The Great Influenza: The Epic Story of the Deadliest Plague in History - John M. Barry (2004)
Part III. THE TINDERBOX
WILSON HAD DEMANDED that “the spirit of ruthless brutality…enter into the very fibre of national life.” To carry out that charge Creel had wanted to create “one white-hot mass,” a mass driven by “deathless determination.” He was doing so. This was truly total war, and that totality truly included the medical profession.
Creel’s spirit even injected itself into Military Surgeon, a journal published by the army for its physicians, which said, “Every single activity of this country is directed towards one single object, the winning of the war; nothing else counts now, and nothing will count ever if we don’t win it. No organization of any kind should be countenanced that has not this object in immediate view and is likely to help in the most efficient way…. Thus the medical sciences are applied to war, the arts are applied in perfecting camouflage, in reviving the spirits of our soldiers by entertainment, etc.”
This medical journal, this journal for physicians whose goal was to save life, also declared, “The consideration of human life often becomes quite secondary…. The medical officer has become more absorbed in the general than the particular, and the life and limb of the individual, while of great importance, are secondary to measures pro bono publico.” And this same journal expressed its opinion of what constituted pro bono publico when it quoted approvingly advice from Major Donald McRae, a combat veteran who said, “If any enemy wounded are found (in the trench) they should be bayonetted, if sufficient prisoners [for interrogation] have been taken.”
Gorgas did not share the views of the journal’s editors. When the investigator funded by Rockefeller found his gangrene antitoxin effective, he wanted to publish his results—which could help the Germans. Both Gorgas and Secretary of War Newton Baker agreed that he should do so, and he did. Welch told Flexner, “I was very glad that both the Secretary and Surgeon General without any hesitation took this position.”
But Gorgas had more important things to do than police the editors of Military Surgeon. He was focusing upon his mission, and he was pursuing it with the obsessiveness of a missionary. For Gorgas had a nightmare.
The U.S. Army had exploded from a few tens of thousands of soldiers before the war to millions in a few months. Huge cantonments, each holding roughly fifty thousand men, were thrown together in a matter of weeks. Hundreds of thousands of men occupied them before the camps were completed. They were jammed into those barracks that were finished, barracks designed for far less than their number, while tens of thousands of young soldiers lived through the first winter in tents. Hospitals were the last buildings to be constructed.
These circumstances not only brought huge numbers of men into this most intimate proximity but exposed farm boys to city boys from hundreds of miles away, each of them with entirely different disease immunities and vulnerabilities. Never before in American history—and possibly never before in any country’s history—had so many men been brought together in such a way. Even at the front in Europe, even with the importation there of labor from China, India, and Africa, the concentration and throwing together of men with different vulnerabilities may not have been as explosive a mix as that in American training camps.
Gorgas’s nightmare was of an epidemic sweeping through those camps. Given the way troops moved from camp to camp, if an outbreak of infectious disease erupted in one, it would be extraordinarily difficult to isolate that camp and keep the disease from spreading to others. Thousands, possibly tens of thousands, could die. Such an epidemic might spread to the civilian population as well. Gorgas intended to do all within his power to prevent his nightmare from becoming real.
By 1917 medical science was far from helpless in the face of disease. It stood in fact on the banks of the river Styx. If it was able to wade into those waters and pull only a few people back from that crossing, in its laboratories lay the promise of much more.
True, science had so far developed only a single one of the “magic bullets” envisaged by Paul Ehrlich. He and a colleague had tried nine hundred different chemical compounds to cure syphilis before retesting the 606th one. It was an arsenic compound; this time they made it work, curing syphilis without poisoning the patient. Named salversan, it was often called just “606.”
But science had achieved considerable success in manipulating the immune system and in public health. Vaccines prevented a dozen diseases that devastated livestock, including anthrax and hog cholera. Investigators had also gone far beyond the first success against smallpox and were now developing vaccines to prevent a host of diseases as well as antitoxins and serums to cure them. Science had triumphed over diphtheria. Sanitary and public health measures were containing typhoid, cholera, yellow fever, and bubonic plague, and vaccines against typhoid, cholera, and plague also appeared. Antitoxin for snake bites went into production. An antiserum for dysentery was found. A tetanus antitoxin brought magical results—before its widespread use, in 1903 in the United States 102 people died out of every 1,000 treated for tetanus; ten years later universal use of the antitoxin lowered the death rate to 0 per 1,000 treated. Meningitis had been checked, if not conquered, largely by Flexner’s antiserum. In 1917 an antitoxin for gangrene was developed; although it was not nearly as effective as other antitoxins, scientists could improve it as they had improved others, over time. The possibilities of manipulating the immune system to defeat infectious disease seemed to hold enormous promise.*
At the management level Gorgas was taking action too. He saw to it that many of the new army doctors assigned to the cantonments were trained at the Rockefeller Institute by some of the best scientists in the world. He began stockpiling huge quantities of vaccines, antitoxins, and sera. He did not rely for these products on drug manufacturers; they were unreliable and often useless. In 1917 in fact New York State health commissioner Hermann Biggs tested commercial products for several diseases and found them so poor that he banned all sales from all drug manufacturers in New York State. So Gorgas assigned production to people he could rely upon. The Army Medical School would make enough typhoid vaccine for five million men. The Rockefeller Institute would produce sera for pneumonia, dysentery, and meningitis. The Hygienic Laboratory in Washington, which ultimately grew into the National Institutes of Health, would prepare smallpox vaccine and antitoxins for diphtheria and tetanus.
He also transformed several railroad cars into the most modern laboratory facilities—the equipping of these cars was paid for not by the government but by the Rockefeller Institute and the American Red Cross—and stationed these rolling laboratories at strategic points around the country, ready, as Flexner told Gorgas’s deputy for scientific matters, Colonel Frederick Russell, to “be sent to any one of the camps at which pneumonia or other epidemic disease prevails.”
Also, even before construction began on the cantonments, Gorgas created a special unit for “the prevention of infectious disease.” He assigned the very best men to it. Welch, who had already toured British and French camps and was alert to possible weak points, headed this unit, and its five other members were Flexner, Vaughan, Russell, Biggs, and Rhode Island’s Charles Chapin. Each of them had international renown. They laid out precise procedures for the army to follow to minimize the chances of an epidemic.
Meanwhile, as troops were pouring into the camps in 1917, Rockefeller Institute colleagues Rufus Cole, Oswald Avery, and others who had turned their focus to pneumonia issued a specific warning: “Although pneumonia occurs chiefly in endemic form, small and even large epidemics are not unknown. It was the most serious disease which threatened the construction of the Panama Canal”—more so even than yellow fever, as Gorgas well knew—“and its prevalence in regions where large numbers of susceptible workers are brought together renders it of great importance…. Pneumonia [seems] especially likely to attack raw recruits. The experience among the small number of troops in the Mexican border, where pneumonia occurred in epidemic form [in 1916], should be a warning of what is likely to happen in our national army when large numbers of susceptible men are brought together during the winter months.”
Gorgas’s army superiors ignored the advice. As a result, the army soon suffered a taste of epidemic disease. It would be a test run, for both a virus and medicine.
The winter of 1917–18 was the coldest on record east of the Rocky Mountains, barracks were jam-packed, and hundreds of thousands of men were still living in tents. Camp hospitals and other medical facilities had not yet been finished. An army report conceded the failure to provide warm clothing or even heat. But most dangerous was the overcrowding.
Flexner warned that the situation “was as if the men had pooled their diseases, each picking up the ones he had not had,…greatly assisted by the faulty laying out of the camps, poor administration, and lack of adequate laboratory facilities.” Vaughan protested impotently and later called army procedures “insane…. How many lives were sacrificed I can not estimate…. The dangers in mobilization steps followed were pointed out to the proper authorities before there was any assembly, but the answer was: ‘The purpose of mobilization is to convert civilians into trained soldiers as quickly as possible and not to make a demonstration in preventive medicine.’”
In that bitterly cold winter, measles came to the army’s barracks, and it came in epidemic form. Usually, of course, measles infects children and causes only fever, rash, cough, runny nose, and discomfort. But like many other children’s diseases—especially viral diseases—when measles strikes adults, it often strikes hard. (Early in the twenty-first century, measles is still causing one million deaths a year worldwide.)
This outbreak racked its victims with high fever, extreme sensitivity to light, and violent coughs. Complications included severe diarrhea, meningitis, encephalitis (inflammation of the brain), violent ear infections, and convulsions.
As infected soldiers moved from camp to camp, the virus moved with them, rolling through camps like a bowling ball knocking down pins. Vaughan reported, “Not a troop train came into Camp Wheeler [near Macon, Georgia] in the fall of 1917 without bringing from one to six cases of measles already in the eruptive stage. These men…distributed its seeds at the encampment and on the train. No power on earth could stop the spread of measles under these conditions.”
Camp Travis outside San Antonio held 30,067 men. By Christmas, 4,571 men had come down with the disease. Funston had an average troop strength of over fifty-six thousand; three thousand were sick enough to require hospitalization. At Greenleaf in South Carolina, Devens in Massachusetts, the numbers were comparable. The 25,260 troops at Camp Cody in New Mexico were free of measles until soon after the arrival of men from Funston. Then measles began roaring through Cody, too.
And some young men began to die.
Investigators could develop neither a vaccine to prevent measles nor a serum to cure it, but most deaths were coming chiefly from secondary infections, from bacteria invading the lungs after the virus had weakened their defenses. And investigators at Rockefeller and elsewhere struggled to find a way to control these bacterial infections. They made some progress.
Meanwhile the army issued orders forbidding men from crowding around stoves, and officers entered barracks and tents to enforce it. But especially for the tens of thousands who lived in tents in the record cold, it was impossible to keep men from crowding around stoves.
Of all the complications of measles, the most deadly by far was pneumonia. In the six months from September 1917 to March 1918, before the influenza epidemic struck, pneumonia struck down 30,784 soldiers on American soil. It killed 5,741 of them. Nearly all these pneumonia cases developed as complications of measles. At Camp Shelby, 46.5 percent of all deaths—all deaths from all diseases, all car wrecks, all work accidents, all training mishaps combined—were a result of pneumonia following measles. At Camp Bowie, 227 soldiers died from disease in November and December 1917; 212 of them died of pneumonia after measles. The average death rate from pneumonia in twenty-nine cantonments was twelve times that of civilian men of the same age.
In 1918 the Republican-controlled Senate held hearings on the Wilson administration’s mistakes in mobilizing the military. Republicans had despised Wilson since 1912, when he reached the White House despite winning only 41 percent of the vote. (Former Republican president and then third-party candidate Teddy Roosevelt and incumbent Republican president William Howard Taft split the GOP vote, and Socialist Eugene Debs also won 6 percent.) Mobilization failures seemed a perfect opportunity to embarrass him. And there was personal bitterness in the attacks: Congressman Augustus Peabody Gardner, son-in-law of Senate Majority Leader Henry Cabot Lodge, had resigned from Congress and enlisted, only to die of pneumonia in camp.
Gorgas was summoned to explain the measles fiasco. His testimony and his report on the epidemic to the chief of staff made front-page news. Like his mentor Sternberg during the typhoid debacle twenty years earlier, he lacerated his War Department colleagues and superiors for rushing troops to cantonments under living conditions that failed to meet minimum public health standards, for overcrowding, for exposing recruits to measles who had no immunity, for using untrained “country boys” to care for desperately sick men in poorly equipped hospitals and sometimes without hospitals at all. And he stated that the War Department seemed to consider the Medical Department of the army unimportant. “I was never in their confidence, no,” he said in response to one senator’s question.
He had hoped his testimony would force the army to give him more power to protect troops. Perhaps it did; the army initiated courts-martial at three cantonments. But his testimony also isolated him. He confided to his sister that, in the War Department, “All my friends seem to have deserted me and everybody is giving me a kick as I pass by.”
Meanwhile, Welch visited one of the worst-hit camps, a camp where measles itself had left but where victims with complications still lingered. He told Gorgas that the mortality rate for troops developing pneumonia after measles “is stated to be 30% but more now in hospital will die. A good statistician needed in hospital—registrar not competent.” To give the men in the hospital a better chance to survive, he continued, “Have Colonel Russell send directions for Avery’s medicine for pneumococcus type work.”
He was referring to the Rockefeller Institute’s Oswald Avery, one of the Canadians there who had been inducted into the army as only a private. Private or not, he soon would be, if he was not already, the world’s leading investigator of pneumonia. And conclusions Avery would reach would have import far—very, very far—beyond that subject. His findings would create a scientific revolution that would change the direction of all genetic research and create modern molecular biology. But that would come later.
Osler called pneumonia “the captain of the men of death.” Pneumonia was the leading cause of death around the world, greater than tuberculosis, greater than cancer, greater than heart disease, greater than plague.
And, like measles, when influenza kills, it usually kills through pneumonia.