Book Review: The Great Influenza by John M. Barry

The Great Influenza

By John M. Barry

(Blogger Note: This review was previously published in "LAMLight," the physician newsletter of the Lynchburg Academy of Medicine.)

  

The 1918 influenza pandemic which began in Kansas and killed an estimated 100 million people world-wide in a 24 day period is examined in great detail in The Great Influenza by John M. Barry.  Although this is an extensively researched book with a tremendous amount of medical and scientific information it is never boring.  This is a story which could have been as sleep-inducing as an M-1 Histology lecture but has the pace of a Grisham novel and the suspense of any best-selling mystery.  In the Prologue Mr. Barry describes his book as “a story of science, of discovery, of how one thinks, and of how one changes the way one thinks.”  The lessons learned in the early 1900s are very appropriate to be reviewed a century later. 

The story is divided into ten sections.  The first “The Warriors” is an overview of American medicine as it existed in the late 1800s and how it was revolutionized mainly by William Henry Welch and the Johns Hopkins Medical School and research laboratories.  Dr. Welch almost single handedly changed American medicine from a field not far removed from the practices of Hippocrates to a rigorous, science based investigative discipline.  Welch, along with William Halsted at Hopkins and Simon Flexner of the Rockefeller Institute brought American medicine into the modern age and enabled the medical response to the 1918 Influenza epidemic.

The following sections “set the stage”.  Section two (“The Swarm”) is a very succinct course on virology, directed to the layman and appreciated by this reviewer who is very deficient in his knowledge of infectious disease.  “The Tinderbox” explains the social and geopolitical factors which contributed to the situation which became the perfect storm for a pandemic.  The U.S entrance into the Great War precipitated a number of amazing circumstances.  For those appalled by the the George W. Bush administration's Patriot Act and its potential for restriction of personal freedoms, Woodrow Wilson’s Sedition Act looks like downright fascism.  The Sedition Act was responsible for the imprisonment of anyone who spoke or published words questioning the federal government.  This Act was eventually upheld as constitutional by none other than Chief Justice Oliver Wendell Holmes.  This law essentially put a lid on any accurate reporting of the flu epidemic.  The facts were thought to be detrimental to public morale and the war effort.   The conscription of most men between 18 and 45 years of age created crowded conditions in training camps, again creating a situation ripe for rapid dissemination of infectious disease.  Physicians were secretly “graded” by local medical societies and the best physicians and almost all nurses were rapidly conscripted into the army and sent over seas, leaving the medical care of the citizenry to older physicians, trained prior to the era of scientific method and regarded as “inferior”.  The Rockefeller Institute was transformed into “Army Auxiliary Laboratory Number One” and entire medical school faculties were sent as units to Europe.

The ensuing sections of the book documents the incredible spread of the disease and the terrible ferocity with which it struck, especially in younger patients.  At one point at Camp Pike in Arkansas, for instance, 13,000 out of 60,000 soldiers were simultaneously sick with influenza.  The death rate among young adults approached 40% and often people woke up feeling fine, had an acute onset of symptoms and were dead within twelve hours.

The modern laboratories established by Welch at Hopkins, Victor Vaughan at Michigan, Charles Eliot at Harvard and William Pepper at Penn as well as Oswald Avery at the Rockefeller Institute, William Park and Anna Williams (virus experts) at the New York City Department of Public Health and Paul Lewis in Philadelphia were all in a race to identify the pathogen responsible for this pandemic and, if possible, develop a vaccine to treat and prevent the disease.  The desperation caused by the presence of death all around them, including within the ranks of their own laboratory workers produced a frenetic research response.  The work produced in 1918 is still evident today.  Pfeiffer discovered the “Influenza Bacillus” (what we call H. Influenza today) which was the bacteria responsible for the rapid demise of the younger patient population.  Avery developed the “chocolate agar” growth medium to expedite growth and identification of H. Influenza, which clarified the role of this pathogen in the pandemic.  Many of the deaths were in fact due to secondary overwhelming bacterial pneumonias and what we recognize today as acute respiratory distress syndrome. 

The concluding sections of the book deal with the aftermath of the pandemic.  The repercussions were felt in every segment of society and in every geographic location.  An interesting historical footnote is that Woodrow Wilson succumbed to influenza during the negotiations at the end of World War I.  After two week convalescence, Wilson backed off of all of his previous demands, conceded to the French and stripped Germany of territory, its army, and crippled its economy.  The author hypothesizes that Wilson was suffering from post-influenza psychosis or mental disturbance and quotes Lloyd George as saying “Wilson suffered a nervous and spiritual breakdown in the middle of the Conference (the Paris Peace Commission).”   Barry concludes: “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.”

The flurry of research activity during and following the pandemic led to the discovery by Avery that the substance that transformed a pneumococcus from one without a capsule to a more virulent one with a capsule was DNA.  A report from Avery, MacLeod and McCarty titled “Studies on the Chemical Nature of the Substance Inducing Transformation of Pnuemococcal Types.  Induction of Transformation by a Desoxyribonucleic Acid Fraction Isolated from Pneumococcus Type III” was published in the February 1944 Journal of Experimental Medicine.  This report demonstrated that DNA carried genetic information, that genes lay within DNA.  This report was the direct result of Avery’s years of research into the cause of the 1918 influenza pandemic.  This information inspired many scientists, including James Watson and Francis Crick to determine the structure of DNA.  Watson wrote in The Double Helix:  "Avery gave us the first text of a new language; or rather he showed us where to look for it.  I resolved to search for this text.”  Barry observes: “In fact, what Avery accomplished was a classic of basic science.  He started his search looking for a cure for pneumonia and ended up opening the field of Molecular Biology.”

The author concludes by warning that although medical science has made incredible strides, the stage could be set for another pandemic.  Overcrowding in urban areas, poor hygiene and sanitary conditions in third world countries (as well as American inner cities) and the “shrinking of the planet” by international travel all contribute to a situation where a virulent new virus, should it occur, could spread rapidly.  The severity of a pandemic similar to “The Great Influenza” would easily and quickly overwhelm the world’s medical system.  The World Health Organization has guidelines in place to accurately assess risk of new diseases and promptly respond to that risk.  These lessons learned from the 1918 experience are largely responsible for the quick identification and limitation of SARS (Severe Acute Respiratory Syndrome, a disease which spread from animals to man in the spring of 2003).  Barry warns, however, that “Every expert on influenza agrees that the ability of the influenza virus to re-assort genes means that another pandemic not only can happen, it almost certainly will happen.”

The Great Influenza by John M. Barry is an excellent book and a tremendous compilation of data and information on this timely subject.