Folk medicine used to heal malaria in Calabria (southern Italy)

In Italy, malaria was an endemic disease that was eradicated by the mid-20th century. This paper evaluates the prophylactic and therapeutic remedies used by folk medicine to cure malaria in Calabria (southern Italy). The data has been collected by analysing works of physicians, ethnographers, folklorists and specialists of the study of Calabrian history between the end of the 19th century and the 20th century. The data collected have allowed us to describe the most common cures used by the Calabrian people to treat malaria and the most evident symptoms of this disease, such as intermittent fever, hepato-spleenomegaly, asthenia and dropsy. This approach uncovered a heterogeneous corpus of empirical, magical and religious remedies, which the authors have investigated as evidences of past "expert medicine" and to verify their real effectiveness in the treatment of malaria.


Background
Malaria is an infectious disease that is caused by the Plasmodium parasite. This disease is transmitted to humans via the Anopheles mosquito. Malaria is a very ancient disease, and although it was not possible to prove its presence in ancient human bones, this disease was probably present among Homo genus ancestors [1]. Different populations, such as the Sumerians, Assyrian-Babylonians, Indians, Egyptians and Chinese, experienced seasonal and intermittent fevers [2]. In the Mediterranean area, particularly in Italy, malaria was an endemic disease that was eradicated by the mid-20th century. Moreover, the persistent and lasting presence of malaria determined an interesting state of debility of the affected subjects and a consequent weakening of the labour force, which led to some important and detrimental socio-economic consequences [3]. Folk medicine approaches were used in an attempt to treat several of the most evident effects of malaria, such as intermittent fever, hepato-spleenomegaly, asthenia and dropsy.
It is our aim in this work to identify folk medical cures that were used by the Calabrian people for the treatment of malaria, as evidenced in writings produced between the 19th and 20th centuries. The authors have also examined whether same remedies were already described by Pliny the Elder, Dioscorides, Galen and Serenus Sammonicus, so to be considered as evidence of past "expert medicine".

Area of Study
It is interesting to point out that in some peninsular and insular areas of Italy, despite all the drainage attempts initiated in the 16th century, malaria-associated mortality was only recently eradicated in the mid-20th century ( Figure 1) [4]. Among the southern regions of Italy, Calabria was one of the regions that was most affected by malaria. The disease was endemic along its coasts (about 738 km), along its most important rivers (Mesima, Lao, Crati, Tacina and Neto) and within the valleys of its broad streams. The disease was prevalent in 52% of the Calabrian territory (7,877.31/15,080.32 km 2 ) ( Figure 2) [5]. Calabria showed both natural and antropic factors that favoured the spread of Plasmodium, as well as the endemic and century-old presence of malaria in its territory. Physical features that may have affected the spreading of malaria are represented by a rich hydrographic reticle and the occurrence of seismic phenomena (bradyseisms and earthquakes), which, at that time, contributed to increase the hydrogeological disorder, thus creating many different wet areas (for example, the single earthquake of 1783 created about 215 lakes), which are the favourite environment of the anopheles mosquito [6]. The antropic factors are represented fundamentally by latifundia, deforestation and the very poor social and economic conditions of the rural Calabrian people [7].
Calabria is the southernmost region of peninsular Italy; it borders with the Ionian Sea to the east and south, with the Tyrrhenian Sea to the west, and with the region Basilicata to the north, and it extends for about 250 km from north to south in the middle of the Mediterranean Sea. Calabria reaches 15,080 km 2 and 42% of its territory is represented by mountains: the Apennine mountain range -the southern Apennines, calcareous, with Pollino Massif ( l.)-. 49% of Calabria's territory is represented by hills and only 9% is flat. The plains are restricted to coastal areas and only three plains extend into the internal areas of the territory (Sibari plain, Saint'Eufemia plain and Gioia Tauro plain).
The climate is Mediterranean, with maximum precipitation during the winter and minimum in the summer and vice versa for the temperature. Precipitation is represented by about 1,041 mm of rainfall per year. The average temperature in the coldest month (January) is about 8.3°C and the warmest month (August) about 24.4°C, with an annual average of 15.8°C [8]. However strong meso-climatic variations occur depending on   From both an anthropological and an ethnobotanical point of view, Calabria is an interesting region, for the historical presence of several populations (Greeks, Romans, Byzantines, Arabs, Normans and Spanish) in the past that influenced the local culture [9]. Finally, it is interesting to note that the Arbëreshe community, of Albanian origins, settled in this region since the 16th century and is currently located in 25 communes in the provinces of Cosenza, Catanzaro and Crotone [10].

Methods
This study is based on the analysis of works written by physicians, ethnographers, folklorists and specialists of the study of Calabrian history between the end of the 19th century and the 20th century, in particular when both ethnographic and anthropological research focused on the study of folk medicine. For this reason, the authors have also consulted the check-lists about works on calabrian folk medicine and beliefs, edited by Lombardi Satriani [11] and Cavalcanti [12]. The sources used in this work are listed in Table 1. The data collected has allowed us to describe the cures used by the Calabrian people to treat malaria and its most evident symptoms, such as intermittent fever, hepato-spleenomegaly, asthenia and dropsy. This approach uncovered a heterogeneous corpus of empirical, magical and religious remedies, which the authors have investigated as an "official medicine" to cure malaria in the treatises by Pliny the Elder (Naturalis Historia) [13][14][15], Dioscorides (De Materia Medica) [16], Galen (Opera Omnia) [17][18][19][20][21] and by Serenus Sammonicus (Liber Medicinalis) [22]. These authors, in fact, have influenced medical practice in latter centuries [23].
The plants used by Calabrian people to cure malaria (N = 53) have been identified as species because the   and with their current use in Calabrian folk medicine, defined by recent fieldworks [49][50][51] [ Table 2]. The family names of the plants recorded in this work follow the Angiosperm Phylogeny Group guidelines [52].

Empirical remedies
The empirical remedies that were used by the Calabrian people, as evidenced by the sources consulted in this work, were used both prophylactically and therapeutically, and were based on drinks, objects, animals, plants and other sources; some of these elements were created ex novo, while others were inherited from the "official" medicine of 1th-3th century AD [Tables 3 and 4].
Empirical therapeutical remedies. Fasting and purging were recommended for the treatment of malaria-associated fevers. Fasting was thought to appease fever, while purging was thought to remove the malaria-causing parasite from the affected organism. In general, purging was achieved via the administration of ricinus seeds (Ricinus communis L.) and by using the root of "savucu" (Sambucus nigra L.) [26]. Fasting and purging were inherited from Galenic medicine. Galen wrote the following about fasting: "(in tertiariis) ... neque quotidie cibum dare oportet, sed alternis diebus abunde fuerit" (with tertian fevers ... food must not be offered every day, but on alternate days) (Ad Glauconem de medendi methodo I, 11) [18]; and about purging: "ac vacuatio quidem excrementorum omni febri est utilissima" (during the fever, no doubt, it is very useful to defecate) (Methodo medendi IX, 10) [17]. Other treatments aimed at purging and restoring the affected subjects were also used. These included the decoction of "gamumilla" (Matricaria chamomilla L), "ordica" (Urtica dioica L., Urtica urens L.), and the decoction of the root of "alivu" (Olea europaea L.) or of the rhizome of "canna" (Arundo donax L.) [26,62,63]. Several empirical therapeutic remedies against malaria-associated fevers were loathsome. These included the ingestion of the subject's own urine, that of young virgin or that of a healthy woman (in particular, the affected subject was advised to drink 100 g of the urine of a non-affected woman early in the morning) [55][56][57]64], the consumption of various animals (or parts of animals), such as earthworms (Lumbricus terrestris) which were previously placed in the oven and pulverized, or two or three bedbugs (Cimex lecturalius) within a Host [56,58,64]. Moreover, patients were encouraged to eat pills of "pappici" (cobweb) [26,56,[63][64][65][66], the head of a viper (Vipera aspis), fried and mixed with absinth [55], goat (Capra hircus) dung within a Host, eaten from morning until midday [26,57], one spoonful of coffee per hour [57] and pills of soot [67,68]. Alternatively, to cure hepato-spleenomegaly were used hedgehog (Erinaceus europaeus) or ox (Bos taurus) gall and goat (Capra hircus) Heliotropium europaeum L.

Magic remedies
Because of the presence of malaria in the daily lives of Calabrian people, this disease was considered a normal life trouble; however, its most dangerous and deadly forms were considered by Calabrian people as a condition of supernatural nature. Therefore, they resorted to magic remedies that were believed to "link" the disease. These included, in particular, wearing a "nuci trischéra o a tri guarri" (a three-valve walnut shell) (Juglans regia L.), a spider that was enclosed between two shells of a walnut or skin, skeleton and fangs of snake, the latter extracted when animal was still alive, as it was believed that the disease would then affect the walnut, the spider or the parts of the snake, and not the subjects who wore these amulets [65,77]. Furthermore, a live "carpurita" (Pachyiulus communis) was sewn into the clothes of the affected subject (without the patient realizing it) or a "paletta" (Opuntia ficus-indica (L.) Mill.) was placed near the fireplace. It was believed that when the animal died, or when the stem of the plant dried, the fever or the hepato-spleenomegaly would disappear [26,60]. In an analogy with the ancient belief in the therapeutic principle of "contact", to defeat spleenomegaly Calabrians were encouraged to place "erba i la crucivia" (Verbena officinalis L.) on the abdomen of the affected subject before sleeping, as it would absorb the "bad blood" [56,57,62]. Finally, every morning the affected subject had to urinate on "cucuzzielli acriesti maturi", the fruits of Ecballium elaterium (L.) A. Rich., to transfer the disease from the subject to the fruit [57].

Religious remedies
Calabrian people alternated or combined both empirical and magical remedies and, very often, used prayers and acts of devotion, as diseases were believed to be associated to divine punishment. Thus, in Cosenza (Northern Calabria) the "Madonna della Febbre" was invoked with prayers, ex voto and pilgrimages [78]; in Castrovillari (province of Cosenza), the prayer to the "Madonna d'Itria" was as follows: "Madonna mia 'i L'Itria, chi stai 'nganna a'sta jumara fammi passà 'sta freva 'i quartana c'u jurnu tuju non vugghiu mangià panu" ("My Lady of Itria, close to the river, let the fever out and on your commemoration day I will not eat bread") [79].

Discussion
The methodology based on the analysis of historical sources regarding Calabrian folk medicine remedies for the prophylaxis and treatment of malaria, if not compared with similar studies, can be considered a case study where the ordinary methodologies of ethno-medical-biological research are combined with the methodologies pertaining to historical-anthropological sciences.
In addition, this is part of a debate regarding the association between ethnobotany and ethnopharmacology and other disciplines, to improve our understanding of the human usage of plants [80]. Moreover, this work complies with De Natale et al. [81], who created a database of the historical use of plants in the popular medicine of the Mediterranean basin. However, this study has revealed some interesting and heterogeneous features regarding Calabrian popular medicine practices used to prevent and treat malaria, some of which were inherited by the Calabrian people from the "expert medicine" of the past centuries. The first type of practices that we have described were characterized by a rational approach. Indeed, the use of medicinal plants, 69% of which (36/52) is recognized by the current pharmacopoeia as having some pharmacological/biological properties, succeeded in assuaging temporarily the most evident sufferings associated with the disease (fever, hepato-spleenomegaly, asthenia and dropsy) as well as its complications, such as the proneness to bacterial infections, even if did not cure the malarial infection. 23% (12/52) of the plants which were used by Calabrian people to treat malaria, have pharmacological/biological properties which did not allow to relieve the symptoms of malaria; however, they did not damage the affected subjects. Finally, 8% (4/52) of these plants were characterized by some pharmacological/ biological properties which could be harmful for a malarial subject; or these properties could even be poisonous both for the malarial and the healthy subject.
The second type of practices were linked to the magic tradition of Calabrian folk medicine which, like the traditions of all Southern Italian regions, is rich in myths, symbolism and fantastic representations [82]. Thus, malaria became a synonym of "malia", or, as Pasquarelli [83] affirmed, it became "an aspect of paludism". Malaria was thought to be a consequence of a malefic element that affected the behaviour and the life of an individual; therefore, only a magic cure could remedy the disease.
The third type of practices were characterized by a strong principle of ineluctability, which is currently present among the Calabrian society: the sick entrusted God with prayers or acts of devotion, with the conviction that only God would be able to provide recovery from the disease.

Conclusions
The use of plants combined with other cures, such as the use of spiders, cantharis and leeches, represents prophylactic or therapeutic elements inherited from ancient medical science, some of which were still used to treat malaria in hospitals and in general by 19 th -century physicians, before the introduction of quinine. This element is very interesting; while the empirical and magic remedies were not based on the symptomatology of the disease (they were rather "psychological and protective" elements [82]), the use of plants represented a real treatment, and served as a popular medicine base to treat various diseases.
In conclusion, the remedies described in this work allow us to establish the link between malaria and Calabrian people, so that Turner's statement that "the more widely or intensively a plant is used, the greater is its cultural significance" [84] can, in this case, be extended to malaria; the more folk remedies are used to cure malaria, the greater is the significance of its historical, medical and social meaning.