The Great Influenza: The Epic Story of the Deadliest Plague in History - John M. Barry (2004)

Part IX. LINGERER

Chapter 32

THE OVERWHELMING MAJORITY of victims, especially in the Western world, recovered quickly and fully. This was after all only influenza.

But the virus sometimes caused one final complication, one final sequela. The influenza virus affected the brain and nervous system. All high fevers cause delirium, but this was something else. An army physician at Walter Reed Hospital investigating serious mental disturbances and even psychoses that seemed to follow an attack of influenza specifically noted, “Delirium occurring at the height of the disease and clearing with the cessation of fever is not considered in this report.”

The connection between influenza and various mental instabilities seemed clear. The evidence was almost entirely anecdotal, the worst and weakest kind of evidence, but it convinced the vast majority of contemporary observers that influenza could alter mental processes. What convinced them were observations such as these:

From Britain: “…profound mental inertia with intense physical prostration. Delirium has been very common…. It has varied from mere confusion of ideas through all grades of intensity up to maniacal excitement.”

From Italy: “…influenzal psychoses of the acute period…as a rule subside in two or three weeks. The psychosis, however, may pass into a state of mental collapse, with stupor which may persist and become actual dementia. In other cases…depression and restlessness…to [which] can be attributed the large number of suicides during the pandemic of influenza.”

From France: “…frequent and serious mental disturbances during convalescence from and as a result of influenza…. The mental disturbances sometimes took on the form of acute delirium with agitation, violence, fear and erotic excitation and at other times was of a depressive nature…fear of persecution.”

From different U.S. Army cantonments:

“…The mental condition was either apathetic or there was an active delirium. Cerebration was slow…. The patient’s statements and assurances were unreliable, a moribund person stating he felt very well…. In other cases, apprehensiveness was most striking.”

“…The mental depression of the patient is often out of all proportion to the other symptoms.”

“…Nervous symptoms appeared early, restlessness and delirium being marked.”

“…melancholia, hysteria, and insanity with suicidal intent.”

“…Toxic involvement of the nervous system was evident in all the more severe cases.”

“…Many patients lay in muttering delirium which persisted after the temperature was normal.”

“…Symptoms referable to the central nervous system were seen at times, as twitching of the muscles of the fingers, forearms, and face,…an active, even maniacal occasional delirium, or more usually the low mumbling type.”

“…Infectious psychosis was seen in 18 cases, from simple transient hallucinations to maniacal frenzy with needed mechanical restraint.”

Contemporary observers also linked influenza to an increase in Parkinson’s disease a decade later. (Some have theorized that the patients in Oliver Sacks’s The Awakening were victims of the 1918 influenza pandemic.) Many believed that the virus could cause schizophrenia, and in 1926, Karl Menninger studied links between influenza and schizophrenia. His study was considered significant enough that the American Journal of Psychiatryidentified it as a “classic” article and reprinted it in 1994. Menninger spoke of the “almost unequalled neurotoxicity of influenza” and noted that two-thirds of those diagnosed with schizophrenia after an attack of influenza had completely recovered five years later. Recovery from schizophrenia is extremely rare, suggesting that some reparable process had caused the initial symptoms.

In 1927 the American Medical Association’s review of hundreds of medical journal articles from around the world concluded, “There seems to be general agreement that influenza may act on the brain…. From the delirium accompanying many acute attacks to the psychoses that develop as ‘post-influenzal’ manifestations, there is no doubt that the neuropsychiatric effects of influenza are profound and varied…. The effect of the influenza virus on the nervous system is hardly second to its effect on the respiratory tract.”

In 1934 a similar comprehensive review by British scientists agreed: “There would appear to be no doubt that influenza exerts a profound influence on the nervous system.”

In 1992 an investigator studying the connection between suicide and the war instead concluded, “World War I did not influence suicide; the Great Influenza Epidemic caused it to increase.”

A 1996 virology textbook said, “A wide spectrum of central nervous system involvement has been observed during influenza A virus infections in humans, ranging from irritability, drowsiness, boisterousness, and confusion to the more serious manifestations of psychosis, delirium, and coma.”

The 1997 Hong Kong virus that killed six of the eighteen people infected provided some physical evidence. Autopsies of two victims showed “edematous brains.” “Edema” means “swelling.” “Most remarkably, bone marrow, lymphoid tissue, liver, and spleen of both patients were heavily infiltrated with [macrophages]…. One patient even had such cells on the meninges”—the membranes surrounding the brain and spinal cord—“and in the white matter of the cerebrum.” The most likely reason for these macrophages to have infiltrated the brain was to follow the virus there, and kill it. And that 1997 pathology report echoes some from 1918: “In cases accompanied by delirium, the meninges of the brain are richly infiltrated by serous fluid and the capillaries are injected.Necropsy in the fatal cases demonstrated congestive lesions with small meningeal hemorrhages and especially in islands of edema in the cortical substance surrounding greatly dilated small vessels…hemorrhages into gray matter of the cord…[brain] tissue cells were altered in these zones of…edema.”

In 2002 Robert Webster, one of the world’s leading experts on the virus at St. Jude Children’s Hospital in Memphis, observed, “These viruses do from time to time get across to central nervous systems and play hell.” He recalled a child in Memphis who was an excellent student, got influenza, and became “a vegetable. I’ve seen enough examples in my lifetime to believe…influenza can get into the brain. It’s tenuous but real. Put the virus into chickens, it can go up the olfactory nerve and the chicken’s dead.”

The 1918 virus did seem to reach the brain. The war fought on that battlefield could destroy brain cells and make it difficult to concentrate, or alter behavior, or interfere with thinking, or even cause temporary psychosis. If this occurred in only a minority of cases, the virus’s impact on the mind was nonetheless real.

But that impact would, by terrible coincidence, have a profound effect indeed.

In January 1919 in France, Congressman William Borland of Kansas died, the third congressmen to be killed by the virus. That same month also in Paris, “Colonel” Edward House, Wilson’s closest confidant, collapsed with influenza—again.

House had first gotten influenza during the first wave in March 1918, was confined to his home for two weeks, went to Washington and relapsed, and then spent three weeks in bed at the White House. Although a spring attack often conferred immunity to the virus, after the Armistice he was struck down a second time. He was in Europe then, and on November 30 he got up for the first time in ten days and met with French premier Georges Clemenceau for fifteen minutes. Afterward he noted, “Today is the first day I have taken up my official work in person for over a week. I have had influenza 10 days and have been exceeding miserable…. So many have died since this epidemic has scourged the world. Many of my staff have died and poor Willard Straight among them.”

Now, in January 1919, he was attacked still a third time. He was sick enough that some papers reported him dead. House wryly called the obituaries “all too generous.” But the blow was heavy: more than a month after his supposed recovery he wrote in his diary, “When I fell sick in January I lost the thread of affairs and I am not sure that I have ever gotten fully back.”

There were affairs of some magnitude to attend to in Paris in early 1919.

Representatives of victorious nations, of weak nations, of nations hoping to be born from the splinters of defeated nations, had all come there to set the terms of peace. Several thousand men from dozens of countries circled around the edges of decision making. Germany would play no role in these decisions; Germany would simply be dictated to. And among this host of nations, this virtual Tower of Babel, a Council of Ten of the most powerful nations supposedly determined the agenda. Even within this tight circle was a tighter one, the “Big Four”—the United States, France, Britain, and Italy. And in reality only three of those four nations mattered. Indeed, only three men mattered.

French premier Georges Clemenceau, known as “the Tiger,” negotiated with a bullet in his shoulder, put there by an assassination attempt during the peace conference on February 19. Prime Minister Lloyd George of Great Britain faced such political problems at home he was described as “a greased marble spinning on a glass table top.” And there was Wilson, who arrived in Europe the most popular political figure in the world.

For weeks and then months the meetings dragged on, and tens of thousands of pages of drafts and memos and understandings went back and forth between ministers and staff. But Wilson, Clemenceau, and George did not much need these thousands of pages. They were not simply ratifying what foreign ministers and staffs had worked out, nor were they simply making decisions on options presented to them. They were themselves doing much of the actual negotiating. They were bargaining and wheedling, they were demanding and insisting, and they were rejecting.

Often only five or six men would be in a room, including translators. Often, even when Clemenceau and George had others present, Wilson represented the United States alone, with no staff, no secretary of state, no Colonel House, who by now had been all but discarded as untrustworthy by Wilson. Interrupted only by Wilson’s relatively brief return to the United States, discussions were interminable. But they were deciding the future of the world.

In October, at the peak of the epidemic in Paris, 4,574 people had died there of influenza or pneumonia. The disease had never entirely left that city. In February 1919, deaths in Paris from influenza and pneumonia climbed back up to 2,676, more than half the peak death toll. Wilson’s daughter Margaret had influenza in February; she was kept in bed in Brussels at the American legation. In March another 1,517 Parisians died, and the Journal of the American Medical Association reported that in Paris “the epidemic of influenza which had declined has broken out anew in a most disquieting manner…. The epidemic has assumed grave proportions, not only in Paris but in several of the departments.”

That month Wilson’s wife, his wife’s secretary, Chief White House Usher Irwin Hoover, and Cary Grayson, Wilson’s personal White House physician and perhaps the single man Wilson trusted the most, were all ill. Clemenceau and Lloyd George both seemed to have mild cases of influenza.

Meanwhile the sessions with George and Clemenceau were often brutal. In late March Wilson told his wife, “Well, thank God I can still fight, and I’ll win.”

On March 29, Wilson said, “M. Clemenceau called me pro-German and left the room.”

Wilson continued to fight, insisting, “The only principle I recognize is that of the consent of the governed.” On April 2, after the negotiations for the day finished, he called the French “damnable”—for him, a deeply religious man, an extreme epithet. He told his press spokesman Ray Stannard Baker, “[W]e’ve got to make peace on the principles laid down and accepted, or not make it at all.”

The next day, April 3, a Thursday, at three P.M., Wilson seemed in fine health, according to Cary Grayson. Then, very suddenly at six o’clock, Grayson saw Wilson “seized with violent paroxysms of coughing, which were so severe and frequent that it interfered with his breathing.”

The attack came so suddenly that Grayson suspected that Wilson had been poisoned, that an assassination attempt had been made. But it soon became obvious the diagnosis was simpler, if only marginally more reassuring.

Joseph Tumulty, Wilson’s chief of staff, had stayed in Washington to monitor political developments at home. Grayson and he exchanged telegrams daily, sometimes several times a day. But the information of the president’s illness was too sensitive for a telegram. Grayson did wire him, “The President took very severe cold last night; confined to bed.” Simultaneously he also wrote a confidential letter to be hand-delivered: “The President was taken violently sick last Thursday. He had a fever of over 103 and profuse diarrhoea….[It was] the beginning of an attack of influenza. That night was one of the worst through which I have ever passed. I was able to control the spasms of coughing but his condition looked very serious.”

Donald Frary, a young aide on the American peace delegation, came down with influenza the same day Wilson did. Four days later he died at age twenty-five.

For several days Wilson lay in bed, unable to move. On the fourth day, he sat up. Grayson wired Tumulty, “Am taking every precaution with him…. Your aid and presence were never needed more.”

Wilson for the first time was well enough to have visitors. He received American commissioners in his bedroom and said, “Gentlemen, this is not a meeting of the Peace Commission. It is more a Council of War.”

Just before getting sick Wilson had threatened to leave the conference, to return to the United States without a treaty rather than yield on his principles. He repeated that threat again, telling Grayson to order the George Washington to be ready to sail as soon as he was well enough to travel. The next day Gilbert Close, his secretary, wrote his wife, “I never knew the president to be in such a difficult frame of mind as now. Even while lying in bed he manifested peculiarities.”

Meanwhile the negotiations continued; Wilson, unable to participate, was forced to rely on House as his stand-in. (Wilson had even less trust in Secretary of State Robert Lansing, whom he largely ignored, than in House.) For several days Wilson continued to talk about leaving France, telling his wife, “If I have lost the fight, which I would not have done had I been on my feet, I will retire in good order, so we will go home.”

Then, on April 8, Wilson insisted upon personally rejoining the negotiations. He could not go out. Clemenceau and George came to his bedroom, but the conversations did not go well. His public threat to leave had infuriated Clemenceau, who privately called him “a cook who keeps her trunk ready in the hallway.”

Grayson wrote that despite “that ill-omened attack of influenza, the insidious effects of which he was not in good condition to resist,…[the president] insisted upon holding conferences while he was still confined to his sickbed. When he was able to get up he began to drive himself as hard as before—morning, afternoon, and frequently evening conferences.”

Herbert Hoover, not part of the American peace delegation but a large figure in Paris because he had charge of feeding a desolated and barren Europe, said, “Prior to that time, in all matters with which I had to deal, he was incisive, quick to grasp essentials, unhesitating in conclusions, and most willing to take advice from men he trusted….[Now] others as well as I found we had to push against an unwilling mind. And at times, when I just had to get decisions, I suffered as much from having to mentally push as he did in coming to conclusions.” Hoover believed Wilson’s mind had lost “resiliency.”

Colonel Starling of the Secret Service noticed that Wilson “lacked his old quickness of grasp, and tired easily.” He became obsessed with such details as who was using the official automobiles. When Ray Stannard Baker was first allowed to see Wilson again, he trembled at Wilson’s sunken eyes, at his weariness, at his pale and haggard look, like that of a man whose flesh has shrunk away from his face, showing his skull.

Chief Usher Irwin Hoover recalled several new and very strange ideas that Wilson suddenly believed, including one that his home was filled with French spies: “Nothing we could say could disabuse his mind of this thought. About this time he also acquired a peculiar notion he was personally responsible for all the property in the furnished place he was occupying…. Coming from the President, whom we all knew so well, these were very funny things, and we could but surmise that something queer was happening in his mind. One thing was certain: he was never the same after this little spell of sickness.”

Grayson confided to Tumulty, “This is a matter that worries me.”

“I have never seen the President look so worn and tired,” Ray Baker said. In the afternoon “he could not remember without an effort what the council had done in the forenoon.”

Then, abruptly, still on his sickbed, only a few days after he had threatened to leave the conference unless Clemenceau yielded to his demands, without warning to or discussion with any other Americans, Wilson suddenly abandoned principles he had previously insisted upon. He yielded to Clemenceau everything of significance Clemenceau wanted, virtually all of which Wilson had earlier opposed.

Now, in bed, he approved a formula Clemenceau had written demanding German reparations and that Germany accept all responsibility for starting the war. The Rhineland would be demilitarized; Germany would not be allowed to have troops within thirty miles of the east bank of the Rhine. The rich coal fields of the Saar region would be mined by France and the region would be administered by the new League of Nations for fifteen years, and then a plebiscite would determine whether the region would belong to France or Germany. The provinces of Alsace and Lorraine, which Germany had seized after the Franco-Prussian War, were moved from Germany back to France. West Prussia and Posen were given to Poland—creating the “Polish corridor” that separated two parts of Germany. The German air force was eliminated, its army limited to one hundred thousand men, its colonies stripped away—but not freed, simply redistributed to other powers.

Even Lloyd George commented on Wilson’s “nervous and spiritual breakdown in the middle of the Conference.”

Grayson wrote, “These are terrible days for the President physically and otherwise.”

As Grayson made that notation, Wilson was conceding to Italy much of its demands and agreeing to Japan’s insistence that it take over German concessions in China. In return the Japanese offered an oral—not written—promise of good behavior, a promise given not even to Wilson personally or, for that matter, to any chief of state, but to British Foreign Secretary Alfred Balfour.

On May 7 the Germans were presented with the treaty. They complained that it violated the very principles Wilson had declared were inviolate. Wilson left the meeting saying, “What abominable manners…. This is the most tactless speech I have ever heard.”

Yet they had not reminded Wilson and the world that he had once said that a lasting peace could be achieved only by—and that he had once called for—“A peace without victory.”

Wilson also told Baker, “If I were a German, I think I should never sign it.”

Four months later Wilson suffered a major and debilitating stroke. For months his wife and Grayson would control all access to him and become arguably the de facto most important policy makers in the country.

In 1929 one man wrote a memoir in which he said that two doctors believed Wilson was suffering from arteriosclerosis when he went to Paris. In 1946 a physician voiced the same opinion in print. In 1958 a major biography of Wilson stated that experts on arteriosclerosis questioned Grayson’s diagnosis of influenza and believed Wilson had instead suffered a vascular occlusion—a minor stroke. In 1960 a historian writing about the health of presidents said, “Present-day views are that [Wilson’s disorientation] was based on brain damage, probably caused by arteriosclerotic occlusion of blood vessels.” In 1964 another historian called Wilson’s attack “thrombosis.” In a 1970 article in the Journal of American History, titled “Woodrow Wilson’s Neurological Illness,” another historian called it “a little stroke.”

Only one historian, Alfred Crosby, seems to have paid any attention to Wilson’s actual symptoms—including high fever, severe coughing, and total prostration, all symptoms that perfectly fit influenza and have no association whatsoever with stroke—and the on-site diagnosis of Grayson, an excellent physician highly respected by such men as Welch, Gorgas, Flexner, and Vaughan.

Despite Crosby, the myth of Wilson’s having suffered a minor stroke persists. Even a prize-winning account of the peace conference published in 2002 observes, “Wilson by contrast had aged visibly and the tic in his cheek grew more pronounced….[It] may have been a minor stroke, a forerunner of the massive one he was to have four months later.”

There was no stroke. There was only influenza. Indeed, the virus may have contributed to the stroke. Damage to blood vessels in the brain were often noted in autopsy reports in 1918, as they were in 1997. Grayson himself believed that Wilson’s “attack of influenza in Paris proved to be one of the contributory causes of his final breakdown.”

It is of course impossible to say what Wilson would have done had he not become sick. Perhaps he would have made the concessions anyway, trading every principle away to save his League of Nations. Or perhaps he would have sailed home as he had threatened to do just as he was succumbing to the disease. Then either there would have been no treaty or his walkout would have forced Clemenceau to compromise.

No one can know what would have happened. One can only know what did happen.

Influenza did visit the peace conference. Influenza did strike Wilson. Influenza did weaken him physically, and—precisely at the most crucial point of negotiations—influenza did at the least drain from him stamina and the ability to concentrate. That much is certain. And it is almost certain that influenza affected his mind in other, deeper ways.

Historians with virtual unanimity agree that the harshness toward Germany of the Paris peace treaty helped create the economic hardship, nationalistic reaction, and political chaos that fostered the rise of Adolf Hitler.

It did not require hindsight to see the dangers. They were obvious at the time. John Maynard Keynes quit Paris calling Wilson “the greatest fraud on earth.” Later he wrote, “We are at the dead season of our fortunes…. Never in the lifetime of men now living has the universal element in the soul of man burnt so dimly.” Herbert Hoover believed that the treaty would tear down all Europe, and said so.

Soon after Wilson made his concessions a group of young American diplomatic aides and advisers met in disgust to decide whether to resign in protest. They included Samuel Eliot Morison, William Bullitt, Adolf Berle Jr., Christian Herter, John Foster Dulles, Lincoln Steffens, and Walter Lippmann. All were already or would become among the most influential men in the country. Two would become secretary of state. Bullitt, Berle, and Morison did resign. In September, during the fight over ratifying the treaty, Bullitt revealed to the Senate the private comments of Secretary of State Robert Lansing that the League of Nations would be useless, that the great powers had simply arranged the world to suit themselves.

Berle, later an assistant secretary of state, settled for writing Wilson a blistering letter of resignation: “I am sorry that you did not fight our fight to the finish and that you had so little faith in the millions of men, like myself, in every nation who had faith in you. Our government has consented now to deliver the suffering peoples of the world to new oppressions, subjections and dismemberments—a new century of war.”

Wilson had influenza, only influenza.