AHA Paper

This presentation will focus on the lingering confusion caused by the diagnostic terms, including leprosy, measles, and smallpox, used by the early Spanish chroniclers in their descriptions of the circa 1524 Andean epidemic. [i] Bartonellosis was a disease unknown to the Spaniards when they arrived in the Andes. However, as you have just seen, bartonellosis may produce symptoms that resemble illnesses already well known to the Spaniards by the time of their arrival in the New World.

European medical science did not come to recognize the symptoms now associated with the eruptive phase of bartonellosis, often called Veruga Peruana, as being those of a distinct pathology until 1630.[ii] Nor was it known until the famous case of Daniel Carrion in 1881 that verruga peruana was an eruptive phase of Oroya Fever. So it is easy to understand how the early Spanish chroniclers might have mis-identified the cause of the 1524 epidemic that killed the Inca and many others, particularly when their knowledge of the event came to them entirely through oral accounts related in Quechua decades later by surviving members of the Inca elite.

When confronted with descriptions of an epidemic that caused fever, skin rash, severe cutaneous eruptions, and a high level of mortality, the Spanish chroniclers naturally thought of smallpox. Even when an epidemic of bartonellosis occurred among their own soldiers, in Pizarro’s third expedition,[iii] this, too, was diagnosed as smallpox:

Licentiate Tomás López, in his “Tratado de los tres elementos,” described in detail the symptoms displayed by the Europeans. He reported that even as the first Spanish reached Puerto Viejo, they fell ill with “a sickness of a certain kind of smallpox or blisters [ampollas], that afflicts them in the whole face, especially in the eyes, and of it some die, and others are left blind and there are few or none at all who escape without feeling this infirmity, and it occurred so quickly that merely upon entering that place it struck them.[iv]

So even given eyewitness accounts in their own language, the Spanish chronicler still misidentified the disease in question. Since there was no better explanation, it went unquestioned for centuries, until medical science began to better understand battonellosis toward the end of the 19^th century. Moreover, the Spanish writers of the early colonial period themselves were not so sure of what the illness really was. As N. D. Cook points out, referring to Sarmiento de Gamboa, “…the chronicler seems confused as to the cause of Huayna Capac’s death, mentioning alternatively fevers, smallpox, and measles.”[v]

In 1913 José Toribio Polo published a survey of epidemics in Peru that began with a two-page discussion of the 1524 event. Since later writers, including Cook and Dobyns, refer to Polo for authority in diagnosing smallpox, his work merits careful re-examination in light of more recent medical studies.[vi] Polo said that: “It is probable that this was an epidemic of smallpox and measles that was being experienced in Ecuador in 1525 or one or two years before, and of which Huayna Capac died.”[vii]

Polo cites the early Spanish chronicler Sarmiento de Gamboa, who names Huayna Capac’s relatives who had already died in Cusco, and says that: “Upon arriving in Quito, after having been on the coast among the Huancavillcas and on Puna, an illness of fevers was given to him, even though others say it was smallpox or measles”[viii] Polo also points to González Suárez who attributed Huayna Capac’s death to intermittent fevers.[ix] But Polo said that the majority of the most qualified authors, naming Cieza, Herrera, Pizarro, Sarmiento, and Cobo, affirm that he died of smallpox, and that Anello Oliva supposed that it was bubas. Then Polo cites Jiménez de la Espada who in his Antigualla Peruana, mentions an epidemic of smallpox at the time of Huayna Capac’s death. The same author in his Relaciones geográficas de Indias, also copied the following regarding Tomebamba: “In which Huayna Capac was during ten years for it was his major residence rather than any other, and in this time befell a very great illness and pestilence in which innumerable people died of a measles that opened everyone to an incurable leprosy of which died Lord Huayna Capac.”[x] Polo states that “The verruga or bubas that the Spanish conquerors suffered, about the year 1530, on the west coast of Columbia from the bay of San Mateo to the south as far as Puerto Viejo, did not flourish among the indigenous (people), nor was it, because of this fact, that which caused the death of the conqueror of Quito (Huayna Capac).”[xi] In closing Polo mentions Pablo Patrón’s earlier study of the verruga of the conquistadors.

Polo says only that smallpox was probably the cause of the epidemic. He bases this on what the majority of the early Spanish sources said, using the word smallpox to translate the Quechua words, and on the fact that the natives did not appear to suffer from the disease that struck Pizarro’s troops. But the Spanish sources also use the word smallpox incorrectly in describing the illness of Pizarro’s men, and the Quechua words Polo points out also describe known symptoms of bartonellosis: the rash during the Oroya fever onset. Moreover, recent studies have shown that it is now known that immunological adaptations over time permit members of endemic foci to become asymptomatic carriers, or to suffer only mild or sub-clinical symptoms.[xii] Thus, based on the knowledge existing in 1913, when Polo wrote, smallpox may have well have seemed the most probable cause. But nothing in what he offers in favor of smallpox rules out bartonellosis, rather, a close reading of Polo’s text, in light of recent medical studies, actually reinforces the case for bartonellosis.

Polo states that Huayna Capac had been on the coast among the Huancavillcas and on Puna. In Ecuador today the majority of reported cases of bartonellosis originate in the Huancavillcas area.[xiii] Polo says the Quechua word the Spanish translated as smallpox or measles really means variously colored spots or speckles. But, this could also describe the rash seen in the clinical symptoms of Oroya fever described by Daniel Carrión and Pablo Partón.[xiv] Because the rash sometimes experienced in the Oroya fever onset is sometimes followed by the more severe and disfiguring lesions of the eruptive phase, or verruga peruana, Polo’s passage wherein “measles” is followed by “leprosy” may well refer to the rash and lesions of these two phases bartonellosis. Seen in this way, Polo’s text actually makes more sense than it does trying to make an interpretation of smallpox out of it.

Juan de Betanzoz (d. 1571), who may be the most reliable of the sources, was a fluent Quechua speaker and official translator for the Spanish government. He was married to the former wife of Inca Atahualpa. As Cook points out, “Betanzoz questioned his wife’s relatives at length…”[xv]

Juan de Betanzoz reported that after the conquest of the province of Yaguarcoche, Inca Huayna Capac returned to Quito and was there six years. At the end of that time, “he came down with an illness which deprived him of his senses and understanding, and gave him a sarna [cutaneous disease] and lepra [leprosy] that made him very debilitated…”[xvi]

I am not suggesting that the illness that killed Huayna Capac or his subjects in the 1520s epidemic or that struck Pizarro's men was leprosy, but there are evident similarities in appearance, at certain phases, between leprosy and verruga peruana that might help to explain Betanzos’s phrase.[xvii] Evidently Quechua had a word for something like leprosy, and since Betanzos describes Huayna Capac as having “sarna” and "lepra," these words describe symptoms we should carefully consider. Betanzos states that Huayna Capac's infant son “had died of the same illness of lepra as his father.” It is certainly possible that the “illness of lepra” reported by Betanzos was caused by bartonellosis, and not by smallpox.

Bartonellosis is typically described as a two stage disease. The first, acute stage -- characterized by severe anemia accompanied by high fever, often called Oroya fever -- is the deadly phase. The second, chronic stage -- in which the characteristic verrucous warts erupt on the skin -- is usually thought to be a sign that the patient has survived the crisis and will recover.

But the disease does not always develop this way. Thomas Salazar’s bachelor’s thesis, "Historia de las verrugas," published in the Gaceta Medica de Lima in 1858, reported important research including the first medical photograph ever published in Peru. This shows the terrible and disfiguring symptoms of verruga peruana on the face and ears of Don Aniceto de la Cruz, the sixth case in Salazar’s report. Don Aniceto “descended into an endemic area from the uplands of central Peru, and died a week after this photograph was made.”[xviii]

The case of Don Aniceto may help us understand the real meaning of Betanzos’s account of the death of Huayna Capac in which the ruler was said to have developed “a sarna [cutaneous disease] and lepra [leprosy] that made him very debilitated…. “ Elsewhere we hear that Huayna Capac suffered from fevers. Certainly these descriptions are consistent with the case of Don Aniceto. Since the photograph clearly shows the unmistakable evidence of verrucous bartonellosis and since Don Aniceto died one week after this photograph was taken, there is reason to believe that Huayna Capac may have died under similar circumstances: Huayna Capac was a highlander who descended into an endemic area on the coast and died after that with symptoms that were described as “leprous.” Like Don Aniceto, then, Huana Capac may have died of bartonellosis after the eruption of the verugas, which may have been concomitant with the acute anemic phase, as appears to have been the case with Don Aniceto recorded by Salazar in 1858.[xix]

Juan B. Lastres’ 3 volume 1951 publication Historia de la medicina Peruana is often cited by later writers, including Cook and Dobyns, for authority in diagnosing smallpox as the cause of Huayna Capac’s death.[xx] But, Lastres clearly states at the outset that “About 1524, … there came a devastating epidemic, whose diagnostic label still can not be fixed.”[xxi] Lastres recites passages from the chroniclers quoted in 1894 by Pablo Patrón, and says:

The mortal illness of Huayna Capac, as Patrón called it, was without doubt an infectious febrile disease with skin rash and high level of mortality. The Inca was ill several days, with delirious phenomena, his body decomposed quickly which was not an obstacle because they embalmed it. It is said that in Cusco an epidemic had already developed in which had died many of his relatives. Was this [epidemic] typhus that developed in the highlands?

To Patrón, the two principal symptoms made him suspect eruptive verruga [bartonellosis]. I am inclined to think, like most of the chroniclers, that it was smallpox. Six long years passed between the introduction of smallpox into New Spain [Mexico], in 1519, by a slave of the Conquistador Pánfilo de Narváez. In those years it could perfectly well have passed overland from the Isthmus [Panama], across Colombia and arrived in Ecuador. Commerce, as is known, was active between Central and South America at the time of the arrival of the white men, at least from town to town and over the Ocean. It is logical to think that the natives were the vectors of these epidemic diseases. Friar Gregorio García indicates the date of 1533 as the introduction of smallpox into Quito. From the installation of the Spaniards in the Isthmus and from the discovery of the South Sea [Pacific Ocean] by Balboa in 1513, several years passed and it is possible to think that smallpox, already endemic in Mexico and in the Isthmus, could have passed through Colombia and arrived in Ecuador. In any case, the diagnostic label of the epidemic of Huayna Capác fluctuates between smallpox and typhus.[xxii]

Lastres then lists other theories maintained by other writers, including fever, plague (bubas), and syphilis. Noting that of all the diagnoses it least resembled syphilis, Lastres concludes “it was a febrile process, highly contagious ‘by air,’ and with a high mortality rate. According to Arcos smallpox officially entered Ecuador in 1533, and he gives no diagnostic label for the disease we have just studied.” So we can see that although, based on existing medical science at the time, Lastres, writing now more than fifty years ago, was inclined to agree with the chroniclers in suspecting smallpox in the epidemic of Huayna Capac, he clearly stated that the diagnosis was still uncertain and also asked if it might have been epidemic typhus, while pointing out several other possibilities raised by other writers, including bartonellosis.

So, rather than demonstrating a positive conclusion, or general agreement on diagnosis among those who have studied the early Peruvian epidemics, Lastres carefully points out a number of differing opinions saying diagnosis “fluctuates” between typhus and smallpox; and that he is “inclined to suspect” smallpox because it is possible to think that smallpox could have traveled overland or by sea to Ecuador by that time and because the chroniclers called it smallpox.

The epidemiological curve began in 1525, before the arrival of the Spaniards. It is known in history as the deadly epidemic of Huayna Capac, that attacked the same Indian monarch. This emperor died of a febrile process with hallucinatory delirium. With him died also various notable Indians, the Inca Apo Illaquita, his uncle Lloque Tópac Inca and several thousand Indians in Tumibamba, near Quito. The influence of smallpox is believed to be seen in this epidemic, and Sarmiento de Gamboa, Garcilaso, and other chroniclers inclined to that belief. Patrón, Valdizán and Lavoría have briefly studied this epidemic, adducing the diagnoses of verruga [Patrón] and epidemic typhus. Gonzáles Suárez thinks it was malaria. Already in another section of this study I have discussed my diagnostic opinion favorable to smallpox. I am inclined to this suspicion owing to the important fact of maritime commerce between the coasts of Ecuador and Colombia and Central America. It is probable that these traders brought, along with their commercial products, the germs of the new diseases that came from the Old World. [xxiii]

It is unclear is exactly how smallpox could have spread, in advance of the Spaniards, to South America.[xxiv] Dobyns said “the pestilence apparently continued across Central America to reach the Inca Empire in 1524, 25, or 26, possibly by sea from Panama.” In spite of his uncertainty as to when and how, Dobyns nevertheless states as fact that “The reigning emperor Huayna Capac caught the disease while campaigning on his northern frontier in modern Ecuador and perished.”[xxv]

Following Dobyns, in 1998 Noble David Cook outlined his thesis that two great Amerindian rulers died of smallpox brought by the invading Spanish forces in his chapter from Born to Die entitled “The Deaths of Aztec Cuitláhuyac and Inca Huayna Capac: The First New World Pandemics”.[xxvi] This followed Cook’s 1981 study, Demographic Collapse of Indian Peru, 1520-1620, in which he stated:

…there is general agreement on diagnosis among those who have studied the early Peruvian epidemics. A list…based on the research of Dobyns, Lastres and Polo and on additional findings presents a relatively complete chronology of the worst epidemics of the period. In the years between 1524 and 1526 hemorrhagic smallpox, introduced from Panama and preceding the Spanish conquerors swept through the Inca Empire. Huayna Capac, his son the legitimate heir to the imperial office, and tens of thousands of Indians perished.[xxvii]

Neither Dobyns nor Cook mention Lastres’ “fluctuating,” uncertain diagnosis. Apparently in citing Lastres Dobyns and Cook interpret his “inclination to suspect” smallpox as sufficient authority to state in their own writings that the disease was smallpox that arrived before the Spanish conquest and that smallpox killed Huayna Capac, among others, without refuting the differing opinions of the other researchers pointed out by Lastres in 1951. [xxviii] So with Dobyns in 1963, reinforced by Cook after 1981, but without demonstrating new evidence, the literature took a leap from a fluctuating diagnostic uncertainty to assured statements of fact. Nevertheless, in light of more recent medical research[xxix], we have shown why Pablo Patrón’s 1894 diagnosis of bartonellosis, noted by Lastres but not mentioned by Dobyns or Cook was well worth considering.[xxx]

In spite of the uncertainty and contradictory opinions pointed out in the very text he himself cited in 1981, Cook declared in 1998 “As in the example of Aztec Mexico, where the ruler Cuitláhuac succumbed to the foreign infection, the Inca ruler Huayna Capac fell victim to a hideous alien disease.”[xxxi] However, a critical reading of his chapter permits a reasonable doubt of the accuracy of his declaration. For example, Cook states that “Written evidence, the true foundation for establishing historical veracity, is incomplete.”[xxxii] This is an understatement, since, as he admits elsewhere, “all accounts are retrospective and therefore suspect.”[xxxiii]

This confusion among the 16^th-century sources, if not their modern interpreters, may be explained by the fact that the Spaniards were relating accounts they had heard from native, Quechua speaking, survivors many years after the fact. In the images we have seen this morning showing clinical cases of smallpox, leprosy and verruga peruana the similarities are self-evident. This simple comparison in light of citations from early Spanish accounts, and in the absence of any mention of the characteristic umbilicated lesions of smallpox, shows how the Spanish chroniclers may have misidentified the 1520s epidemic. They called it smallpox based on their understanding of oral reports of Quechua-speaking witnesses, just as they clearly misidentified as smallpox the 1530’s cases of verruga peruana [bartonellosis] contracted by the Spanish soldiers on the Manabi coast.

Cook states in his conclusion that “Archaeological evidence that might verify or disprove the massive impact of the initial epidemics of smallpox and measles is spotty and difficult to evaluate.”[xxxiv] Yet based on this “incomplete” and “spotty” evidence, Cook declares that “the death of Huayna Capac provides a vivid illustration of what invariably occurred elsewhere in America when Old World epidemic disease was introduced, the virus that caused the death of Huayna Capac was not an isolated one; it was part of a great pandemic that swept vast regions of the Americas.”[xxxv] This is a marvelously bold and sweeping declaration to make, when only a few pages later we learn that there is, as yet, no evidence that can prove it.[xxxvi] Of course smallpox did come to the Andes and when it did it was a terrible killer. But to state as fact that smallpox caused the death of Huayna Capac during the circa 1524 epidemic that swept the Andes from Cusco to Quito may be premature.

As Cook himself has said, “Certainly, it is difficult to be totally accurate in the diagnosis of the historic epidemics.”[xxxvii] In the absence of a conclusive demonstration, Cook’s case for smallpox as the cause of Huayna Capac’s death remains a bold speculation, or his “best guess.” But, following the lead of Pablo Patrón, we believe, based on what is now known, the cause of Huayna Capac’s death was more probably bartonellosis.

[i] Dr. John S. Marr, MD. MPH, and I have previously presented extensive detailed evidence demonstrating why the Inca Huayna Capac probably died from bartonellosis and not from smallpox. See “The Great Andean Epidemic of 1524-5: Smallpox or Bartonellosis?” James B. Kiracofe, John S. Marr, MD, presented at the Inter-American Institute conference “Disease and Disaster in Pre-Columbian and Colonial America,” Washington DC, April 13, 2002, where we were privileged by the presence of our distinguished colleagues Dr. Robert McCaa and Dr. Rodolfo Acuña-Soto; and “Marching to Disaster: The Catastrophic Convergence of Inca Imperial Policy, Sand flies, and El Niño in the 1524 Andean Epidemic,”James B. Kiracofe, John S. Marr, MD, MPH, presented at the 2002 Dumbarton Oaks Pre-Columbian symposium El Niño, Catastrophism, and Culture Change in Ancient America, October 12-13. 2002, in press, Trustees for Harvard University, Dumbarton Oaks pre-Columbian Symposium.

[ii] After referring to a 1540 eyewitness account of the epidemic among Pizarro’s men at the Bay of Coaque in which Miguel de Estete described the “warts full of blood,” Dr. Uriel García-Caceres points out that “it was not until 1630 that Pedro Gago de Vadillo, a Spanish surgeon, compiled the first medical account of verruga peruana.” Garcia-Caceres, MD, Uriel, and Fernando U. Garcia, MD. "Bartonellosis, An Immunodepressive Disease and the Life of Daniel Alcides Carrion." American Journal of Clinical Pathology April (Suppl. 1) 1991 Vol 95 no. 4 (Suppl. 1) s58-s66. pp. S60-S61.

[iii] along the Manabi Coast south of the Bay of Coaque, in 1531, many members of the party became ill, and a quarter of them, as many as 60, died, see: Schultz, Myron G. “A History of Bartonellosis (Carrión’s Disease)” American Journal of Tropical Medicine and Hygiene, Vol 17, No. 4(1968):503-515, p. 508. However, it should be noted that Schultz did not believe that Pizarro’s men suffered from bartonellosis, to the contrary, Schultz states that the arid coastal zone would not have supported the sand fly vector, and that there has never been a case of bartonellosis reported in Coaque since Pizarro’s time, and so the disease must have been caused by some other pathogen. Schultz suggests treponematosis, or yaws. However, since Schultz wrote in 1968, other medical doctors, including some who have treated patients with the disease in Ecuador, have expressed other opinions, including those found in: Ollague, Wenceslao, and Angela Guevara de Veliz. “Verruga peruana en el Ecuador.” Medicina Cutánea Ibero-Latino-Americana, 4(1977):235-240. Drs. Ollague and Guevara de Veliz state that: “[Bartonellosis] has been known in Ecuador since very early in the epoch of the conquest in which the Spaniards suffered severe epidemics that decimated their troops in Coaque and Puerto Viejo. Since that time up until our days there have been reported cases in different zones of Ecuador.” My translation. Furthermore, in Alexander, Bruce. "A review of Bartonellosis in Ecuador and Colombia,” American Journal of Tropical Medicine and Hygiene, 52(4), 1995, pp. 354-359. Dr. Alexander, speaking of bartonellosis in Ecuador, states that: “Most cases in recent years have been from the provinces of Manabi and Guayas, particularly from the uplands of Pajan and Chongon-Colonche, which constitutes a range of low hills whose highest elevation is only 634 meters above sea level.” P. 356.

[iv] Cook, Noble David. Born to Die, Disease and New World Conquest, 1492-1650.Cambridge: Cambridge University Press, 1998. p. 92. Cook cites: Manuscript Collection of the Real Academia de la Historia, Madrid, document A/69 4806, 134v . Considering this description of blisters [ampollas] cited by Cook, we may refer to a 1949 medical study of the clinical manifestations of Carrión’s disease [bartonellosis] where it is stated that: “these blood filled blisters or warts appear in crops in a centrifugal distribution and may persist for months or years, during which time the patient may or may not complain of accompanying fever and rheumatic pains. Ricketts, W. E. “Clinical Manifestations of Carrion’s disease.” Archives of Internal Medicine, 84 (1949): 751-781. Cited in Philip Cooper, et al. “Bartonellosis in Zamora Chinchipe province in Ecuador.” Transactions of the Royal Society of Tropical Medicine and Hygiene (1996) 90:241-243, p. 241. See also Jimenez-Lucho, Victor, MD. “Verruga peruana.” Images in Clinical Medicine. New England Journal of Medicine, 13 August 1998, p. 450. As both Newson and Cook point out, Friar Pedro Ruiz Navarro wrote that some died “from attacks of smallpox and buboes… and from which others were left disfigured and exceptionally ugly.” See: Newson, Linda A. “Epidemics in Early Colonial Ecuador” in Secret Judgments of God, Old World Diseases in Colonial Spanish America. Ed. Noble David Cook and W. George Lovell. Norman: University of Oklahoma Press, 1991, pp. 84-112. p. 92, same passage cited in Cook, Born to Die, p. 85. The term buboes could refer to bubonic form plague that affects regional lymph nodes. But in a 1991 medical study, not mentioned by Cook or Newson, it was stated that “While the red blood cells are being invaded [by Bartonella bacilliformis during the acute hematic Oroya fever phase of bartonellosis] there is general malaise, with fever and enlargement of the lymph nodes, liver and spleen.”García-Carceres et al. “Bartonellosis…” p. s59. According to Cook and Newson, the location of the sores on the face, residual scarring, and the impact on the health of the Europeans but not the native Americans, leads to the likely diagnosis of verruga peruana [bartonellosis]. As they show, there was severe bleeding associated with the “reddish boils with the texture of nuts, which form on the face and the nose and in other places.” Cook, Born to Die, p. 85. However, it is noteworthy that nowhere in any of these early Spanish accounts is there any mention or description of the umbilicated form that has been the diagnostic hallmark of mature smallpox lesions since the time of Rhazes, as may be seen in the following comparison of the symptoms of these two diseases. Ali-Razi (Rhazes) 864-936 AD, Persian physician practicing in hospitals of Baghdad, he took notes on his cases, and wrote many medical treatises, including “On smallpox and measles,” that was still used up till the 18^th century in Europe to help distinguish between the two diseases.

[v] Cook, Born to Die, p. 80.

[vi] Cook, Noble David. Demographic Collapse of Indian Peru, 1520-1620. Cambridge University Press, Cambridge, 1981, p. 59, where he also cites Juan B Lastres and Henry Dobyns.

[vii] Polo, José Toribio. “Apuntes sobre las epidemias del Perú.” Revista Histórica, 5(1913):50-109, p. 52: My translation of Polo’s Spanish text: “Es probable que fuera esta la epidemia de viruelas y sarampión que se experimentara en el Ecuador, en 1525 ó uno ó dos años antes, y de la que murrió Huaina Cápac.”

[viii] Polo. “Apuntes…” p. 52: My translation of Polo’s Spanish text: “Al llegar el Inca á Quito, después de estar en la costa entre Huancavillcas y en la Puná, díole una enfermedad de calenturas, aunque otros dicen que de virgüelas y sarampión.”

[ix] Based on a description given by Garcilaso of the Inca falling ill after bathing in a lake and being stricken with chills and fevers that became worse and worse over several days. Polo. “Apuntes…” p. 53.

[x] Polo. “Apuntes…” p. 53: .” My translation of Polo’s Spanish text: “En la cual estuvo (Huayna Capac) diez años, por ser tierra de major habitación que no otra parte; y en este tiempo sobrevino una enfermadad y pestilencia muy grande en que se murieron innumerable gente de un sarampión que se abrian todos de una lepra incurable, de la cual murrió este señor Guainacápac…” Polo, “Apuntes…” p. 53, clarifies the meaning of the Quechua word muru “which signifies measles and smallpox, because the real meaning of this word is thing of various colors, with stained (or soiled) spots (or speckles); alluding to the aspect presented by the illness. Muru is also grain or seed. Tikti is verruga; and Huanti the name given to bubas.” My translation of Polo’s Spanish text: “...muru en quechua significa sarampión and viruela, porque el valor proprio de la palabra, es cosa de varios colores, con pintas, manchada; aludiendo al aspecto que presenta la enfermedad. Muru es también grano, semilla. Tikti es verruga; y Huanti el nombre que se dio á las bubas.”

[xi] Polo. “Apuntes…” p. 53: My translation of Polo’s Spanish text: “La verruga ó bubas que sufrieron los conquistadores españoles, hacia 1530, en la costa occidental de Colombia, desde la bahía de San Mateo al sur, hasta Puerto-viejo, no grasó entre los indígenes; ni fue, según está acreditado, la que ocasionó la muerte del Conquistador de Quito.”

[xii] Amano, Yasuji, et al. “Bartonellosis in Ecuador: Serosurvey and current Status of Cutaneous Verrucous Disease.” American Journal of Tropical Medicine and Hygiene 52(2), 1997, pp. 174-179. p. 178: “The data support the hypothesis that mild or subclinical infections occur with regularity.”

[xiii] Alexander. "A review …” p. 356.

[xiv] But see also: Strong, Richard P. Stitt’s Diagnosis, Prevention and Treatment of Tropical Diseases, Seventh Edition. Philadelphia: Blakiston Co., 1945. p. 1007-8: Symptomology, Oroya Fever Stage.

The incubation period is usually given as about 3 weeks (16-22 days, Escomel, 1938), and the onset of the disease is marked by malaise and apathy, to be followed by rapidly developing anaemia, of the pernicious anemia type, with an irregular fever of a remittent character fluctuating between 100° and 102°F. and only exceptionally going up to 104°F. Pains in the head, joints, and bones are common. The tenderness over the bones is apparently associated with the marked changes in the bone marrow and may be particularly marked over the sternum.

The patient rapidly develops a very severe anaemia and death results in 20 to 40 per cent of cases in 2 or 3 weeks. Delirium is often noted. The spleen and lymphatic glands are somewhat enlarged. Associated with the profound anaemia there may be oedema of the legs and about the joints, and functional cardiac murmurs. The kidneys are not generally seriously affected, although albumin is apt to be found I the urine. There is no eruption in the severe febrile stage. In severe cases, various manifestations of haemorrhagic character, as petechial spots and bleeding from the gums have been recorded.

[xv]Cook, Born to Die, p. 76. She was also the niece of Inca Huayna Capac.

[xvi]Cook, Born to Die, p. 76, in footnote 52 Cook cites his source as: Juan de Betanzos, Suma y narración de los incas. Madrid:Atlas 1987, p. 200.

[xvii]Cook, Born to Die, p. 77. Concerning this passage Cook states: Use of the words sarna or lepra by Betanzos to identify the illness simply indicates symptoms of severe skin rash and inflammations. These words had directly translatable equivalents in Quechua, the general language of the Incas found in the 1586 dictionary of Antonio Ricardo: sarna is “caracha” and lepra is “caracha llecte” (grime or filth).

[xviii] García-Caceres, et al. “Bartonellosis...” p. s61.

[xix]Since Salazar’s report is highly relevant to the case of Huayna Capac, I will include it here in its entirety. The text of this passage was kindly transcribed for me from the original in Lima by Jorge Lossio and sent to me together with the negatives of the photographs taken by Jorge Lossio of the original photograph of Don Aniceto de la Cruz taken by Thomas Salazar :

Thomas Salazar. “Historia de las verrugas.” La Gaceta Médica de Lima 2:2 (Marzo de 1858):161; 175-178.

Observation number 6.

Aniceto de la Cruz, native of Moya, living in Juaja, 40 years of age, of limphatic termperment, of debilitated constitution, of andoperuvian race, entered the Hospital of San Andrés the 21 June of 1857, he was placed in bed number 490, department of Dr. Rios.

He complained of intermittent fevers, for which he was given sulphate of quinine, infarction of the spleen was recognized, for which he was given chloride of ammonia first associated with the (antiperiódico), then by itself; this patient was very demarcated and presented several verrugas, and even though they were in small numbers they were notable for their form and location: in the soft part of the ear there was one that appeared like a teardrop earing, of violet color the size of a pigeon egg, the skin that covered it presented varicose veins, it was soft to the touch, narrow at its upper part and of elliptical shape.

The patient told me that about a year earlier he was in Santa Olaya and that two months later a wart came out on his heel without being preceded by pains; now, in addition to the two already mentioned, others existed on his face.

In the months of July, August, and September the patient was subjected to a tonic regimen, taking iodide of iron with carbonate and the muriatic tincture of iron, Vallet’s pills, and sulphate of quinine to which it was necessary to return for the frequent relapses of the intermittent fevers. In all this time was noted the slowness with which the verrucose eruption appeared and developed, the smallness and frequency of the pulse in spite of the ferruguinous tonics.

In the months of October and November the illness acquired great increment, the condition of cachexia continued, the verrugas developed in great number, the photograph that accompanies this represents the patient and the progress of the verrugas on his face can be seen, on the upper part of the back of his nose these tumors begin, in the interior angle of his eye and on the upper part of his forehead they have grown in volume, of the two that are on the left cheek, the smaller is soft to the touch and violet in color, the larger is in a more advanced state and it is covered with scabs which give it a rough appearance, in the outer angle of the eye is a verruga in the hemorrhagic phase, and the discoloration that can be seen on the outer part of the eyelid and cheek is actually from blood flowing from the verruga, the most notable verruga in the picture is the one at the level of the ear lobe, at the beginning of this story we said that it was the size of a pigeon egg, later I came to acquire it with a small knife, it ulcerated on its surface and a ligature was applied to the pedicle, but in spite of this the verruga did not fall, a portion of its smaller part detached and offered the aspect seen in the photograph.

One of the large verrugas that detached itself by means of the ligature is deposited in the Museum of the school of Medicine. In spite of the strengthening treatment to which the patient was submitted, each day saw a diminishment of his forces, the verrugas grew larger and beginning to ulcerate gave off an odor so disagreeable that it was necessary to isolate the patient from the others, topicals of calcium chloride were applied to the ulcerated verrugas, the disease making greater progress, the subject fell into a profound prostration and died the 3 December, 1857. It was not possible for me to make an autopsy, which I greatly regretted. My translation from original Spanish.

[xx] Cook, Demographic Collapse, p. 59 and 62. Dobyns, Henry F. “An Outline of Andean Epidemic History to 1720.” Bulletin of the History of Medicine 37(1963):493-515, p. 496.

[xxi] Lastres. “Historia…” Vol. 1, pp. 149. my translation.

[xxii] Lastres. “Historia…” Vol. 1, pp. 150-151. my translation.

[xxiii] Lastres. “Historia…” Vol. 2, pp. 75-76. my translation.

[xxiv] For a thorough review of the literature and sources concerning the transmission of smallpox into Mexico, see McCaa, Robert. “Spanish and Nahuatl Views on Smallpox and Demographic Catastrophe in the Conquest of Mexico.” Journal of Interdisciplinary History, 25:3(Winter 1995), 397-431.See also: McCaa, Robert. “Was the 16^th century a demographic catastrophe for Mexico? An answer using non-quantitative historical demography.” Presented at the V Renunión Nacional de Investigación Demográfica en México, El Colegio de México, México, D.F. 5-9 de junio de 1995. Henry F. Dobyns’ 1963 study, “An Outline of Andean Epidemic History to 1720” cited by Cook and other writers, stated as fact that `“…aboriginal disease environment conditions terminated in the Andes several years prior to Spanish conquest. As a result, full accounts of the initial impact of Old World disease agents on a virgin population of susceptible individuals lacking immunities do not exist.“ He based this statement on the certain knowledge that smallpox arrived on the island of Hispaniola during December 1518, and its subsequent arrival by 1520 in Mexico from Cuba, according to many with a Negro slave onboard Panfilo de Naváez’s ship

[xxv] Dobyns. “An Outline…” p. 496.

[xxvi] Cook, Born to Die, pp. 95-133.

[xxvii] Cook. Demographic Collapse, p. 62.

[xxviii] Linda A. Newson, in her 1991 study “Old World Epidemics in Early Colonial Ecuador” does discuss alternative diagnoses for the 1524 epidemic, including fever, measles, malaria, and typhus. Newson. “Epidemics…” Newson has also carefully studied the various early Spanish accounts of the death of Huayna Capac. She notes that “Cieza de León maintains that the disease was viruelas (smallpox), which was ‘so contagious that more than 200,000 souls died.’ Similarly, Cobo suggests that the disease was smallpox, of which ‘many died.’” But she then goes on to cite Cabello de Balboa, who said only that Huayna Capac died from “’a deadly fever,’ recording that at the same time ‘a widespread and incurable pestilence’ was raging in Cusco.’” However, even more circumspect was Sarmiento de Gamboa, who, according to Newson, “states that Hyauna Capac died in Quito in 1524 of ‘fever, though others say it was smallpox and measles.’” However, Newson, too, states flatly as fact that “Towards the end of 1524, Huayna Capac died of smallpox in Quito some time after a number of his relatives died in a similar epidemic in Cusco. Newson. “Epidemics…”.p. 90.

[xxix] including that mentioned by Professor McCaa this morning concerning new knowledge about the requirements for the transmission of smallpox McCaa, Robert, Aleta Nimlos, and Teodoro Hampe-Martinez. “Why Blame Smallpox? The Death of the Inca Huayna Capac and the Demographic Destruction of Ancient Peru (Tawahntinsuys).” MS Paper for AHA January 2004. McCaa et all cite Fenner, F., D. A. Henderson, I. Arita, Z. Jezek, and I. D. Ladnyi. 1988, Smallpox and Its Erradication, WHO; and Baxby, Derrick 1999. “Communication” Vaccines for Smallpox,” Lancet 354 (July 31); 422-3. See in particular pages Fenner et al. pp.199-207. This passage was kindly pointed out to me by Dr. McCaa in personal communication in which he credited Francis Brooks for the reference.

[xxx] Lastres was referring to Patrón, Pablo. “La enfermedad mortal de Huayna Cápac”. Lima: La Crónica Médica XI:131 (15 de junio de 1894): 179-183. It should be noted that Cook does mention Carrion’s disease [bartonellosis] as a disease that existed in South America before the Spaniards arrived, but he incorrectly identifies Carrion’s disease as leishmaniasis, which is a sand-fly borne disease of South America like bartonellosis, but it is not the same disease as bartonellosis and is caused by a different pathogen, and results in different symptoms that are not similar to smallpox, and which he describes in detail in Cook and Lovel. “ Unraveling…” pp. 229-230.

[xxxi] Cook, Born to Die, p. 72 While Cook cited Lastres in earlier writing for authority in diagnosing smallpox [Demographic Collapse…p. 62], in this passage of Born to Die there is no citation given immediately after the statement that Huayna Capac died of “a hideous alien disease,” however after explaining that the Incas had no writing system to record the death of Huayna Capac, and that the Spaniards only became interested in the event in the early 1540s he cites his earlier work Demographic Collapse among others.

[xxxii] Cook, Born to Die, p. 93

[xxxiii] Cook, Born to Die, p. 81, footnote 62 in which Cook cites David Henige, “Counting the Encounter: the Pernicious Appeal of Verisimilitude,” Colonial Latin American Historical Review 2(1993): 325-61. See Also Crosby, Alfred W. Jr. “ Conquistador y Pestilencia: The First new World Pandemic and the Fall of the Great Indian Empires.” First published in Hispanic American Historical Review, XLVII (August 1967), 321-327, in The Columbian Exchange: Biological and Cultural consequences of 1492. Westport: Greenwood Press, 1973, p. 51: “Our evidence for the first post-Columbian epidemic in Incan lands is entirely hearsay, because the Incan people had no system of writing.”

[xxxiv] Cook, Born to Die, p. 93.

[xxxv] Cook, Born to Die, pp. 81-82

[xxxvi] Alfred Crosby Jr. was more circumspect when, in 1967, he said of the same epidemic “We dare not, four hundred years later, state unequivocally that the disease was not one native to the Americas. …Smallpox seems the best guess…” Crosby. Columbian… p. 52. See also his endnote 38 on p. 62, in which he further qualifies his tentative smallpox identification by pointing out that “some examples of the famous naturalistic Mochica pottery show Indians with pustules and pocks which bear a very close resemblance to those of smallpox… and there are several other diseases native to the north-western section of South America, such as the dreadful verrugas, which have superficial dermatological similarity to smallpox. Furthermore, the aborigines of the Incan Empire told Pedro Pizzaro that they had no acquaintance with smallpox in pre-Columbian times.” Crosby cites Pizarro, Relation, 1:196.

[xxxvii] Cook, Demographic Collapse, p. 62.