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This page intentionally left blank
fm.plagues 4/19/04 3:12 PM Page i

PLAGUES & POXES

T H E I M PA C T
OF HUMAN HISTORY
ON EPIDEMIC DISEASE
This page intentionally left blank
fm.plagues 4/19/04 3:12 PM Page iii

PLAGUES & POXES

T H E I M PA C T
OF HUMAN HISTORY
ON EPIDEMIC DISEASE

Alfred Jay Bollet, M.D.

NEW YORK
fm.plagues 4/19/04 3:12 PM Page iv

Demos Medical Publishing, Inc.

386 Park Avenue South, New York, NY 10016, USA
Visit our website at www.demosmedpub.com

© 2004 by Demos Medical Publishing, Inc. All rights reserved. This book is
protected by copyright. No part of it may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without the prior written permission of
the author or publisher.
Library of Congress Cataloging-in-Publication Data
Bollet, Alfred J.
Plagues & poxes : the impact of human history on epidemic disease /
Alfred Jay Bollet.— 2nd ed.
p. ; cm.
Includes bibliographical references.
ISBN 1-888799-79-X (hardcover)
1. Epidemiology—History.
[DNLM: 1. Disease Outbreaks—history. 2. Communicable
Diseases—history. 3. Epidemiology—history. WA 11.1 B691p 2004] I.
Title: Plagues and poxes. II. Title.
RA649.B65 2004
614.4’9—dc21
2003011450
Made in the United States of America
fm.plagues 4/19/04 3:12 PM Page v

TO AUDREY

“We’ve known so much of happiness,

We’ve had our cup of joy,
And memory is one gift of God
That death cannot destroy.”

From “Should You Go First,” by AK Rowswell, in Poems that Live Forever, ed. by Hazel Felleman,
Garden City, NY, Doubleday, 1965.
This page intentionally left blank
fm.plagues 4/19/04 3:12 PM Page vii

ACKNOWLEDGMENTS

I would like to thank the publisher of Demos Medical Publishing, Dr. Diana
M. Schneider, for her assistance and interest in this work. She has been an
enormous help both as advisor and editor.

vii
This page intentionally left blank
fm.plagues 4/19/04 3:12 PM Page ix

CONTENTS

PREFACE xi

INTRODUCTION UNINTENTIONAL CAUSES OF EPIDEMIC DISEASES

THE IMPACT OF HUMAN HISTORY ON DISEASE 1

PART ONE INFECTIOUS DISEASES 15

BUBONIC PLAGUE
THE PROTOTYPE OF PANDEMIC DISASTERS 17

THE “LITTLE FLIES” THAT BROUGHT DEATH, PART 1

MALARIA OR THE BURNING AGUE 31

THE “LITTLE FLIES” THAT BROUGHT DEATH, PART 2

YELLOW FEVER 45

SYPHILIS
THE GREAT POX 67

THE SMALL POX 75

CHOLERA AND THE WORLDWIDE PLAGUES OF THE

NINETEENTH CENTURY 91

THE GREAT INFLUENZA PANDEMIC OF 1918-1919

PRESIDENT WOODROW WILSON AND THE BLITZKATARRH 103

POLIOMYELITIS
WHY DID FRANKLIN DELANO ROOSEVELT
GET INFANTILE PARALYSIS AS AN ADULT? 119

ix
fm.plagues 4/19/04 3:12 PM Page x

x ◆ plagues and poxes

PART TWO NONINFECTIOUS DISEASES 139

BERIBERI
AN EPIDEMIC AFFECTING RICE-EATERS 141

THE PELLAGRA EPIDEMICS

THE THREE M’S PRODUCE THE FOUR D’S 153

SCURVY
THE PURPURA NAUTICA 173

RICKETS
THE ENGLISH DISEASE 191

GOUT
THE DISEASE OF GOOD LIVING 197

PART THREE INTENTIONALLY INDUCED AND NEWLY

EMERGING DISEASES 203

ANTHRAX
FROM WOOLSORTER’S DISEASE TO TERRORISM 205

BOTULISM
FROM BAD FOOD TO TERRORISM 215

THE SARS EPIDEMIC

A NEW DISEASE RETRACES THE EXPERIENCE WITH OLDER DISEASES 221

INDEX 231
fm.plagues 4/19/04 3:12 PM Page xi

PREFACE

T he first edition of Plagues and Poxes concentrated on the recurrent appear-

ances and disappearances of new diseases in various parts of the world, and
the impact of those diseases on history, especially political and military history.
Since its appearance so many new diseases of great importance have appeared that
the point of the book is no longer news or surprising. Examples include AIDS, of
course, the most important and devastating of the new diseases, but Lyme disease,
a new devastating form of asthma, a new form of viral encephalitis, West Nile
virus, and a new form of viral hepatitis, hepatitis C, has come to the fore and is
now the most serious form of that disease. So many new diseases have appeared
that we have books and papers on “Emerging Diseases” and, more specifically,
emerging viruses. At the same time, established but relatively new diseases have
waned in frequency, most notably peptic ulcers, cancer of the stomach, and
rheumatic fever, and deaths from heart disease have decreased considerably. But a
new phenomenon has come to the forefront of public consciousness—intention-
ally caused disease, or bioterrorism. Thinking about the history of disease, these
new concerns have brought to mind the fact that historical phenomena—military,
political, and technological—have impacted the occurrence and severity of dis-
ease for as far back as history goes. This new edition shifted the emphasis to the
impact of history on disease, rather than the reverse.
Historical developments have always been causal factors in the production of
disease, at least since the first agriculturalists domesticated previously wild ani-
mals and caught their diseases. Measles, smallpox, and a variety of bacterial dis-

xi
fm.plagues 4/19/04 3:12 PM Page xii

xii ◆ plagues and poxes

eases are examples. Knowledge of the deadly nature and contagiousness of dis-
ease has lead to military efforts to induce disease in enemies, especially during
sieges; bubonic plague and syphilis are major examples dating back to the four-
teenth and sixteenth centuries.
On the other hand, knowledge of how diseases are spread has led to useful
and sometimes successful efforts to control outbreaks of disease, beginning with
quarantine for bubonic plague and, most notably, the successful containment of
an outbreak of a serious severe respiratory disease in 2003 (SARS).
Knowledge of the factors that have been of importance in the international
spread of major epidemic diseases in the past, both infectious and non-infectious,
is worth reviewing in detail, and that is the subject of this new, revised edition of
Plagues and Poxes.
ch01.plagues 4/19/04 1:43 PM Page 1

INTRODUCTION

UNINTENTIONAL CAUSES
OF EPIDEMIC DISEASES
T H E I M PAC T O F
HUMAN HISTORY
ON DISEASE

M any of the worst diseases of the past—infections

such as typhoid fever, smallpox, and plague—have now become rare, at
least in developed countries. In contrast, noninfectious diseases, such as cancer
and coronary heart disease, have replaced them as major epidemic causes of death.
It is usually human actions, including warfare, commercial travel, social adapta-
tions, and dietary modifications, that precipitate the rise and fall of diseases.
Some infectious diseases that have caused the most devastating mass mortal-
ity in human history can trace their origin and mode of spread to human activ-
ity and behavior. Many other diseases, both infectious and noninfectious, have
been caused and spread by technological changes that benefited society as a
whole, but had serious side effects that resulted in epidemic disease. For exam-
ple, changes in food technology, mainly the availability of new foods or new
means of processing old foods, have inadvertently brought on massive outbreaks
of disease. Beriberi and pellagra are prime examples of this phenomenon. In both
instances, new technology made more food available and thus supported a much
larger population; at the same time, because micronutrients and the conse-

1
ch01.plagues 4/19/04 1:43 PM Page 2

2 ◆ plagues and poxes

quences of lack of them were not yet known, they induced nutritional deficiency
diseases.
Such phenomena are avoidable, and those diseases caused by human actions
are preventable. We have seen a most important example of this in recent times
in the decreased incidence of coronary heart disease that resulted from changes
in smoking and dietary habits in the United States and Western Europe. A clear
knowledge of how and why epidemic diseases appear and spread is important in
curbing the damage they do. (Although chemical pollution of the environment
threatens to cause severe epidemic diseases, thus far only localized outbreaks of
illnesses have been caused by air or water pollution. A discussion of the threat
posed by these phenomena requires a separate volume and will not be covered
here.)
Plagues and Poxes concentrates on the history of major outbreaks of both
infectious and noninfectious disease caused by human action through the ages.
Prime historical examples of how human action resulted in epidemics of infec-
tious diseases include the search for gold in the New World, which spread small-
pox and measles among previously unexposed Native American populations;
the corresponding introduction of syphilis into the Old World by European
adventurers; and the importation of African slaves into the Western hemi-
sphere, which introduced devastating new diseases such as malaria and yellow
fever. Such interchange of disease still occurs, with the AIDS epidemic probably
the most important example in recent decades. An analysis of the historic spread
of these diseases may be useful in preventing new epidemics.
Most of the diseases discussed in the following chapters are side effects—the
consequences of human actions that unintentionally caused them. Today, how-
ever, we are faced with concern for the intentional spread of disease through acts
of bioterrorism. Several chapters are thus devoted to the history and knowledge
of those diseases that are thought to be potential candidates for bioterrorism.

ORIGINS OF SOME INFECTIOUS DISEASES. Before agriculture, humans lived in

small hunter-gatherer tribes. A high infant mortality rate probably kept the pop-
ulation small, although evidence suggests that intentional measures, such as
infanticide, lengthening the birth interval through prolonged lactation-amenor-
rhea, sexual abstinence, or abortion, were also used to keep tribal size down to
levels that the food supply could support. Most clans or tribes were nomadic, fol-
lowing the seasonal patterns of availability of game and vegetation. Based on
bone and skeletal analyses, paleontologic evidence shows that hunter-gatherers
(at least the ones who survived to adulthood) were healthy people, maybe even
healthier than populations that developed after the introduction of agriculture.1
ch01.plagues 4/19/04 1:43 PM Page 3

unintentional causes of epidemic diseases ◆ 3

The development of agriculture resulted in a considerable increase in the

human population in those areas that adopted the new techniques. With agri-
culture came a more settled existence that led to larger population units and
more complex social structures, including administrative or political systems
involving kings, bureaucrats, and taxes. Large clusters of humans thus gave rise
to true civilizations in which some people were able to devote their efforts to
administrative or artistic skills instead of to simply obtaining food.
Unfortunately, these larger and more condensed population groups also gave rise
to “crowd diseases.” Large groups of people allowed the spread and perpetuation
of infectious diseases agents because susceptible, nonimmune people kept
appearing in sufficient numbers to keep a disease from dying out.
The domestication of animals occurred along with organized agriculture.
This resulted in larger numbers and greater varieties of animals living in close
proximity to humans. Some of the diseases of these animals now could affect
humans, or perhaps become genetically modified to become epidemic human
diseases. The genetic structure of the relevant organisms provides clues that the
animal diseases listed in Table 1-1 are closely related to human diseases. Other
diseases may belong on this list, the most important being AIDS, which may be
a simian disease that has spread to humans.
Another disease that might be discussed is typhus. However, although a great
deal has been written about typhus in history, in many outbreaks it is hard to
establish that the diseases being described before the mid-nineteenth century
were in fact typhus. For example, typhoid fever was not distinguished as a sep-
arate entity distinct from typhus until the 1830s, and was named for its clinical
resemblance to typhus. After that time typhus was less and less commonly diag-
nosed and typhoid became more and more a dominant disease and cause of
death. There is a lot of evidence that typhus became common after the begin-
ning of the sixteenth century, especially among armies, and that it was spread

Table 1-1. Human Diseases and Their Animal Counterparts

Human disease Genetically related animal disease

Measles Rinderpest of cattle
Tuberculosis Tuberculosis of cattle
Smallpox Pox viruses of domestic animals, including
cowpox
Influenza Influenza in pigs, ducks, and chickens
Whooping cough Similar disease in pigs and dogs
Falciparum* malaria Malaria in birds (perhaps chickens and ducks)

* The most severe form of malaria, which causes high rates of mortality in humans.
ch01.plagues 4/19/04 1:43 PM Page 4

4 ◆ plagues and poxes

primarily by the troops during wars.2 It became a constant threat to prisoners in

jails (where it was often called “jail fever”), to people crowded on ships (“ship
fever”), and when troops were gathered together for training (“camp fever”).
During the American Civil War there were virtually no cases of typhus diag-
nosed despite optimal conditions for its spread. Soldiers existed in crowded liv-
ing conditions and virtually all the soldiers and officer on both sides were heavily
infested with lice; in addition, many of the soldiers were recent immigrants from
European areas where typhus was common. But typhoid was the major killer
disease while typhus—well known to Civil War doctors—was very rare. In view
of the voluminous literature on typhus and doubts as to the accuracy of the diag-
noses before the mid-nineteenth century, I have omitted coverage of that dis-
ease.

EPIDEMICS OF NONINFECTIOUS DISEASES. Histories of epidemic disease con-

centrate on those infectious diseases that caused famous outbreaks and affected
the course of historic events, but great epidemics of noninfectious diseases
occurred as well. These epidemics were possibly less dramatic because of their
gradual onsets. However, many were as devastating as many infectious diseases
in terms of numbers of deaths they caused. The most notable examples are the
nutritional deficiency diseases, scurvy being the most famous from the stand-
point of its effect on history. However, the concept of a deficiency of a specific,
individual nutrient as a cause of disease was not understood before the early
twentieth century. From the late eighteenth century onward, it was believed
that disease was caused by the presence of something abnormal; how then, could
it be due to the absence of something? Once the concept of micronutrient defi-
ciency was understood, measures to limit the occurrence of these diseases began.
Modern scientific methods soon identified deficient nutritional components,
isolated them, and synthesized them so that supplements could be made avail-
able in adequate quantities to combat these dietary diseases.
The first deficiency diseases appeared when early human populations settled
into farming communities, and the wide variety of foods enjoyed by nomadic
hunter-gatherer groups was no longer available. Through paleopathology—the
study of ancient remains—we can safely guess that the first epidemic nutritional
deficiency disease was probably iron-deficiency anemia. In long-standing iron-
deficiency anemia, bones, especially those of the skull, show changes caused by
an increase in the size and number of blood forming spaces filled by the bone mar-
row, along with a corresponding enlargement of the marrow as it tries to com-
pensate for the lack of iron by making more red blood cells. Such bony changes,
called porotic hyperostosis, are seen in modern humans with long-standing anemia,
ch01.plagues 4/19/04 1:43 PM Page 5

unintentional causes of epidemic diseases ◆ 5

especially those caused by genetic deficiency syndromes that begin in childhood.

Although data is limited, a higher frequency of such changes has been found in
the skulls and bones of early agricultural societies compared to the bones of
hunter-gatherer groups. These findings most likely point to a lack of dietary iron,
a vital nutrient present mainly in red meat but mostly absent in vegetables. As
agriculture led to a more settled, less nomadic existence, the human diet changed
from one of primarily meat, in the form of game, to vegetables and grains. This
inevitably led to iron deficiency.
Although the domestication of animals provided new sources of meat, pale-
opathologic evidence of iron deficiency shows that these supplies were often
inadequate for the burgeoning population. To compound the problem, settled
agricultural societies are more prone to parasitic infections spread by the fecal
contamination of water supplies; many of these parasites cause intestinal blood
loss, thus aggravating the problem of anemia. Iron deficiency is most severe in
individuals who need iron most—growing children and menstruating women.
Iron deficiency causes functional impairment, including weakness, lassitude,
and a general lack of energy. Other enzymes in the body require iron in addition
to hemoglobin, and the effects of iron deficiency are widespread in the body, as
shown by the clinical observation that treatment of such patients with iron
results usually in marked symptomatic improvement before the hemoglobin
level begins to rise.
Changes in the availability and nature of specific foods continued to affect
both the size of population groups and the health of these groups throughout
history. For example, when New World maize (corn) was introduced to Europe,
the greater caloric yield per acre resulted in a considerable population increase
in areas that grew it, especially Spain and Italy. Potatoes introduced into Ireland
from the New World resulted in a great increase in population there.
In Ireland during the 1840s and 1850s, severe famine resulted from the loss
of the potato crops to a fungal infestation, coupled with British laws that
required the export of food that was raised. The population of Ireland had risen
from about 2 million to about 4 million after the potato was introduced. Deaths
from famine (with scurvy diagnosed in a high proportion of the people), coupled
with emigration, resulted in the population decreasing back to 2 million within
a decade.
The effect of maize on population growth was similar to that of the potato,
but the reason for the epidemic disease that followed was quite different. In both
cases, the problem was the fragile nutritional state that results when any single
vegetable crop is the main source of food. However, in the case of maize, an epi-
demic of pellagra resulted from the almost exclusive use of maize as a staple food.
The epidemic was severe in southern Europe late in the eighteenth century and
ch01.plagues 4/19/04 1:43 PM Page 6

6 ◆ plagues and poxes

continued to be so at least through the nineteenth century; pellagra appeared in

the United States late in the nineteenth century, causing millions of cases and
hundreds of thousands of deaths. The cause of pellagra is not famine, but a defi-
ciency in the amino acid lysine. A change in the method of milling corn resulted
in the loss of the marginal amounts of lysine it contains, and the diet of those
people dependent on cornmeal as their main staple was now deficient in this
amino acid.
A similar epidemic of a nutritional disease occurred in the Far East late in the
nineteenth century. Populations dependent on rice as their main source of calo-
ries and protein developed a new disease, beriberi, when the method of milling
the rice was changed by new food processing technology that removed the nutri-
tious outer layers of the rice kernel in the process of “polishing” it. Although the
total quantity of food available increased as spoilage was diminished, diets that
previously maintained health became deficient. As another example, rickets—a
Vitamin D deficiency disease—became epidemic when children no longer
received enough sunlight because of the crowded urban conditions and heavy
smoke cover in cities during the burgeoning Industrial Age.

A BRIEF HISTORY OF BIOLOGICAL WARFARE. Biological warfare is not a new

phenomenon. Although war has always helped to spread disease, attempts have
been made to intentionally cause epidemic disease almost since the dawn of
recorded history. For example, since antiquity, wells and other water sources for
armies and civilian populations under attack have been purposely contaminated
with animal or human cadavers as well as with excrement. Among the earliest
recorded examples of the use of agents thought to cause disease in battle are the
actions of Scythian archers, who used arrows dipped in blood, manure, or fluids
from decomposing bodies when trying to stop the invading Assyrians in the sev-
enth century BCE.
Spontaneous diarrhea and dysentery have always been the scourge of armies
in the field, vastly impairing the effectiveness of soldiers. In the fighting among
the Greeks in the sixth century BCE, Solon of Athens had water supplies poi-
soned with hellebore, a purgative. During the American Civil War when diar-
rhea was ubiquitous—Walt Whitman said the war was “about nine hundred and
ninety-nine parts diarrhea to one part glory”—a tradition arose not to shoot a
man “while he is attending to the urgent call of nature” and was honored by
both sides throughout the war.
As described in the chapter on bubonic plague, human cadavers were used in
the fourteenth century in an attempt to spread disease during the outbreak of
plague called the “Black Death.” The epidemic began in an area of Russia, near
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