The Miraculous Fever-Tree

by Fiammetta Rocco

  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 – o
r 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 co
ld 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.