The medical corps told enlisted men to masturbate instead of using prostitutes. It produced posters with such slogans as, 'A Soldier who gets a dose is a traitor.' It examined enlisted men twice a month for venereal disease, required any men infected to identify the person with whom or the building in which they had had sex, docked the pay of soldiers or sailors sick with venereal disease, and also made them subject to court-martial. With support from the most senior political leadership, the military by law prohibited prostitution and the sale of alcohol within five miles of any base (and the military had seventy bases with ten thousand or more soldiers or sailors scattered around the country. The health boards of twenty-seven states passed regulations allowing detention of people suffering venereal infection 'until they are no longer a danger to the community.' Eighty red-light districts were shut down. Even New Orleans had to close down its legendary Storyville, where prostitution was legal, where Buddy Bolden, Jelly Roll Morton, Louis Armstrong, and others had invented jazz in the whore-houses. And New Orleans mayor Martin Behrman was no reformer; he headed a political machine so tight it was called simply 'the Ring.'
But if Gorgas had the power to act decisively on venereal disease, if engineers listened to his sanitary experts in designing water supplies, the army paid him little heed on anything else. On no subject where he had only science behind him, science without political weight, could he get even a hearing from army superiors. Even when an American researcher developed an antitoxin for gangrene, Gorgas could not convince them to fund testing at the front. So Welch arranged for the Rockefeller Institute to pay the expenses of a team of investigators to go to Europe, and for the British army to test the antitoxin in British hospitals. (It worked, although not perfectly.)
In many ways, then, Gorgas, Welch, Vaughan, and their colleagues operated as a team independent of the army. But they could not operate independently in regard to epidemic disease, and they could not operate either independently or alone as camps filled with hundreds of thousands (in fact, millions) of young men.
*
When the war began there were one hundred forty thousand physicians in the United States. Only 776 of them were serving in the army or navy. The military needed tens of thousands of physicians, and it needed them immediately. It would make no exceptions for scientists. Most would volunteer anyway. Most wanted to participate in this great crusade.
Welch and Vaughan joined the military, despite their being one hundred pounds overweight and past the regular army's mandatory retirement age, and they were not alone. Flexner joined at age fifty-four. Flexner's protegé Paul Lewis at Penn, Milton Rosenau at Harvard, and Eugene Opie at Washington University joined. All around the country laboratory scientists were joining.
And to avoid losing scientists piecemeal either as volunteers or to the draft, Flexner suggested to Welch that the entire Rockefeller Institute be incorporated into the army. Welch carried the idea to Gorgas, and Gorgas's deputy wired Flexner, '[U]nit will be arranged as you desire.' And so the Rockefeller Institute became Army Auxiliary Laboratory Number One. There would be no auxiliary laboratory number two. Men in uniforms marched down laboratory and hospital corridors. An army adjutant commanded the technicians and janitors, maintained army discipline among them, and drilled them on parade on York Avenue. Lunch became 'mess.' A mobile hospital unit on wheels with buildings, wards, labs, laundry, and kitchen was rolled into the front yard of the institute from Sixty-fourth to Sixty-sixth Streets to treat soldiers with intractable wounds. Sergeants saluted scientists who (except for two Canadians who became privates) received officer rank.
This was no mere cosmetic change to allow life to go on as usual.* At Rockefeller the fiber of the work was rewoven. Nearly all research shifted to something war-related, or to instruction. Alexis Carrel, a Nobel laureate in 1912 who pioneered the surgical reattachment of limbs and organ transplantation as well as tissue culture (he kept part of a chicken heart alive for thirty-two years) taught surgical techniques to hundreds of newly militarized physicians. Others taught bacteriology. A biochemist studied poison gas. Another chemist explored ways to get more acetone from starch, which could be used both in making explosives and to stiffen the fabric that covered airplane wings. Peyton Rous, who had already done the work that would later (decades later) win him a Nobel Prize, redirected his work to preserving blood; he developed a method still in use that led to the first blood banks being established at the front in 1917.
The war also consumed the supply of practicing physicians. Gorgas, Welch, and Vaughan had already laid plans for this. In December 1916 they had, through the Council of National Defense, asked state medical associations to secretly grade physicians. Roughly half of all practicing physicians were judged incompetent to serve. So when America did enter the war, the military first examined every male graduate of medical school in 1914, 1915, and 1916, seeking, as Vaughan said, the 'best from these classes.' This would supply approximately ten thousand doctors. Many of the best medical schools also sent much of their faculty to France, where the schools functioned as intact units, staffing and unofficially lending their names to entire military hospitals.
Yet these moves could not begin to satisfy the need. By the time the Armistice was signed thirty-eight thousand physicians would be serving in the military, at least half of all those under age forty-five considered fit for service.
The military, and especially the army, did not stop there. In April 1917 the army had fifty-eight dentists; in November 1918 it had 5,654. And the military needed nurses.
*
There were too few nurses. Nursing had, like medicine, changed radically in the late nineteenth century. It too had become scientific. But changes in nursing involved factors that went beyond the purely scientific; they involved status, power, and the role of women.
Nursing was one of the few fields that gave women opportunity and status, and that they controlled. While Welch and his colleagues were revolutionizing American medicine, Jane Delano, Lavinia Dock (both of whom were students in Bellevue's nursing program while Welch was exposing medical students there to new realities) and others were doing the same to nursing. But they fought not with an entrenched Old Guard in their own profession so much as with physicians. (Sometimes physicians, threatened by intelligent and educated nurses, waged a virtual guerrilla war; in some hospitals physicians replaced labels on drug bottles with numbers so nurses could not question a prescription.)
In 1912, before becoming surgeon general, Gorgas had anticipated that if war ever came, the army would need vast numbers of nurses, many more than would likely be available. He believed, however, that not all of them would have to be fully trained. He wanted to create a corps of 'practical nurses,' who lacked the education and training of 'graduate nurses.'
Others were also advancing this idea, but they were all men. The women who ran nursing would have none of it. Jane Delano had taught nursing and had headed the Army Nurse Corps. Proud and intelligent as well as tough, driven, and authoritarian, she had then just left the army to establish the Red Cross nursing program, and the Red Cross had all responsibility for supplying nurses to the army, evaluating, recruiting, and often assigning them.
She rejected Gorgas's plan, telling her colleagues it 'seriously threatened' the status of professional nursing and warning, 'Our Nursing Service would be of no avail with these groups of women unrelated to us, organized by physicians, taught by physicians, serving under their guidance.' She told the Red Cross bluntly that 'if this plan were put through I should at once sever my connection with the Red Cross' [and] every member of the State and Local Committee would go out with me.'*
The Red Cross and the army surrendered to her. No training of nursing aides commenced. When the United States entered the war it had 98,162 'graduate nurses,' women whose training probably exceeded that of many (if not most) doctors trained before 1910. The war sucked up nurses as it sucked up everything else. In May 1918 roughly sixteen thousand nurses were serving in the military. Gorg
as believed that the army alone needed fifty thousand.
After Gorgas again pleaded with the Red Cross 'to carry out the plans already formulated,' after learning confidential information about the desperation in combat hospitals, Delano reversed herself, supported Gorgas, and tried to convince her colleagues of the need for 'practical' nurses.
Her professional colleagues rebuffed them both. They refused to participate in organizing any large training program of such aides, and agreed only to establish an Army Nursing School. By October 1918 this new nursing school had produced not a single fully trained nurse.
The triumph of the nursing profession at large over the Red Cross and the United States Army, an army at war, was extraordinary. That the victors were women made it more extraordinary. Ironically, this triumph reflected as well a triumph of George Creel's Committee on Public Information over the truth, for Creel's propaganda machine had prevented the public from learning just how profound the need for nurses was.
In the meantime the military's appetite for doctors and nurses only grew. Four million American men were under arms with more coming, and Gorgas was planning for three hundred thousand hospital beds. The number of trained medical staff he had simply could not handle that load. So the military suctioned more and more nurses and physicians into cantonments, aboard ships, into France, until it had extracted nearly all the best young physicians. Medical care for civilians deteriorated rapidly. The doctors who remained in civilian life were largely either incompetent young ones or those over forty-five years of age, the vast majority of whom had been trained in the old ways of medicine. The shortage of nurses would prove even more serious. Indeed, it would prove deadly, especially in civil society.
All this added kindling to the tinderbox. Still more kindling would come.
CHAPTER ELEVEN
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 Inst
itutes 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.'
The Great Influenza Page 16