What Killed Prisoners of War?—A Medical Investigation

Editor’s Note: This article contains graphic medical descriptions.

Throughout the Revolutionary War, prisoners learned that dysentery accompanied starvation. Confined to the prison ship Jersey in 1781, Christopher Hawkins described rations “not sufficient to satisfy the calls of hunger.” In the next two sentences, Hawkins mentioned that “the bloody flux or dyssenterry” prevailed on the Jersey, from which “many died on board her.” Like other prisoners of war, Hawkins was certain he witnessed epidemic dysentery. Caused either by the ameba Entamoeba histolytica or by several species of bacteria, dysentery is characterized by diarrheal expulsions mixed with blood and mucus. Like many victims of starvation, however, prisoners probably had the non-contagious condition known as “hunger diarrhea” or “famine diarrhea.” Famine diarrhea figured in two major scandals of prisoner neglect in the Revolutionary War, New York in 1776 and Charles Town (present-day Charleston), South Carolina in 1780.[1]

In a succession of hunger crises in the nineteenth and twentieth centuries, medical professionals gradually distinguished famine diarrhea from dysentery. During the Irish Potato Famine (1845-1850), Dr. Daniel Donovan distinguished “famine dysentery” from “ordinary dysentery.” Donovan, however, still mistook the ailment for a contagion. Doctors in the Finnish Famine of 1866-1868 realized famine diarrhea was noninfectious. In the Madras Famine of 1877-1878, British physicians in Madras, India identified “famine diarrhoea” as a noncontagious affliction, a result of prolonged starvation, and a sign that the patient was near death. Serving as Assistant Director of Medical Services for the 6th (Poona) Division of the Indian Army, Maj. Gen. Sir Patrick Hehir observed famine diarrhea during the Turkish Army’s 148-day siege of British and Indian troops at Kut, in modern Iraq (1915-1916).[2]

During World War II, healthcare professionals documented three stages to death from starvation. Danish healthcare workers, arrested by German forces for resistance activity, contributed to a collection of postwar studies of “famine disease” in concentration camps. In the Warsaw Ghetto, established by Nazis in occupied Poland, Polish doctors arrested for their Jewish heritage conducted a series of clandestine studies of “hunger disease,” a collection of essays smuggled from the Warsaw Ghetto in 1942. Danish and Polish researchers documented famine diarrhea as an ordeal of the third stage of starvation, the terminal stage.[3]

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In the first stage of famine disease, people experienced rapid weight loss. The transformation reminded Polish doctors of prewar “reducing cures” at vacation spas. The second stage of hunger disease reminded one Polish research team of animal hibernation. To avoid burning its own tissues for fuel, the body slowed metabolism, reduced exertion to a minimum and increased the demand for rest. In this quasi-hibernation, weight loss slowed or even halted, but sufferers looked prematurely aged. The third phase of famine disease was terminal “hunger cachexia” (severe emaciation and muscle atrophy), often accelerated by famine diarrhea. In this terminal phase of starvation, diarrhea killed people in just a few weeks or even a few days.[4]

In the landmark Minnesota Starvation Experiment (1944-1945) researchers at the University of Minnesota subjected volunteers to twenty-four weeks of semi-starvation, anticipating the need for famine relief in postwar Europe, and compiled data from historic famines. This humanitarian research had support from three pacifist denominations prominent in the Founding Generation, the Church of the Brethren (popularly known as “Dunkards” or German Baptists during the American Revolution), Mennonites, and the Society of Friends (Quakers). Based on historic famines, Minnesota researchers confirmed diarrhea can typify end-stage starvation, but sufferers can also die with diarrhea in abeyance and edema predominating, with patients swollen from retained fluid.[5]

Hunger disease stems from a severe, long-term caloric deficiency. A healthy person needs 50 calories daily for every kilogram of body weight. Polish researchers estimated a healthy person of average weight and stature needed about 3,000 calories per day. Subjects in the Minnesota Starvation Experiment received an average of 1,570 calories per day for twenty-four weeks (six months) and lost an average of twenty-five percent of their pre-hunger body weight. Ancel Keys of the Minnesota experiment warned that forty percent was usually fatal, though some individuals can survive losing fifty percent of their initial weight. In the Warsaw Ghetto, a research team headed by Dr. Julian Fliederbaum estimated their patients got about 1,100 calories per day; a team headed by Dr. Emil Apfelbaum-Kowalski estimated their patients, for many months, only got 600 to 800 calories per day. For Danish political prisoners, the daily caloric intake from concentration camp rations ranged from 700 to 1,100 calories. Food parcels from the Danish or Swedish Red Cross could give Danish prisoners an additional 1,000 to 1,500 calories per day.^[6]

Historians can only guess the daily caloric intake of prisoners during the American Revolution. Historian Edwin G. Burrows estimated prisoners of the British Army received no more than 1,640 calories per day and prisoners of the British Navy received about 1,556 calories per day. Burrows cautioned his nutritional assessment of official rations was generous, and prisoners often received less than their official allotment. Privates Thomas Boyd and William Darlington of Chester County, Pennsylvania, for instance, described rations more meagre than British claims of what was provided.^[7]

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Gen. Sir William Howe probably held over 3,000 captive Continental soldiers by December 1776. From August 27, 1776 to November 20, 1776, the British and Hessian forces under Howe brought 4,114 American soldiers and 305 American officers as captives to New York City. While the military officers enjoyed parole within the occupied city, the British warehoused the privates on prison ships and confiscated buildings like sugarhouses and non-Anglican churches. Joshua Loring, a Loyalist who served the British as Commissary General of Prisoners, indicated over 700 of 4,114 captive soldiers offered to enlist with British recruiters. The recruitment of 700 to 800 soldiers left Howe with about 3,300 to 3,400 Continental soldiers. The naval forces under Howe’s brother, Adm. Richard, Viscount Howe, took prisoner perhaps a few hundred sailors from the Continental Navy, several state navies and privateer crews.[8]

The experience of American prisoners epitomized the progression of hunger disease. For several months, British and Loyalist observers associated American prisoners with “filthiness” and “laziness.” Writing for the British press and claiming informants in British-occupied New York City, “Politicus” blamed the unhealthiness of the prisoners on “their own Listlessness and Sluggishness,” “their own Laziness and Filth.” Admiral Howe mentioned “the indolence of the Prisoners.” In his diary for November 12, 1776, British staff officer Maj. Frederick Mackenzie described the prisoners as “low spirited creatures” whose “dirty, unhealthy, and desponding appearance” was “enough to shock one.” The November 25, 1776 issue of Loyalist newspaper The New-York Gazette; and the Weekly Mercury likewise noted the “Filthiness” of the prisoners.[9]

British and Loyalist commentary captured the quasi-hibernation phase of hunger disease. The first symptom of hunger is not emaciation but laziness. After witnessing semistarvation in London with mass unemployment in 1837-1838, Dr. Richard Baron Howard wrote, “The first indications of a deficiency of food . . . are languor, exhaustion, and general debility.” According to one research team in the Warsaw Ghetto, “The hungry person becomes lazy . . . hoarding the last of his vital energy.” According to another Polish medical team, starvation transformed “busy, energetic people” into “apathetic, sleepy beings.”[10]

In November 1776, neither Major Mackenzie nor the anonymous contributor to the New-York Gazette mentioned gauntness among captive Americans. Of course, publicly acknowledging weight loss among prisoners was politically damaging. Even in the privacy of his diary, however, Mackenzie did not mention emaciation. Mackenzie even rejected the claim that American prisoners were starving. Two major factors might account for Mackenzie’s failure to see emaciation among the prisoners. First, even clinical researchers who see starving people every day, or at regular intervals, will fail to notice gradual weight loss. Secondly, as researchers in the Warsaw Ghetto learned from patient interviews, severe emaciation might take several months to develop.[11]

The “filthiness” of American prisoners was probably another misunderstood symptom of starvation. During the Potato Famine, Donovan found that the skin released a foul odor “and was covered with a brownish, filthy-looking coating, almost as indelible as varnish.” At first, Donovan mistook the discoloration for “encrusted filth.” In Madras, Alexander Porter wrote of “Famine skin,” “It had the general appearance of dirt, as if the person had not washed for some time, but soap and water would not remove it; nothing short of scraping would do this.” Researchers in the Warsaw Ghetto and the Minnesota experiment associated semistarvation with pale, grayish skin, sometimes cyanotic, but also vulnerable to splotches of “dirty,” “brownish” pigmentation. Danish resistance members collapsed the discoloration into a single spectrum of “‘dirty,’ greyish-brown complexion.” In 492 autopsies of people who died from starvation in the Warsaw Ghetto, doctors Joseph Stein and Henryk Fenigstein found skin discoloration in 466 (almost 95 percent) of the cases. Stein and Fenigstein classed 385 instances (82.5 percent) of discoloration as “pale, almost cadaverlike” and 81 cases (17.5 percent) as “dark brown.”  Of the 81 autopsy subjects with brownish pigmentation, only 20 had edema and 61 had “dry” cachexia, the dehydrated emaciation often associated with diarrhea.[12]

Of the 4,114 rank and file held by General Howe, the largest contingent (about 63 percent) were the 2,607 privates who surrendered after the Battle of Fort Washington (November 16, 1776). If conditions and food were bad enough, it was possible for prisoners taken as late as November 16 to develop hunger diarrhea by the end of December. During World War II, for example, the Germans arrested Danish resistance members as well as the Danish police, to forestall possible armed revolt. The latter experienced better conditions and received better food than members of the Danish resistance while incarcerated. Among Danish police who developed hunger diarrhea in Nazi custody, 56 percent developed diarrhea after about two months. For members of the resistance who developed hunger diarrhea, 84 percent developed it after about two months. The average was about one and three-quarter months. Danish political prisoners who received no relief parcels, living only on camp rations, lost between twenty and thirty percent of their initial weight before the onset of diarrhea.[13]

Diarrhea started as intermittent and, in the fatal stage of starvation, became constant. Eigil Hess Thaysen and Jørn Hess Thaysen described a “vicious circle:” weight loss intensified diarrhea, diarrhea intensified weight loss, “and most of the patients died in extreme cachexia.” Irish doctors noticed the same vicious cycle during the Potato Famine. Donovan wrote, “The discharges continued unabated; the body wastes to a skeleton.” Dr. F. J. Lynch described famine victims who survived fever only to reach an interval, “from one to three weeks,” during which “the patients became living skeletons, uncontrollable diarrhea returned, and quickly carried them off.”[14]

Perhaps surviving a contagion cost starving bodies the last of their strength. Patrick Hehir wrote that men starving in Kut “could stand little in the shape of illness.” Significantly, many of the prisoners preemptively released by Howe from New York in the winter of 1776-1777 had smallpox. Caring for American prisoners in a Charles Town, South Carolina, hospital in September and October 1780, Dr. Peter Fayssoux witnessed famine diarrhea kill undernourished prisoners as they recovered from smallpox. Fayssoux recalled that British officers permitted American surgeons to inoculate prisoners but let them provide no further care. The prisoners, Fayssoux lamented, were “fed on salt provisions, without . . . any proper kind of nourishment.” Ideally, inoculation resulted in a case of smallpox milder than naturally contracted smallpox. Instead, starvation and neglect led to “a small-pox with a fever of the putrid type; and to such as survived the small-pox, a putrid dysentery.” British officers only let prisoners go ashore for treatment after the smallpox pustules erupted. Tending to prisoners onshore, Fayssoux found that putrid fever and “dysentery” caused “the death of at least one hundred and fifty of the unhappy victims.” Fayssoux’s 1785 recollection did not indicate what proportion of his patients 150 represented, but he considered the losses catastrophic.[15]

Accounts of prisoners in late 1776 associated diarrhea with terminal starvation. A captured Continental officer on parole in New York City, Col. Ethan Allen, visited captive soldiers warehoused in confiscated churches. Allen wrote, “The filth in these churches (in consequence of the fluxes) was almost beyond description. The floors were covered with excrements.” Pvt. Thomas Boyd mentioned expulsions becoming problematic after he described the onset of starvation, implying fluxes became worse after prolonged hunger. Ethan Allen more explicitly associated the fluxes with death from starvation. Allen recalled, “I have seen in one of these churches several dead . . . lying among the excrements of their bodies.”[16]

Famine diarrhea killed quickly. Danish researchers explained the terminal phase of starvation was epitomized by any prisoner who reached a state known as “the Mussulman” (Muslim). The Mussulman was stooped from weakness like a humble penitent. With a slow metabolism, without insulating fat, the Mussulman was sensitive to cold and liable to drape his blanket over his shaven head, accentuating his supposed resemblance to a religious pilgrim. Horrifically, Thaysen and Thaysen observed, “The duration of the Mussulman phase . . . usually only extends over a couple of weeks.”[17]

Sadly, hunger diarrhea might kill in even less than a week. Hehir noted that most soldiers at Kut recovered from diarrhea, “but many of them became intensely collapsed and died on the second, third or fourth day.” For Stein and Fenigstein, the brevity of famine diarrhea was a critical difference from dysentery. Bacillary or amebic, dysentery was a long-term illness. In autopsies of famine victims, however, Stein and Fenigstein found that diarrhea inflicted damage “probably in the last days or weeks of life.” Famine diarrhea most resembled dysentery in the final days of starvation.[18]

Famine diarrhea killed quickly in 1776. Although some prisoners died in November, Pvt. John Adlum recalled that prisoners “began to die very fast in the month of December,” namely, “the latter part of December.”  Confined to a prison ship, Pvt. John Caryl implied prisoner deaths increased after December 25, 1776. Caryl associated the increased mortality with a change in prisoner rations and the introduction of a “very bitter” burgoo (oatmeal gruel). Caryl did not specify diarrhea, but Danish researchers confirmed a change of diet could cause fatal famine diarrhea among people already poorly nourished.[19]

By the end of 1776, American prisoners exhibited several symptoms of terminal starvation, including the reduction of the voice to a whisper. Ethan Allen witnessed several prisoners “speechless, and near death.” Another Continental officer on parole, Lt. Jonathan Gillet, also visited the prison-churches and found “want of food” among prisoners meant “some almost loose their voices.” Describing prisoners returning to Connecticut, Col. John Chester wrote, “They are mere skeletons, unable to creep or speak in many instances.” In Pennsylvania, Rev. Hugh Henry Brackenridge indicated the typical returnee was an emaciated man with a voice “shrill, feeble, and not to be distinctly heard.”[20]

During the Siege of Kut, Hehir specifically noted the absence of “the change in the voice met with in cholera.” Other doctors, however, compared starvation’s reduction of the human voice to vox cholerica (Latin for “cholera voice”), the debilitating effect of cholera on speech. In the Warsaw Ghetto, a research team headed by Julian Fliederbaum wrote, “In the terminal stage of cachexia . . . the voice becomes hoarse, like vox cholerica.” With the onset of emaciation and debility, Donovan noted, “the voice is so weak as to resemble the cholera whine.” Lynch wrote that when diarrhea became constant (that is, with the onset of end-stage famine diarrhea), victims suffered “increasing debility,” a “remarkable tendency to emaciation,” and an “altered, whispering, whining voice.”[21]

In his portrait of the typical returnee, Brackenridge mentioned “legs swollen, and from the ankle to the knee of an equal shape.” In many starvation deaths, edema subsided as hunger diarrhea dehydrated and emaciated the victim. Edema in the lower extremities, however, could persist. Paul Thygesen and JørnKieler found the emaciated Mussulmans rarely had edema, except for those with swelling in the lower legs. Thygesen and Kieler were shocked by the contrast between skeletal thighs and swollen calves. In the Warsaw Ghetto, edema appeared randomly around the body throughout the course of hunger disease. In the terminal stage, however, edema concentrated in the lower legs. In 492 autopsies of starvation victims in the Warsaw Ghetto, 164 (33.3 percent) had edema. Of 164 starving people who died with edema, 160 (97.6 percent) had edema in the lower extremities. Only 21 (12.8 percent) showed edema in the upper extremities and only 18 (about 11 percent) in the torso.[22]

Curiously, during the Madras Famine, Alexander Porter found edema concentrated in the feet. The principal of Madras College, Porter operated a famine relief camp. Conducting autopsies on a sampling of famine victims, Porter noted a high incidence of “Oedema of the feet” in “emaciated cases.” Porter found edema of the feet in 139 (44.8 percent) of 310 emaciated men, women and children. In his later book, Porter recorded the figure as 140 of 310 (about 45 percent). Edema rarely occurred elsewhere. Edema of the hands, for instance, was only present in six men and three women (2.9 percent of overall emaciated cases, or 3.6 percent of emaciated adults).[23]

End-stage starvation also exposed American prisoners to the macabre risk of premature burial. During the Potato Famine, Donovan wrote, “Great attention should . . . be paid to the subject of interments, as from the influence of cold on those suffering from starvation, many may be buried alive whilst in a state of asphyxia.” Donovan knew two cases of children mistakenly put on the dead cart only to show signs of life before or just after landing in a mass grave. In 1777 depositions, privates Thomas Boyd and James Stuart recalled several prisoners in New York were mistakenly thrown into mass graves while still alive. Stuart, “on his oath declares,” that one sick man, “reviving after being thrown with the dead in the pit,” “with help got out.”[24]

Death from starvation, even with famine diarrhea, was so quiet and uneventful that the dead were mistaken for living and the living for dead. Patrick Hehir wrote of semistarvation, “In fatal cases so imperceptibly does life ebb away that it is sometimes not easy to say whether the man is really dead or not.” Dropped with other prisoners at South Amboy, New Jersey, Pvt. John Adlum helped a stumbling fellow-returnee step from the boat. Adlum spotted his new friend a moment later, at the fireplace of a household that opened its door to prisoners. “I went to ask him how he was when to my astonishment he was dead. The crowd about the fire I presume kept him from falling for none of those at it knew at the time that he was dead.”[25]

Several avitaminoses (diseases of vitamin deficiency) can cause symptoms akin to hunger disease. Pellagra (niacin deficiency) can cause diarrhea. Scurvy (Vitamin C deficiency) can cause swelling of the legs. Vitamin requirements, however, are proportional to caloric intake. Typically, a severe calorie deficit precludes vitamin deficiencies. However paradoxically, American prisoners probably suffered no vitamin deficiency while starving to death.[26]

General Howe witnessed perhaps the most shocking aspect of hunger diarrhea, its lethality. Howe started December with about 3,300 Continental soldiers, leverage to demand an exchange of 3,300 British rank and file from American custody. In a December 3, 1776 letter to Lord George Germain, Britain’s Secretary of State for the colonies, Howe complained of the “great expense and inconvenience” of accommodating prisoners, implying most of the prisoners were still very much alive. In the last days of December 1776 and the first days of January 1777, Howe suddenly learned he held about 1,100 corpses and about 2,200 stumbling, whispering skeletons.[27]

From about December 21, 1776 to January 27, 1777, Howe shipped surviving prisoners to American-held territory. He tried to get living prisoners into American hands. In their stage of starvation, however, recovery was unlikely. As Hehir learned at Kut, “there is a stage . . . in chronic starvation from which recuperation cannot take place.” Indeed, several of Howe’s prisoners died on the transport ships taking them from New York to Connecticut or New Jersey. Most of returnees probably died before the end of February 1777. George Washington complained that Howe released prisoners “in so emaciated and languished a State,” as to render their death “almost certain and inevitable.” As one Connecticut resident lamented, “Their constitutions are broken . . . they cannot recover, they die.”[28]

Washington agonized that the prisoners might have survived, if only Howe released them sooner, “before these ill fated men were reduced to such extremity.” Howe could not have recognized the necessity of the mass release any sooner. Like Major Mackenzie, Howe could not believe sluggish American prisoners were really dying of starvation. Alas, by the time Howe’s prisoners looked like they were starving, it was too late to save them.[29]

[1]Christopher Hawkins, The Adventures of Christopher Hawkins, ed. Charles I. Bushnell (New York: Privately Printed, 1864), 66; Carl P. Borick, Relieve Us of This Burthen: American Prisoners of War in the Revolutionary South, 1780-1782 (Columbia: The University of South Carolina Press, 2012), 4-5, 15-26; K. David Patterson, “Bacillary Dysentery,” Kenneth F. Kiple, The Cambridge World History of Human Disease (Cambridge: Cambridge University Press, 1993), 605; K. David Patterson, “Amebic Dysentery,” Cambridge World History, 570; K. David Patterson, “Dysentery,” Cambridge World History, 696; Brian Patrick O’Malley, “1776—The Horror Show,” Journal of the American Revolution, January 29, 2019, allthingsliberty.com/2019/01/1776-the-horror-show/.

[2]Daniel Donovan, “Observations on the Diseases to which the Famine of 1847 Gave Origin, and on the Morbid Effects of Insufficient Nourishment: Dysentery,” Dublin Medical Press, Vol. 19 (May 3, 1848): 275; E. Hess Thaysen and J. Hess Thaysen, “Hunger Diarrhoea,” in Per Helweg-Larsen, Henrik Hoffmeyer, Jorgen Kieler, Eigil Hess Thaysen, JørnHess Thaysen, Paul Thygesen, Munke Hertel Wulff, “Famine Disease in German Concentration Camps: Complications and Sequels,” Acta Medica Scandinavica, Supplement 274 (1952), Wiley Online Library, onlinelibrary.wiley.com/toc/16000447/1953/28/s83(Famine Disease), 125-126; Leela Sami, “The Epidemiological, Health and Medical Aspects of Famine: Views from the Madras Presidency (1876-78),” in Society, Medicine and Politics in Colonial India, ed. Biswamoy Pati and Mark Harrison (New York: Routledge, 2018), 156-159, 167.

[3]Israel Milejkowski, “Introduction,” 3-5, in Hunger Disease: Studies by the Jewish Physicians in the Warsaw Ghetto, ed. Myron Winick, trans. Martha Osnos (New York: John Wiley & Sons, Inc., 1979), 3-5 (Hunger Disease); Joseph Stein and Henry Fenigstein, “Pathology Anatomy of Hunger Disease,” Hunger Disease, 222-224; Julian Fliederbaum, Ari Heller, Kazimierz Zweibaum, Jeanne Zarchi, “Clinical Aspects of Hunger Disease in Adults,” Hunger Disease, 15-16; Helweg-Larsen, et al., Famine Disease.

[4]E. Hess Thaysen, J. Hess Thaysen, J. Kieler, P. Thygesen, “Hunger Cachexia,” Famine Disease, 81, 83, 84, 86, 90-91; Fliederbaum et al., “Clinical Aspects,” 15-16, 36; Emil Apfelbaum-Kowalski, Ryszard, Jeanne Zarchi (medical student), Ari Heller, Zdzislaw Askanas, “Pathophysiology of the Circulatory System in Hunger Disease,” in Hunger Disease, 127, 149-150; P. Thygesen and J. Kieler, “The Mussulman,” Famine Disease, 251-254; Stein and Fenigstein, “Pathological Anatomy,” 223; Patrick Hehir, “Effects of Chronic Starvation During the Siege of Kut,” The British Medical Journal 1 (1922): 867, www.jstor.org/stable/20420147.

[5]Ancel Keys, Josef Brožek, Austin Henschel, Olaf Mickelsen, Henry Longstreet Taylor, Biology of Human Starvation, 2 vols.(Minneapolis: The University of Minnesota Press, 1950), 1:xxvii; 63-64, 70; 2:955; Todd Tucker, The Great Starvation Experiment: Ancel Keys and the Men Who Starved for Science (Minneapolis: The University of Minnesota Press, 2007 [2006]), 37.

[6]Julian Fliederbaum, Ari Heller, Kazimierz Zweibaum, Suzanne Szejnfinkel, Regina Elbinger, Fajga Ferszt, “Metabolic Changes in Hunger Disease,” Hunger Disease, 86; Apfelbaum-Kowalski, “Pathophysiology of the Circulatory Systerm,” 127; J. Kieler, “Deportation,” Famine Disease, 45-48, 50-51, 53; Thaysen, et al., “Hunger Cachexia,” 87-89; Thygesen and Kieler, “Avitaminoses Incident to Semistarvation,” 226-227; E. Hess Thaysen and J. Hess Thaysen, “Hunger Oedema,” Famine Disease, 98; Tucker, Great Starvation Experiment, 96; David Baker and Natacha Keramidas, “The Psychology of Hunger,” APA Monitor on Psychology 44 (October 2013): 66, www.apa.org/monitor/2013/10/hunger; W. W. Abbot, editorial note 5, at Peter Hog to George Washington, January 27, 1756, Founders Online, founders.archives.gov/documents/Washington/02-02-02-0304.

[7]Edwin G. Burrows, Forgotten Patriots: The Untold Story of American Prisoners During the Revolutionary War (New York: Basic Books, 2008), 251-253; “Quantity of Provisions…,” January 19, 1778, enclosed in William Howe to George Washington, January 19, 1778, Founders Online, founders.archives.gov/documents/Washington/03-13-02-0238; Affidavit of Thomas Boyd, February 27, 1777, Pennsylvania Evening Post, May 3, 1777 (Boyd Affidavit); Affidavit of William Darlington, February 27, 1777, Pennsylvania Evening Post, May 3, 1777 (Darlington Affidavit).

[8]Joshua Loring, “Return of Prisoners taken during the Campaign, 1776” December 1, 1776, enclosed in Sir William Howe to Lord George Germaine, December 3, 1776, The New-York Gazette; and the Weekly Mercury, March 17, 1777; Joshua Loring, “State of the Prisoners,” undated, Elias Boudinot Papers, Library of Congress; Edwin G. Burrows, Forgotten Patriot, 276-277n15; Timothy Parker and Others to Governor Jonathan Trumbull, December 9, 1776, Naval Documents of the American Revolution, ed. Michael J. Crawford, vol. 13(Naval History and Heritage Command, Department of the Navy, 1964-2019), 7: 421, www.history.navy.mil/research/publications/publications-by-subject/naval-documents-of-the-american-revolution.html (Naval Documents); Affidavit of William Gamble, February 8, 1777, Pennsylvania Evening Post, April 29, 1777.

[9]Politicus, “Case of the Rebel Prisoners Truly Stated,” The Public Advertiser (London), August 13, 1777, Newspapers.com, www.newspapers.com/clip/25390612/sluggish-prisoners/; Richard Howe to George Washington, January 17, 1777, Founders Online, founders.archives.gov/documents/Washington/03-08-02-0095; Frederick Mackenzie, The Diary of Frederick Mackenzie , 2 vols. (New York: New York Times, 1968 [1930]), 1:103; “New-York, November 25,” The New-York Gazette; and the Weekly Mercury, November 25, 1776.

[10]Richard Baron Howard, An Inquiry into the Morbid Effects of Deficiency of Food… (London: Simpkin, Marshall, & Co., 1839), 19; Apfelbaum-Kowalski, et al., “Pathophysiology of the Circulatory System,” 127; Fliederbaum, et al., “Clinical Aspects,” 34.

[11]Richard Howe to George Washington, January 17, 1777; William Howe to George Washington, April 21, 1777, Founders Online , founders.archives.gov/documents/Washington/03-09-02-0211; Mackenzie,Diary, 103-104; Keys, et al., Biology of Human Starvation, 1: 132-133; Apfelbaum-Kowalski, et al., “Pathophysiology of the Circulatory System,” 127; Thygesen and Kieler, “The Mussulman,” 254.

[12]Daniel Donovan, “Observations on the Peculiar Diseases to which the Famine of Last Year Gave Origin, and on the Morbid Effects of Insufficient Nourishment,” Dublin Medical Press 19 (February 2, 1848): 67; Alexander Porter, The Diseases of the Madras Famine of 1877-78 (London: H. K. Lewis, 1889), 207-208; Russell M. Wilder, “Forward,” Biology of Human Starvation, 1: xx; Keys, et al., Biology of Human Starvation, 1: 237-238; Ancel Keys, “Caloric Undernutrition and Starvation, with Notes on Protein Deficiency,” Journal of the American Medical Association 138 (1948): 505; Fliederbaum, et al., summarizing a lost paper by Dr. B. Raszkes, “Clinical Aspects,” 16; Stein and Fenigstein, “Pathological Anatomy,” 218-219, 227; Michal Szejnman, “Changes in Peripheral Blood and Bone Marrow in Hunger Disease,” Hunger Disease, 165; Thaysen, et al., “Hunger Cachexia,” 83.

[13]J, Kieler, “Deportation,” 64; Thaysen and Thaysen, “Hunger Diarrhoea,” 137; Thaysen, et al., “Hunger Cachexia,” 86, 141-142.

[14]Thygesen and Kieler, “The Mussulman,” 254; Donovan, “Observations on the Disease,” 276; “Report upon the Recent Epidemic Fever in Ireland,” The Dublin Quarterly of Medical Science Vol. 7 (February and May 1849), 401; Thaysen and Thaysen, “Hunger Diarrhoea,” 133.

[15]Hehir, “Effects of Chronic Starvation,” 867; Jonathan Trumbull, Sr. to George Washington, February 7, 1777, Founders Online, founders.archives.gov/documents/Washington/03-08-02-0289; Borick, Relieve Us of This Burthern, 18; Peter Fayssoux to David Ramsay, March 26, 1785, in William Moultrie, Memoirs of the American Revolution…, Vol. 2 (New York: David Longworth, 1802), 2: 399.

[16]Boyd Affidavit; Ethan Allen, A Narrative of Colonel Ethan Allen’s Captivity (Philadelphia: Robert Bell, 1779), 29-30.

[17]Thaysen, et al., “Hunger Cachexia,” 83; Thygesen and Kieler, “The Mussulman,” 253; JørnKieler, Resistance Fighter: A Personal History of the Danish Resistance Movement 1940-1945, trans. Eric Dickens(New York: Gefen Publishing House, 2007), 275.

[18]Stein and Fenigstein, “Pathological Anatomy,” 223; Thaysen and Thasyen, “Famine Diarrhoea,” 156-157.

[19]John Adlum, Memoirs of the Life of John Adlum in the Revolutionary War, ed. Howard H. Peckham (Chicago: The Caxton Club, 1968), 98, 125 (Adlum Memoirs); Affidavit of John Caryl, February 17, 1777, Pennsylvania Evening Post, May 3, 1777; Thaysen and Thaysen, “Hunger Diarrhoea,” 133, 143-144; Boyd Affidavit; Darlington Affidavit.

[20]John Chester to Samuel Blachley Webb, January 17, 1777, in Correspondence and Journals of Samuel Blachley Webb , ed. Worthington Chancey Ford (Lancaster, PA: Wickersham Press, 1893), 184; Hugh Henry Brackenridge, “The Bloody Vestiges of Tyranny,” in Hugh Henry Brackenridge, A Hugh Henry Brackenridge Reader, 1770-1815, ed. Daniel Marder (Pittsburgh: University of Pittsburgh Press, 1970), 66; Allen, Narrative, 29; Jonathan Gillet to Elizabeth Gillet, December 2, 1776, in Letters from the Prisons and Prison-Ships of the Revolution, ed. Henry R. Stiles (New York: Privately Printed, 1865), 11.

[21]Hehir, “Effects of Chronic Starvation,” 867; Donovan, “Observations on the Peculiar Diseases,” 67; Donovan, “Observations on the Diseases,” 267; “Report upon the Recent Epidemic Fever,” 400; Fliederbaum, et al., “Clinical Aspects,” 19; Howard, Inquiry, 19.

[22]Fliederbaum, et al., “Clinical Aspects,” 17-18; Stein and Fenigstein, “Pathology Anatomy,” 218, 219 (Table 5), 227. This paper slightly adjusts the figures of Martha Osnos’s English translation of Stein and Fenigstein (the original Polish manuscript was consulted for this paper). Column C in Table 5 transposes the total number of edema cases (95) for the specific number of edema cases in the lower extremities (91) in Period C (July 1, 1941-December 31, 1941). The changes are slight, the preponderance of lower-extremity edema remains. Where this paper finds lower-extremity edema in 160 of 164 cases (97.6 percent), Stein and Fenigstein find it in 157 of 160 cases (98.1 percent); Stein and Fenigstein, “Pathological Anatomy,” 217, 219, 227.

[23]Alexander Porter, “Notes on Famine Diseases,” The Dublin Journal of Medical Science, 83 (January-June 1887): 135-136; Porter, Diseases of the Madras Famine, 72, 73

[24]Donovan, “Observations on the Peculiar Diseases,” 68; Boyd Affidavit; Affidavit of James Stuart, February 27, 1777, Pennsylvania Evening Post, May 3, 1777.

[25]Hehir, “Effects of Chronic Starvation,” 867; Fliederbaum, et al., “Clinical Aspects,” 36; Adlum Memoirs, 137.

[26]William Clowes, A Profitable and Necessarie Books of Observations, 3rd ed.(London: M. Dawson, 1637 [1596]), 40, Crawford Historical Books, University of Maryland, Baltimore, http://hdl.handle.net/2027/uc1.31378008343157; Stewart R. Roberts, Pellagra: History, Distribution, Diagnosis, Prognosis, Treatment, Etiology(St. Louis, Missouri: C. V. Mosby Company, 1913), 128; Fliederbaum, et al., “Metabolic Changes,” 101-105; P. Thygesen and J. Kieler, “Avitaminoses Incident to Semistarvation,” Famine Disease, 215, 226-227, 233-234; Thaysen and Thaysen, “Hunger Diarrhoea,” 134; Thaysen and Thaysen, “Hunger Oedema,” 99-100.

[27]William Howe to George Germain, December 3, 1776, Peter Force, American Archives, Series 3, Vol. 3 (Washington, DC: St. Clair Clarke and Peter Force, 1853), 1055, Northern Illinois University Digital Library, digital.lib.niu.edu/islandora/object/niu-amarch%3A88768; Thygesen and Kieler, “The Mussulman,” 253.

[28]Jabez Fitch, The New-York Diary of Lieutenant Jabez Fitch, ed. William H. Waldon Sabine (New York: The New York Times & Arno Press, 1971 [1954]), 92; James McHenry to George Washington, January 31, 1777, Founders Online,  founders.archives.gov/documents/Washington/03-08-02-0214; Connecticut Journal, January 8, 1777; Adlum Memoirs, 124; Thomas Hartley to Washington, February 12, 1777, Founders Online, founders.archives.gov/documents/Washington/03-08-02-0341; Samuel Holden Parsons to Washington, February 19, 1777, Founders Online, founders.archives.gov/documents/Washington/03-08-02-0406; “A Madras Correspondent…,” February 24, 1877, The Times (London), March 28, 1877, Newspapers.com, www.newspapers.com/clip/55083644/famine-diarrhea-madras/; Thaysen and Thaysen, “Hunger Diarrhoea,” 134, Hehir, “Effects of Chronic Starvation,” 868; Thygesen and Kieler, “The Mussulman,” 253; George Washington to William Howe, April 9, 1777, Founders Online , National Archives, founders.archives.gov/documents/Washington/03-09-02-0103; Miserecors (pseud.), “Messieurs Greens,” The Connecticut Journal (New Haven), January 30, 1777.

[29]Washington to Howe, April 9, 1777.