The Great Influenza Read online

  Snow and Budd needed no scientific knowledge, no laboratory findings, to reach their conclusions. And they did so in the 1850s, before the development of the germ theory of disease. Like Louis's study that proved that bleeding was worse than useless in nearly all circumstances, their work could have been conducted a century earlier or ten centuries earlier. But their work reflected a new way of looking at the world, a new way of seeking explanations, a new methodology, a new use of mathematics as an analytical tool.*

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  At the same time, medicine was advancing by borrowing from other sciences. Insights from physics allowed investigators to trace electrical impulses through nerve fibers. Chemists were breaking down the cell into its components. And when investigators began using a magnificent new tool (the microscope equipped with new achromatic lenses, which came into use in the 1830s) an even wider universe began to open.

  In this universe Germans took the lead, partly because fewer French than Germans chose to use microscopes and partly because French physicians in the middle of the nineteenth century were generally less aggressive in experimenting, in creating controlled conditions to probe and even manipulate nature. (It was no coincidence that the French giants Pasteur and Claude Bernard, who did conduct experiments, were not on the faculty of any medical school. Echoing Hunter's advice to Jenner, Bernard, a physiologist, told one American student, 'Why think? Exhaustively experiment, then think.')

  In Germany, meanwhile, Rudolf Virchow (both he and Bernard received their medical degrees in 1843) was creating the field of cellular pathology, the idea that disease began at the cellular level. And in Germany great laboratories were being established around brilliant scientists who, more than elsewhere, did actively probe nature with experiments. Jacob Henle, the first scientist to formulate the modern germ theory, echoed Francis Bacon when he said, 'Nature answers only when she is questioned.'

  And in France, Pasteur was writing, 'I am on the edge of mysteries and the veil is getting thinner and thinner.'

  Never had there been a time so exciting in medicine. A universe was opening.

  Still, with the exception of the findings on cholera and typhoid (and even these won only slow acceptance) little of this new scientific knowledge could be translated into curing or preventing disease. And much that was being discovered was not understood. In 1868, for example, a Swiss investigator isolated deoxyribonucleic acid, DNA, from a cell's nucleus, but he had no idea of its function. Not until three-quarters of a century later, at the conclusion of some research directly related to the 1918 influenza pandemic, did anyone even speculate, much less demonstrate, that DNA carried genetic information.

  So the advances of science actually, and ironically, led to 'therapeutic nihilism.' Physicians became disenchanted with traditional treatments, but they had nothing with which to replace them. In response to the findings of Louis and others, in 1835 Harvard's Jacob Bigelow had argued in a major address that in 'the unbiased opinion of most medical men of sound judgment and long experience' the amount of death and disaster in the world would be less, if all disease were left to itself.'

  His address had impact. It also expressed the chaos into which medicine was being thrown and the frustration of its practitioners. Physicians were abandoning the approaches of just a few years earlier and, less certain of the usefulness of a therapy, were becoming far less interventionist. In Philadelphia in the early 1800s Rush had called for wholesale blood-letting and was widely applauded. In 1862 in Philadelphia a study found that, out of 9,502 cases, physicians had cut a vein 'in one instance only.'

  Laymen as well were losing faith in and becoming reluctant to submit to the tortures of heroic medicine. And since the new knowledge developing in traditional medicine had not yet developed new therapies, rival ideas of disease and treatment began to emerge. Some of these theories were pseudoscience, and some owed as little to science as did a religious sect.

  This chaos was by no means limited to America. Typical was Samuel Hahnemann, who developed homeopathy in Germany, publishing his ideas in 1810, just before German science began to emerge as the dominant force on the Continent. But nowhere did individuals feel freer to question authority than in America. And nowhere was the chaos greater.

  Samuel Thomson, founder of a movement bearing his name that spread widely before the Civil War, argued that medicine was simple enough to be comprehended by everyone, so anyone could act as a physician. 'May the time soon come when men and women will become their own priests, physicians, and lawyers when self-government, equal rights and moral philosophy will take the place of all popular crafts of every description,' argued his movement's publication. His system used 'botanic' therapeutics, and he charged, 'False theory and hypothesis constitute nearly the whole art of physic.'

  Thomsonism was the most popular layman's medical movement but hardly the only one. Dozens of what can only be called sects arose across the countryside. A Thomsonian rhyme summed up the attitude: 'The nest of college-birs are three, / Law, Physic and Divinity; / And while these three remain combined, / They keep the world oppressed and blind /' Now is the time to be set free, / From priests' and Doctors' slavery.'

  As these ideas spread, as traditional physicians failed to demonstrate the ability to cure anyone, as democratic emotions and anti-elitism swept the nation with Andrew Jackson, American medicine became as wild and democratic as the frontier. In the 1700s Britain had relaxed licensing standards for physicians. Now several state legislatures did away with the licensing of physicians entirely. Why should there be any licensing requirements? Did physicians know anything? Could they heal anyone? Wrote one commentator in 1846, 'There is not a greater aristocratic monopoly in existence, than this of regular medicine - neither is there a greater humbug.' In England the title 'Professor' was reserved for those who held university chairs, and, even after John Hunter brought science to surgery, surgeons often went by 'Mister.' In America the titles 'Professor' and 'Doctor' went to anyone who claimed them. As late as 1900, forty-one states licensed pharmacists, thirty-five licensed dentists, and only thirty-four licensed physicians. A typical medical journal article in 1858 asked, 'To What Cause Are We to Attribute the Diminished Respectability of the Medical Profession in the Esteem of the American Public?'

  By the Civil War, American medicine had begun to inch forward, but only inch. The brightest lights involved surgery. The development of anesthesia, first demonstrated in 1846 at Massachusetts General Hospital, helped dramatically, and, just as Galen's experience with gladiators taught him much anatomy, American surgeons learned enough from the war to put them a step ahead of Europeans.

  In the case of infectious and other disease, however, physicians continued to attack the body with mustard plasters that blistered the body, along with arsenic, mercury, and other poisons. Too many physicians continued their adherence to grand philosophical systems, and the Civil War showed how little the French influence had yet penetrated American medicine. European medical schools taught the use of thermometers, stethoscopes, and ophthalmoscopes, but Americans rarely used them and the largest Union army had only half a dozen thermometers. Americans still relieved pain by applying opiate powders on a wound, instead of injecting opium with syringes. And when Union Surgeon General William Hammond banned some of the violent purgatives, he was both court-martialed and condemned by the American Medical Association.

  After the Civil War, America continued to churn out prophets of new, simple, complete, and self-contained systems of healing, two of which, chiropractic and Christian Science, survive today. (Evidence does suggest that spinal manipulation can relieve musculoskeletal conditions, but no evidence supports chiropractic claims that disease is caused by misalignment of vertebrae.)

  Medicine had discovered drugs (such as quinine, digitalis, and opium) that provided benefits, but, as one historian has shown, they were routinely prescribed indiscriminately, for their overall effect on the body, not for a specific purpose; even quinine was prescribed generally, not to trea
t malaria. Hence Oliver Wendell Holmes, the physician father of the Supreme Court justice, was not much overstating when he declared, 'I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind (and all the worse for the fishes.)'

  There was something else about America. It was such a practical place. If it was a nation bursting with energy, it had no patience for dalliance or daydreaming or the waste of time. In 1832, Louis had told one of his most promising protegés (an American) to spend several years in research before beginning a medical practice. The student's father was also a physician, James Jackson, a founder of Massachusetts General Hospital, who scornfully rejected Louis's suggestion and protested to Louis that 'in this country his course would have been so singular, as in a measure to separate him from other men. We are a business doing people' . There is a vast deal to be done and he who will not be doing must be set down as a drone.'

  In America the very fact that science was undermining therapeutics made institutions uninterested in supporting it. Physics, chemistry, and the practical arts of engineering thrived. The number of engineers particularly was exploding (from 7,000 to 226,000 from the late nineteenth century to just after World War I) and they were accomplishing extraordinary things. Engineers transformed steel production from an art into a science, developed the telegraph, laid a cable connecting America to Europe, built railroads crossing the continent and skyscrapers that climbed upward, developed the telephone - with automobiles and airplanes not far behind. The world was being transformed. Whatever was being learned in the laboratory about biology was building basic knowledge, but with the exception of anesthesia, laboratory research had only proven actual medical practice all but useless while providing nothing with which to replace it.

  Still, by the 1870s, European medical schools required and gave rigorous scientific training and were generally subsidized by the state. In contrast, most American medical schools were owned by a faculty whose profits and salaries (even when they did not own the school) were paid by student fees, so the schools often had no admission standards other than the ability to pay tuition. No medical school in America allowed medical students to routinely either perform autopsies or see patients, and medical education often consisted of nothing more than two four-month terms of lectures. Few medical schools had any association with a university, and fewer still had ties to a hospital. In 1870 even at Harvard a medical student could fail four of nine courses and still get an M.D.

  In the United States, a few isolated individuals did research (outstanding research) but it was unsupported by any institution. S. Weir Mitchell, America's leading experimental physiologist, once wrote that he dreaded anything 'removing from me the time or power to search for new truths that lie about me so thick.' Yet in the 1870s, after he had already developed an international reputation, after he had begun experiments with snake venom that would lead directly to a basic understanding of the immune system and the development of antitoxins, he was denied positions teaching physiology at both the University of Pennsylvania and Jefferson Medical College; neither had any interest in research, nor a laboratory for either teaching or research purposes. In 1871 Harvard did create the first laboratory of experimental medicine at any American university, but that laboratory was relegated to an attic and paid for by the professor's father. Also in 1871 Harvard's professor of pathologic anatomy confessed he did not know how to use a microscope.

  But Charles Eliot, a Brahmin with a birth defect that deformed one side of his face (he never allowed a photograph to show that side) had become Harvard president in 1869. In his first report as president, he declared, 'The whole system of medical education in this country needs thorough reformation. The ignorance and general incompetency of the average graduate of the American medical Schools, at the time when he receives the degree which turns him loose upon the community, is something horrible to contemplate.'

  Soon after this declaration, a newly minted Harvard physician killed three successive patients because he did not know the lethal dose of morphine. Even with the leverage of this scandal, Eliot could push through only modest reforms over a resistant faculty. Professor of Surgery Henry Bigelow, the most powerful faculty member, protested to the Harvard Board of Overseers, '[Eliot] actually proposes to have written examinations for the degree of doctor of medicine. I had to tell him that he knew nothing about the quality of the Harvard medical students. More than half of them can barely write. Of course they can't pass written examinations' . No medical school has thought it proper to risk large existing classes and large receipts by introducing more rigorous standards.'

  Many American physicians were in fact enthralled by the laboratory advances being made in Europe. But they had to go to Europe to learn them. Upon their return they could do little or nothing with their knowledge. Not a single institution in the United States supported any medical research whatsoever.

  As one American who had studied in Europe wrote, 'I was often asked in Germany how it is that no scientific work in medicine is done in this country, how it is that many good men who do well in Germany and show evident talent there are never heard of and never do any good work when they come back here. The answer is that there is no opportunity for, no appreciation of, no demand for that kind of work here' . The condition of medical education here is simply horrible.'

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  In 1873, Johns Hopkins died, leaving behind a trust of $3.5 million to found a university and hospital. It was to that time the greatest gift ever to a university. Princeton's library collection was then an embarrassment of only a few books - and the library was open only one hour a week. Columbia was little better: its library opened for two hours each afternoon, but freshmen could not enter without a special permission slip. Only 10 percent of Harvard's professors had a Ph.D.

  The trustees of Hopkins's estate were Quakers who moved deliberately but also decisively. Against the advice of Harvard president Charles Eliot, Yale president James Burril Angell, and Cornell president Andrew D. White, they decided to model the Johns Hopkins University after the greatest German universities, places thick with men consumed with creating new knowledge, not simply teaching what was believed.

  The trustees made this decision precisely because there was no such university in America, and precisely because they recognized the need after doing the equivalent of market research. A board member later explained, 'There was a strong demand, among the young men of this country, for opportunities to study beyond the ordinary courses of a college or a scientific school' . The strongest evidence of this demand was the increased attendance of American students upon lectures of German universities.' The trustees decided that quality would sell. They intended to hire only eminent professors and provide opportunities for advanced study.

  Their plan was in many ways an entirely American ambition: to create a revolution from nothing. For it made little sense to locate the new institution in Baltimore, a squalid industrial and port city. Unlike Philadelphia, Boston, or New York, it had no tradition of philanthropy, no social elite ready to lead, and certainly no intellectual tradition. Even the architecture of Baltimore seemed exceptionally dreary, long lines of row houses, each with three steps, crowding against the street and yet virtually no street life - the people of Baltimore seemed to live inward, in backyards and courtyards.

  In fact, there was no base whatsoever upon which to build except the money, another American trait.

  The trustees hired as president Daniel Coit Gilman, who left the presidency of the newly organized University of California after disputes with state legislators. Earlier he had helped create and had led the Sheffield Scientific School at Yale, which was distinct from Yale itself. Indeed, it was created partly because of Yale's reluctance to embrace science as part of its basic curriculum.

  At the Hopkins, Gilman immediately recruited an internationally respected (and connected) faculty, which gave it instant credibility. In Europe, people like Huxley saw t
he Hopkins as combining the explosive energy and openness of America with the grit of science; the potential could shake the world.

  To honor the Hopkins upon its beginnings, to honor this vision, to proselytize upon this new faith, Thomas Huxley came to America.

  The Johns Hopkins would have rigor. It would have such rigor as no school in America had ever known.

  The Hopkins opened in 1876. Its medical school would not open until 1893, but it succeeded so brilliantly and quickly that, by the outbreak of World War I, American medical science had caught up to Europe and was about to surpass it.

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  Influenza is a viral disease. When it kills, it usually does so in one of two ways: either quickly and directly with a violent viral pneumonia so damaging that it has been compared to burning the lungs; or more slowly and indirectly by stripping the body of defenses, allowing bacteria to invade the lungs and cause a more common and slower-killing bacterial pneumonia.

  By World War I, those trained directly or indirectly by the Hopkins already did lead the world in investigating pneumonia, a disease referred to as 'the captain of the men of death.' They could in some instances prevent it and cure it.

  And their story begins with one man.

  CHAPTER TWO

  NOTHING ABOUT the boyhood or youth of William Henry Welch suggested his future.

  So it is apt that the best biography of him begins not with his childhood but with an extraordinary eightieth-birthday celebration in 1930. Friends, colleagues, and admirers gathered for the event not only in Baltimore, where he lived, but in Boston, in New York, in Washington; in Chicago, Cincinnati, and Los Angeles; in Paris, London, Geneva, Tokyo, and Peking. Telegraph and radio linked the celebrations, and their starting times were staggered to allow as much overlap as time zones made possible. The many halls were thick with scientists in many fields, including Nobel laureates, and President Herbert Hoover's tribute to Welch at the Washington event was broadcast live over American radio networks.