Sunday, March 29, 2020

Episode 142 Disease in the Revolution

I said last week I would be covering Burgoyne’s Northern Army as it prepared to attack Fort Ticonderoga.  However, I changed my mind.  I’m going to do something a little different this week.  Normally, I cover a specific event in time during the American Revolution.  But as the Covid-19 pandemic spreads across the world, I thought it would be interesting to take a broader look at disease in the American Revolution.

Mortality Rates

In the eighteenth century, disease was a part of life, and a common cause of death.  For twenty-first century listeners who take antibiotics and advanced medical care as a given, it may be hard to appreciate how far we’ve come from a time when amputations with dirty saws and unwashed hands were the norm, and a simple cold could kill you.

The eighteenth century was a time that, if you lived to adulthood, you had beaten the odds.  Infant mortality rates from that era, which are sketchy and can vary greatly depending on your source, seem to show that your odds of making it to ten years old were about 40%.  Less than a third made it to age twenty.

George Washington visits sick at Valley Forge (from ArtNet)
Europeans had brought many diseases to North America, which famously wiped out more than 90% of the native population.  The reason the Pilgrims were able to settle in Plymouth, Massachusetts and found good farming land ready for planting, was that explorers had traveled through that same area while infected with smallpox a few years earlier and wiped out every member of the tribe that had lived there.

Disease in the colonial era was always a problem. Wars only made a bad situation worse.  Crowding people together in large groups, providing inadequate food, poor access to fresh foods, and exposure led to high death rates among the military without a shot being fired.  The British army calculated that it lost 11% of its soldiers just transporting them across the Atlantic Ocean.  It was an expectation that an army would lose a fair portion of its soldiers to disease in any given year.

On the American side, less than seven thousand soldiers were killed in action.  Conservative estimates say at least 17,000 died from disease, and that is probably an underestimate. A great many sick soldiers went home or left for civilian care and died from their disease without being counted.   Some estimates put the number at over 60,000, or about nine times the number of battle deaths.

That’s also just counting soldiers.  The movement of troops spread disease all over the continent.  Civilians and soldiers alike contracted disease and died.  In only one year, 1777, and from only one of many diseases, smallpox, estimates are that over 100,000 soldiers and civilians died.

Smallpox was one of the most virulent killers of the era.  If you caught smallpox and survived, you had immunity.  George Washington had traveled to Barbados as a teenager and contracted the disease there.  This probably saved his life during the war as smallpox ravaged his army.  However, he had pock marks on his face for his entire adult life as a result of contracting the disease.  Some have speculated that smallpox may have rendered Washington unable to have children.  Infertility is sometimes the result of a smallpox infection.

By the way, Washington was not traveling to Barbados for spring break.  He went with his older brother Lawrence, who had contracted tuberculosis.  It was thought that the climate there would help Lawrence to recover.  It did not.  As I said, Washington contracted smallpox. The two brothers spent a few miserable months on the island before returning home.  Lawrence died from tuberculosis the following year at age 33.  Upon his death, George inherited the home that his brother named after the man he had served under while a marine with the British Navy, Admiral Edward Vernon.


Smallpox was the most deadly disease of the era.  Typically, among Europeans, the death rate was around 30%.  Without any real prevention or cure, it would spread through regions until enough people had died off and the rest had socially distanced themselves that it went away.  It would usually come back again in a few years when people had gone back to normal living and another infected person introduced it into the community.

Smallpox Patient
(from Wikimedia)
A smallpox infection initially presented itself by causing headache, chills, backache, high fever, vomiting, and anxiety. These occurred about twelve days after exposure, giving the infected person time to spread it to others before falling ill.  About four days after feeling symptoms, the victim would suffer a rash on the face, chest, arms, back, and legs.  The rash would turn into sores around the mouth, throat, and nasal passages. After that, pustules or “pox” would pop up all over the skin of the person.  The density of the pox usually an indicated the chance of death.  If the patient survived, the pox would turn into scabs and eventually fall off, leaving a scar on the skin.  If the patient survived this for about a month, he or she would likely recover.  The patient would no longer be infectious only once all the scabs had fallen off.

A smallpox epidemic broke out in Boston during the siege in 1775.  The British Commander, General Thomas Gage had to quarantine infected patients to limit its spread among the British regulars as well as the civilian population.  In November, he forced several hundred sick civilians to leave the city, where they passed through the American lines.  This, of course, spread the disease to the Continental Army as well.

There, General Washington had to order quarantines, or what they called "isolation" to help prevent its spread.  It was one of his first orders of business.  The day before he formally took command of the Continental Army on July 3, 1775, the army received orders that called for the appointment of a "suitable person" to make daily inspections of the men of each company for illness, and any soldier showing symptoms of smallpox to be isolated immediately. Two days later, Washington issued orders cautioning against soldiers traveling to infected areas "as there may be danger of introducing smallpox into the army."

A few weeks later, Washington wrote to Congress, saying that  he had "been particularly attentive to the least Symptoms of the Small Pox, hitherto we have been so fortunate, as to have every Person removed so soon, as not only to prevent any Communication, but any Apprehension or Alarm it might give in the camp. We shall continue the utmost Vigilance against this most dangerous Enemy."

Although smallpox is very deadly, it is not as contagious as some diseases. You have to have direct contact with someone who is sick in order to catch it. Therefore, quarantines could be relatively effective if strictly enforced.  Even so, hundreds of soldiers died of the disease at the siege of Boston.

When General Gage expelled the sick from Boston, Washington had to issue orders to "prevent any of your officers from any intercourse with the people who ... came out of Boston." As Washington explained "there is great reason to suspect that the smallpox is amongst them, which every precaution must be used to prevent its spreading." In January 1776, the Continentals established a hospital at Dorchester, Massachusetts, to isolate American officers and soldiers who contracted the disease.

General John Thomas,
Smallpox victim
(from Mass. Hist. Soc.)
Smallpox proved to be an even worse scourge for the northern army that invaded Quebec.  Almost as soon as Benedict Arnold’s forces arrived in December 1775, word of smallpox outbreaks began to circulate.  One reason General Richard Montgomery opted to attack Quebec on December 31 was that he was concerned that the disease would only continue to ravage his army (see Episode 79).  Those who were not sick wanted to leave before they caught it.  Few recruits wanted to join the army that appeared to be a breeding ground for smallpox.

During the siege of Quebec, Continentals reported at times more than three-fourths of their soldiers unfit for duty.  The inability to implement strict quarantines as had happened in Boston meant that the disease ran rampant.  When Major General John Thomas was sent to command the army in Canada, he fell ill with smallpox within days of his arrival and quickly died.

Smallpox continued to plague the army over the course of the entire war.  It was almost certainly the single largest killer of soldiers.


One reason smallpox became less of a problem in the later part of the war was inoculations.  There had been an inoculation for smallpox available for decades.  In fact, there is evidence that the Chinese understood how to perform inoculations for centuries.  Inoculation seems to have reached the western world in the late seventeenth century.  It was used in Boston as early as the 1720’s.

Cotton Mather (from Art)
There were, however, some problems with inoculation.  Many ministers opposed inoculation as “playing God”.  Many believed that disease was a curse from God and that trying to prevent it through actions other than prayer and obedience to God’s law was wrong.  That said, one of the earliest proponents of inoculation was a minister, Cotton Mather, who greatly encouraged its use in Boston in the early 18th century. Inoculations also first became common as ways of protecting Native Americans and negro slaves.  For many colonists the practice took on a “heathen” connotation, or something that was necessary only for the lower classes.

Religious and racist concerns aside, there were also some good arguments in the age of reason for not inoculating.  One of the big ones was that inoculation gave you a mild version of smallpox.   Some small percentage of those inoculated, in some cases as many as 2%, died from the inoculation.  Another famous New England minister, Jonathan Edwards received the inoculation and died as a result.

Some argued that dangerous inoculations violated the hippocratic oath of doctors to “do no harm.” Inoculation also made you a carrier, even if you did not get as sick as others.  For a period of time, an inoculated person could pass the disease to others, who would in turn get the full deadly version of the disease.  Thus, inoculation made you a danger to others.

Many colonies had laws against inoculation as a result.  People did not routinely get inoculated and instead simply hoped they would not get sick.

Jonathan Edwards
(from Wikimedia)
The British Army did, as a matter of routine, inoculate its soldiers.  Unlike civilians, soldiers were likely to come into contact with many different people in their travels, and had a much higher likelihood of catching the disease at some point.  Inoculations also meant that they could get sick at a convenient time when they could get proper treatment and be contained, as opposed to getting sick in the field where they could spread the disease and at a time when they might be needed for battle.  However, even though soldiers did often receive inoculation, many did not.  This is why it was still a problem for General Gage during the Siege of Boston.

The Americans had no inoculation plan.  As I said, inoculations were illegal in many parts of America.  Beyond that, commanders could not afford to have their entire army sick for several weeks while they were in the field and in the face of the enemy.  Therefore, they largely relied on isolation measures to keep it under control.  As I said, in many places this was not strict enough to be effective and had devastating results.

In some cases, soldiers inoculated themselves against orders and were court martialed.  Now you may think, how can you punish a soldier for protecting himself?  Consider that making yourself sick made you unavailable for duty at a possibly critical time.  Also, by infecting yourself, you put all of your fellow soldiers at risk since you could spread the disease to them.

At the same time, inoculation under the right conditions became the sensible action for most.  As I mentioned in an earlier episode, Martha Washington received an inoculation in May 1776 before joining her husband at his command of the army.

Members of Congress had advised General John Thomas to get inoculated before he took command of the northern army in Canada. Thomas demurred.  He wanted to be an example to his men, who were not allowed to be inoculated.  As a result, his death became an example of what happens when you enter a smallpox infected area without protection.

By early 1777, General Washington was convinced of the necessity of inoculation.  In a letter to William Shippen in January, he wrote:
Finding the smallpox to be spreading much and fearing that no precaution can prevent it from running thro' the whole of our Army, I have determined that the Troops shall be inoculated. This Expedient may be attended with some inconveniences and some disadvantages, but yet I trust, in its consequences will have the most happy effects. Necessity not only authorizes but seems to require the measure, for should the disorder infect the Army, in the natural way, and rage with its usual Virulence, we should have more to dread from it, than from the sword of the enemy. ... If the business is immediately begun and favored with the common success, I would fain hope [the soldiers] will be soon fit for duty, and that in a short space of time we shall have an Army not subject to this, the greatest of all calamities that can befall it, when taken in the natural way.
Even after some officers became convinced of the importance of inoculation, they continued to face opposition.  When Major General William Heath announced a plan to inoculate his army, local officials in Massachusetts voted to stop it for fear his inoculated soldiers would spread the disease to local civilians.  At times, more than one third of the Continental Army was unfit for duty, largely due to smallpox.

Edward Jenner
(from Wikimedia)
Despite opposition, by 1777, Washington ordered that his soldiers be inoculated and that new recruits be inoculated and isolated for several weeks before joining the army in the field.  Even so, it took time to implement these orders.  Washington was still reporting small outbreaks in 1778.  Despite some lapses, the inoculations had the intended effect.  In 1778 and 1779, rates of soldiers unfit for duty due to illness dropped from heights of over one-third to less than ten percent.

It was not until after the war ended, that a better inoculation came into being.  In 1796 a British scientist named Edward Jenner figured out that a similar, but less deadly disease, known as cowpox, was similar enough to smallpox that victims of cowpox were immune to smallpox.  He developed an inoculation that did not subject recipients to even a small risk of death and which would not transmit smallpox to others.  Jenner named his cure after the Latin name for cowpox, which is vaccinia.  And that, boys and girls, is where we get the name vaccine.

It would take nearly 200 years of the use of Jenner’s vaccine to eradicate smallpox.  The last known naturally occurring infection ended in 1977.

Disease Prevention

Smallpox was the worst but was far from the only disease that ravaged the continent during the Revolution.  Measles, mumps, typhus, typhoid, malaria, influenza, dysentery, and others all struck the army at various times leading to illness and sometimes death, although the death rates were much lower than for smallpox.

When the British army invaded the south in the later part of the war, it suffered greatly from malaria and other tropical diseases.  Local patriots who had contracted malaria at earlier times, had developed some immunity, giving them a real advantage.

Early 19th Cent. cartoon an overcrowded room, captioned
wonderful effects of cowpox (from Army Heritage)
Many diseases were caused simply by poor conditions.  Soldiers would urinate and defecate in camps rather than digging latrine pits.  Although science did not understand germs, there was an understanding that such conditions, in addition to creating a horrible stench, did somehow lead to disease.

In 1776 a German manual called “The Diseases Incident to Armies With the Method of Cure" was published in Philadelphia.  It gave advice such as providing fresh foods when possible, and not cramming soldiers together in small spaces for prolonged periods of time.  It also recommended good clothing and selecting dry areas for setting up camps.

General Washington put a particular emphasis on cleanliness and ordered punishments for soldiers who did not comply.  Dr. Benjamin Rush, who served in the Continental Congress, published a pamphlet called “Directions for preserving the health of soldiers” where he divided his advice into five sections: Dress, Diet, Cleanliness, Encampments, and Exercise.

General Friedrich von Steuben, a veteran of the Prussian army who is probably best remembered for bringing organized drill to the Continental Army at Valley Forge, was also a big proponent of maintaining clean conditions in order to prevent disease. He wrote that:
The preservation of the soldiers health should be [a regimental commander’s] first and greatest care; and as that depends in great measure on their cleanliness and manner of living, he must have a watchful eye over the officers of companies, that they pay the necessary attention to their men in those respects.
Von Steuben went on to instruct that officers must remove anyone with an infectious disease to a hospital immediately, or if no hospital available, isolate the solder to prevent the spread of infection.  He also noted the shared responsibility to keep camps clean for health purposes.  Important rules included keeping latrines at least three hundred feet from tents, and that latrine pits, which he called “sinks” be filled and redug at least every four days, more often in warm weather.

Despite the good advice, and efforts to enforce better conditions, I’ve seen estimates that death rates from disease in the Continental Army were nearly twice that of the British and Hessian Armies.  Part of that can probably be attributed to the more strict implementation of rules among the professional European armies and built up immunity among soldiers who had been exposed to disease over many past campaigns.  Part of it could also be attributed to the Continental army having less money to feed, clothe, and provide shelter for soldiers in the field.

Although this disparity in deaths from disease seemed to narrow over the course of the war, it remained the leading cause of death by far for both sides.  Experienced soldiers knew that the real threat did not come from the enemy.  It came from an invisible attacker that was far more lethal.

Next week: Burgoyne's Northern Army in Canada prepares to invade upstate New York.

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Next Episode 143 Burgoyne's Northern Army

Previous Episode 141 Congress Returns to Philadelphia

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Further Reading


Museum of the American Revolution “Fighting Infection”

A Deadly Scourge: Smallpox During the Revolutionary War:

Becker, Ann M. “Smallpox in Washington's Army: Strategic Implications of the Disease during the American Revolutionary War.” The Journal of Military History, vol. 68, no. 2, 2004, pp. 381–430.

Bayne-Jones, Stanhope The Evolution of Preventive Medicine in the United States Army, 1607-1939, Part III The American Revolutionary War and First Years of the Republic:

Kantrow, Louise. “Life Expectancy of the Gentry in Eighteenth and Nineteenth-Century Philadelphia.” Proceedings of the American Philosophical Society, vol. 133, no. 2, 1989, pp. 312–327:

Blanco, Richard L. “Military Medicine in Northern New York, 1776–1777.” New York History, vol. 63, no. 1, 1982, pp. 39–58. JSTOR,

Free eBooks
(from unless noted)

Rush, Benjamin, Directions for preserving the health of soldiers : addressed to the officers of the Army of the United States, Philadelphia : Printed for Thomas Dobson, Fry and Kammerer, printers, 1808 (originally published 1777).

Swieten, Gerard, Freiherr van The diseases incident to armies: With the method of cure, Philadelphia: R. Bell, 1776.

Gillett, Mary C. The Army Medical Department 1775-1818, Center of Military History, 1981 (

Thacher, James The American Revolution: from the commencement to the disbanding of the American army; given in the form of a daily journal, with the exact dates of all the important events; also, a biographical sketch of all the most prominent generals, American Subscription Pub. House, 1860 (originally published 1823) (or buy a printed copy, see below).

Books Worth Buying
(links to unless otherwise noted)*

Abrams, Jeanne E. Revolutionary Medicine: The Founding Fathers and Mothers in Sickness and in Health, NYU Press, 2013.

Coss, Stephen The Fever of 1721: The Epidemic That Revolutionized Medicine and American Politics, Simon & Schuster, 2016.

Fenn, Elizabeth A. Pox Americana: The Great Smallpox Epidemic of 1775-82, Hill and Wang, 2001.

Petriello, David Bacteria and Bayonets: The Impact of Disease in American Military History, Casemate, 2016.

Reiss, Oscar Medicine and the American Revolution: How Diseases and Their Treatments Affected the Colonial Army, McFarland & Company, 1998 (book recommendation of the week).

Thacher, James An Army Doctor's American Revolution Journal, 1775–1783, Dover Publications, 2019 (reprint of free ebook, see above).

* As an Amazon Associate I earn from qualifying purchases.

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