An Age-Old Problem
Throughout history, the greatest threat to most armies was not enemy swords, spears, bayonets, bombs, or bullets. Until at least World War II, disease and infection killed or incapacitated more soldiers than combat. Even today, during the Coronavirus pandemic, there are reports of infections within the military at much higher rates than the general population. Like many people worldwide, I have been staying at home and watching a global epidemiological disaster unfold, while trying to ignore the uncomfortable fact that I am at the center of it. As are we all. This naturally led me to reflect on the topic in the context of the times of the Yankee Doodle Spies.
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| The Black Death wreaked havoc and terrorized over centuries of outbreaks |
Disease in War
In a strange irony, war unites people. Not just through direct clashes between enemies but through the essential bonding of close-knit units who are forced to eat, sleep, train, and fight together. Camps and garrisons turn into breeding grounds, especially when hygiene is neglected. It is this very closeness that makes them so vulnerable when different outbreaks occur.
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| Gathering of soldiers in military camps was ground-zero for the spread of disease |
Epidemics have weakened armies, sometimes rendering them unfit for combat, outbreaks have halted military operations, and of course, there is the impact on civilian populations that armies come into contact with. Geography influences the spread of disease, with both bitter cold and scorching hot climates playing a role. Swamps, coastal areas, and cities all provide environments conducive to various types of illness. Additionally, the transportation of armies involves moving soldiers to new lands where they can encounter unfamiliar diseases and potentially bring their own to affect local populations.
Yankee Doodle Disease
The American Revolution, in many ways, exemplifies all of these factors. Men from farms and forests mixed with men from towns and seaports. Undernourished, often poorly dressed and exposed to the elements, these men (and women) often faced an enemy worse than any redcoat or Hessian—a foe invisible to the naked eye that, in most cases, even the best medicine of the time could not understand or fight. Simply put, they faced germs that delivered a punch as deadly as any .69-inch musket ball or 17-inch bayonet. Diseases such as smallpox, dysentery, and malaria were common among American, British, and Hessian soldiers alike. This enemy didn't pick sides. Given the close quarters of 18th-century camps, these diseases spread through a camp like a windstorm across the high plains.
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| Disease killed more men than musket balls or bayonets |
A Different Kind of Battle
The soldier of the American Revolution faced highly professional armies equipped with the best weapons of the late 18th century. But if musket and cannon did not kill the soldier, the state-of-the-art treatment for a wound or illness might. Data indicates the typical combatant had a 98% chance of surviving battle but about a 75% chance of walking (or limping) out of the hospital. Unsanitary conditions, ignorance of vectors, and lack of practical remedies combined in a tragically unfair fight for the wounded or sick patriot. There were no antibiotics, but plenty of bleeding. No anesthetic, but plenty of bullets to bite. And if things looked really serious? Not to worry — there was an abundance of trained surgeons and their assistants who could cut off a limb or bleed the lifeblood from you.
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| State-of-the-art medical kit of the Rev War |
A Different Kind of Surgeon
During the American Revolution, almost anyone could claim to be a doctor and start practicing medicine as long as they apprenticed with another doctor for a few years. Very few were trained surgeons from Edinburgh or London. Even if they were, medical science at the time was based on theories—often false—not on real scientific knowledge. This was especially true for illnesses, particularly infectious diseases. Doctors often believed most illness resulted from “an imbalance of the humors”—blood, yellow bile, black bile, and phlegm. How to restore the humors’ balance? The common methods included bloodletting or using herbal mixtures to induce vomiting or bowel movements. Many approaches aimed to rebalance the humors.
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| Bleeding was a common treatment for bad humors |
A Different Kind of Pharmacist
Medicine during the time of the Yankee Doodle Spies was hard to find. Before the war, medicine, like nearly everything else, had to come from England. That was one reason we rebelled. The war broke that supply chain until the French alliance in 1778. A new supply line from France brought medicine to America. But even when medicine reached the army camps, most of it was of limited use, if not dangerous. In a medical field that had no anesthetics, opiates were the main painkillers, followed by hard liquor and the bullet previously mentioned. For various ailments, some surgeons used mercury compounds, lavender spirits, and cream of tartar.
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| Medicines of the day were interesting |
Climate Change
Disease could strike regardless of climate. Winter brought seasonal flu and pneumonia that overwhelmed soldiers with their own lungs. The years of the American Revolution saw harsh winters, partly due to a mini-ice age. Many perished at Valley Forge, Morristown, Newburgh, and other winter cantonments. Summer, especially in the South, swamps, and low-lying coastal flats, produced noxious vapors—often malaria, but more frequently deadly yellow fever. Of course, these vapors, traditionally called miasmas, were not the actual cause. Insects, specifically mosquitoes, were the real vector.
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| Swamps along the Georgia and Carolina littoral were a breeding ground for the"noxious and bilious vapors" that plagued both sides |
The war in the South was heavily affected by disease. It was one of the biggest concerns for the British high command, who had experience sending soldiers into warmer regions. The outbreak of disease repeatedly weakened General Charles Cornwallis’s army in the Carolinas, affecting battles and strategy. At crucial moments, key lieutenants got sick, as did Cornwallis himself. When he finally had a reasonably fit and equipped force at Wilmington, he chose to move north to Yorktown instead of back into South Carolina, partly to get his army into a healthier climate. We know how that turned out.
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| Disease factored into the strategy of Lord Cornwallis, with unpredictable results |
Mother of All Maladies
Smallpox was a deadly disease during the time of the Yankee Doodle Spies. It could leave permanent scars even if it didn't kill you. Armies and their camp-followers were highly vulnerable, and outbreaks threatened both sides. Smallpox somewhat resembles the coronavirus in how it appears. It spreads through direct contact, not through insects or other vectors. The incubation period can be up to two weeks before symptoms appear. Its symptoms are similar to those of the flu and COVID-19, including fevers, headaches, and body aches.
However, smallpox also causes pustules to form across the body. Soldiers suffered for about another two weeks before they either recovered or succumbed. The disease killed about one out of three infected (a 30% mortality rate, in Dr. Fauci’s terms), and survivors often took weeks to fully recover. Of course, the characteristic scars served as a constant reminder for both the individual and those around them.
The Continental Army experienced outbreaks during the siege of Boston and the defense of New York, when large numbers of soldiers were gathered in cramped conditions. There were two main approaches to fighting the disease, neither of which was particularly effective when it came to waging war.
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| Soldiers from over a half-dozen states gathered outside Boston, providing conditions ripe for the spread of disease |
Social Distancing
The first was quarantine, the social distancing of the day. Hard to do when men are organized in units such as companies, regiments, and brigades. Harder to do in winter quarters, where men huddled freezing around smoky campfires and shared common meals together. Meals were often sparse and unnutritious. The Continental Army could not telework. Well, at least not for long.
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| Winter cantonments such as Valley Forge, Morristown and Newburgh offered little chance for social distancing |
Variolation
As controversial in the time of the Yankee Doodle Spies as it is today, smallpox was one of the few diseases preventable by inoculation, then called variolation. The variolator used a lancet with fresh matter taken from the pustule of someone with active smallpox. The material was then scraped onto the arms or legs of the recipient, or introduced through the nose. There were risks associated with this; recipients often developed symptoms like fever and a rash. However, fewer people died from variolation than if they had contracted smallpox naturally. In a study conducted during an outbreak in Boston in 1722, those without variolation died at a rate of 14%, while the variolated died at 2% (.14 versus .02 in Dr. Fauci's terms). This might have been one of the earliest examples of data in medical science.
Surgeon-in-Chief
Besides serving as commander-in-chief and spymaster-in-chief, General George Washington was the ultimate decision-maker on medical procedures used to fight outbreaks. He had a mild case of smallpox earlier in life during an expedition to the West Indies. However, military needs in 1775 and 1776 prevented him from ordering widespread variolation. Meanwhile, the British were administering it to any recruits coming to America.
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| The year 1777 required forced inoculation to prevent the army from wasting away from smallpox |
By 1777, the situation shifted. A series of outbreaks that year claimed as many as 100,00 lives in North America. The colonies had only 2.5 million residents, not including native tribes in the colonies, Spanish America, and Canada. But that's still a pretty large “numerator,” as the good doctor would say. Washington had to weigh the risk that mass inoculation might weaken the Continental Army and finally approved the procedure, starting with all new recruits. By the next year, however, a significant number of men had still somehow avoided the process. This time, Washington issued strict orders that these men would undergo inoculation. Washington made variolation for smallpox "settled science."
Father of Public Health
Just as the ravages of infectious disease helped signal the end of the Roman Empire, Medieval Europe, and other civilizations, the major smallpox outbreaks in America during the fight for independence may have achieved what large numbers of redcoats and Hessians could not—break the resolve of the patriots. It is not hyperbole to say that the mass inoculation ordered by Washington saved the army and, consequently, the American cause. He may even add the honorific, the “Father of Public Health,” in addition to the “Father of His Country.”
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| First in War, First in Peace, First in Public Health |
