This Distemper is the King of Terrors to America this year. — John Adams, 1776 As the winter of 1776 deepened, General George Washington, Commander in Chief of the Continental Army, read the pointed note from General Horatio Gates, his commander in northern New York, explaining why the army was melting away. "The very great desertion from this army has, I believe, been principally occasioned by the dread of the smallpox." Washington could only agree. During 1776, the Continental Army had sustained 1200 men wounded and 1000 killed in action. Smallpox had claimed another 10,000. Word had gotten around that smallpox was a hazard of military duty in Washington's army. Fear of smallpox had reduced the flow of new recruits to a trickle. A Destroying Angel Smallpox is a viral disease with the scientific name of variola. In its heyday it could sweep through populations like a scythe. For all its killing power smallpox's onset was deceptively ordinary. About two weeks after infection, usually by inhaling the virus on airborne droplets, a victim developed a fever and splitting headache, often accompanied by a backache, chills and vomiting. Two or three days later, as these symptoms began to fade, the first sign of the rash appeared, starting on the tongue and palate and spreading rapidly on to the forehead and face and then to the limbs and the trunk. The spots filled with fluid, growing and hardening. The result was painfully disfiguring. The victim was covered with swollen pustules, sometimes so severe that they forced his eyes closed. At this point, 10 to 16 days after onset, death was most likely to occur. The pattern of the pustules was often a good prognosticator. If the sores did not touch (discrete smallpox) mortality was less than 10%, if they ran into each other to form huge pustules, mortality was 50 % (confluent smallpox). If bleeding erupted beneath the surface of the skin, and from the nose and mouth (hemorrhagic smallpox, purpura variolosa, black smallpox) death was certain. If the patient survived this stage there was a gradual subsidence of the symptoms, with scabbing and healing. About 75% of the time the victim was branded with pockmarks for life. Washington was intimately familiar with smallpox. In 1751, when he was nineteen, he had accompanied his brother Lawrence by boat to Barbados. The trip, the only one he ever made outside the colonies, resulted in his contracting smallpox. Washington nearly died from the attack. His physician attributed his survival to his youth and the fact that Washington was a physical giant for the time (about 6 foot 3 inches) and of "robust constitution." The disease also left his face severely pocked. Paintings of Washington with smooth skin were artistic license, a common practice of the time. The same would be done with the pockmarks left on one of his successors as President — Andrew Jackson. Washington's near fatal encounter with smallpox left him with a healthy respect for the disease, and an appreciation of what it could do to his army. Variolation The American Revolution was fought nearly twenty years before Edward Jenner discovered the process of vaccination. For the person who contracted smallpox in 1776 smallpox there was no cure. Death occurred in one out of four cases. The disease accounted for one-third of the blindness in Europe and North America. Even though there was neither cure nor vaccine, there was another process, called variolation, that had shown some success. Variolation took several forms, but in essence it involved deliberately infecting a person with smallpox through a break in the skin made by a needle or a lancet. A small amount of either pus or a portion of ground up scab from a smallpox patient was then placed in the wound. After variolation, both arms swelled. A rash appeared upon the face after about three days. On the seventh or eighth the patient might become feverish and a small number of pustules appear. By the fourteenth day, the patient usually recovered and was immune. The advantage of variolation was that the smallpox was milder than through the normal route and almost never scarred the patient. But there were problems and risks associated with the procedure. A variolated person had to be isolated. In essence he had smallpox and could transmit it to another person through the usual respiratory route. Anyone infected by a variolated person developed a full-blown case of smallpox with the associated 25% mortality level and the disfigurement. The other risks came from the smallpox matter itself. Though they were supposed to collected from relatively mild cases, they often were not. A variolated person could discover, to his horror, that he had contracted hemorrhagic smallpox and die. At the same time he could be infected with other diseases, such as syphilis, that the source patient had had. But variolation did have the saving grace of only having a 1% mortality rate, versus the 25% mortality rate of natural smallpox. Still, variolation was opposed by a large percentage of American medical men. While a 1% risk sounded low, many medical men questioned the value of exposing someone to that risk when, in the natural course of events, they might never encounter smallpox at all. The other problem was the enforced quarantine period — only the very rich could afford to be away from their responsibilities for two-three weeks. The other risk was to the community in general — ariolated persons could, and had caused, epidemics. To variolate an entire army, in essence, removing portions of it from combat status, developing a system of isolation and knowing that you were going to cause the death of some of them by the process. Though the process had been introduced from Turkey to Europe in 1711, no army commander had ever variolated his troops. The risks were simply too great. Smallpox And The Siege Of Boston After the battle of Bunker's Hill in June 1775 Washington and his men lay in wait around beleaguered, British-occupied Boston for nine months, refusing to attack. In addition to the British troops inside the city, Boston was having a full blown smallpox epidemic. It barely bothered the British under General Sir William Howe. Smallpox had been endemic in Britain for several centuries and most of the British soldiers had had the disease as children, and hence were immune. By comparison smallpox was not a common disease among the colonists except in the port cities where it would flare up from time to time. Hence, while only a handful of Howe's troops were susceptible, Typical smallpox pustules virtually all of Washington's army was unprotected. The specter of smallpox doing to his army what it had done to him, haunted Washington. On July 21st he wrote the Continental Congress that "I have been particularly attentive to the least symptoms of smallpox, and hitherto we have been so fortunate as to have every person removed as soon as noting them, to prevent any communication, but I am apprehensive it may gain in the camps. We shall continue the utmost vigilence (sic) against this most dangerous enemy." As the siege of Boston dragged on, Washington began to suspect that the British were deliberately planting smallpox victims among the refugees they permitted out of the town. Their intent, he believed, was to infect the Continental Army. On December 3, 1775 Robert H. Harrison, addressing the provincial council of Massachusetts, voiced Washington's concerns: "I am commanded by [Washington] to inform you that four deserters have just arrived at headquarters giving an account that several persons are to be sent out of Boston, this evening or tomorrow, that have lately been inoculated with the smallpox with the design to spread the infection in order to distress us as much as possible." On December 11, 1775, Washington wrote the Congress of his misgivings: "The information that the Enemy intended spreading Small pox among us I could not suppose them capable of. I must now give some credit to it as it made its appearance on several of those who last came out of Boston. Every necessary precaution has been taken to prevent it from being communicated to the Army and the General Court will take care that it does not spread throughout the country." Washington's concerns about a British attempt to employ biological warfare against his army was not a case of excessive anxiety. In 1763, during the French and Indian War, the British commander-in-chief of the American colonies, Jeffrey, Lord Amherst had responded to an Indian rebellion by attempting to annihilate the tribe. He ordered that blankets taken from the beds of smallpox patients be given to the natives. A few months later, smallpox broke out and the Indians were ravaged by disease. Unable and unwilling to assault the city, partly because of the fear of smallpox, Washington continued the siege. On March 15, 1776 the British Commander Howe sent word that his troops were preparing to evacuate (and threatened to burn the city if the withdrawal were challenged). With the prize he had sought for nine months within his grasp, Washington was still wary and concerned about the possibility that the smallpox epidemic in the city might spread to his troops. He issued a general order declaring the city off limits to his own men: "As the enemy has with malicious assiduity spread the smallpox through the Town, no officer or soldier may go into Boston when the enemy evacuates the Town." When the British finally left on March 17th, Washington lifted the ban, ordering that "One thousand men, who had had the smallpox" take possession of the city. Two days later, he was forced to send in the most of his men to secure the badly needed supplies left by the British against the civilians who were pouring back into Boston. Smallpox struck some of the troops but a general epidemic was avoided by rapidly isolating the afflicted. Smallpox: Savior Of Canada While Washington was deadlocked at Boston, smallpox was moving to center stage in Quebec, to star as Defender of Canada. The colonials had decided to attack eastern Canada to prevent the British from using it as a base against them. They also expected to win a large new territory as well. Quebec was unprepared for such an attack. The overconfident Governor, Guy Carleton had earlier dispatched most of his troop to Boston. This left him fewer than six hundred regulars to defend the entire province. In the fall of 1775, General Montgomery led two thousand men from Crown Point, up the western side of Lake Champlain, capturing Montreal in September. Benedict Arnold led another 1000 men out of Boston overland along the Kennebec River and across to the Chaudiere River, which they followed to the St. Lawrence at Quebec City. Carleton retreated from Montreal to lead the defense of Quebec. Montgomery and part of his forces then joined Arnold for a combined assault on the fortified Canadian capital. If the colonials had taken Quebec City, the province would have been theirs. The first assault, amidst a snowstorm on 31 Dec. 1775 was repulsed. Arnold was wounded and Montgomery killed. The colonials laid siege. Major General John Thomas arrived on May 1, 1776 to assume command of the colonial force. By that time, nearly half of the colonial troops were ill with smallpox. Where the smallpox came from was debated then and now. Montgomery's men might have taken the smallpox from Boston to Montreal and then to Quebec City. Others believed that the British took advantage of the colonial army's long absence from home to intentionally introduce the infection into the colonial ranks by sending young infected women out of Quebec City. Regardless of where it came from, it disabled the colonial army, killing hundreds, and rendering most of the rest unfit for duty. In desperation Arnold ordered the men variolated. Thomas countermanded the order. A physician himself, he opposed variolation as a greater danger to his army than the smallpox. He ominously warned Dr. Lewis Beebe, the area medical officer that it would be "death for any person" to variolate the troops. Every variolated person was sent to Montreal and away from his army. Thomas' bizarre behavior may have been due to the onset of smallpox and its accompanying high fever. In a letter to Congress sent the day Thomas overruled his subordinate, Benjamin Franklin, visiting the embattled army with his co-commissioners Charles Carroll and Samuel Chase, wrote to the Congress that "The small pox is in the army, and General Thomas has unfortunately never had it." A few days later Beebe confirmed the diagnosis. Thomas' illness caused the army to drift into inertia. It also exacerbated the uncertain state of affairs. "Very few general orders are given," wrote Beebe in his diary, "and they are usually countermanded within a few hours." When British reinforcements arrived later in the month, the colonials abandoned the siege of Quebec City and fled. The line of retreat extended thirty miles. A great part of the retreating troop were sick with smallpox. On May 31, Brigadier General John Sullivan arrived with six regiments from Boston. On June 2nd, smallpox finally claimed Thomas at Fort Chambly, where his grave may still be seen. Smallpox stayed with the army. The army was in no better shape. Colonel John Trumbull recorded in his diary that he could "not look into a tent or hut in which I did not see either a dead or dying man." Sullivan, now the commanding officer, reported to Washington in late June that the situation was growing desperate. "The raging of smallpocs (sic) deprives us of whole regiments in the course of a few days. Of the remaining regiments, from 50-60 in each are taken down in a day." The American army, facing annihilation from both the approaching British reinforcements from Boston and the ravages of smallpox within, retreated to Crown Point. In Philadelphia, John Adams, chairman of the War Committee of the Second Continental Congress knew the source of the disaster. "Our misfortunes in Canada are enough to melt a heart of stone. The smallpox is ten times more terrible than the British, Canadians and Indians together. This was the cause of our precipitate retreat from Quebec." General Smallpox had defeated the American bid for Canada. As Washington held Gates' note in his hand, it seemed on the brink of dashing the colonies' hope for independence. Without an army there was no America. A Desperate Gamble Washington continued his ongoing battle with smallpox throughout 1776. Already the disease had prevented his attack in Boston, had made an exercise in futility of his Canadian campaign and now threatened to dissolve his entire army without hope of replacement by re-enlistment. At the same time Washington had been forbidden by the Congress to variolate anyone — it was too great a risk, argued the Medical Committee, and could destroy the entire army. It left him few options. He could try segregation and isolation of the sick. This had been his approach in Boston and it had failed. He could use immune troops, those who had contracted smallpox the natural way. This had also been tried in Boston, but their number was too small and a means of congregating and transporting them did not exist. Adding to his problems was the initiative of some of his own men. Fearful of catching smallpox some had taken to secretly variolating themselves or clandestinely visiting variolators. The process protected them, but the unisolated patients spread smallpox to their unprotected colleagues. Frustrated, Washington did the only thing he could. He had his wife, Martha, a frequent visitor to the camps, variolated for her own protection. As 1776 drew to a close, Washington's dilemma grew more acute. He could no longer to continue to fight a two front war against both the British and smallpox. The British could not be defeated by an army that did not exist. Two of his camp physicians, Nathaniel Bond and John Cochran argued that variolating the army was the only way to save it. Washington had already come to the same conclusion. By exerting absolute discipline, he was convinced that he could organize the variolation of the army and at the same time protect the rest of the men by rigid isolation. Variolating his men meant that they would obtain immunity to smallpox in about a fortnight — half the time it took to recover from a natural infection, when one recovered, from the natural disease. But it also meant that he would be acting without Congress' approval, and that some men would die. In January 1777 Washington and his army were in Morristown. From there he wrote Shippen and informed him that he had ordered the secret variolation of the Continental Army with him. Shippen was asked to do the same for the American troops in Philadelphia. "I have determined that the troops be [variolated] so that in a short space of time we shall have an Army not subject to this greatest of all calamities that can befall it ..." Thus, Washington, in the face of a skeptical medical profession, made one of the greatest medical decisions ever conceived by a military man. He became the first general to order his army immunized against a disease. That he did so with no authority clearly indicates the extent of his desperation. He was willing to risk approbation to save the army. On February 14th Washington, still acting on his own and not mentioning the orders he had given, wrote the Congress that "if the army which I hope we shall have in the field this year, is suffered to smoulder away by sickness, as it did in the last, we must look for reinforcement from some other places, than from our own states." This veiled, but obvious, reference to the use of mercenaries shows the delicate balance that Washington felt himself to be in between diseas eon the one hand and his ability to recruit n army on the other. It was also intended to spur the Congress to some sort of action. On February 15th, the Medical Committee, chaired by Doctor Benjamin Rush, authorized the army's variolation. Washington ordered Shippen to variolate new recruits "as fast as they arrive." Washington's orders were the first instance of compulsory variolation on a large scale. In the first three months of 1777 mass variolation was carried out not only on the troops in Morristown and Philadelphia, but also on recruits throughout New York, New Jersey, Pennsylvania, Virginia and New England. Soldiers went through the procedure, in groups, at intervals of five to six days. Private houses with armed guards in front of them and public buildings such as churches, served as treatment centers. Morristown's civilians paid a high price for providing the venue for Washington's public health measure. The Presbyterian Church, which for a time was turned into one of the several inoculation centers in the town, lost sixty-eight members to smallpox. Other religious groups reported similar numbers of deaths from the disease. But the grand experiment was, as Washington wrote Connecticut Governor Jonathan Trumbull, "attended by amazing success." Surprisingly none of the variolated soldiers died. By April the Continental Army was, for all intents and purposes, immune to smallpox. The effect of the outcome of Washington's decision should be taken in context. It was not the sole factor in the American colonists achievement of independence. The military genius of Washington, the desperate plight of England in the face of a sizable Irish rebellion, her war with Spain and France and the strong feeling on the parts of many Englishmen in favor of the American claims were just as important, if not more so. But Washington's decision to intelligently and properly apply the only known method of defeating smallpox freed his army, for the rest of the of the war, from the brink of destruction it had teetered on in 1775-76 because of the disease. Epilogue In December 1979, after a ten year assault on man's ancient adversary, the World Health Organization certified that "smallpox has been eradicated from the world." Since then not a single naturally acquired case of the disease has occurred — anywhere. On June 30, 1999, after two earlier stays of execution, the remaining stocks of smallpox virus will be destroyed. This event, which will be simultaneously conducted at both the Centers for Disease Control & Prevention in Atlanta and at the Moscow Institute for Viral Preparation, is epochal. The 500 remaining samples will be placed in a simple laboratory autoclave and subjected to 266 F for 45 minutes. When the cycle is completed, it will signal the execution of the greatest serial killer in the history of mankind. Smallpox will be gone. Forever. Sources Cash, P. American Medical Men at the Siege of Boston. Philadelphia: American Philosophical Society, 1973. Dann, JC ed. The Revolution Remembered. Chicago: University of Chicago Press, 1980 Eccles, WJ. France in America. New York: Harper & Row, 1973. Fleming, Thomas. 1776: Year of Illusions. New York: WW Norton, 1975 Gibson, JE. Dr Bodo Otto and the Medical Background of the American Revolution. Springfiled,IL: Charles C Thomas, 1973. Hopkins, DR. Princes & Peasants. Chicago: University of Chicago Press, 1983. Kirkland, FR ed. "Journal of a Physician on the Expedition against Canada, 1776." Pennsylvania Magazine of History & Biography 59:325-7 (1935) Thursfield, H. "Smallpox in the American War of Independence" Annals of Medical History 3d Series, 2:312-8 Back to Cry Havoc #23 Table of Contents Back to Cry Havoc List of Issues Back to MagWeb Master Magazine List © Copyright 1998 by David W. Tschanz. This article appears in MagWeb (Magazine Web) on the Internet World Wide Web. Other military history articles and gaming articles are available at http://www.magweb.com