Working Paper

A new investigation, begun in Spring 2000, of the Andean epidemic of 1524-5 described by the early Spanish sources has re-examined the cause of the outbreak, believed by many to have been smallpox brought by the Spanish. Following a rigorous study of the evidence we conclude, in a report titled "The Great Andean Epidemic of 1524-5, Smallpox or Bartonellosis?" that bartonellosis was more likely the cause of the outbreak, and not smallpox as has been maintained in the prevailing literature for many years.

The paper, critically reviewing the smallpox theory and presenting our research and conclusions in favor of bartonellosis, was presented at the conference Disease and Disaster in Pre-Columbian and Colonial America, 13-14 April, 2002, in Washington DC and further revised and presented at the American Historical Association meeting in Washington DC, 2003.

In the 1530's a band of Spanish adventurers conquered the Inca Empire. Their chroniclers recorded accounts of a devastating epidemic circa 1524. Over two hundred thousand people were said to have succumbed.[i] The Emperor Huayna Capac, campaigning with his army along the southern coast of Ecuador, learned from a messenger that in Cusco, some 1,500 km. to the South, many of his relatives and countless others had already perished. Immediately thereafter he became ill with fevers and died, [ii] along with many in his army.[iii]

Noble D. Cook has stated that this epidemic was smallpox of Old World origin brought by the Spaniards.[iv] However, in 1894 a respected Peruvian ethno-historian, Pablo Patrón, published a well-reasoned diagnosis of what is now called bartonellosis.[v] In light of medical studies of recent epidemics of bartonellosis in Ecuador and Peru, re-visiting the events surrounding the death of Inca Huayna Capac, at the edges of recorded history, may illuminate this still mysterious disease that remains endemic in the Andean region.[vi]

Bartonellosis is a lethal New World arthropod-borne bacterial disease long endemic in the Andean region. During its fulminant hemolytic anemic phase, Bartonellosis is also known as Oroya fever, after the 1871 outbreak in the Rimac Valley of Peru along the Lima-La Oroya railroad line that killed 8,000 railroad workers.[vii] The subsequent or concomitant chronic phase of the disease is known as verruga peruana (or Peruvian wart) after the characteristic skin eruption. Before 1913 the disease was known as Carrión’s disease, named after the Peruvian medical student Daniel Carrión who, in 1885, gave his live discovering the common infectious linkage between Oroya fever and verruga peruana. Transmitted by a sand fly vector, this disease is caused by a specific bacterium, Bartonella bacilliformis, named in honor of the Peruvian bacteriologist, Alberto Barton, who in 1909 first noted these bacillus-like organisms in red blood cells (RBC’s) of patients suffering from Oroya fever.

In historic times epidemics of bartonellosis occurred in public works projects and armies on the march. The Incas mobilized tens of thousands of rotational laborers from various regions of the empire, concentrating them on vast construction projects. The symptoms of Huayna Capac’s illness reported in the early Spanish accounts, including fevers and severe skin rash, while resembling smallpox in some ways, more accurately correspond with clinically documented symptoms of bartonellosis. The evident similarities at certain stages of these two diseases has caused much confusion. There are, therefore, good reasons to consider bartonellosis as the cause of Huayna Capac’s death. But, before arguing the case for bartonellosis, let us first review the contention that the disease was smallpox -- sustained in the literature since 1913.[viii]

The first to diagnose smallpox as the cause of the 1524 Andean epidemic were the Spanish chroniclers, who had never experienced bartonellosis before arriving in South America. When confronted with descriptions, given in Quechua, the language of the Incas, of an epidemic that caused fever, skin rash, severe cutaneous eruptions, and a high level of mortality, they naturally associated this with smallpox, a disease they too well: Even when an epidemic of bartonellosis occurred among their own soldiers, in Pizarro’s third expedition, 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, [ix] 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.[x]

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.”[xi] So even given eyewitness accounts in their own language, the Spanish chronicler still misidentified the disease in question.

There are neither contemporaneous eye-witness accounts of the death of Inca Huayna Capac nor of the epidemic that swept through Cusco and other areas of the Inca realm in the 1520s. Moreover, the Spanish writers of the early colonial period themselves were not so sure of what the illness really was. As 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.”[xii]

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 refer to Polo for authority in diagnosing smallpox, his work merits re-examination in light of more recent medical studies. 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.”[xiii] 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”[xiv]

Polo also points to González Suárez who, from 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, attributed Huayna Capac’s death to intermittent fevers. 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.”[xv]

Polo 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.”[xvi]

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).”[xvii] 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 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.[xviii] 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.[xix] Polo says the Quechua word the Spanish translated as smallpox or measles really means variously colored spots or speckles. This could also describe the rash seen in the clinical symptoms of Oroya fever described by Daniel Carrión and Pablo Partón cited below.[xx] 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 B. Lastres’ 3 volume 1951 publication Historia de la medicina Peruana is often cited by later writers for authority in diagnosing smallpox as the cause of Huayna Capac’s death. But, Lastres clearly states at the outset that “About 1524, … there came a devastating epidemic, whose diagnostic etiquette 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 etiquette 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 etiquette for the disease we have just studied.” So we can see that although Lastres was inclined to agree with the chroniclers in diagnosing smallpox in the epidemic of Huayna Capac, he clearly states that the diagnosis is still uncertain and also asks 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]

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.[xxiv] But what is less certain is how the disease spread, in advance of the Spaniards, to South America. 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 make any mention of Lastres’ “fluctuating,” uncertain diagnosis. Instead, pointing to Lastres for authority, they conclusively diagnose smallpox and state as fact that it was smallpox that killed Huayna Capac. 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. However, she 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.”[xxviii]

Apparently in citing Lastres Dobyns and Cook interpret his “inclination to suspect” smallpox as sufficient authority to conclude in their own writings that the disease was, in fact, smallpox and did, in fact, arrive before the Spanish and did, in fact, kill Huayna Capac, among others, without exploring, or even mentioning, the differing opinions of the other researchers pointed out by Lastres in 1951. So with Dobyns in 1963, reinforced by Cook after1981, but without any new evidence, the literature took a sudden leap from a fluctuating diagnostic uncertainty to assured statements of fact. Nevertheless, in light of more recent medical research, we will demonstrate in what follows why Pablo Patrón’s 1894 diagnosis of bartonellosis, noted by Lastres but not mentioned by Dobyns, Cook, or Newson, was well worth considering.[xxix]

In spite of the uncertainty and contradictory opinions pointed out in the very text he himself cited, Cook declared “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.”[xxx] 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.”[xxxi] This is an understatement, since as he admits elsewhere, “all accounts are retrospective and therefore suspect.”[xxxii] This echoes Alfred Crosby Jr. who said in 1967 “Our evidence for the first post-Columbian epidemic in Incan lands is entirely hearsay, because the Incan people had no system of writing.”[xxxiii]

Newson has also carefully studied the various early Spanish accounts of the death of Huayna Capac.[xxxiv] 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.’”[xxxv]

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. As Cook explains, the Quechua language used overlapping terms to describe smallpox and measles. He says “It is instructive to note that Ricardo defines both sarampión (measles) and viruelas (smallpox) as “muru oncoy” in Quecha. The definition of “muru” is seed, and here one should think of the seed of the large-kerneled Andean corn, which almost perfectly describes the seed-like rash. Oncoy simply translates as malady, or illness.”[xxxvi]

This contemporary image below shows skin eruptions in a case of verruga peruana.[xxxix]

In these images showing clinical cases of smallpox above and verruga peruana cases recently treated in Peruvian hospitals below, the similarities are self-evident. Cook’s reference to “a seed-like rash” almost perfectly describes the rash seen on the arms of the man and the legs of the children in these images of verruga. This simple comparison in light of Cook’s description and citations from early Spanish accounts, and in the absence of any mention of the characteristic umbilicated lesions seen in the photographs of smallpox shown above, shows how the Spanish chroniclers may have misidentified the 1520s epidemic they called 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. This side by side comparison shows the similarities the symptoms can present.

From the “incomplete” body of written evidence Cook offers a recitation and interpretation of early colonial accounts describing the illness that killed Inca Huayna Capac and the epidemics in Cusco prior to Huayna Capac’s death and in Quito contemporaneously. He 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.”[xliii]

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.”[xliv] This is a marvelously bold and sweeping declaration to make, when only a few pages later we learn that there is no evidence that can prove it. 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…”[xlv] In the absence of a conclusive demonstration, then, Cook’s case remains a bold, but circumstantial, speculation, or “best guess.”

Cook adds in closing: “Clearly, further investigation needs to be undertaken before we can completely evaluate the nature and impact of the dissemination of the first great pandemics of the sixteenth century on the vulnerable native American population.”[xlvi] We will begin our further investigation with a review the evidence of verruga peruana in pre-Columbian times, and return to some further comparative considerations of the smallpox argument after developing the case in favor of bartonellosis.

In his paper, "A review of bartonellosis in Ecuador and Colombia,” Bruce Alexander presents this startling image, seen here, of a pre-Columbian ceramic showing verruga peruana in a severe manifestation, such as described by the Spanish chroniclers.[xlvii] Alexander states :

Alexander includes this map to better illustrate the area described in his text, clearly the same area where Pizarro’s men became infected with bartonellosis.[xlix]

Marvin J. Allison, et al, present other pre-Columbian evidence of the presence of bartonellosis in their paper “A Case of Carrion’s Disease Associated with Human Sacrifice from the Huari Culture of Southern Peru.”[lii] Their discovery of the mummified remains of a ritually sacrificed young man demonstrates that armies on the march were an important triggering mechanism for epidemic bartonellosis in the pre-Columbian world, as they have been in modern times:

“The time at which this man died was one of unrest along the coast due to invasion by the Tiahuanaco people, who eventually conquered the existing Nazca people. The route of invasion in this part of Peru was through the Department of Ayacucho to reach the Nazca principal city of Kahuachi. This route of invasion must pass through areas that even today are known as endemic centers for Carrion’s disease. (Torrealva, personal communication). If this young man was a member of an invading army, he must surely have camped in areas where he would be bitten by the vector of Carrion’s disease, Phlebotomus verrucarum, a type of sand fly.”[liii]

“Pedro Pizarro (1571) distinguished between this disease and syphilis by the appearance of the lesions. Herrera y Tordesillas (1601) described verruga that attacked the Spaniards in Puerto Viejo, Ecuador, and many other early explorers mentioned this disease on their arrival in South America. The presence of this disease is then well established in the Americas before the arrival of the white man, and it has been depicted as long ago as 2,000 years on ceramic vases (D’Harcourt, 39). Until now a case of this disease has never been described in a pre-Columbian Indian from the New World.”[liv]

Bartonellosis and Endemic Foci

Bartonellosis exists in endemic nidalities throughout northwestern South America. The pathogenic organism resides in a human reservoir where its infectivity endures over extended periods. Recently the possibility that another mammalian, rodent, reservoir may exist has been suggested.[lv] Bartonellosis typically has two stages, an acute hemolytic anemic phase (Oroya Fever) and a subsequent chronic phase characterized by eruptive skin lesions known as verruga peruana. However, as Barbara A. Ellis, et al. pointed out, “…it has been noted that the cutaneous phase of the disease does not always follow the anemic phase.”[lvi] In addition, the anemic stage may overlap and include the dermatological presentation. [lvii] Between the acute and chronic manifestations there may be an asymptomatic intermediate period.[lviii] It is transmitted indirectly from person to person by an intermediate arthropod vector, plebotomine sand flies, as Barbara A. Ellis, et al. summarized:

Bartonella bacilliformis is thought to be transmitted to humans by crepuscular and nocturnal-feeding phlebotomine sand flies of the genus Lutzomyia. Transmission of B. bacilliformis has been documented after interdermal injection of infected, homogenized L. verrucarum into monkeys, and after wild L. verrucarum have been allowed to feed on macaques. Lutzomyia noguchii, L. peruensis, and other sand fly species may also be competent vectors, since there have been documented outbreaks of bartonellosis in areas devoid of L. verrucarum. To date, a natural, non-human vertebrate reservoir has not been identified for B. bacilliformis.[lix]

However, in response to this question of a non-human reservoir, Garret M. Ihler has said:

It has been suggested that humans are the sole host for B. Bacilliformis. However, Hertig made this disconcerting observation: "The total population of Verrugas Canyon consists of the families and hired labor of two farms at the mouth of the Canyon (10 to 20 persons), several railway employees and guards who live at the bridge (1 to 12 persons) and occasional migratory goatherds. It is noteworthy that this classic site of verruga, and in particular the site of the bridge itself, notorious for the high incidence and severity of the disease, is normally populated by a mere handful of people." Bacteremia follows Oroya fever and may continue for as long as 15 months, so that B. Bacilliformis could be retransmitted back to sand flies during this time.[lx]

This is an important observation, since the incident at the railway bridge he mentions was the single most deadly outbreak recorded in modern times. It was described by Garcia-Caceres as follows:

In 1868, the American entrepreneur Henry Meiggs (nicknamed the Yankee Pizarro) obtained the concession for building the Central Railroad of Peru. He hired qualified laborers in Chile and in the coastal cities of Peru, two areas where bartonellosis is unknown. As a result, as soon as the railroad construction reached the altitude of 1,000 meters in 1869 and until it reached the level of 3,000 meters in 1873, a passage that extended along the Rimac river, an epidemic decimated the workers; it is estimated that at least 8,000 died.... Since that time, a viaduct of the railroad erected in one of the areas most infested by the insect vector has been named Puente de Verrugas.[lxi]

Ihler states that it is “said to have killed more than 7000 of the 10000 workers building the railroad between Lima and La Oroya.”[lxii] This would mean a general mortality rate in excess of 70%. This exceeds the typical mortality rates of smallpox, stated to have been 20-40% or more, in the standard text, and the stated case mortality rate for plague of 50-60%.[lxiii] Ihler states, “Untreated, Oroya fever comes close to having the highest death rate of all infectious diseases, 40-85%, since essentially 100% of the red cells can be parasitized, and because of secondary bacterial infection.”[lxiv] Thus, even in isolated areas even with little apparent human reservoir population, bartonellosis can quickly become a deadly killer with extremely high mortality rates, because the sand fly vector can effectively spread the disease, rapidly infecting thousands of victims among concentrated non-immune groups of humans entering the area, such as armies or construction workers.

Over time, the human reservoir population of an endemic foci may develop immunological adaptations to the disease so that while many or most members of the community are infected with the disease, the signs and symptoms may be minimal, sub-clinical or asymptomatic.[lxv] New, potentially epidemic, outbreaks and subsequent development of additional endemic foci may be established when members of an asymptomatic infected population travel through or settle in a non-immune area where the sand fly vector is present, or when non-immune members of outside communities pass through endemic areas into other areas not yet exposed to the disease. Thus, in any area with a human population where the sand fly vector lives, or may live, bartonellosis may be introduced either by an infected insect or by an asymptomatic carrier or overtly infected human.

Asymptomatic members of endemic foci may nevertheless carry the disease in their blood and may pass it via a vector to non-immune populations, resulting in high mortality rates.[lxvi] During a 1990 epidemic outbreak in the Peruvian Andes in a village where bartonellosis had not been endemic “the case fatality rate for patients who did not receive antibiotics was 88%. … The overall case fatality rate was 50%.”[lxvii] Significantly, the local water source, running in unprotected open canals through the village, was contaminated with “coliforms,” demonstrating that water-borne bacterial infections are an important co-factor in bartonellosis mortality.[lxviii] The illustration shows the relationship between case households and the infected water canals.

Ollantaytambo in the Urubamba Valley near Cusco, is perhaps the only example of Inca urban planning to survive more or less as built in a continuously inhabited community. The unfinished ceremonial center cut into the mountainside adjacent to the town was unfinished when the Spanish conquistadors arrived in the 1530s. Under the Spanish, Mediterranean architectural elements were superimposed on existing dwellings, but the distinctive trapezoidal grid plan of the streets has remained in place together with the hydraulic system that provides water throughout the town through open canals that run down the edges of the stone paved streets. [lxix] The water from these canals in Ollantaytambo was still being routinely used for household purposes during my visit in 1994.

Between April and May of 1998 an epidemic of bartonellosis occurred in the Urubamba region, during which patients reported for treatment in Urubamba, Calca, and Ollantaytambo.[lxx] This was an area of Peru not previously believed to be endemic for bartonellosis. However, results of the study “…may indicate that Cusco is an endemic area of transmission that was previously unrecognized, and that adults in this area are at least partially immune to [bartonellosis].”

“the only sand fly species encountered in the Urubamba area was Lutzomyia peruensis, known to feed on dogs and humans. This is the first report of sequence-confirmed B. bacilliformis from this species of Lutzomyia, though a report from 1942 suggested that L. peruensis may be associated with transmission of bartonellosis.”

“favored harborage and breeding areas for Lutzomyia include adobe walls inside homes, and stone walls outdoors. Many of the homes in the area had these constructions, and we collected Lutzomyia by aspiration from adobe and stone walls in case and control households.”[lxxi]

Stone and adobe were the favored construction materials in the area when Ollantaytambo was being built by the Incas. The typical architecture of domestic residences, both elite and commoner, as well as military barracks incorporated these materials and techniques, making them as hospitable then to the deadly sand fly vector as now.[lxxii]

Bartonellosis and the 1531 Spanish expedition on Ecuador’s Manabi coast

Archaelogical evidence shows that bartonellosis existed in pre-Columbian times, in endemic foci, and in the very regions through which Pizarro passed with his troops in 1531-2 when they were struck by the disease. Comparing Alexander’s map with this map of Pizarro’s path in 1531-2, taken from John Hemmings’ The Conquest of the Incas[lxxiii], it is clear that Pizarro’s march traversed an area long endemic for bartonellosis. His non-immune Spanish soldiers paid a terrible price for their intrusion along the Manabi coast:

In Coaque were found many mattresses of ceyna [a wool-like fiber made from the dried seed pods of kapok Ceiba pentandra] these being from a tree they grow. It so happened that some of the Spaniards who rested on these woke up paralyzed, so that their arms could not be bent or their legs straightened without considerable effort; this occurred to certain of them and it was understood that this was the onset of a sickness that caused warts, so bad and grievous that it caused many to be much fatigued. They toiled in great pain as if they had buboes, until they broke out in warts that covered the whole body, some as large as eggs. On being burst these produced matter and blood, so that it was necessary to cut them off and place upon the sores strong potions to remove the root. Others were as small as measles that covered the whole of the men’s bodies. Few escaped the disease, although some suffered more than others. Others will say that this sickness was caused by some fish that they ate in Porto Viejo, that the Indians in their wickedness gave to the Spanish.[lxxiv]

Stiffness of the joints associated with pain and fatigue followed by the eruption of warts and lesions corresponds precisely with the classic signs and symptoms of the progress of bartonellosis from its onset with anemic Oroya fever phase through its eruptive phase marked by the lesions of verruga peruana.[lxxv] Of the same incident at the Bay of Coaque,.Garcilaso de la Vega reported that:

...The excrescences broke out all over their bodies, but principally on their faces. They thought at first that these were warts. But as time passed, they grew larger and began to ripen like figs, of which they had both the size and shape; they hung and swung from a stem, secreted blood and body fluids, and nothing more frightful to see or more painful, because they were very sensitive to touch. The wretched men afflicted with the disease were horrible to look at, as they were covered with these purplish-blue fruits hanging from their foreheads, their eyebrows, their nostrils, their beards and even from their ears nor did they know how to treat them. Indeed, some died of them while others survived.[lxxvi]

When Myron G. Schultz, DVM, MD, wrote his “History of Bartonellosis (Carrion’s Disease)” in 1968 he stated that he did not believe that the illness the Spaniards suffered at Coaque was bartonellosis.[lxxvii] This was because the epidemic at Coaque occurred on the coast at less than 500 feet above sea level, and according to Schultz, “it would be the only one that has ever occurred, either in ancient or modern times outside the range of 2,500 to 8,000 feet.” However, as more recent medical discoveries, including Alexander’s 1995 report, have shown:

…it appears that the information that appears in most texts regarding bartonellosis is oversimplified. The disease is not restricted to elevations greater than 800 meters and occurs in areas where the Lu. Verrucarum is absent. …the identity of the species that transmits Bartonella in Ecuador remains unknown. While occasional cases continue to be reported from the Andean regions of [Colombia and Ecuador], bartonellosis in Manabi and Guayas has been reported at least since the 16^thcentury from low-lying coastal areas that are different from the classic foci such as the Rimac valley of Peru.[lxxviii]

Since these later discoveries, Schultz’s opinion that the Spanish soldiers at Coaque did not suffer from bartonellosis has been superceded by a general consensus among medical and social historians that now accepts bartonellosis as the correct diagnosis.

In 1547, 16 years after the incident at the Bay of Coaque, following the Spanish conquest when Francisco Pizarro rebelled against the Spanish Crown, an army was sent from Panama to quell the revolt. They landed at Manta, on the Manabi coast of Ecuador. On the way from Manta to Porto Viejo, many became ill, as was graphically reported by Juan Cristobal Calvete de Estrella:

…warts as big or bigger than nuts on their noses, eyebrows or beards, of a pestilential humor between red and black. They may last four or five months and until they begin to dry up do not cease to cause pain. Finally they begin to heal and those that have suffered them remain clean and healthy. It is thought by the men of these lands that these warts and other diseases which occur below the equator are due to certain constellations, the influence of which is stronger here than elsewhere.[lxxx]

Citing the same incident and Spanish source, N. D. Cook points out that “Medical historian Lastres wondered if it might have been ‘smallpox.’ But, given the context of the illness infecting mostly the Europeans, a more likely diagnosis is Verruga peruana, a form of Carrion’s disease.” [lxxxi]

Like others before them, Pizarro and Calvete de Estrella discovered that the Manabi coast of Ecuador is a dangerous land. Even today, as Alexander points out, “Most of the suspected and confirmed cases of bartonellosis in Ecuador have been reported from Manabi, which is an arid, coastal province whose name derives from the Quechua words mana pi, meaning no water.”[lxxxii]

The Conquest of the Manabi coast, Huayna Capac’s Last Campaign

During the last years of his reign, Huayna Capac sought to complete the conquest and pacification of coastal Ecuador. Even though it is not known if the Incas were successful in bringing these coastal regions into their hegemony, there is little doubt that they wished to do so. According to Maria Rostworowski de Diez Canseco, “One motive of the Incas for the conquest of Manta, Puerto Viejo, and La Puna was precisely to obtain direct access to the mullu shells.”[lxxxiii]

Colin McEwan and María Isabel Silva demonstrate late Inca presence along the Manabi coast by identifying grave goods of imperial, Cusqueño manufacture in a ritual burial site at Isla de la Plata, and other sites nearby, including Agua Blanca, 8 km. inland, near Puerto López. McEwan and Silva state that it is indisputable that there was an established Inca presence on the continental coast of Ecuador and conclude that references made by Betanzos and other chroniclers to Inca activities along the Manabi coast can not be taken lightly as “fables” without foundation, or on the other hand interpreted as simply imperial propaganda. [lxxxiv]

Elizabeth J. Currie reported her findings at the nearby site of López Viejo on the coast of the shell working industry as it existed at the time of first Spanish contact. She states:

Excavations at Valdivia sites along the southern coast: San Pablo, Valdivia itself and San Isidro [where the pre-Columbian ceramic depicting severe verruga eruption shown above was said to have been found] all contain reports of mother-of-pear together with Spondylus.[lxxxv]

María I. Silva identified Aqua Blanca as the principal seat of the Señorío de Salangome, an independent pre-Columbian polity between the valley of Rio Buenavista and the valley of Jipijapa that attracted much attention from the Incas, beginning with Topa Inca Yupanqui, who, according to Cabello Valboa, had his first glimpse of the sea from the heights of the hills nearby.[lxxxvi] Jipijapa is significant because it remains an endemic foci and is, along with Pajan nearby, the source of the majority of reported cases of bartonellosis in Ecuador today.[lxxxvii]

This area around Jipijapa and the adjacent coast, that was the Señorío de Salangome, was the center of an independent and lucrative long distance maritime trade network based on a local industry producing specialized luxury shell artifacts. These were highly valued by the Incas, among others, for religious, ceremonial, and sumptuary purposes. Therefore, the Incas especially wished to control this señorio, its industry, maritime technology, and its trade routes.

The sources show that to secure the Manabi coast Huayna Capac traveled with a large army along the coast of Ecuador from Puna to Manta, and most probably passing though Señorío de Salangome.[lxxxviii] From Manta they continued on to the equator and back, subduing, we are told, the tribes along the way. The Caranques, north of Manta, rebelled, and he returned with an army to crush the rebellion.

Mestizo chronicler Garcilaso de la Vega was born in Cusco, April 12, 1539 of a union between Captain Sebastian de la Vega Vargas and the former Inca Princess Nusta Chimpu Ocllo. Garcilaso’s account of Huayna Capac’s later days was based, at least in part, on stories he heard as a boy in his mother’s house told by former members of the Inca elite, including his uncle Francisco Huallpa Túpac Yupanqui, Cusi Huallpa, and Juan Pechuta and Chauca Rimachi, “who had been commanders under the emperor Huaina Cápac.”[lxxxix]

Relating Huayna Capac’s last campaigns, Garcilaso was probably as well informed as any author since he personally listened to stories told by military commanders who served in them and survived. He also tells of an earlier expedition with 40,000 upland soldiers along the northern coast of Peru during which the soldiers were regularly rotated, two or three times in two years, back to their villages in the Inca heartland:

…the Inca had his army replaced two or three times: the replacement of the soldiers by others was caused by the danger to health which the uplanders experience when they leave their own cold climate for the hot coastal region.[xc]

His Book Nine, Chapter VIII “The gods and customs of the Manta tribe; their subjugation and that of other savage peoples,” tells that after further campaigns elsewhere Huayna Capac “gave orders for an army of fifty thousand warriors to be raised in the provinces of Chinchasuyu, to the north of Cusco. They were to assemble in the confines of Túmbez,“[xci] From Tumbez they went to the Island of Puna and spent “some days.”[xcii]

From Puna, they began the march north to the Manabi coast: “Huaina Cápac directed his march toward the seacoast for the conquest he desired to undertake there. He reached the borders of the province known as Manta, the district in which the port the Spaniards call Puerto Viejo lies.”[xciii]

The Inca continued north “to the conquest of another great province called Caranque.” Having obtained their submission he continued until he arrived in the lands of the Passau, “who live exactly on the equator.” Garcilaso describes how they painted their faces and notes that he himself saw them on his way to Spain in 1560, when his ship stopped there for water and fuel and he saw the Passau who came out on reed rafts to haggle large fish. But, as Garcilaso notes, the Inca is said to have remarked “’Let us retire, they do not deserve to have us as their masters.’…This said, he bade his army return, leaving the natives of Passau as brutish and ignorant as before.”[xciv]

Garcilaso glosses over some serious resistance Huayna Capac encountered from these rebellious coastal peoples. But he notes that in bestowing many favors and honors on Atahualpa

“He behaved like father smitten with passionate love for his son, and wished to spend the rest of his life in Quito and its district, taking this decision partly to favor and further Atahualpa’s reign, and partly to subdue and pacify the newly won provinces of the coast and interior, which had still not settled down under the rule and administration of the Incas, but behaved like warlike though savage bestial people. For this reason it was necessary to shift many of these tribes to other provinces, and bring in quiet and peaceful races in their stead, the remedy that those kings usually resorted to to secure themselves against rebellion, as we explained at length in speaking of the emigrants, called mítmac.[xcv]

Pedro Sarmiento de Gamboa, writing before 1572 (and before Garcilsao) gives a slightly different account of the coastal campaign:

…Huayna Capac went out of Tomebamba to put in order [concierto] the nations that had been conquered around Quito and Pasto and Guancabilicas. And so he arrived at the river called Angasmayo, between Pasto and Quito, where he put boundary stones at the end and terminus of the land he had conquered, and in the boundary stones he put certain golden stakes for greatness and memory. And he followed the same river down to get to the sea, looking for people to conquer, for he had news that there were a great quantity of people down there.

And in this road the army of Huayna Capac suffered great danger and work for the lack of water in some great sandy areas through which they passed. One day, at the time of dawn, the people of the Inca found themselves surrounded by an infinitude of people without knowing who they were: for fear of which they hurried to return to the Inca. And the soldiers of the Inca being determined to flee, a servant came to Huayna Capac and said “Lord, do not be afraid, these are the ones we came looking for! Let’s go for them!” The which seemed good to the Inca and he ordered that with great speed they attack them, making an unobstructed breakthrough through which each one made his escape. And with this they gave such art to the encircling force that before long they were free of the encirclement. And they routed them and followed them to their towns, which were on the sea coast, near Coaques, where they found a great sum of rich booty and very rich emeralds and turquoises and a great amount of very rich mollo, which is an aggregate made of sea shells more highly esteemed among them than gold or silver.

Here he received messengers from the ruler of the island of Puna, with whom he sent a great present and gift which was sent to receive service at his island of Puna. Guayna Capac did this in this manner, from where he went to Guancabilica, to where he met up with the rest of his army which he had left there. And there he learned how in Cusco there was a great pestilence, of which were dead his governors Apo Hilaquita, his uncle, and Auqui Topa Inga, his brother, and his sister Mama Coca with many other relatives. And to give order in the lands he had conquered there, he departed for Quito in order that from there to go to Cuzco to rest.

Before he was at Quito, he was given an illness of fevers, even though others say that it was smallpox or measles. Because he sensed he would die from it, he called to the privileged nobles his relatives, who asked him who he named as his successor.[xcvi]

Huayna Capac assembled an army of fifty thousand soldiers from the highlands north of Cusco and marched them from Puna past Manta and Porto Viejo along the Manabi coast to Coaque on the equator and back, probably rotating them at regular intervals back to their homes in the Inca heartland. As the Spanish expedition led by Pizarro through this very same area discovered less than a decade later, and at great cost, this was an area already hyper-endemic for bartonellosis. Furthermore, Huayna Capac employed the standard Inca “remedy” for dealing with recalcitrant populations, “shifting” many of these tribes along the Manabi coast, forcibly incorporated into the empire, to other provinces and replacing them with colonists from “peaceful” areas.

Following this campaign along the Manabi coast, Huayna Capac and much of his army became ill and died. But this was not before they learned of an epidemic that had already swept through Cusco, killing many of his relatives among countless others. We can now clearly see how a regularly rotated army of 50,000 highland soldiers and an unknown number of relocated coastal tribes from the endemic Manabi coast, may all have carried in their blood the seeds of a great disaster.[xcvii]

Because the Jipijapa-Pajan area is now, and apparently was even in Pre-Inca time, endemic for bartonellosis; and because there is solid archaeological evidence of an Inca presence in this area; and because the most direct route from Puna or Guayaquil to Manta passes through Pajan and Jipijapa; and because the early Spanish sources say that Huayna Capac operated in this area with his army; I believe it is the area most likely to have spawned the epidemic of 1524.

The Death of Huayna Capac

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. She was also the niece of Inca Huayna Capac. As Cook points out, “Betanzoz questioned his wife’s relatives at length…”[xcviii]

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 saran [cutaneous disease] and lepra [leprosy] that made him very debilitated…”[xcix]

Here are some other images of advanced cases of leprosy,[c] and there is a similarity in the manifestation in these images to the pre-Columbian ceramics depicting verruga peruana pictured above and to Pedro Pizarro’s description of the bartonellosis outbreak that afflicted his compatriots during their early expedition.

I am not suggesting that the illness that killed Huayna Capac or other of his subjects in the 1520s epidemic or that struck Pizarro's men was Hansen disease (leprosy), but there are evident similarities in appearance, at certain phases, between leprosy and verruga peruana that might help to explain Betanzos’s phrase.

Use of the words saran 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: saran is “caracha” and lepra is “caracha llecte” (grime or filth).[ci]

Evidently Quechua had a word for something like leprosy, and since Betanzos describes Huayna Capac as having “saran” 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.”[cii] Since Salazar’s report is highly relevant to the case of Huayna Capac, I will include it here in its entirety :

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

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.

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 saran [cutaneous disease] and lepra [leprosy] that made him very debilitated…. “ Elsewhere we hear that Huayna Capac suffered from fevers. Certainly these descriptions are consistant 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.

However, even if Batanzoz was not referring to verrucous symptoms of bartonellosis in a manifestation of the disease that would have paralleled the case of Don Aniceto, a pronounced skin rash can be present at the onset of the hemolytic anemic Oroya fever stage of the disease that might offer an alternative explanation still consistent with Betanzos’s description of a “leprous” disease.

There is another phrase in Betanzos's account that bears careful scrutiny in light of what is now known about bartonellosis. Betanzos, as quoted in Cook, said “...he came down with an illness which deprived him of his senses and understanding..." However, a slightly different and more complete rendering of Betanzos's account may be found in another English translation. In this version Betanzoz reported the following description of the Inca Huayna Capac's death:

At the end of those six years in Quito, he fell ill and the illness took his reason and understanding and gave him a skin irritation like leprosy that greatly weakened him. When the nobles saw him so far gone they came to him; it seemed to them that he had come a little to his senses and they asked him to name a lord since he was at the end of his days. To them he replied that he named as lord his son Ninancuyochi, who was barely a month old and was in the province of the Cañares. Seeing that he had named such a baby, they understood that he was not in his right mind and they left him and went out. They sent for the baby Ninacuyochi, whom he had named as lord. The next day they returned and entered and asked him again whom he named and left as the ruler. He answered that he named as lord Atahualpa his son, not remembering that the day before he had named the above mentioned baby. The nobles went immediately to the lodgings of Atahualpa, whom they told was now lord, and they gave him their respects as such. He told them that he had no wish to be the ruler even though his father had named him. The next day the nobles returned to Huayna Capac and in view of the fact that Atahualpa did not wish to be ruler, without telling him anything of what happened the day before, they asked him to name a lord and he told them it would be Huascar his son. ... Huascar retired for a period of fasting after he heard the news in Cusco. Here we will leave him and return to Huayna Capac, who was in his final days. After having named Huascar as ruler in the way we have described, he died in four days. After he died, the messengers who had gone for the baby who had been named as ruler by Huayna Capac returned. The baby had died the same day they arrived of the same leprous diseaseas his father. [civ]

Echoing Don Aniceto’s case, Huayna Capac suffered a skin irritation like leprosy that greatly weakened him, the illness also took his reason and understanding, but then he came a little to his senses, suggesting a period of relative lucidity following delirium. He did not remember what had happened from one day to the next or what he had said. Then, four days after his last reported communication, he died.

J. O. Trelles et al. give detailed descriptions of nine clinical cases of bartonellosis treated in hospitals in Lima between 1945 and 1955 involving lesions within the brain (encephalitis).[cv] Some of the patients experienced delirium and temporal-spatial disorientation. Case eight experienced loss of vision, nausea and vomiting followed by loss of consciousness. These symptoms were preceded by a brief period of delirium and "talking to himself." But, nevertheless, the next day he was lucid. Subsequently his fever increased dramatically and he died five days later of bronchopneumonia.[cvi] Case nine entered the hospital in a comatose condition, but four days later when he was able to begin the interrogatory process with the doctors he evidently suffered amnesia, stating that he had no recollection of events during the previous period of his illness beginning two days before his entering the hospital.[cvii] In these cases death followed onset in 13-34 days. Treatment with antibiotics did not prevent death.

Huayna Capac's death parallels the findings of the neurological forms of Carrión's disease (bartonellosis) published by Trelles et al. It is, therefore, likely that Huayna Capac suffered from a cerebral form of Carrion's disease (bartonellosis) similar to those cases described in Trelles et al.

Analysis of duration of incubation to onset and death provides further evidence in favor of bartonellosis as opposed to smallpox. In eight of the nine cases of neurological Carrión's Disease cited by Trelles et al. death followed onset of symptoms in 13 to 34 days.[cviii] In the famous case of Daniel Carrión's experiment, the duration between his auto-inoculation until death was 39 days.

Daniel Carrión,[cix] regarded as a hero of Peruvian medicine, was a young medical student in Lima.[cx] Carrión decided to inoculate himself with material from a patients lesions on August 27, 1885. Twenty-one days later his first symptoms appeared, thereafter he kept a clinical diary until he was no longer able to write, when his medical student colleagues continued it for him.

On September 17 Carrión felt a vague discomfort and pains in his left ankle. He was not bothered greatly until two days later, when fever began. This was accompanied by strong, teeth-chattering chills, abdominal cramp and pains in all the bones and joints of his body (this mode of onset is typical of Oroya fever). He was unable to eat anything, and he commented in his diary that his thirst was devastating. His urine became dark red and scanty. On the fourth day of his illness he noted that his skin had taken on an icteric tint and that small reddish spots resembling flea bites had become visible. His illness continued unchanged in the next few days and by September 26 he had become too weak to maintain his diary. His task was taken up by his classmates who were keeping vigil at his bedside. ... Carrión's friends [were] impressed by the rapidity with which the anemia had developed. This is not surprising, since today it is known that the hemolytic anemia of Oroya fever can be one of the most rapidly developing and severe of any of the anemias of man. At the same time as the appearance of the anemia, a systolic murmur became audible at the base of Carrión's heart. The murmur was perceived by Carrión in his own internal cartoid arteries, and as it grew in intensity it became a constant source of harassment to him. His pulse remained rapid. The abdominal pain persisted, he vomited frequently, his bowel movements were loose and fetid, and he slept poorly. Gradually, all signs of his usual vivacity ebbed from him. His eyes were sunken and surrounded by dark circles. His face was vacant. On October 1, when fasciculations appeared in his arm muscles, his classmates had little remaining doubt of the fate that awaited their friend.

Up to today, I thought I was only in the invasive stage of the verruga as a consequence of my inoculation, that is in that period of anemia that precedes the eruption. But now I am deeply convinced that I am suffering from the fever that killed our friend, Orihuela. Therefore, this is the evident proof that Oroya fever and the verruga have the same origin, as Dr. Alarco once said.

In the evening he was completely delirious and rambled on about the different opinions that existed on the pathology of verruga peruana, On October 5, 39 days after the inoculation, he was in coma. Most of what he uttered was incomprehensible, but his last words were heard clearly by one of his friends. He said: "Enrique, c'est fini."[cxi]

So from the onset of symptoms on September 17 until his death on October 5, following delirium and coma, eighteen days elapsed. This is consistent with the cases studied by Trelles et al. who reported death following onset of symptoms in 13 to 34 days.

Analysis of the duration of the illness after onset of symptoms is important because 16th-century documents state that Huayna Capac first felt ill at Tumibamba, and returned from there to Quito where he died. According to Cook:

Cabello Balboa reports that after Huayna Capac completed conquests in the north, he paused in Tumibamba. He continued to the coast and reached the island of Puná, where he may have first been notified of the arrival Viracocha –the European. At Puná, Huayna Capac also “received very sad news from Cusco, where they informed him that there was an incurable and general pestilence that had taken his brother Auqui Topa Inca and his uncle Apo Illaquita, whom he had left as governors when he left Cusco, and his sister Mama Toca, and other principal lords of his lineage.” Profoundly saddened by the news, Huayna Capac continued toward Tumibamba. …From Tumibamba, “feeling indisposed and in ill health, he continued to Quito with the greatest and best part of the army, and arriving there his malady worsened, and turned into deadly fevers.” … Cabello Balboa gives the date of the ruler’s death as “according to our count, in the year 1525.”[cxii]

It is impossible to know the exact travel time of Huayna Capac’s journey, John Hyslop’s study of the Inca road system suggests 60 km per day as the extreme distance for carriers in the eighteenth century, 50 km for guides on his field trip, and 40 km per day is given as the speed of Pizarro's army's movement. [cxiii] There are 350 km between Tumibamba and Quito. At 40 km per day the travel time would be approximately ten days, but no less than six days traveling at the highest rate of speed reported.

Huayna Capac came “a little to his senses" following a period of delirium. We are not told how long he had been in the city following his return from Tumibamba. On the day when he returned to lucidity, and on each of the two following days he was questioned by the nobles about his successor. Then after four more days he died. Taken together, this makes seven days. Added to an estimated ten days of travel time, not including any time that may have elapsed not accounted for in the sources, this makes at least 17 days, over 2 weeks, during which time his illness progressed from indisposition to death. As Cabello Balboa reports, upon arriving in Quito, "his malady worsened, and turned into deadly fevers," so from this one might assume that there was some additional, but unknown, period of time not accounted for in this estimate of 17 days.

These symptoms and time frames are consistent with the clinically reported onset of the Oroya Fever phase of bartonellosis. The likelihood of this disease being smallpox is lower than bartonellosis, due to the more rapid onset and progress to crisis of smallpox:

Smallpox, or variola major, was a systemic viral disease caused by Variola virus, a species of Orthopoxvirus. Incubation period lasted from 7-19 days; commonly 10-14 days to onset of illness and 2-4 days more to onset of rash. Onset was sudden, with fever, malaise, headache, prostration, occasional abdominal pain and vomiting. After 2 to 4 days the fever began to fall and a deep seated rash developed in which individual lesions containing infectious virus progressed through successive stages of macules, paupules, vesicles, pustules and crusted scabs which fell off after three to four weeks. Fatalities usually occurred between the 5^th and 7^th day, occasionally as late as the second week. The disease was communicable from appearance of earliest lesions to disappearance of all scabs, about 3 weeks. The patient was most contagious during the preeruptive period by aerosol droplets from oropharyngeal lesions. Fatality rate among unvaccinated populations was 20-40% or more. Less than 3% of variola major cases experienced the fulminating disease. Such hemorrhagic cases were rapidly fatal, the usual rash did not appear.[cxiv]

So, 7 to 19 days after initial infection the symptoms of fever, malaise, headache and prostration described suddenly appeared, followed by the onset of the rash after 2 to 4 days. Then 2 to 4 days later the fever began to subside while the macular (red, raised lesions) rash progressed to vesicles (raised clear blisters) through its stages culminating in the characteristic umbillicated papules and then pustules and finally scabs, with death usually occurring between the 5^th to 7^th day after onset. Thus, the statement by Cabello Balboa that upon arriving in Quito, after an estimated ten days of travel, "his malady worsened, and turned into deadly fevers" is hard to reconcile with the clinical progress of smallpox, where death usually occurs between the 5^th to 7^th day after onset, but certainly corresponds with the eyewitness accounts of Daniel Carrión’s death and the cases reported by Trelles et al., where death occurred following onset of symptoms in 13 to 34 days. Therefore, correlating typical times elapsed from onset to death in both diseases with what the sources tell us about Huayna Capac’s activities after the reported onset of illness in Tumibamba and the time required to travel on foot, or in a litter borne by footmen, from Tumibamba to Quito, where the accounts say he died, we can only conclude that bartonellosis was a more likely cause of death than smallpox.

Even though some later medical writers have not believed that Huayna Capac’s death was caused by bartonellosis, Schultz did at least discuss the possibility, citing Richard P. Strong, who wrote:

Over four centuries ago, during the reign of the Inca, Huayna Capac, thousands of lives were swept away, supposedly by this malady, and in the history of the conquest of Peru by Zarate, published in 1545, it is stated that the disease is more destructive than smallpox and almost as disastrous as the plague itself. [cxv]

Apparently Strong had read Pablo Patrón’s 1894 paper, “La enfermedad mortal de Huayna Cápac”. [cxvi] Schultz pointed out that Huayna Capac conquered the island of Puná and large portions of Ecuador. He related that his general Minacnacamay "and many other officers" died along with Huayna Capac after leaving Tumibamba for Quito. Schultz said "We are told by the chronicler that their faces were covered with a rash."[cxvii] As we have seen, this would be consistent with the rash, or “small reddish spots, resembling flea bites,” that Carrion himself experienced on the fourth day of his illness and recorded in his diary.

Moreover, Pablo Patrón provided an additional important insight concerning this mention of rash on the face:

It is very instructive, in this respect, a case of verruga peruana observed precisely in Piura and described by Dr. Jose Gariazzo, without having known the disease. Mr. Juan Elias Bonnemaison, after having suffered in other places of Peru several diseases, came to Piura in September 1858 and by the end of October he developed a rash of warts. Since that moment “Mr. Elias had noticed,” says Dr. Gariazzo, “some pink spots similar to the blotches left by zancudos [large mosquitos] that in fact he thought it was. Sometimes he assumed that it was the excessive hot weather reigning in that place. In November 4, the day of my arrival, the sick person showed those marks to me and I myself assumed it was the same cause he believed it was”. Until the 20^th, the number of red blotches had grown and that same day he was in bed with a strong headache, 126 pulsations per minute, dry mouth, dilated pupils, reddish skin, hard breathing “and so dazed that his answering was very late to my questions and without sense (Gariazzo). Twenty four hours later the sick person was covered of a facial rash that since that moment was advancing until December 29 day in which it started to decrease.” On November 26 the rash “did not leave a small circle on the uncovered face and the blotches were convex formed, rounded and its dimensions were from 8 to 12 millimeters of diameter. His surface was uncovered and no blotch produced pus nor had an ulcerous aspect.”[cxviii]

Pablo Patrón, who was a well-known Peruvian historian and ethno-linguist, also discussed the problem of translating words that were used to describe these symptoms in his 1894 paper. Patrón said:

The contradiction between what was reported by the indigenous and the word of the chroniclers is more apparent than real. The former included smallpox and measles among pimples and rash, then called all of these diseases with the same name of muru-muru; mullcu-mullcu or murcu-murcu, they [the Spanish writers] believed that was smallpox or measles when it could easily be any other eruptive disease similar to rash.[cxix]

Citing Strong's contention that the cause of death was Carrión's disease, Schultz asks: "If the epidemic was due to Carrión's disease, the descriptions of the verrucose stage are striking by their absence. It would seem that such an obvious external manifestation would have been noted in those who survived the Oroya fever stage." [cxx] But in a 1999 study, “the cutaneous phase of the disease does not always follow the anemic phase.”[cxxi] Moreover, Schultz wrote in 1968, before the discovery and publication of a complete manuscript copy of Betanzos's account in Madrid in 1987. Since then a corrected English translation was published in 1996. Before this time only the first 18 chapters of Part One were known from a partial manuscript. This portion did not include Chapter 48, "Huayna Capac Dies in Quito," cited at length and discussed above. As we have seen, Betanzos does refer to a "leprous" disease as having killed Huayna Capac and his son.

Carrión’s diary and the example cited by Patrón, show that even in the onset Oroya fever stage a pronounced facial skin rash may be present. Recalling now that, as Cook pointed out, the “Use of the words saran or lepra by Betanzos to identify the illness simply indicates symptoms of severe skin rash and inflammations,”[cxxii] we can see that Betanzos may well have been referring to a skin rash brought on by Oroya fever and not by smallpox.

Tantalizing Temptations, Missing Links, and the Great New World “Pandemic”

The weight of the evidence supports an interpretation in favor of bartonellosis, but contradicts Schultz who said

The descriptions of a rash together with the high fever and high mortality of the native Andeans are suggestive of an exanthematous disease. Furthermore, the great rapidity of its spread and the intriguing fact that Huayna Capac fell ill after he had received a messenger from Cusco, the epidemic center, also suggest that this was a disease spread by contact rather than one spread by an anthropod vector.[cxxiii]

Skin rash, high fever, and high mortality are all characteristic of bartonellosis, as is its rapid spread by the sand fly vector as seen in the Lima-La Oroya R.R Bridge case. If the messenger was the carrier of smallpox that came from Cusco, “the epidemic center,” as Schultz seems to suggest, there is no mention of his suffering the symptoms of smallpox, which would have been advanced and noteworthy. [cxxiv]

Nor is there any mention anywhere in the sources of others around Huayna Capac, from whom he could have contracted the disease, at that time suffering from the contagious symptoms of smallpox, as would have been noteworthy and necessary for Huayna Capac to have contracted smallpox while in the area. On the other hand, inhabitants of the endemic areas through which Huayna Capac would have recently passed would have been immunologically adapted to bartonellosis over time, and need not have been suffering or presenting visible symptoms to have been bacteremic reservoirs from whom sand fly vectors could have transmitted bartonellosis. Huayna Capac and the others could have remained asymptomatic for up to 210 days after having become infected, although the typical incubation period has recently been placed at 61 days.[cxxv]

Nevertheless, unwilling to give up on smallpox in spite of the obvious problems with evidence and logic, Woodrow Borah offered this explanation in his introduction to one of Cook’s books on the subject:

The epidemic that devastated the Inca realm in the middle 1520s, killing the reigning Inca and his heir and unleashing the war of succession that opened the realm to Spanish conquest, likely came from the Rió de la Plata basin, for the disease moved from south to north in the Andes.[cxxvi]

We are not told, however, exactly how the disease came to the Rio de la Plata, nor how it moved from there to Cusco. Elsewhere we may learn of the lengthy sea voyages of Juan Diaz de Solis and Sebastian Cabot.[cxxvii]

If some of the crewmen sailing on these expeditions from Spain had not already been infected by smallpox in their upbringing in Spain -- where the disease was quite common -- and if somehow, pre-eruptive symptoms of smallpox were undetected by the captains prior to embarkation, but introduced by an asymptomatic sailor before illness began on-board during this long journey, the few suseptibles would have presumably become infected and died (or recovered) during the course of the three month voyage. After recovery, of course, they would no longer have been a source of contagion. In such a small, confined environment it is difficult to believe that smallpox would have maintained its viability during the passage. So, in light of the lengthy sea voyage it is unlikely that smallpox was transmitted by these expeditions.

But even if smallpox had arrived with Diaz de Solis in January 1516 or Cabot in the summer of 1526, given the probably uneven and largely unknown settlement patterns then existing over the vast stretches of terrain separating these points of contact along the Rio de la Plata and Cusco, and the known requirements for dense populations to sustain and transmit smallpox over time and space, much more work than a casual suggestion would have to be done to convincingly demonstrate the hypothesis that smallpox arrived in Cusco from the vicinity of modern Montevideo in the Rio de la Plata basin by 1524 or 1525 when the Spanish sources say Huayna Capac died.

While the timing of the outbreaks is not in dispute, it seems unnecessary to propose an introduction from Rio de la Plata to explain this pattern of occurrence. The source of infection for both outbreaks may have been the southern coast of Ecuador. Huayna Capac died in Quito immediately after he had returned from the coast, where he had been punishing the Huancavilca and Puna for their treachery. This suggests (Sarmiento de Gamboa 1960:265) that he may have contracted the disease on the coast. At that time the Inca were trying to extend dominion over the coast, having established a fort at Tumbez. Some of these involved in coastal campaigns came from the sierra (Cieza de Leon 1984:77-8), and it is possible that the disease was carried back to Cuzco by soldiers some time before Huayna Capac arrived on the coast to seek his revenge.[cxxviii]

There is simply no mention in any of the sources of any Spaniard or any other person traveling with Pizarro’s coastal expeditions suffering from smallpox. Instead, as Lastres showed, the early Spanish sources agree and state that smallpox was introduced into Ecuador and Quito in 1533. As Newson points out,

In 1522 Pascual de Almagro explored 200 miles of the Pacific coast of Colombia, and in 1524 Francisco de Pizarro and Diego de Almargo explored the same coast as far south as Puerto de la Hambre. It was not until 1526 to 1527 that Bartolome Ruiz and Francisco Pizarro explored the Ecuadoran and Peruvian coasts as far south as the Santa River. The most obvious source of the first disease to strike the Inca Empire were the latter expeditions. When Spaniards reached Ecuador and Peru, however, seafaring crews had not been in contact with Panama for some time, and there is no evidence that they were suffering from any infections. It is possible that the virus was carried in clothing or dust, in which condition it may survive for up to eighteen months, but the spread of the disease by this means is not common. (Christie 1977:259-60). The normal channel of infection is direct face-to-face contact. An alternative source of the infection could have been one of the earlier expeditions that touched the coast of Columbia, from where it could have spread overland or along the coast from group to group.[cxxix]

The fact that such a notable event as a shipboard outbreak of smallpox was not recorded by any of the sources makes such an occurrence unlikely, as Newson shows. But, more to the point, it should be noted that in her conclusion, Newson states that the illness Pizarro’s men suffered on the coast in 1531 was Oroya fever and verruga peruana, and that sixteenth-century “Fevers on the coast of Ecuador were probably the result of starvation or Oroya fever spread by sand flies.”[cxxx]

No matter how tempting it is to assume that somehow someone brought smallpox to somewhere along the Ecuadoran coast, or over the Andes from Panama, or up from the Rio de la Plata, there simply is no hard evidence to support such claims, only circumstantial speculation or casual suggestion makes the connection in the chain of transmission theorized by the promoters of the smallpox “pandemic” theory that claims Huayna Capac died of a “hideous alien disease.” Nevertheless, Newson is probably correct in her analysis postulating that Huayna Capac contracted his fatal illness while on the coast, like Don Aniceto, and that his soldiers carried with them back into the highlands the seeds of the epidemic that swept Cusco.

A more probable explanation results from simply applying what we know about bartonellosis and the location of Pre-Columbian endemic foci to what we know about Huayna Capac’s movements and the movements of his soldiers prior to his death. Huayna Capac marched 50,000 soldiers recruited in the highlands through coastal areas endemic for bartonellosis. During the course of the campaign, these highland soldiers were probably regularly rotated back to their homelands. Unknown numbers of uprooted rebellious tribesmen from the same endemic coast were relocated to pacified areas long under Inca rule. It takes no leap of faith nor stretch of the imagination nor manipulation of the evidence to understand how the highlands could have been infected with the disease by an exposed human carrier population of endemic coastal tribesmen and infected soldiers returning from the Manabi coast. Once physically transported to the highlands in the blood of these carriers, the disease could have been rapidly spread to others by sand flies prior to Huayna Capac’s infection or onset of symptoms.

With an average incubation period of two months, but sometimes up to six months, much longer than smallpox, there would have been plenty of time before onset of bartonellosis for the soldiers to return home and for dispersed groups of relocated tribesmen to have been settled into their new “peaceful” areas of the empire. But traveling the 1,500 odd kilometers from Tumibamba, even at the maximum rate of speed, a soldier returning with smallpox would have been debilitated or dead long before reaching Cusco. Logically applying what we know about the duration of incubation and onset, the likelihood is that if the epidemic had been smallpox, it would, necessarily, have spread from the coast towards Cusco rather than from Cusco to the coast as reported in the sources.

Applying Occum’s Razor to a rigorous study of all the scientific and historical evidence now available, I am brought inescapably to the same conclusion as Pablo Patrón over 100 years ago when he asked the same question:

What disease could Huayna Capac and his army have contracted along the coast of Ecuador? I lean towards believing that it was Carrion’s disease. This explains everything: the fever, the rash, and the fact that many have died simply of this without a single rash.[cxxxii]

There are three important additional points I would like to make before closing the argument. The first is to emphasize again that mortality rates for bartonellosis are dramatically increased when other systemic bacterial infections are present. Maguina and Gotuzzo point out among these “salmonella typhimurium. In addition to these infections, patients may have toxoplasmosis, disseminated histoplasmosis, sepsis (Staphylococcus aureus, Enterobacter bacteria, Shigella dysenteriae), pneumocystosis, and Plasmodium vivax.”[cxxxiii] Moreover, as Ellis, et al. point out:

Case fatality ratios (CFRs) of untreated Oroya fever exceed 40% but may reach more than 90% when superinfection with Salmonella species occurs.[cxxxiv]

Public water supply systems using open canals, such as described in the 1987 case of the Peruvian Andean village studied by Gray, et al., and as may be seen today at Ollantaytambo in these images above and numerous other Inca sites, may become contaminated with coliforms, fecal material, both human and animal. This may contain Salmonella, or other bacteria that produce dysentery or other illnesses. [cxxxv]

Leaving aside any consideration of the sanitary conditions among an army of 50,000 foot soldiers, if large Inca population centers, such as Cusco, relied on public water delivery systems that were susceptible to coliform contamination, this may have caused a condition of endemic gastrointestinal disorders, as may be seen even today in many parts of Latin America, including the Andean region.

In rural farming areas drawing water directly from natural springs or rivers similar contamination may have occurred, as it does today in rural areas of Latin America and elsewhere.[cxxxvi] While the rural and urbanized Inca population may have routinely tolerated this kind of public health problem, as many populations do today, willingly or not, when suddenly confronted by the additional burden of a new type of systemic infection of the blood, such as bartonellosis, a catastrophic epidemic outbreak may have ensued among non-immune populations. Here it is necessary to remember that the ascendancy of Inca power was not old during the reign of Huayna Capac.

The second major point I wish to make is to call attention to the magnitude and rapidity of the ecological changes brought about during the reign of Huayna Capac, from approximately 1498 to 1524. Indeed many of the vast public works for which the Inca Empire has become so famous, were still works in progress when the Spaniards arrived. This is to say that the construction of large private elite estates and of sophisticated urban systems and the consequent concentration of population was still under way. These were young cities and villas, at a time when the empire was still rapidly expanding into new territories, absorbing and relocating new ethnic groups who may have brought with them new diseases to the non-immune Inca heartland from the remote endemic periphery of the empire. Huayna Capac put into the field armies of 40 and 50,000 soldiers, soldiers who were rotated regularly. The Inca state mobilized ten of thousands of rotational laborers to work on public projects. Even larger numbers worked on royal estates. Huayna Capac himself mobilized over 150,000 laborers “from throughout the empire” on his estate alone.[cxxxvii]

Concentrating a human workforce of this magnitude, composed of rotational laborers working in a relatively confined area for a sustained period of time, stretching over several years certainly begs the question of how they were fed and housed and how even rudimentary sanitation was managed, if it existed at all. The fact that many if not most of the workers were employed in hydraulic works brings with it additional questions about coliform contamination that dramatically increases mortality rates in epidemic bartonellosis.

Beyond this is the more haunting question of non-human reservoirs recently raised by Ihler, among others:

The source of the bacteria which colonize sandflies is not known. Because of the close phylogenetic relationship to the former Grahamella species, which are widely prevelent in small woodland animals, it seems possible that a mammilian reservoir for B. Bacilliformis might exist. It seems also possible to me that B. Bacilliformis might grow on some plant or fruit debris with which the sand flies associate, eat, or obtain fluids.[cxxxviii]

In another recent study of epidemic bartonellosis in Ecuador, Philip Cooper, et al. closely examined the possibility of a non-human reservoir.[cxxxix] They found dead rodents present only in the case houses and suggest that the outbreak may have followed increased rodent invasion of houses due to food shortages because of draught conditions. They point out that

All case houses were located in isolated areas at the margin of forest and the presence of dead rodents was reported only in case houses. We suggest that human bartonellosis is a zoonosis with a natural rodent reservoir and that migrant humans infected in this way may become a temporary reservoir host in populated areas.[cxl]

This important finding about wild rodents may have a direct bearing on the epidemic of 1524 for several reasons. Firstly, because one of the major goals of Inca state and imperial policy was to increase the ability to produce food by mobilizing immense human work forces implementing vast terracing programs on royal estates and elsewhere. Not only did the relatively sudden creation of terrace walls built of coursed stone presenting millions of square feet of vertical surface as new habitat for sand flies, creating their “favored [outdoor] harborage and breeding areas,” but also the terraces themselves greatly increased food production, not only for the human population, but no doubt for the expanding wild rodent populations as well. Secondly, because along with the construction of the famous Inca Road, still one of the wonders of the world, there was also a systematic construction of special infrastructure, built at regular intervals all along the road, for maintaining and distributing food supplies, principally consisting of grains.[cxli] Not only would this have provided needed food for the human population, but, again, it also would have provided the means for expanding the wild rodent populations. Similarly, rapidly expanding human urban populations, such as in Cusco, may also have contributed to a corresponding increase in wild rodent populations within the urban precincts.

Therefore, if, as Cooper et al. suggest on the basis of their recent investigation, human bartonellosis is a zoonosis with a natural rodent reservoir, the relatively sudden expansion of the rodent reservoir in response to greater availability of food from intensified human agriculture may have played an all important role in the epidemic of 1524. Furthermore, if, as seen in the case Cooper et al. studied, hydroclimatological conditions, such as drought, tend to intensify rodent invasion of houses, leading to epidemic outbreaks or intensified epidemic outbreaks, then this too must be considered in the analysis of the 1524 event.

Clearly the reign of Huayna Capac saw unprecedented ecological changes resulting from construction and military campaigns, the former resulting in the concentration of enormous human workforces and the expansion of urban populations, while the latter moved large bodies of soldiers great distances into new territories and back. Increased mass mobility at a time of increased construction. This was not a time of stasis, but a time of great and rapid change, large scale ecological change brought about deliberately by human activity organized and manipulated on a vast scale by imperial command at the state level, creating new conditions and new opportunities, not only for the human population, but also, perhaps, for the florescence of microbial pathogens.

Finally, the third major point I want to make in closing is to call attention to recent, ground breaking research by Jiayu Zhou, Richard Andre, and others, that demonstrates a linkage between epidemic outbreaks of bartonellosis and “el Niño” weather patterns.[cxlii] When seasonal air temperatures increase above normal during periods of “el Niño” weather phenomena, the vector sand fly population increases correspondingly, resulting in dramatically increased incidence of bartonellosis outbreaks. In the 1997/98 event they studied, “…the monthly disease case number was almost doubled and the disease transmission lasted much longer.” But, perhaps even more importantly for this investigation of the epidemic of 1524-25, their research showed that “During 1997/98 El Niño event, the disease epidemics expanded to the southern part of the country, where bartonellosis had not been recorded earlier.” My ongoing research will attempt to determine if the outbreak of 1524-25 may have been influenced or exacerbated by a convergence of factors including a possible El Niño event.

Until we identify mummified remains of a human known to have died in the 1524-25 epidemic, it will be impossible to demonstrate absolutely that bartonellosis was the cause of this disaster. Nevertheless, as has been clearly demonstrated here, the application of current medical science to the existing archaeological and documentary evidence makes bartonellosis a more likely diagnosis than smallpox for the death of Huayna Capac and his subjects. NOTES:

[i] Pedro de Cieza de León. Del Señorío de los Incas. Alberto Mario Salas, ed. Buenos Aires: Ediciones Argentinas “Solar,” 1943, p. 194.

[ii] Sarmiento de Gamboa, P. Historia Indica. Buenoa Aires: Espasa-Calpe Argentina S. A., 1942, p. 131. Cabello Balboa, Miguel. Miscelánea Antártica. Lima: Universidad Nacional mayor de San Marcos, 1951, p. 393.

[iii] Pachacuti Yamqui Salcamayhua, Juan de Santa Cruz. “Relación de antiqüedades deste Reyno del perú[1613].” In Tres relaciones de antigüdades peruanas. Ed, M. Jiménez de la Espada, pp. 207-281. Asunción del paraguay: Editora Guaranía, 1950. Cited in Lastres, Juan B. Historia de la medicina peruana. Lima: Impr. Santa María, 1951, Vol. 1, p. 150.

[iv] Cook, Noble David. Born to Die Disease and New World Conquest, 1492-1650, Cambridge: Cambridge University Press, 1998, pp. 72-94 (and elsewhere) The following is a partial listing of publications since 1900 attributing the death of Huayna Capac and others during the circa -1524 Andean epidemic to smallpox:

Polo, José Toribio.“Apuntes sobre las epidemias del Perú.” Revista Histórica, 5(1913):50-109; Lastres, Juan B. Historia de la medicina peruana. Lima: Impr. Santa María, 1951; Dobyns, Henry F. “An Outline of Andean Epidemic History to 1720.” Bulletin of the History of Medicine 37(1963):493-515.; Cook, Noble David. Demographic Collapse: Indian Peru, 1520-1620. Cambridge: Cambridge University Press, 1981; _______________. Born to Die, Disease and New World Conquest, 1492-1650.Cambridge: Cambridge University Press, 1998; Cook, Noble David, and W. George Lovell, eds. The Secret Judgments of God: Native Peoples and Old World Disease in Colonial Spanish America. Norman: University of Oklahoma Press, 1992; Borah, Woodrow. “Introduction.” In The Secret Judgments of God: Native Peoples and Old World Disease in Colonial Spanish America, ed. Cook, Noble David, and W. George Lovell, pp. 3-19. Norman: University of Oklahoma Press, 1992, Newson, Linda A. “Old World Epidemics in Early Colonial Ecuador.” In The Secret Judgments of God: Native Peoples and Old World Disease in Colonial Spanish America, ed. Cook, Noble David, and W. George Lovell, pp. 86-114. Norman: University of Oklahoma Press, 1992. Crosby, Alfred W. “Conquistador y Pestilencia: The First New World Pandemic and the Fall of the great Indian Empires,” Hispanic American Historical Review 47(1967):321-37; _____________. The Columbian Exchange: Biological and Cultural Consequences of 1492. Westport: Greenwood Press, 1972; _____________. “Virgin Soil Epidemics as a Factor in the Aboriginal Depopulation in America.” William and Mary Quarterly 33(1976):289-99; Lovell, W. George. “’Heavy Shadows and Black Night,’ Disease and Depopulation in Colonial Spanish America.” In The Americas before and after 1492: Current Geographical Research, Annals of the Association of American Geographers, Vol. 82, No. 3, September 1992; Cook, Noble David and W. George Lovell. “Unraveling the Web of Disease.” In The Secret Judgments of God: Native Peoples and Old World Disease in Colonial Spanish America, ed. Cook, Noble David, and W. George Lovell, pp. 215-244. Norman: University of Oklahoma Press, 1992.

[v] Patrón, Pablo. “La enfermedad mortal de Huayna Cápac”. Lima: La Crónica Médica XI:131 (15 de junio de 1894): 179-183.

[vi] Gray, Gregory C., et al. “An Epidemic of Oroya Fever in the Peruvian Andes.” American Journal of Tropical Medicine and Hygiene, 42(3), 1990, pp. 215-221, p. 215: “Bartonellosis, or Carrion’s disease, although described many years ago, remains a mysterious disease.” See also Ihler, Garret M. "Bartonella Bacilliformis: dangerous pathogen slowly emerging from deep background.” FEMS Microbiology Letters 144(1996):1-11.

[vii] 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. p. 59.

[viii] The following is a partial listing of publications since 1950 attributing the death of Huayna Capac and others during the circa -1524 Andean epidemic to smallpox:

Lastres, Juan B. Historia de la medicina peruana. Lima: Impr. Santa María, 1951; Dobyns, Henry F. “An Outline of Andean Epidemic History to 1720.” Bulletin of the History of Medicine 37(1963):493-515.; Cook, Noble David. Demographic Collapse: Indian Peru, 1520-1620. Cambridge: Cambridge University Press, 1981; _______________. Born to Die, Disease and New World Conquest, 1492-1650.Cambridge: Cambridge University Press, 1998; Cook, Noble David, and W. George Lovell, eds. The Secret Judgments of God: Native Peoples and Old World Disease in Colonial Spanish America. Norman: University of Oklahoma Press, 1992; Borah, Woodrow. “Introduction.” In The Secret Judgments of God: Native Peoples and Old World Disease in Colonial Spanish America, ed. Cook, Noble David, and W. George Lovell, pp. 3-19. Norman: University of Oklahoma Press, 1992, Newson, Linda A. “Old World Epidemics in Early Colonial Ecuador.” In The Secret Judgments of God: Native Peoples and Old World Disease in Colonial Spanish America, ed. Cook, Noble David, and W. George Lovell, pp. 86-114. Norman: University of Oklahoma Press, 1992. Crosby, Alfred W. “Conquistador y Pestilencia: The First New World Pandemic and the Fall of the great Indian Empires,” Hispanic American Historical Review 47(1967):321-37; _____________. The Columbian Exchange: Biological and Cultural Consequences of 1492. Westport: Greenwood Press, 1972; _____________. “Virgin Soil Epidemics as a Factor in the Aboriginal Depopulation in America.” William and Mary Quarterly 33(1976):289-99; Lovell, W. George. “’Heavy Shadows and Black Night,’ Disease and Depopulation in Colonial Spanish America.” In The Americas before and after 1492: Current Geographical Research, Annals of the Association of American Geographers, Vol. 82, No. 3, September 1992; Cook, Noble David and W. George Lovell. “Unraveling the Web of Disease.” In The Secret Judgments of God: Native Peoples and Old World Disease in Colonial Spanish America, ed. Cook, Noble David, and W. George Lovell, pp. 215-244. Norman: University of Oklahoma Press, 1992.

It is noteworthy that these authors retrospectively cite each other for authority. However, in unraveling this web of scholarship, it becomes apparent that, for more than fifty years, a critical review of the underlying premises identifying smallpox as the cause of the1524 outbreak has been missing.

[ix] 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.

[x] Cook, Born to Die, 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.” Newson, “Epidemics…,” 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-Caceres, “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. Further discussion of this 1531 outbreak among the Spanish soldiers on the Manabi Coast follows below.

[xi] García-Carceres et al. “Bartonellosis…” pp. S60-S61.

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

[xiii] Polo, José Toribio. “Apuntes sobre las epidemias del Perú.” Revista Histórica, 5(1913):50-109, p. 52: “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.” My translation.

[xiv] Polo. “Apuntes…” p. 52: “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.” My translation.

[xv] Polo. “Apuntes…” p. 53: .” “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…” my translation.

[xvi] Polo. “Apuntes…” p. 53: “...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.” My translation.

[xvii] Polo. “Apuntes…” p. 53: “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.” My translation.

[xviii] Amano, Yasuji, et al. “Bartonellosis in Ecuador: Serosurvey and current Status of Cutaneous Verrucous Disease.” American Journal of Tropical Medicine and Hygiene52(2), 1997, pp. 174-179. p. 178: “The data support the hypothesis that mild or subclinical infections occur with regularity.”

[xix] Alexander, Bruce. "A review of Bartonellosis in Ecuador and Colombia,” American Journal of Tropical Medicine and Hygiene, 52(4), 1995, pp. 354-359. p. 356.

[xx] 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.

[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.

[xxv] Dobyns, Henry F. “An Outline of Andean Epidemic History to 1720.” Bulletin of the History of Medicine 37(1963):493-515, p. 494.

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

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

[xxviii] Newson. “Epidemics…” p. 90. [edited by N. D. Cook and W. George Lovel]

[xxix] 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 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.

[xxx] Cook, Born to Die, p. 72

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

[xxxii] Cook, Born to Die, p. 81, footnote 62. But see also Crosby, Columbian… 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.”

[xxxiii] 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.

[xxxiv]Newson, Linda A. “Epidemics in Early Colonial Ecuador” in Secret Judgments of God, Old World Disease in Colonial Spanish America. Ed. Noble David Cook and W. George Lovell. Norman: University of Oklahoma Press, 1991, pp. 84-112.

[xxxv] This and Preceding citations: Newson, “Epidemics…” pp. 88-9.

[xxxvi] Cook, Born to Die, p. 77. Here Cook cites Antonio Ricardo, Vocabulario y phrases en la lengua general de los indios del Perú, llamada quichua (Lima: San Marcos, 1951); the first edition was published in Lima in 1586.

[xxxvii] These images are copied from: http://phil.cdc.gov/Phil/default.asp

[xxxviii]The following images are from: Strong, Richard P., et al. Report of the first expedition to South America. Cambridge: Harvard University Press, 1915.

[xxxix]The image above of symptoms of verruga peruana posted by Dr. A. Tejada.,"Verruga peruana: más zonas endémicas." Gaceta San Marquina 8(32) Feb.1998, at www.unsm.udu.pe/imt/imt/carrion.htm

[xl] Symptoms of Verruga peruana copied from: http://www.usuhs.mil/pmb/TPH/bartonella.html

[xli] This image copied from: http://phil.cdc.gov/Phil/default.asp

[xlii] Odriozola, Ernesto. La enfermedad de Carrión o Verruga Peruana. Lima: Revista de la Sanidad de Policía, 1944. (Translated into Spanish from the original version published in Paris, 1898) p. 164.

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

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

[xlv] 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. See below for examples and discussion of pre-Columbian ceramics showing unmistakable signs of verrucose bartonellosis, or verruga peruana.

[xlvi] Cook, Born to Die, pp. 93-94 In fairness to Cook, it must be pointed out that he states elsewhere that “accurate diagnosis of disease symptoms reported by nonspecialists for nonmedical purposes is fraught with difficulty,” Cook and Lovell. “Unraveling…” p. 217. and that “the problem is that other diseases could have been confused with smallpox as it passed through its progressive stages.” Cook and Lovell. “Unraveling…” p. 218.

[xlvii] Alexander, “A Review…” pp. 354-359.

[xlviii] Alexander, “A Review…” p. 355.

[xlix] For additional images of other similar ceramics, see Appendix 3

[l] Alexander, “A Review…” p. 356.

[li] Cook and Cook. The Discovery…, p. 469.

[lii] Allison, Marvin J., et al. “A Case of Carrion’s Disease Associated with Human Sacrifice from the Huari Culture of Southern Peru.” American Journal of Physical Anthropology,19?? 41:295-300.

[liii] Alison et al., ‘’A Case…’’ p. 298.

[liv] Alison et al., ‘’A Case…’’. 295

[lv] Cooper, Philip, et al. « An outbreak of bartonellosis in Zamora Chinchipe Province in Ecuador. » Transactions of the Royal Society of Tropical Medicine and Hygiene (1997) 91: 544-546.

[lvi] Barbara A. Ellis, et al. ‘’An outbreak of Acute Bartonellosis (Oroya fever) in the Urubamba Region of Peru, 1998.“ American Journal of Tropical Medicine and Hygiene, 61(2), 1999, pp. 344-349, p. 348.

[lvii] See: Salazar, Thomas. “Historia de las verrugas.” La Gaceta Médica de Lima 2:2 (Marzo de 1858):161-164; 175-178; Observación 6, Aniceto de la Cruz. Image republished in: GarcIa-Caceres et al. “Bartonellosis…” p. s61.

[lviii] Ciro Maguiña MD, and Eduardo Gotuzzo, MD, FACP. “Bartonellosis Old and New.” Emerging and Re-emerging Diseases in Latin America, Infectious Disease Clinics of North America, Volume 14, number 1, March 2000, pp.1-22, p. 5.

[lix] Ellis, et al. ‘’An outbreak…” p. 344.

[lx] Ihler, Garret M. "Bartonella Bacilliformis: dangerous pathogen slowly emerging from deep background.” FEMS Microbiology Letters 144(1996):1-11, p. 2.

[lxi] Garcia-Caceres, et al. “Bartonellosis…” p. 61.

[lxii] Ihler, et al. “Bartonella…”. p. 2.

[lxiii] Chin, James. Control of Communicable Diseases Manual. Washington DC: American Public Health Association, 2000, p. 456 and 381.

[lxiv] Ihler. “Bartonella...” p. 2.

[lxv] Yasuji Amano, et al. “Bartonellosis in Ecuador: Serosurvey and Current Status of Cutaneous Verrucose Disease.” American Journal of Tropical Medicine and Hygiene, 57(2), 1997, pp. 174-79, p. 178.

[lxvi] Alexander, “Review of…” p. 357.

[lxvii] Gray et al. « An Epidemic…” p. 219. Illustration from p. 217.

[lxviii] Gray et al, ”An Epidemic…” p. 220.

[lxix] See: Jean-Pierre Protzen. Inca Architecture and Construction at Ollantaytambo. New York: Oxford University Press, 1993. See also Kenneth R. Wright, et al, “Ancient Machu Pichu Drainage Engineering,” Journal of Irrigation and Drainage Engineering, November 1999, pp. 360-369. or at http://www.wrightwater.com/wpi/wpihome.html

[lxx] Ellis, et al. ‘’An outbreak …” p. 345.

[lxxi] This and previous: Ellis et al, “An Outbreak…” p. 348.

[lxxii] For more information on sand flies, see: http://cipa.snv.jussieu.fr/

[lxxiii] Hemmings, John, The Conquest of the Incas. San Diego: Harcourt Brace Jovanovich, 1970. p. 13.

[lxxiv] Alexander, “A Review…,” p. 355-6.

[lxxv]See for example Margaret Kosek, et al. “Natural History of Infection with Bartonella bacilliformis in a Nonendemic Population.” Journal of Infectious Disease, 2000:182(September) pp. 865-872, p. 866

[lxxvi] Schultz, Myron G., "A history of Bartonellosis." American Journal of Tropical Medicine and Hygiene, 17(1968)4:503-515, p. 508. Schultz cites: Garcilaso de la Vega, 1617. Commentarios Reales. Córdoba. English translation by Maria Jones, Avon Co. New York, 1961.]

[lxxvii] Schultz. “A History…” p. 508.

[lxxviii] Alexander, “A Review…,” p. 358.

[lxxix] Yasuji Amano et al. “Bartonellosis in Ecuador: Serosurvey and Current Status of Cutaneous Verucous Disease.” American Journal of Tropical Medicine and Hygiene, 57(2), 1997, pp. 174-179, p. 175.

[lxxx] Alexander, “A Review…,” p. 356.

[lxxxi] Cook. Born to Die. p. 108. Cites Juan. B. Lastres. Historía de la medicina peruana, 3 vols. Lima: San Marcos, 1951, 2:76. However, on the title page of this book on the top line is written Universidad Nacional Mayor de San Marcos, but at the bottom may be seen: Imprenta Santa María, Lima – 1951. Cook is quick, in this instance, to point out the improbability of Lastres’ suggestion that the epidemic in this eyewitness report might have been smallpox and why, according to Cook, verruga peruana [bartonellosis] is “a more likely diagnosis.” Yet elsewhere Cook and others rely on Lastres for authority in identifying the fatal disease of Huayna Capac as smallpox. Lastres was, according to Cook, wrong to suspect smallpox in the incident reported by de Estrella.

[lxxxii] Alexander, “A Review of…” p. 355. While Pizarro’s expeditionary force was small, a more recently documented epidemic outbreak of bartonellosis occurred as a result of the 1932-34 war between Colombia and Peru. Alexander notes that:

The disease was apparently unknown in Colombia until 1936 when an outbreak occurred in the southwestern province of Narino…. The epidemic peaked during 1938-40 and began to subside from 1941 onwards. The fact that cases were reported among people of all ages in the indigenous population suggests that the area may not have been previously endemic for Bartonella. The apparent arrival of bartonellosis in Colombia occurred a few years after the war against Peru (1932-34), which suggests that B bacilliformis had been introduced by soldiers returning from that conflict. …The first recorded epidemic of bartonellosis in Colombia lasted into the 1940s, when more than 6,000 cases were reported.

Armies on the march, large or small, are a known cause of the spread of epidemic bartonellosis.

[lxxxiii] (red Spondylus were considered precious for use in ritual performance.) Rostworowski de Diez Canseco, Maria. History of the Inca Realm. Harry B. Iceland, trans. Cambridge: Cambridge University press, 1999. p. 72. map p. 20.

[lxxxiv] McEwan, Colin and María Isabel Silva I. “¿Que fueron hacer los Incas en la Costa Central del Ecuador?” In 5000 Años de Ocupación, Parque Nacional Machalilla. Ecuador, Centro Cultural: Ediciones abya-yala, 1992, pp. 71-102. My translated paraphrase of their text.

[lxxxv] Curie, Elizabeth J. Prehistory of the Southern Manabí Coast, Ecuador. López Viejo. Oxford: B.A.R., 1995, Chapter 5., p. 51.

[lxxxvi] McEwan and Silva. “Que fueran hacer…” pp. 74-75, citing María Isabel Silva. “Toponymic reconstruction as a basis for analysing social, economic, and political relationships among contact period settlements on the central coast of Ecuador.” Paper presented at the XI Annual Mid-west Conference on Andean and Amazonian Archaelolgy and Ethnohistory. Bloomington, 1983; and María Isabel Silva.”Pescadores y agricultores de la costa central del Ecuador: un modelo socio económico de asentamientos precolombinos.” MA thesis, University of Illinois at Champaign-Urbana, 1984. and Cabello Valboa, Miguel. Miscelánea antartica. [1586] Lima: Universidad Nacional Mayor de San Marcos, 1951, p. 322.

[lxxxvii] Alexander. “A Review...” p. 356. “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. Eight of the 10 bartonellosis cases treated at luis Vernaza Hospital in Guayaquil between 1968 and 1978 … were from Pajan or Jipijapa…”

[lxxxviii] See: “Carta de la provincia de Quito 1750: Pedro Vicente Maldonado” in Nuevo Atlas del Ecuador. Quito: Ediguias C. ltda., 1999. This map shows a road from Quayaquil to Xipixapa, calling it ‘Camino desierto.” Given the geography, the descriptions of him movements in the sources, and Huayna Capac’s objectives, it seems likely that he would have passed this way.

[lxxxix]Garcilaso de la Vega. Royal Commentaries of the Incas and general History of Peru, Part One. Austin: University of Texas Press, 1966. p. xx. Garcilaso, who wrote his history in Spain after leaving Peru forever in 1560, drew from many of the early Spanish accounts already published as well as from his own recollections of stories heard in his mother’s house. He has been much criticized for distorting the chronology of Inca history by portraying the process of Inca imperial expansion as something that occurred gradually over a long period of time through the reigns of many heroic rulers. Many modern historians believe that the process occurred more rapidly, under only two or three particularly gifted leaders. See John Howland Rowe. “Absolute Chronology in the Andean Area,” American Antiquity, 3, 1945, pp. 265-284.

[xc] Garcilaso, Commentaries…, Book Nine, Chapter 11, p. 546.

[xci] Garcilaso, Commentaries… p. 549

[xcii] Garcilaso, Commentaries… p. 551. Hamilton’s map shows the Four Quarters of the Inca Empire, including that of Chinchasuyu, to the north of Cusco, as mentioned in Garcilaso’s text. See: Hamilton, Roland, Ed. Bernabe Cobo, History of the Inca Empire. Austin: University of Texas Press, 1983, p. xii.

[xciii] Garcilaso, Commentaries… p. 559, See also the map from Alain Gheerbrant’s translation of Garcilaso, showing the areas of Hyauna Capac’s activities described in Garcilaso’s account: Garcilaso de la Vega. The Incas. Ed. Alain Gheerbrant. New York: Avon Books, 1961, p. 126.

[xciv]Garcilaso, Commentaries… p. 560-61.

[xcv]Garcilaso, Commentaries…p. 568.

[xcvi] Sarmiento de Gamboa, Pedro. Historia Indica. Roberto Levillier, ed. Buenos Aires: Espasa-Calpa Argentina S.A., 1942, pp 130-131, my translation. “Guancabilicas” refers to Huancavillca, or more or less the area south of a line running east and west through Chongon, including Guayaquil and the Point of Santa Elena.

[xcvii] It should be noted that even after full recovery from bartonellosis, the survivor may become an asymptomatic carrier, as may also happen in the case of survivors of typhoid fever, staphylococcal infections, among others. These “carriers” can act as “seeds.” Dr. John S. Marr, MD, personal communication.

[xcviii]Cook, Born to Die, p. 76.

[xcix]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.

[c]These images of Hansen's Disease (Leprosy) from: http://wwwihm.nlm.nih.gov/</ Image on left from WHO files.

[ci]Cook, Born to Die, p. 76.

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

[ciii] Photograph originally published in: Thomas Salazar. “Historia de las verrugas.” La Gaceta Médica de Lima 2:2 (Marzo de 1858):161-164; 175-178. This copy made from a photograph of the original taken for me by Jorge Lossio.

[civ] Betanzoz, Juan de. Narrative of the Incas. Trans. & ed. by Roland Hamilton and Dana Buchanan, Austin: University of Texas Press, 1996, pp. 183-184.

[cv] Trelles, J. O., et al "Formas neurologicas de la enfermedad de Carrión," Revista de neuro-psiquiatria. 1969, 32 (4): 245-306.

[cvi] Trelles et al., ‘’Formas… ‘’ pp. 265-66

[cvii] Trelles et al., ‘’Formas…’’ p. 269.

[cviii] The ninth was a case of 25 years duration of a different category.

[cix] Daniel Carrión from: http://www.usuhs.mil/pmb/TPH/bartonella.html

[cx] For an illuminating discussion of the socio-political environment that may have contributed to his decision to experiment on himself, see: Cueto, Marcos. “Tropical Medicine and Bacteriology in Boston and Peru: Studies of Carrión’s Disease in the early Twentieth Century.” Medical History, 1996, 40:344-364.

[cxi]This and preceding: Schultz, Myron G. "Daniel Carrión"s Experiment." New England Journal of Medicine, Vol. 278, June, 1968.

[cxii]Cook, Born to Die, pp. 80-81. Cook cites: Miguel Cabello de Balboa. Miscelánea antártica. Lima: San Marcos, 1951, pp. 393-394. Miguel Cabello Balboa, a soldier turned missionary who entered the Americas about 1566 and took Holy Orders in 1571. He began working on his history in 1576, having learned Quechua.

[cxiii] Hyslop, John. The Inka Road Project. New York: Academic Press, Inc., 1984, p. 297.

[cxiv] Chin, James, ed. Control of Communicable Diseases Manual. Washington DC: American Public Health Association, 2000, pp. 455-457. This is a re-arranged condensation of Chin’s text, containing verbatim transcriptions.

[cxv]Schultz. "A History…” p. 506. Stitt’s Diagnosis, Prevention and Treatment of Tropical Diseases, chapter XXIX. 1945, Maple Press Company, by Richard Strong, MD, ScD, DSM, CB, Professor of Tropical Medicine, Emeritus, Harvard University. Consultant in Tropical Medicine to the Massachusetts General Hospital and the Boston City Hospital.

[cxvi] Patrón, Pablo. “La enfermedad mortal de Huayna Cápac”. Lima: La Crónica Médica XI:131 (15 de junio de 1894): 179-183.

[cxvii] Schultz, “A History…” p. 506.

[cxviii] Patrón, “Enfermedad…” For a comparative discussion of Zancudos, mosquitos and sand flys, see Newson, “Epidemics…” 103-4.

[cxix]Patrón, “Enfermedad…”

[cxx] Schultz, “A History…” p. 506.

[cxxi] Barbara A. Ellis, et al. ‘’An outbreak of Acute Bartonellosis (Oroya fever) in the Urubamba Region of Peru, 1998.“ American Journal of Tropical Medicine and Hygiene, 61(2), 1999, pp. 344-349, p. 348.

[cxxii] Cook, Born to Die, p. 76.

[cxxiii]Schultz, “History…” p. 506.

[cxxiv] The distance from Cusco to Tumibamba, as the crow flies, is greater than 1,500 kilometers. At Hyslop’s extreme rate of 60 kilometers per day, this would require at least 25 days of travel. If the messenger had been infected with smallpox in Cusco on the day of his departure, even taking the extreme duration of incubation to onset after infection of 19 days, and allowing more 4 days before rash, by the 25^th day after leaving Cusco his symptoms would have already been well developed, at least to the point of prostration if not death. And this still does not explain how smallpox could have arrived in Cusco before breaking out on the coast, where the Spaniards had reportedly already made landfalls.

If the messenger did not himself come from Cusco, but was only the last in a series of relays, and if the disease he brought came from Cusco, “the epidemic center,” then each of the preceding relay runners in the chain must have passed the infection along. Betty J. Meggers has said that “”Along this road, messages were carried by relay runners from Quito to Cuzco, a distance of 1980 km, in eight days.” [ Meggers, Betty J. Ecuador. New York: Frederick A. Praeger publishers, 1966, p. 161.]This would mean a rate of 154 miles per day, or a constant velocity of 6.4 miles per hour. We might then assume 6 days for Cusco to Tumibamba, and assuming that three relays of 8 hours per day were made, that would mean a total of 18 different runners from Cusco to Tumibamba before the message and anything else would be transmitted to Huayna Capac, the 19^th person in this chain of transmission.

Smallpox is considered a highly contagious disease with an incubation period of 10-14 days before the abrupt onset of fever, headache and prostration, followed two to four days later by a rash - which is the source of contagion. It is a disease historically associated with a moderate to dense and susceptible human population as might exist in cities or confined areas of habitat. Prior to the onset of a rash (12-18 days after first exposure) the affected individual is quite sick, but not infectious to others. To postulate a successful continuum of infectious contacts along a sparsely populated area is difficult. More likely, the initial individual might infect nearby groups, the epidemic propagated in concentric waves, and not in a linear fashion. The probability of a string of 19 successful infectious encounters over such a short period, especially when a runner became ill (but not infectious for a few days) seems to be statistically remote.
While even this is possible, even if it were so it still does not explain how the disease got to Cusco in the first place, and why Huayna Capac could not have contracted smallpox from someone who contracted it from the Spaniards who were reported making landfalls along the coast about that time.

[cxxv] Ciro Maguiña MD, and Eduardo Gotuzzo, MD, FACP. “Bartonellosis Old and New.” Emerging and Re-emerging Diseases in Latin America, Infectious Disease Clinics of North America, Volume 14, number 1, March 2000, pp.1-22., p. 5.

The disease has two stages, anemic (Oroya fever) and eruptive (Peruvian wart), with an asymptomatic intermediate period. After an incubation period of about 61 days (range 10 to 210) acute infection results in bacteremic illness (Oroya fever) with nonspecific prodromal symptoms; onset is usually gradual with malaise, fever, headache, and mild chills. Common symptoms include fever, weakness, headache, pain in the back and extremities, and prostration, and the clinical picture is dominated by severe anemia.

[cxxvi]Borah, Woodrow. “Introduction,” in “Secret Judgments of God” Old World Disease in Colonial Spanish America, Eds. Noble David Cook and W. George Lovell. Norman: University of Oklahoma Press, 1991, pp. 3-19, p. 15.

[cxxvii] Juan Diaz de Solis sailed from San Lucar de Baremeda, near Cadiz, 8 October 1515, with sixty men on three small ships and arrived at the mouth of the Rio de la Plata on the 20^th of January 1516, after a voyage of 103 days. He planted a cross on the shore in the vicinity of the modern city of Montevideo, buried one of his crew on an island in the bay, and was himself killed by local Indians while ashore with a few companions as the rest of his crew looked on helplessly from the boats. On the return to Spain, one of the boats foundered off Brazil, leaving 18 sailors abandoned. The survivors integrated themselves into the coastal conditions, some later serving as guides and translators to Diego García and Sebastián Cabot in 1526. Cabot sailed from Cadiz, 5 April 1526, and arrived in the Rio de la Plata in the summer of 1526 with 150 men in three ships. Cabot explored the river and built permanent buildings, remaining in the area over three years before returning to Spain in 1530. See: Ventura Fuentes, Transcribed by Joseph E. O'Connor, “Juan Díaz de Solís.” In The Catholic Encyclopedia, Volume IV Copyright © 1908 by Robert Appleton Company, Online Edition Copyright © 1999 by Kevin Knight, citing: Frejeiro, Juan Díaz de Solís y el Descubrimiento del Rio de la Plata (1879-80); Trelles, Diego Garcia, Primer Descubridor del Rio de la Plata (Buenos Aires, 1879); Berra, Bosquejo Historico de la Republica Oriental del Uruguay (Montevideo, 1881), and Otto Hartig Transcribed by Matthew Reak. “Sebastián Cabot” In In The Catholic Encyclopedia, Volume IV Copyright © 1908 by Robert Appleton Company, Online Edition Copyright © 1999 by Kevin Knight, citing: Winship, Cabot Bibliography (London, 1900), gives a list of the extensive bibliography on the subject in 579 titles; Biddle, Memoir of Sebastian Cabot (London, 1831); D'Avezac, Les navigateurs terre-neuviens Jean et Sébastien Cabot (Paris, 1869); Nicholls, Life, Adventures, and Discoveries of Sebastian Cabot (London, 1869); Harrisse, Jean et Sébastien Cabot (Paris, 1882); idem, The Discovery of North America (Paris, 1892); Markham, ed. and tr., The Journal of Christopher Columbus and Documents Relating to the Voyages of John Cabot and Gaspar Corte Real (London, 1893), No. 86 of the publications of the Hakluyt Society; Beazley, John and Sebastian Cabot (London, 1898); The Voyages of Columbus and of J. Cabot, ed. Bourne (New York, 1906).

[cxxviii] Newson. “Epidemics…” p. 91.

[cxxix] Newson. “Epidemics…” p. 90.

[cxxx] Newson. “Epidemics…” pp. 111-112.

[cxxxi] William of Occum 1300-1349. It is vain to do with more what can be done with less. [Occum's Razor]

[cxxxii] Patrón, “Enfermadad…”

[cxxxiii] (Maguina and Gotuzzo, “Bartonellosis…,” pp. 5-6)

[cxxxiv] Ellis, et al., ‘’An Outbreak…,’’ p. 344.

[cxxxv] These images show Ollantaytambo in January 1994. Note free ranging pig in street near water canal at left of street and donkey and donkey manure in the street near water canal.

[cxxxvi] Rural home near Pisac, January 1994, note stream in foreground that is the domestic water source.

[cxxxvii] Niles, Susan A. The Shape of Inca History, Narrative and Architecture in an Andean Empire. Iowa City: University of Iowa Press, 1999. p. 296.

[cxxxviii] Ihler. « Bartonella… » p. 2.

[cxxxix] Cooper, Philip, et al. “An Outbreak…”

[cxl] Cooper, Philip, et al. “An Outbreak…”, p. 544.

[cxli] See : LeVine, Terry Y. Inka Storage Systems. Norman: University of Oklahoma Press, 1992.

[cxlii] Zhou, Jiayu, et al. ‘’The effect of Regional Climate Variability on Outbreak of Epidemics of Bartonellosis in Peru.” Preprints of the 3rd Symposium on Environmental Applications: Facilitating the Use of Environmental Information, American Meteorological Society 82nd Annual Meeting, 3-17 January 2002, Orlando, Florida.