The Great Influenza Read online

  When it came, they placed their lives in the path of the disease and applied all their knowledge and powers to defeat it. As it overwhelmed them, they concentrated on constructing the body of knowledge necessary to eventually triumph. For the scientific knowledge that ultimately came out of the influenza pandemic pointed directly (and still points) to much that lies in medicine's future.

  Part I

  THE WARRIORS

  CHAPTER ONE

  ON SEPTEMBER 12, 1876, the crowd overflowing the auditorium of Baltimore's Academy of Music was in a mood of hopeful excitement, but excitement without frivolity. Indeed, despite an unusual number of women in attendance, many of them from the uppermost reaches of local society, a reporter noted, 'There was no display of dress or fashion.' For this occasion had serious purpose. It was to mark the launching of the Johns Hopkins University, an institution whose leaders intended not simply to found a new university but to change all of American education; indeed, they sought considerably more than that. They planned to change the way in which Americans tried to understand and grapple with nature. The keynote speaker, the English scientist Thomas H. Huxley, personified their goals.

  The import was not lost on the nation. Many newspapers, including the New York Times, had reporters covering this event. After it, they would print Huxley's address in full.

  For the nation was then, as it so often has been, at war with itself; in fact it was engaged in different wars simultaneously, each being waged on several fronts, wars that ran along the fault lines of modern America.

  One involved expansion and race. In the Dakotas, George Armstrong Custer had just led the Seventh Cavalry to its destruction at the hands of primitive savages resisting encroachment of the white man. The day Huxley spoke, the front page of the Washington Star reported that 'the hostile Sioux, well fed and well armed' had just carried out 'a massacre of miners.'

  In the South a far more important but equally savage war was being waged as white Democrats sought 'redemption' from Reconstruction in anticipation of the presidential election. Throughout the South 'rifle clubs,' 'saber clubs,' and 'rifle teams' of former Confederates were being organized into infantry and cavalry units. Already accounts of intimidation, beatings, whippings, and murder directed against Republicans and blacks had surfaced. After the murder of three hundred black men in a single Mississippi county, one man, convinced that words from the Democrats' own mouths would convince the world of their design, pleaded with the New York Times, 'For God's sake publish the testimony of the Democrats before the Grand Jury.'

  Voting returns had already begun to come in (there was no single national election day) and two months later Democrat Samuel Tilden would win the popular vote by a comfortable margin. But he would never take office as president. Instead the Republican secretary of war would threaten to 'force a reversal' of the vote, federal troops with fixed bayonets would patrol Washington, and southerners would talk of reigniting the Civil War. That crisis would ultimately be resolved through an extra-constitutional special committee and a political understanding: Republicans would discard the voting returns of three states (Louisiana, Florida, South Carolina) and seize a single disputed electoral vote in Oregon to keep the presidency in the person of Rutherford B. Hayes. But they also would withdraw all federal troops from the South and cease intervening in southern affairs, leaving the Negroes there to fend for themselves.

  The war involving the Hopkins was more muted but no less profound. The outcome would help define one element of the character of the nation: the extent to which the nation would accept or reject modern science and, to a lesser degree, how secular it would become, how godly it would remain.

  Precisely at 11:00 A.M., a procession of people advanced upon the stage. First came Daniel Coit Gilman, president of the Hopkins, and on his arm was Huxley. Following in single file came the governor, the mayor, and other notables. As they took their seats the conversations in the audience quickly died away, replaced by expectancy of a kind of declaration of war.

  Of medium height and middle age (though he already had iron-gray hair and nearly white whiskers) and possessed of what was described as 'a pleasant face,' Huxley did not look the warrior. But he had a warrior's ruthlessness. His dicta included the pronouncement: 'The foundation of morality is to have done, once and for all, with lying.' A brilliant scientist, later president of the Royal Society, he advised investigators, 'Sit down before a fact as a little child, be prepared to give up every preconceived notion. Follow humbly wherever and to whatever abysses nature leads, or you shall learn nothing.' He also believed that learning had purpose, stating, 'The great end of life is not knowledge but action.'

  To act upon the world himself, he became a proselytizer for faith in human reason. By 1876 he had become the world's foremost advocate of the theory of evolution and of science itself. Indeed, H. L. Mencken said that 'it was he, more than any other man, who worked that great change in human thought which marked the Nineteenth Century.' Now President Gilman gave a brief and simple introduction. Then Professor Huxley began to speak.

  Normally he lectured on evolution, but today he was speaking on a subject of even greater magnitude. He was speaking about the process of intellectual inquiry. The Hopkins was to be unlike any other university in America. Aiming almost exclusively at the education of graduate students and the furtherance of science, it was intended by its trustees to rival not Harvard or Yale (neither of them considered worthy of emulation) but the greatest institutions of Europe, and particularly Germany. Perhaps only in the United States, a nation ever in the act of creating itself, could such an institution come into existence both so fully formed in concept and already so renowned, even before the foundation of a single building had been laid.

  'His voice was low, clear and distinct,' reported one listener. 'The audience paid the closest attention to every word which fell from the lecturer's lips, occasionally manifesting their approval by applause.' Said another, 'Professor Huxley's method is slow, precise, and clear, and he guards the positions which he takes with astuteness and ability. He does not utter anything in the reckless fashion which conviction sometimes countenances and excuses, but rather with the deliberation that research and close inquiry foster.'

  Huxley commended the bold goals of the Hopkins, expounded upon his own theories of education (theories that soon informed those of William James and John Dewey) and extolled the fact that the existence of the Hopkins meant 'finally, that neither political nor ecclesiastical sectarianism' would interfere with the pursuit of the truth.

  In truth, Huxley's speech, read a century and a quarter later, seems remarkably tame. Yet Huxley and the entire ceremony left an impression in the country deep enough that Gilman would spend years trying to edge away from it, even while simultaneously trying to fulfill the goals Huxley applauded.

  For the ceremony's most significant word was one not spoken: not a single participant uttered the word 'God' or made any reference to the Almighty. This spectacular omission scandalized those who worried about or rejected a mechanistic and necessarily godless view of the universe. And it came in an era in which American universities had nearly two hundred endowed chairs of theology and fewer than five in medicine, an era in which the president of Drew University had said that, after much study and experience, he had concluded that only ministers of the Gospel should be college professors.

  The omission also served as a declaration: the Hopkins would pursue the truth, no matter to what abyss it led.

  In no area did the truth threaten so much as in the study of life. In no area did the United States lag behind the rest of the world so much as in its study of the life sciences and medicine. And in that area in particular the influence of the Hopkins would be immense.

  By 1918, as America marched into war, the nation had come not only to rely upon the changes wrought largely, though certainly not entirely, by men associated with the Hopkins; the United States Army had mobilized these men into a special force, focused and discipli
ned, ready to hurl themselves at an enemy.

  *

  The two most important questions in science are 'What can I know?' and 'How can I know it?'

  Science and religion in fact part ways over the first question, what each can know. Religion, and to some extent philosophy, believes it can know, or at least address, the question, 'Why?'

  For most religions the answer to this question ultimately comes down to the way God ordered it. Religion is inherently conservative; even one proposing a new God only creates a new order.

  The question 'why' is too deep for science. Science instead believes it can only learn 'how' something occurs.

  The revolution of modern science and especially medical science began as science not only focused on this answer to 'What can I know?' but more importantly, changed its method of inquiry, changed its answer to 'How can I know it?'

  This answer involves not simply academic pursuits; it affects how a society governs itself, its structure, how its citizens live. If a society does set Goethe's 'Word' supremely high,' if it believes that it knows the truth and that it need not question its beliefs, then that society is more likely to enforce rigid decrees, and less likely to change. If it leaves room for doubt about the truth, it is more likely to be free and open.

  In the narrower context of science, the answer determines how individuals explore nature (how one does science. And the way one goes about answering a question, one's methodology, matters as much as the question itself. For the method of inquiry underlies knowledge and often determines what one discovers: how one pursues a question often dictates, or at least limits, the answer.

  Indeed, methodology matters more than anything else. Methodology subsumes, for example, Thomas Kuhn's well-known theory of how science advances. Kuhn gave the word 'paradigm' wide usage by arguing that at any given point in time, a particular paradigm, a kind of perceived truth, dominates the thinking in any science. Others have applied his concept to nonscientific fields as well.

  According to Kuhn, the prevailing paradigm tends to freeze progress, indirectly by creating a mental obstacle to creative ideas and directly by, for example, blocking research funds from going to truly new ideas, especially if they conflict with the paradigm. He argues that nonetheless researchers eventually find what he calls 'anomalies' that do not fit the paradigm. Each one erodes the foundation of the paradigm, and when enough accrue to undermine it, the paradigm collapses. Scientists then cast about for a new paradigm that explains both the old and new facts.

  But the process (and progress) of science is more fluid than Kuhn's concept suggests. It moves more like an amoeba, with soft and ill-defined edges. More importantly, method matters. Kuhn's own theory recognizes that the propelling force behind the movement from one explanation to another comes from the methodology, from what we call the scientific method. But he takes as an axiom that those who ask questions constantly test existing hypotheses. In fact, with a methodology that probes and tests hypotheses (regardless of any paradigm) progress is inevitable. Without such a methodology, progress becomes merely coincendental.

  Yet the scientific method has not always been used by those who inquire into nature. Through most of known history, investigators trying to penetrate the natural world, penetrate what we call science, relied upon the mind alone, reason alone. These investigators believed that they could know a thing if their knowledge followed logically from what they considered a sound premise. In turn they based their premises chiefly on observation.

  This commitment to logic coupled with man's ambition to see the entire world in a comprehensive and cohesive way actually imposed blinders on science in general and on medicine in particular. The chief enemy of progress, ironically, became pure reason. And for the bulk of two and a half millennia (twenty-five hundred years) the actual treatment of patients by physicians made almost no progress at all.

  One cannot blame religion or superstition for this lack of progress. In the West, beginning at least five hundred years before the birth of Christ, medicine was largely secular. While Hippocratic healers (the various Hippocratic texts were written by different people) did run temples and accept pluralistic explanations for disease, they pushed for material explanations.

  Hippocrates himself was born in approximately 460 B.C. On the Sacred Disease, one of the more famous Hippocratic texts and one often attributed to him directly, even mocked theories that attributed epilepsy to the intervention of gods. He and his followers advocated precise observation, then theorizing. As the texts stated, 'For a theory is a composite memory of things apprehended with sense perception.' 'But conclusions which are merely verbal cannot bear fruit.' 'I approve of theorizing also if it lays its foundation in incident, and deduces its conclusion in accordance with phenomena.'

  But if such an approach sounds like that of a modern investigator, a modern scientist, it lacked two singularly important elements.

  *

  First, Hippocrates and his associates merely observed nature. They did not probe it.

  This failure to probe nature was to some extent understandable. To dissect a human body then was inconceivable. But the authors of the Hippocratic texts did not test their conclusions and theories. A theory must make a prediction to be useful or scientific (ultimately it must say, If this, then that) and testing that prediction is the single most important element of modern methodology. Once that prediction is tested, it must advance another one for testing. It can never stand still.

  Those who wrote the Hippocratic texts, however, observed passively and reasoned actively. Their careful observations noted mucus discharges, menstrual bleeding, watery evacuations in dysentery, and they very likely observed blood left to stand, which over time separates into several layers, one nearly clear, one of somewhat yellowy serum, one of darker blood. Based on these observations, they hypothesized that there were four kinds of bodily fluids, or 'humours': blood, phlegm, bile, and black bile. (This terminology survives today in the phrase 'humoral immunity,' which refers to elements of the immune system, such as antibodies, that circulate in the blood.)

  This hypothesis made sense, comported with observations, and could explain many symptoms. It explained, for example, that coughs were caused by the flow of phlegm to the chest. Observations of people coughing up phlegm certainly supported this conclusion.

  In a far broader sense, the hypothesis also conformed to the ways in which the Greeks saw nature: they observed four seasons, four aspects of the environment (cold, hot, wet, and dry) and four elements (earth, air, fire, and water.)

  Medicine waited six hundred years for the next major advance, for Galen, but Galen did not break from these teachings; he systematized them, perfected them. Galen claimed, 'I have done as much for medicine as Trajan did for the Roman Empire when he built the bridges and roads through Italy. It is I, and I alone, who have revealed the true path of medicine. It must be admitted that Hippocrates already staked out this path' . He prepared the way, but I have made it possible.'

  Galen did not simply observe passively. He dissected animals and, although he did not perform autopsies on humans, served as a physician to gladiators whose wounds allowed him to see deep beneath the skin. Thus his anatomic knowledge went far beyond that of any known predecessor. But he remained chiefly a theoretician, a logician; he imposed order on the Hippocratic body of work, reconciling conflicts, reasoning so clearly that, if one accepted his premises, his conclusions seemed inevitable. He made the humoral theory perfectly logical, and even elegant. As historian Vivian Nutton notes, he raised the theory to a truly conceptual level, separating the humours from direct correlation with bodily fluids and making them invisible entities 'recognizable only by logic.'

  Galen's works were translated into Arabic and underlay both Western and Islamic medicine for nearly fifteen hundred years before facing any significant challenge. Like the Hippocratic writers, Galen believed that illness was essentially the result of an imbalance in the body. He also thought that balance could be restored by i
ntervention; a physician thus could treat a disease successfully. If there was a poison in the body, then the poison could be removed by evacuation. Sweating, urinating, defecating, and vomiting were all ways that could restore balance. Such beliefs led physicians to recommend violent laxatives and other purgatives, as well as mustard plasters and other prescriptions that punished the body, that blistered it and theoretically restored balance. And of all the practices of medicine over the centuries, one of the the most enduring (yet least understandable to us today) was a perfectly logical extension of Hippocratic and Galenic thought, and recommended by both.

  This practice was bleeding patients. Bleeding was among the most common therapies employed to treat all manner of disorders.

  Deep into the nineteenth century, Hippocrates and most of those who followed him also believed that natural processes must not be interfered with. The various kinds of purging were meant to augment and accelerate natural processes, not resist them. Since pus, for example, was routinely seen in all kinds of wounds, pus was seen as a necessary part of healing. Until the late 1800s, physicians routinely would do nothing to avoid the generation of pus, and were reluctant even to drain it. Instead they referred to 'laudable pus.'

  Similarly, Hippocrates scorned surgery as intrusive, as interfering with nature's course; further, he saw it as a purely mechanical skill, beneath the calling of physicians who dealt in a far more intellectual realm. This intellectual arrogance would subsume the attitude of Western physicians for more than two thousand years.

  This is not to say that for two thousand years the Hippocratic texts and Galen offered the only theoretical constructs to explain health and disease. Many ideas and theories were advanced about how the body worked, how illness developed. And a rival school of thought gradually developed within the Hippocratic-Galenic tradition that valued experience and empiricism and challenged the purely theoretical.