Black Death by Graham Twigg (review)

BOOK REVIEWS Black Death. By Graham Twigg. New York: Schocken Books, 1985. Pp. 254. $23.50. In the 1950s the dean at Harvard Medical School exhorted the incoming students to develop skepticism of dogma with the statement, "One half of what you learn in the next four years will ultimately prove to be untrue—I only wish I could tell you which half." The Black Death by Graham Twigg is an exercise in creative skepticism. The retrospective analysis of epidemic events which occurred more than 500 years ago must reflect the experience and biases of the analyst. The Black Death of the Middle Ages has usually been approached from the viewpoint of the historian, the demographer, the microbiologist, the physician, the epidemiologist , or the political scientist. The author brings a zoologist's experience to bear on the evidence supporting the formulation that the Black Death was caused by Yersinia pestis carried by fleas feeding on the black rat. He finds the evidence unconvincing on the basis of analyses that suggest that the black rat population in Great Britain and Europe was insufficient to support a great plague epidemic and that the seasonal and geographic distribution of human plague in wellstudied areas was contrary to the seasons and places in which the black rat populations would be largest. Having done significant damage to the thesis that black rats were the important reservoir for the disease, the author has the choice of seeking another rodent reservoir to explain the spread of the plague bacillus or of seeking a different disease to explain the available epidemiologic and clinical facts. He chooses the latter course and suggests that the Black Death was in fact inhalation anthrax caused by the burgeoning wool trade in Europe and England with augmentation by person-to-person spread. Because my bias is that of a clinician-epidemiologist, I have several problems with accepting this formulation . My chief concern is that anthrax has not been known to produce major epidemics of human disease in modern times despite its high endemicity in animals and its continued occurrence in humans in many parts of Asia and Africa. From a clearly clinical viewpoint, the malignant pustule of anthrax is characterized by an enormous amount of surrounding edema, a major clinical finding that tends to distinguish anthrax pustules from pustules caused by other microorganisms. The absence of this striking finding in the descriptions of the Black Plague make me reluctant to accept anthrax as a strong candidate agent. The descriptions of the dark skin lesions appearing shortly before death most closely resemble the purpuric lesions associated with disseminated intravascular Permission to reprint a book review printed in this section may be obtained only from the author. Perspectives in Biology and Medicine, 29, 4 · Summer 1986 \ 63 1 coagulation in a late phase of septic illness caused by a wide variety of bacterial and viral pathogens. Having made some telling points against the black rat's role in the Black Death, the author gives only brief consideration to the possibility that the disease was indeed caused by Yersinia pestL· but that other small animals such as hares or squirrels might have served as important reservoirs. Finally, there is insufficient attention paid to the concept of postparasite adaptation . Over the years the mortality of smallpox diminished dramatically, even though no specific therapy existed. It seems more likely than not that an organism such as Yersinia pestis would make alterations and adaptations in both its rodent and its human ecologie relationships over the centuries and that the discoveries about the behavior of the bacillus in the era of modern medicine and epidemiology may relate only imperfectly to the situation in medieval times. Despite these reservations, I found The Bfack Death a fresh and challenging reappraisal of a widely accepted formulation which caused me to rethink what I thought was bedrock fact. Today's "facts" should be constantly scrutinized, and I thank the author for a stimulating book. Pierce Gardner Departments of Medicine and Pediatrics University of Chicago The Captured Womb. By Ann Oakley. New York: Basil Blackwell Publisher, 1984. Pp. 351, illustrated. $16.95. Anyone who writes history, whether a professional historian or a talented amateur, approaches...