Yankee Doodle Disease

An Age-Old Problem

Throughout the course of history, the bane of most armies was not enemy swords, spears, bayonets, bombs, or bullets. Up until at least the second world war, disease and infection killed or disabled more men than battle. Even with today’s Corona Virus Pandemic, there are reports of infections in the military at much higher rates than the regular population. Like so many people around the world, I have been sitting at home and watching a global epidemiological disaster unfold, while trying to ignore the inconvenient fact that I am at the center of it. As are we all. This led me, naturally, to ruminate on the topic in terms of the times of the Yankee Doodle Spies.

The Black Death wreaked havoc and terrorized
over centuries of outbreaks

Disease in War

In a strange irony, war brings people together. Not just the face to face clash of foes but the necessary formation of close-knit units who are thrown together to eat, sleep, train and fight. Camps and garrisons become breeding grounds, especially when hygiene is not maintained.  It is that very closeness that makes them so vulnerable when various outbreaks occur.

Gathering of soldiers in military camps was
ground-zero for the spread of disease

Epidemics have weakened armies, sometimes rendering them unfit for combat operations, outbreaks have frozen military operations, and of course, there is the effect on civilian populations armies come in contact with. Geography plays a role, with both bitter cold and steaming hot climates playing a role in the spread of illness. Swamps, littorals, and cities all present environments supportive of various types of disease. And of course, the transports of armies, placing soldiers in strange new lands where they can encounter new diseases and bring their own to impact the locals. 

Yankee Doodle Disease

The American Revolution in many ways exemplifies all of these factors. Men from farms and forests thrown together with men from towns and seaports. Undernourished, often poorly dressed and exposed to the elements, these men (and women) often faced a foe worse than any redcoat or Hessian. A foe invisible to the naked eye and who, in most cases, the best medicine of the age did not comprehend and could not combat. Simply put, they faced an array of germs that packed a punch as bad as any .69-inch musket ball or 17-inch bayonet. Diseases such as smallpox, dysentery, and malaria, were commonly suffered by American and British and Hessian soldiers alike. They were an enemy that did not choose sides. Given the close-quarters environments of 18^th century encampments these diseases would spread through a camp like a windstorm across the high plains.

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 18^th 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 stood a 98% chance of surviving battle, but around a 75% chance to walk (or limp) from the hospital. Unsanitary conditions, lack of knowledge of vectors, lack of practical remedies combined in a tragically unfair fight for the wounded or sick patriot. No antibiotics, but plenty of bleeding. No anesthetic, but plenty of bullets to bite. And if things really looked 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.

State of the art medical kit of the Rev War

A Different Kind of Surgeon

During the time of the American Revolution, pretty much anyone could claim to be a doctor and begin practicing medicine as long as they spent a few years of apprenticing with another doctor. Very few were trained surgeons from Edinburgh or London. And even if they were, medical science of the day was based on theories (often bogus), not on real scientific knowledge. This was especially true when it came to illness, especially infectious disease. Doctors of the period thought most illness was brought about by “an imbalance of the humors” -- blood, yellow bile, black bile, and phlegm. How to regain the balance in the humors?  The typical procedure used was bloodletting or sometimes herbal concoctions to help induce vomiting or bowel movements. Lots of ways to restore the balance.

Bleeding was a common treatment for bad humors

A Different Kind of Pharmacist

Medicine in the time of the Yankee Doodle Spies was hard to come by. Prior to the war, medicine, like almost everything else, had to come from England. One reason we rebelled.  The war broke that supply chain until the French alliance in 1778. A new supply chain from France brought medicine to America. But even when medicine reached the army camps, most were of limited value, if not dangerous. In a medical field that lacked anesthetics, opiates were the go-to painkillers, followed by hard liquor, and the previously mentioned bullet. For various ailments, some surgeons used mercury compounds, lavender spirits, and cream of tartar.

Medicines of the day were, interesting

Climate Change

Disease would strike in any climate. Winter brought seasonal flu and resultant pneumonia that drowned the soldier in his own lungs. And the years of the American Revolution had some savage winters thanks to a mini-ice age. Many died at Valley Forge, Morristown, Newburgh, and other winter cantonments. Summer, especially in the south and in the swamps and low-lying coastal flats, brought the noxious vapors, often malaria but more often deadly yellow fever. Of course, the vapors, typically called miasmas, were not the vector. Insects provided that. In the case of the latter, the lowly mosquito.  

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 impacted greatly by disease. It was one of the biggest concerns of the British high command, who had experience sending soldiers into warmer climes. The outbreak of disease chronically weakened General Charles Cornwallis’s army in the Carolinas, impacting battles and strategy. At critical junctures, key lieutenants got ill, as did Cornwallis. When he finally had a reasonably fit and equipped force in hand at Wilmington, he decided to move north to Yorktown and not back into South Carolina in part to get his army into a healthier climate. We know how that turned out.

Disease factored into the strategy
 of Lord Cornwallis, with unpredictable results

Mother of All Maladies

Smallpox was a real killer in the time of the Yankee Doodle Spies. And it could leave permanent scarring when it did not actually kill you. Armies and their camp-followers were very susceptible to the disease and outbreaks threatened both sides. Smallpox in some ways resembles the Corona Virus in its manifestation. It spreads from direct contact, not other vectors such as insects. It can incubate a fortnight before victims are symptomatic. It manifests with some of the similar to Corona and the flu bringing fevers, headaches, and body aches. 

But the smallpox piles on with the outbreaks of pustules on the body. Soldiers suffered for about another fortnight before succumbing. It killed one out of three people infected (.3 mortality rate in Dr. Fauci terms) and the survivors take weeks and weeks to recover. Of course, the tell-tale scars make sure you (and those around you) never forget.

The Continental Army suffered outbreaks during the siege of Boston and the defense of New York, again large numbers of soldiers in a relatively confined area. There were two approaches to combating the disease, neither helpful when you are trying to wage a war.

Soldiers from a 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 unit sets, such as companies, regiments, and brigades. Harder to do in winter quarters, where men huddled freezing around smokey campfires and shared common meals together. Meals often sparse and un-nutritious. The Continental Army could not telework. Well, at least not for long.

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 today, the 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 matter was then scraped on the arms or legs of the recipient, or introduced through the nose.  There were risks to this, recipients often developed the symptoms like fever and a rash. But fewer people died from variolation than if they had acquired smallpox naturally. In a study conducted during an outbreak in Boston in 1722, those without variolation died at the rate of 14%, the variolated died at 2% (.14 versus .02 in Dr. Fauci terms). This might have been one of the first instances of data in medical science.

Surgeon-in-Chief

In addition to being commander-in-chief and spymaster-in-chief, General George Washington was the final arbiter on the use of medical procedures to battle outbreaks. He himself had a mild version of smallpox earlier in life during an expedition to the West Indies. Yet military exigencies in 1775 and 1776 precluded him from ordering widespread variolation. The British, meanwhile, were using it on any recruit coming to America. 

The year 1777 required forced inoculation to
prevent the army from wasting away from smallpox

By 1777 the situation changed. A series of outbreaks that year would take as many as 100,00 lives in North America. Only 2.5 million lived in the colonies, not counting the native tribes in the colonies, the Spanish-America and Canada. But a pretty large “numerator” as the good doctor would say. Washington had to take the risk that mass inoculation would not debilitate the Continual Army and finally approved the procedure, beginning with all new recruits. By the following year, however, a considerable number had still somehow avoided the procedure. This time, Washington gave strict instructions 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 bring the death-knell of the Roman Empire, Medieval Europe and other civilizations, the great outbreaks of smallpox in America during the struggle for independence might well have done what masses of redcoats and Hessians could not do, break the will of the patriots.  It is not hyperbole to say that the mass inoculation ordered by Washington saved the army and thus the American cause. And he may be able to add the honorific, the “Father of Public Health” in addition to the “Father of His Country.”

First in War, First in Peace,
First in Public Health