PODCAST#20 … Review of Pox Americana: The Great Smallpox Epidemic of 1775-82, by Elizabeth A. Fenn

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Imagine there’s a virus sweeping across the land claiming untold victims, the agent of the disease poorly understood, the population in terror of an pox americanaunseen enemy that rages mercilessly through entire communities, leaving in its wake an exponential toll of victims.  As this review goes to press amid an alarming spike in new Coronavirus cases, Americans don’t need to stretch their collective imagination very far to envisage that at all. But now look back nearly two and a half centuries and consider an even worse case scenario: a war is on for the existential survival of our fledgling nation, a struggle compromised by mass attrition in the Continental Army due to another kind of virus, and the epidemic it spawns is characterized by symptoms and outcomes that are nothing less than nightmarish by any standard, then or now. For the culprit then was smallpox, one of the most dread diseases in human history.

This nearly forgotten chapter in America’s past left a deep impact on the course of the Revolution that has been long overshadowed by outsize events in the War of Independence and the birth of the Republic. This neglect has been masterfully redressed by Pox Americana: The Great Smallpox Epidemic of 1775-82, a brilliantly conceived and extremely well-written account by Pulitzer Prize-winning historian Elizabeth A. Fenn.  One of the advantages of having a fine personal library in your home is the delight of going to a random shelf and plucking off an edition that almost perfectly suits your current interests, a volume that has been sitting there unread for years or even decades, just waiting for your fingertips to locate it. Such was the case with my signed first edition of Pox Americana, a used bookstore find that turned out to be a serendipitous companion to my self-quarantine for Coronavirus, the great pandemic of our times.

As horrific as COVID-19 has been for us—as of this morning we are up to one hundred thirty four thousand deaths and three million cases in the United States, a significant portion of the more than half million dead and nearly twelve million cases worldwide—smallpox, known as “Variola,” was far, far worse.  In fact, almost unimaginably worse. Not only was it more than three times more contagious than Coronavirus, but rather than a mortality rate that ranges in the low single digits with COVID (the verdict’s not yet in), variola on average claimed an astonishing thirty percent of its victims, who often suffered horribly in the course of the illness and into their death throes, while survivors were frequently left disfigured by extensive scarring, and many were left blind. Smallpox has a long history that dates back to at least the third century BCE, as evidenced in Egyptian mummies. There were reportedly still fifteen million cases a year as late as 1967. In between it claimed untold hundreds of millions of lives over the years—some three hundred million in the twentieth century alone—until its ultimate eradication in 1980. There is perhaps some tragic irony that we are beset by Coronavirus on the fortieth anniversary of that milestone …

I typically eschew long excerpts for reviews, but Variola was so horrifying and Fenn writes so well that I believe it would be a disservice to do other than let her describe it here:

Headache, backache, fever, vomiting, and general malaise all are among the initial signs of infection. The headache can be splitting; the backache, excruciating … The fever usually abates after the first day or two … But … relief is fleeting. By the fourth day … the fever creeps upward again, and the first smallpox sores appear in the mouth, throat, and nasal passages …The rash now moves quickly. Over a twenty-four-hour period, it extends itself from the mucous membranes to the surface of the skin. On some, it turns inward, hemorrhaging subcutaneously. These victims die early, bleeding from the gums, eyes, nose, and other orifices. In most cases, however, the rash turns outward, covering the victim in raised pustules that concentrate in precisely the places where they will cause the most physical pain and psychological anguish: The soles of the feet, the palms of the hands, the face, forearms, neck, and back are focal points of the eruption … If the pustules remain discrete—if they do not run together— the prognosis is good. But if they converge upon one another in a single oozing mass, it is not. This is called confluent smallpox … For some, as the rash progresses in the mouth and throat, drinking becomes difficult, and dehydration follows. Often, an odor peculiar to smallpox develops… Patients at this stage of the disease can be hard to recognize. If damage to the eyes occurs, it begins now … Scabs start to form after two weeks of suffering … In confluent or semiconfluent cases of the disease, scabbing can encrust most of the body, making any movement excruciating … [One observation of such afflicted Native Americans noted that] “They lye on their hard matts, the poxe breaking and mattering, and runing one into another, their skin cleaving … to the matts they lye on; when they turne them, a whole side will flea of[f] at once.” … Death, when it occurs, usually comes after ten to sixteen days of suffering. Thereafter, the risk drops significantly … and unsightly scars replace scabs and pustules … the usual course of the disease—from initial infection to the loss of all scabs—runs a little over a month. Patients remain contagious until the last scab falls off …  Most survivors bear … numerous scars, and some are blinded. But despite the consequences, those who live through the illness can count themselves fortunate. Immune for life, they need never fear smallpox again. [p16-20]

Smallpox was an unfortunate component of the siege of Boston by the British in 1775, but—as Fenn explains—it was far worse for Bostonians than the Redcoats besieging them.  This was because smallpox was a fact of life in eighteenth century Europe—a series of outbreaks left about four hundred thousand people dead every year, and about a third of the survivors were blinded. As awful as that may seem, it meant that the vast majority of British soldiers had been exposed to the virus and were thus immune. Not so for the colonists, who not only had experienced less outbreaks but frequently lived in more rural settings at a greater distance from one another, which slowed exposure, leaving a far smaller quantity of those who could count on immunity to spare them. Nothing fuels the spread of a pestilence better than a crowded bottlenecked urban environment—such as Boston in 1775—except perhaps great encampments of susceptible men from disparate geographies suddenly crammed together, as was characteristic of the nascent Continental Army. To make matters worse, there was some credible evidence that the Brits at times engaged in a kind of embryonic biological warfare by deliberately sending known infected individuals back to the Colonial lines. All of this conspired to form a perfect storm for disaster.

Our late eighteenth-century forebears had a couple of things going for them that we lack today. First of all, while it was true that like COVID there was no cure for smallpox, there were ways to mitigate the spread and the severity that were far more effective than our masks and social distancing—or misguided calls to ingest hydroxychloroquine, for that matter.  Instead, their otherwise primitive medical toolkit did contain inoculation, an ancient technique that had only become known to the west in relatively recent times. Now, it is important to emphasize that inoculation—also known as “variolation”—is not comparable to vaccination, which did not come along until closer to the end of the century. Not for the squeamish, variolation instead involved deliberately inserting the live smallpox virus from scabs or pustules into superficial incisions in a healthy subject’s arm. The result was an actual case of smallpox, but generally a much milder one than if contracted from another infected person. Recovered, the survivor would walk away with permanent immunity. The downside was that some did not survive, and all remained contagious for the full course of the disease. This meant that the inoculated also had to be quarantined, no easy task in an army camp, for example.

The other thing they had going for them back then was a competent leader who took epidemics and how to contain them quite seriously—none other than George Washington himself. Washington was not president at the time, of course, but he was the commander of the Continental Army, and perhaps the most prominent man in the rebellious colonies. Like many of history’s notable figures, Washington was not only gifted with qualities such as courage, intelligence, and good sense, but also luck. In this case, Washington’s good fortune was to contract—and survive—smallpox as a young man, granting him immunity. But it was likewise the good fortune of the emerging new nation to have Washington in command. Initially reluctant to advance inoculation—not because he doubted the science but rather because he feared it might accelerate the spread of smallpox—he soon concluded that only a systematic program of variolation could save the army, and the Revolution! Washington’s other gifts—for organization and discipline—set in motion mass inoculations and enforced isolation of those affected. Absent this effort, it is likely that the War of Independence—ever a long shot—may not have succeeded.

Fenn argues convincingly that the course of the war was significantly affected by Variola in several arenas, most prominently in its savaging of Continental forces during the disastrous invasion of Quebec, which culminated in Benedict Arnold’s battered forces being driven back to Fort Ticonderoga.  And in the southern theater, enslaved blacks flocked to British lines, drawn by enticements to freedom, only to fall victim en masse to smallpox, and then tragically find themselves largely abandoned to suffering and death as the Brits retreated. There is a good deal more of this stuff, and many students of the American Revolution will find themselves wondering—as I did—why this fascinating perspective is so conspicuously absent in most treatments of this era?

Remarkably, despite the bounty of material, emphasis on the Revolution only occupies the first third of the book, leaving far more to explore as the virus travels to the west and southwest, and then on to Mexico, as well as to the Pacific northwest. As Fenn reminds us again and again, smallpox comes from where smallpox has been, and she painstakingly tracks hypothetical routes of the epidemic. Tragic bystanders in its path were frequently Native Americans, who typically manifested more severe symptoms and experienced greater rates of mortality.  It has been estimated that perhaps ninety percent of pre-contact indigenous inhabitants of the Americas were exterminated by exposure to European diseases for which they had no immunity, and smallpox was one of the great vehicles of that annihilation. Variola proved to be especially lethal as a “virgin soil” epidemic, and Native Americans not unexpectedly suffered far greater casualties than other populations, resulting in death on such a wide scale that entire tribes simply disappeared to history.

No review can properly capture all the ground that Fenn covers in this outstanding book, nor praise her achievement adequately. It is especially rare when a historian combines a highly original thesis with exhaustive research, keen analysis, and exceptional talent with a pen to deliver a magnificent work such as Pox Americana. And perhaps never has there been a moment when this book could find a greater relevance to readers than to Americans in 2020.