it down and build the towering pink Baroque church that still stands today. From there the Society sent its priests out into the countryside to make contact with the local Indian communities and urge them to renounce the animist gods they had worshipped for centuries in favour of a Christian Almighty.

The Inca world was ruled by spirits and superstition. Every village was surrounded by secret places – trees, rocks, springs and caves – that had a magical significance. The Incas collected unusual objects, and in every house there were canopas, or household deities, displayed in a niche in a corner or stowed in a special place, wrapped in cloths. They observed rituals throughout their daily lives, sprinkling chicha or coca when ploughing, saying prayers and incantations when crossing rivers, making sacrifices on particular occasions and always leaving an object on the pile of stones that is still often to be found at the top of every pass.

The Incas lived in fear of the sorcerers, the old men who foretold the future by studying the shape of ears of corn, the entrails of animals or the movement of the clouds, and were terrified of the magic spells they cast to cause love or grief in their victims. But they also revered them, for many of the sorcerers were medicine men as well as magicians. In some parts of Peru they would undertake trepanning, cutting open the skull to let out evil spirits and to offer the patient some relief from pain or swelling. The rich Quechua language shows that the Incas had a fine knowledge of anatomy and medicine, with words such as hicsa for abdomen, cunca oncoy for angina, susuncay for putting to sleep, siqui tullu for coccyx, husputay for haemorrhage, hanqqu for nerve and rupphapacuy for fever.

They amassed a great store of knowledge about local plants and how to use them to treat different ailments, and were particularly expert on poisons and plants with hallucinogenic qualities – every man would carry upon him a little packet of coca leaves for chewing on. They also used the trumpet-shaped Solanaceae, or datura as it is better known, in magic spells to cast their enemies into a trance, sarsaparilla as a diuretic, tembladera (Equisetum bogotense) against pyorrhoea, a plant they called llaquellaque (Rumex cuneifolius) as a purgative of the blood, ortiga (Urtica magellanica) to cure sciatica, and payco (Chenopodium ambrosoides) against worms.

The two volumes of El Libro de Viáticos y Almacén show just how elaborately Brother Salumbrino and his fellow Jesuit priests would prepare for a trip out of the city. Every traveller would be issued with a mule for riding on, and another for carrying their supplies. Many of the mules’ names survive in the records: La Cabezuda, La Caminante, La Mulata, El Galán. The supplies would include hay for the mules, for the desert of northern Peru in particular was short of fodder, and often of water too. The traveller would also be equipped with a bowl, a spoon for the table and a knife for cutting meat, a bedroll and a sheet, a roll of sealing wax, spices in the form of saffron, pepper and cinnamon, wine, a sombrero, a soutane and a cape to keep out the cold in the mountains. The grandest inventories included travelling altars, supplies of wine and wheat hosts for offering communion, and even silver candlesticks. But, grand or simple, each traveller’s list concludes with patacones, fried plantain chips, for an Indian guide, and more patacones for el gasto del camino, the road toll.

Despite the rips in the pages of these ancient books, they still summon, nearly three centuries on, a pervasive and enormously fierce sense of just how energetic and enterprising the Jesuits were. On 26 April 1628, the earliest entry in the book that mentions Brother Salumbrino, the pharmacist sent the Jesuit college at Arequipa, at least three weeks’ ride south of Lima, not far from Lake Titicaca, four cases of drugs, including eight libras of caña fistula. The following month he sent the college another eight libras of caña fistula and a copy of the Meditations of St Ignatius Loyola. In August of that same year he despatched supplies of tobacco and cocoa and another three boxes of caña fistula, and the following April the mule load to Arequipa would include four bottles with different drugs ‘sent by Brother Agustín’.

San Pablo was making a name for itself as a trading post, and it was not confined to medicines. It imported textiles from England, Spain, France and the Low Countries, Italy and the Philippines, and large quantities of black taffeta from China. It provided Jesuit schools in the region with ink and paper imported from Italy—in 1629 San Pablo despatched three thousand pens in a single huge shipment that went to the Jesuit College in Santiago, Chile. Farm tools such as ploughs, sickles and hoes were in great demand. San Pablo shipped those off too, along with saddles and harnesses, tallow candles and pottery, shoes and clothing for children as well as adults, needles and nails. In 1628 the college sent twelve baras of tailors’ needles from France to Arequipa, while three years later another two thousand needles, described as finas de Sevilla, were needed. Between 1628 and 1629 San Pablo also sent twelve thousand nails to Potosí, ten thousand to Arequipa, and more than twenty thousand to Chile.

As this trade blossomed, Brother Salumbrino’s influence also soon extended beyond the walls of the college. Like the library at San Pablo, which ordered books from Europe and sent them out to colleges all over the viceroyalty, the pharmacy became an early distribution centre of medicines and medical information for other Jesuit institutions in the area. Salumbrino supplied medicines to the Jesuits who left San Pablo on long missions among the Indians in the Andes, and to other Jesuit outposts

The Libro de la Botíca neatly lists everything that San Pablo supplied to the other Jesuit colleges in the viceroyalty: agua fuerte and aguardiente, powdered mother of pearl, pine resins, black and white balsam, bezoar stone, nicotiana in powder, caña fistula, cinnamon, nutmeg, sal volatile – the original smelling salts – mercurio dulce or mercury sulphide for treating syphilis, black pepper, ambergris, senna, tamarind, sugar, camphor, sweet and bitter almonds, almond oil, tobacco from Seville, essence of roses and violets, rhubarb, chocolate and, of course, cinchona bark, that would eventually be despatched, dried in strips or in powder, in huge quantities all over the continent and also across the Atlantic.

From the earliest years the Jesuits of San Pablo were of the clear belief that conversion of the Indians would come about not by force, but by education and persuasion. For that reason they were quick to send young priests out into the field. Many of the young Jesuits who were posted to Peru made it a priority to learn Quechua and the other Indian languages, and to accustom themselves to the Indians’ way of life.

The Jesuits in the field, especially those who had been sent north-east of Lima, to Loxa in the Andes, began to persuade the local Indians to seek out the árbol de las calenturas, the ‘tree of barks’, as Bernabé Cobó, another Jesuit and a colleague of Salumbrino’s, would describe cinchona in his Historia del Nuevo Mundo in 1639. They taught them how to cut off the bark in vertical strips so as not to kill the tree, and to plant five new trees for every one they cut down. The Jesuits would place the saplings in the ground in the shape of a cross, in the belief that God would then help them grow better. More than two centuries later, an English plant-hunter and bark-trader would observe: ‘Always when passing [these plantations] my Indians would go down on their knees, hat in hand, cross themselves, [and] say a prayer for the souls of the Buenos padres.’

After they stripped off the bark, the cascarilleros or barkhunters would cut it into pieces and leave it to dry in the sun. Taking care not to break the fragile, powdery strips, they would wrap them carefully in pieces of cloth and then in watertight leather packs for transporting down the hills by mule to Lima.

San Pablo began to distribute cinchona bark – or cascarilla as it was known in Spanish – to the other Jesuit colleges in the viceroyalty, and even as far as Panama and Chile. Eventually Brother Salumbrino also began sending supplies of cinchona to Europe.

The first person listed in the Libro de Viáticos y Almacén as leaving San Pablo with a quantity of cinchona bound for Europe is a Father Alonso Messia Venegás, an elderly Jesuit priest who carried a small supply of it in his bags when he travelled to Rome in 1631. Father Alonso knew, as every Jesuit did, how malarious the Holy City was, and had heard accounts of the terrible conclave of 1623 when so many of the visiting cardinals died. Rome was in dire need of a cure for the fevers, and Brother Salumbrino was eager to see if the plant that stopped people from shivering could be put to use curing the chills that were a symptom of the marsh fever. Little did he know that not only did it stop the shivering, it could also be used to treat the disease.

The physicians in Rome found that the bark was indeed an effective treatment for the intermittent fever, and thereafter every Procurator who left San Pablo for the Holy City to represent the Peruvian Jesuits at the congress that elected the Jesuit Vicar-General every three years would take with him new supplies of the febrifuge bark. Shortly after Father Bartolomé Tafur, who served as the Peruvian representative at the congress of 1649, arrived in Rome he renewed his acquaintanceship with Cardinal Juan de Lugo, who was then in charge of the apothecary at the Santo Spirito hospital, and was becoming cinchona’s champion in the Holy City. In 1667 Felipe de Paz took with him a trunk filled with the corteza de la calenturas, and in 1669 Nicolás de Miravál arrived with 635 libras of cinchona for distribution in the curia, having left a similar amount in Spain.

By the second half of the seventeenth century, according to an early map of Lima in the state archive, the citizens of the capital had begun calling the street in front of the Jesuit infirmaries Calle de la cascarilla, Bark Street. Now part of the long, fume-laden Jirón Azangaro, which runs through downtown Lima from the Palacio de la Justicia as far as the Franciscan convent near the river, Calle de la cascarilla would remain up to the start of the republican period in 1825 as a public testimony to San Pablo’s role in distributing cinchona first in Peru and then around the world, and it appears in many of the maps of that time.

The final decade of the botíca at San Pablo saw Brother Salumbrino’s ambitions come to fruition. The pharmacy itself, where the cinchona bark was weighed out and packed, was beautifully furnished. On its wall hung a large portrait of Salumbrino which his fellow Jesuits had commissioned in 1764 at a cost of 140 pesos, and which bore the legend: ‘Agustino Salumbrino, first founder of this pharmacy of San Pablo’.

The walls were covered from floor to ceiling with solid oak shelves laden with bottles and flasks. Several tables and chairs were spread around the room, made of wood imported from Chile, and in the centre of the room was a long, wide mahogany counter of a beautiful reddish-brown colour. On top of the counter, in sharp contrast to the dark heavy wood, rested four delicate scales.

The three black employees who worked in the pharmacy spent their day in the laboratory, a forest of glazed earthenware and shiny instruments, some of lead or bronze, some of pure silver. The laboratory was filled with large jugs, scales, all kinds of stills used for distilling liquids, glass and metal funnels of all shapes and sizes, crystal flasks, retorts and matrasses, gridirons and hand mills, pumping engines and ovens, condensers and cauldrons, handsaws and sieves.

Brother Salumbrino’s Jesuit masters might have been uncomfortable in that room, with its heavy fumes and thick, unpleasant odours of medicines and chemicals, but they would have been happy to know that in San Pablo’s pharmacy he and his brother pharmacists had the means to preserve and restore the health of the hundreds of priests working in the field. The final inventory of the pharmacy includes more than five hundred medicines, in addition to the books in the library and the vast quantity of stills, bottles and other material that filled the laboratory’s shelves. Of the medicines in the pharmacy, by far the most valuable was una grande tinafa – a great jar – of cinchona bark, which is valued at one hundred pesos.

Despite the excellence of its pharmacy, the small world of San Pablo was about to be engulfed in political events that were fuelled, as so often happens, by fear and greed. Secret orders had arrived from Madrid: the Society of Jesus was to be expelled from the whole of the Spanish Empire on the orders of King Charles III, who feared its swelling power and longed to own its properties and who finally, after many decades, had chosen to believe the Jesuits’ enemies who had long tried to discredit them in the eyes of Charles and his court.

At four o’clock in the morning of 9 September 1767 the Viceroy, Don Manuel de Amat, had everything ready to carry out the King’s instructions in Peru. Four hundred soldiers were stationed within the viceregal palace. In the dead of night a number of the most important men in Lima also arrived at the back door of the palace, summoned by a handwritten note from Amat that read, ‘I need you for matters of great service to the King, and I warn you to come so secretly that not even those of your household would realise that you had gone out.’

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