Fever of War: The Influenza Epidemic in the U.S. Army during World War I 9781479867059

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Fever of War

Fever of War The Influenza Epidemic in the U.S. Army during World War I

Carol R. Byerly

a NEW YORK UNIVERSITY PRESS New York and London

new york university press New York and London www.nyupress.org © 2005 by New York University All rights reserved Library of Congress Cataloging-in-Publication Data Byerly, Carol R. Fever of war : the influenza epidemic in the U.S. Army during World War I / Carol R. Byerly. p. cm. Includes bibliographical references and index. ISBN 0–8147–9923–X (cloth : alk. paper) — ISBN 0–8147–9924–8 (pbk. : alk. paper) 1. Influenza Epidemic, 1918–1919—Europe. 2. World War, 1914–1918—Health aspects. 3. United States. Army—Medical care—History. I. Title. RC150.4.B946 2005 614.5'18'09041—dc22 2004022337 New York University Press books are printed on acid-free paper, and their binding materials are chosen for strength and durability. Manufactured in the United States of America c 10 9 8 7 6 5 4 3 2 1 p 10 9 8 7 6 5 4 3 2 1

Dedicated to Crystal Viguerias

Contents

List of Figures

ix

List of Abbreviations

xi

Acknowledgments

1 2 3 4 5 6

xiii

Prologue: Eddie

1

Introduction

4

Medical Heroes: Medical Officers’ Confidence as They Prepare for War

14

Building a Healthy Army: Government Control and Accountability

39

Worst-Case Scenario: The Influenza Epidemic of 1918 in the Camps

69

Fighting Germs and Germans: Influenza in the American Expeditionary Forces

97

Postmortem: The Trauma of Failure, 1918–1919 “Except for the Flu . . .”: Writing the History of the Epidemic

125 153

Conclusion: Memory and the Politics of Disease and War

181

Notes

191

Select Bibliography

227

Index

237

About the Author

251

vii

Figures

1. William C. Gorgas, Surgeon General of the Army

17

2. Executive Committee of the General Medical Board

27

3. Staff officers, base hospital, Camp Jackson, South Carolina

35

4. Staff nurses, base hospital, Camp Jackson, South Carolina

36

5. Enlisted personnel, base hospital, Camp Jackson, South Carolina

37

6. Victor C. Vaughan

41

7. Stretcher bearers in the AEF

47

8. Inoculating troops at the Army Medical School

52

9. Graph of influenza deaths in the U.S. Army, 1918–1919

77

10. Emergency hostipal during the influenza epidemic

83

11. Pie chart of deaths by disease in the U.S. Army, 1917–1919

91

12. Graph showing the “terrible W” age distribution of influenza deaths

91

13. Troop train in France

95

14. Bunks aboard troop transport ship

101

15. Flu ward in AEF hospital no. 45, Aix de Bains, France

117

16. Postmortem room, base hospital, Fort Riley, Kansas

127

17. Portraits of deceased nurse and soldiers

140–141

18. Merritte W. Ireland, Surgeon General of the Army

155

19. Cemetery at U.S. Base Hospital No. 3, Vauclaire, France

180

ix

Abbreviations

AEF

American Expeditionary Forces

AHR

American Historical Review

AIM

Archives of Internal Medicine

AJMS

American Journal of Medical Science

AJN

American Journal of Nursing

AJPH

American Journal of Public Health

AMA

American Medical Association

BHM

Bulletin of the History of Medicine

BMJ

British Medical Journal

CR

Congressional Record

CSJM

California State Journal of Medicine

JAH

Journal of American History

JAMA

Journal of the American Medical Association

JEM

Journal of Experimental Medicine

JID

Journal of Infectious Disease

JHMAS

Journal of the History of Medicine and Allied Sciences

JLCM

Journal of Laboratory and Clinical Medicine

JNMA

Journal of the National Medical Association

MCNA

Medical Clinics of North America

MDWW Medical Department in the World War, volumes 1–15 Washington, D.C., 1923–1929

xi

xii | Abbreviations

MHI

U.S. Army Military History Institute, Carlisle Barracks, PA

MS

Military Surgeon

NARA

National Archives and Records Administration

NLM

Division of History, National Library of Medicine, Bethesda, MD

NYT

New York Times

PHR

Public Health Reports

PHS

Public Health Service

RG 90

Records of the Public Health Service

RG 107

Records of the Secretary of War

RG 112

Records of the Surgeon General of the Army

RG 120

Records of the American Expeditionary Forces

RG 153

Records of the Judge Advocate General (Army)

RG 163

Records of the Selective Service

RG 200

Records of the American Red Cross

RG 391

Records of the U.S. Regular Army Mobile Units

RG 407

Records of the Office of Adjutant General

SHM

Social History of Medicine

WDAR, 1917

War Department Annual Report, 1917

WDAR, 1918

War Department Annual Report, 1918

WDAR, 1919

War Department Annual Report, 1919

Acknowledgments

I am fortunate to have been able to write this book in a community of warm, generous, and thoughtful friends and colleagues, and hope here to let them know how much I appreciate their support. I have many people to thank at the University of Colorado. First, I am grateful to Julie Greene and Susan Kingsley Kent for suggesting the influenza epidemic of 1918 to me for my dissertation when I entered the graduate program in the Department of History. Given my interest in catastrophic disease and politics, they pointed out that the flu of 1918 needed investigation. They were right, of course, and this study has sustained my interest throughout the long years of research and writing. I was also lucky to have Julie Greene as my adviser, friend, and mentor throughout graduate school. She helped me think more deeply about history, and to write more clearly and bravely. Susan Kingsley Kent and Susan D. Jones have been both friends and teachers, and helped me in many ways. I also want to thank Philip Deloria, Mark Pittenger, and Richard D. Lamm for their careful readings of this project in dissertation form, and Martha Hanna, Ralph Mann, Scott Miller, and Thomas Zeiler in the History Department for their support over the years. My thinking about history and this project was also shaped and enriched by my graduate student colleagues, especially Constance Arneson Clark, John Enyeart, Thomas Krainz, Todd Laugen, and Gerald Ronning. I also received fine encouragement from the participants in the dissertation-writing workshop sponsored by the Townsend Center for Humanities at Berkeley. As this dissertation became a book, I benefited from careful and thoughtful readings by Adele Logan Alexander, Fred Anderson, Radford Byerly, Stephen C. Craig, Mary DeCredico, Abigail Dyer, Elizabeth A. Fenn, Thomas Krainz, Hannah Nordhaus, Diana Shull, and my editor, Deborah Gershenowitz. Nancy Bristow, Elizabeth Dungan, John T.

xiii

xiv | Acknowledgments

Greenwood, Robert J. T. Joy, and Dale C. Smith gave me timely advice and assistance that I needed and appreciated. Historians depend on archivists, and I have been most fortunate. I especially want to thank Mitchell Yockelson, archivist at the National Archives, for teaching me how to negotiate the thousands of cubic feet of wonderful material there. He has been a good friend and colleague as well. I appreciate the help I have received from Jeff Karr at the American Society for Microbiology and Archives; Darcie Faust at the Adjutant General Corps Museum, Fort Jackson, South Carolina; as well as archivists at the Military History Institute at the Carlisle Barracks, Pennsylvania; the Division of History at the National Library of Medicine; the U.S. Quartermaster Museum, Fort Lee, Virginia; the Library of Congress; the Hoole Special Collections at the University of Alabama in Tuscaloosa; the Butler Library at Columbia University; the L. Tom Perry Special Collections Library at Brigham Young University; and the Carl A. Kroch Library at Cornell University. I have benefited from generous financial assistance, for which I am grateful. The Department of History at the University of Colorado at Boulder was supportive of my graduate work, and I especially thank John Greenwood, director of the Office of Medical History, Office of the Army Surgeon General, and his staff for their interest in my project and for providing financial support through the Fielding Garrison Dissertation Fellowship. I also am indebted to the Townsend Center for Humanities at the University of California at Berkeley, the University of Colorado Beverly Sears Dean’s Small Grant, and the Annie S. Timmons Award for their financial assistance. With gratitude and affection I also acknowledge the support and sustenance of friends and family: Cindy and Tracy Basing, Bill and Nancy Bonner, Kathy Brandenburg, Betty and Don Brenner, Laura Byerly and Will Neuhauser, Hamp and Lauri Byerly, Charles and Juliet Byerly, Mary Griffin, Peggy Lamm, Anne Meyering, Alma Moore, Hannah Nordhaus, Dan Ries, Erica Rosenberg and Daniel Sarewitz, Harry Reed and Mitch Stahl, Kathy Strand and Eldon Haakinson, and Irazema Viguerias. I never heard a discouraging word. I owe a special debt to my parents, Stanley and Mary Ries, for teaching me to love knowledge and to be always curious. My mother’s unconditional support never ceases to amaze me, and I hope one day to emulate my father’s passion for and excellence in teaching and research.

Acknowledgments | xv

Finally, I delight in my life with Rad Byerly. His love and encouragement have been the bedrock upon which I have been able to pursue my love of history. He has traveled with me through my life as student and independent scholar with enthusiasm, a ready ear, a wise mind, and tireless support. For this and much more, I am grateful.

Fever of War

Prologue Eddie

When he went to war in 1917, Ward J. MacNeal, M.D., Ph.D., was a professor of pathology and bacteriology at New York Graduate Medical School.1 The author of a textbook on microbiology and a leading researcher on pellagra, a nutritional disease, MacNeal joined the Medical Reserve Corps as a captain and was soon assigned to help set up and run the central medical laboratory for the American Expeditionary Forces (AEF) in Dijon, France. At the age of thirty-six, MacNeal said good-bye to his wife, Mabel, and three sons in Forest Hills, New York, and traveled to Europe. In Dijon he joined one of the first cadres of medical officers in France, a close-knit group, which included his co-researcher on pellagra, Joseph F. Siler, Columbia bacteriologist Hans Zinsser, and Zinsser’s student, Stanhope Bayne-Jones. Their job was to help control infectious diseases in the AEF by conducting sanitary inspections, providing laboratory services to medical personnel, and recommending ways to prevent and contain outbreaks.2 Staff at the lab screened thousands of soldiers for tuberculosis, syphilis, and typhoid, and conducted hundreds of thousands of tests on blood, urine, sputum, spinal fluid, and tissue samples from wounded and diseased soldiers. They also autopsied the deceased and traveled throughout France to investigate disease outbreaks in military and civilian communities. In April 1918, as American soldiers were beginning to arrive in France in great numbers, the lab began to receive reports of influenza outbreaks in the Bordeaux region of southern France and areas of Italy and Spain. Medical officers reported that soldiers with these early cases of flu usually recovered within a few days, and according to MacNeal, “complications were so rare as to be non-existent.”3 In May, other flu outbreaks occurred in the AEF, including one near Chaumont, which sickened 30 percent of the men in a single unit.4 The appearance of flu in

1

2 | Prologue

the army was not particularly alarming until late August, when MacNeal recognized a frightening change. The disease, he wrote, had become “distinctly more malignant and a complicating fatal broncho-pneumonia has become alarmingly frequent.”5 The laboratory staff investigated. MacNeal inspected an army unit at Claye-Souilly, outside Paris where 128 men had fallen ill and seventeen had died. He cultured bacteria from patients, autopsied several of the victims, and determined that this was no ordinary flu—in these cases, the mortality rate from influenzal pneumonia was almost 100 percent, involving all lobes of the lungs and “extensive toxic changes occurred in the liver, spleen and kidneys.”6 As the AEF prepared to enter the largest battle in American history, MacNeal found himself facing an enemy more deadly to American soldiers than gunfire—the influenza virus of 1918. This danger was not confined to Europe but spread throughout the world, following troop transports and supply ships to all six continents. More than 25 percent of all American soldiers, and indeed a quarter of the whole world, would catch the flu. “Thus,” observed MacNeal, “once again a great pandemic of pestilence has followed in the wake of war.”7 After the Armistice came and the epidemic finally subsided, MacNeal wrote one of the first and most comprehensive reports on influenza and pneumonia in the AEF. From his vantage point at Dijon, he provided a detailed analysis of the clinical symptoms and bacteriology of the disease, as well as the results from hundreds of autopsies conducted by AEF medical officers. From the autopsy reports MacNeal identified two major types of pneumonia, the appalling “fulminant cases” that involved a “picture of malignant coalescing bronchopneumonia which rapidly involved almost all of the pulmonary tissues,” and a more chronic version, with “distinct foci of older gray consolidation; usually multiple with recent more extensive, even general spread of the pneumonic process.”8 MacNeal filed his report on 27 December and submitted it to the Archives of Internal Medicine for publication in June 1919.9 His job done, he boarded a ship for home. Despite his close proximity to so much sickness and death, MacNeal had escaped two waves of the influenza epidemic. He would not be so lucky with the third wave. Landing in New York in February 1919, he took the Long Island Railroad from Pennsylvania Station to his home in Forest Hills. Expecting a warm homecoming, he was surprised to find only one of his sons, Herbert, at the station to greet him. Herbert explained that the other two boys, Perry and Edward, had the flu and that

Prologue | 3

their mother was home nursing them. Alarmed, MacNeal joined his wife, Mabel, in caring for the boys. The parents stayed by the bedside, taking turns through the night, seeking to quell the fevers and comfort their sons. Perry soon recovered, but Eddie became weaker. His father, despite his medical degree and Ph.D. and his intimate knowledge of influenza, could do nothing for him. On 4 March 1919, five days after his father returned from the war, Eddie, age twelve, died. MacNeal conducted the autopsy on his son. It showed that bacterial endocarditis, a secondary infection resulting from the viral attack, had destroyed the boy’s heart. After failing to save his son’s life, he expressed his grief in a poem: “Now come the sad days when death has broken through / The circle of our loved ones / And taken him for whom we dreamed so much.”10 The global catastrophe had struck home. Ward MacNeal’s war experience merged with the influenza epidemic and shaped his life thereafter. His daughter, Ruth, born four years after the war, would write a short story portraying Eddie’s death in the epidemic as a defining moment in her father’s life. In 1946, at a memorial service for MacNeal, Ernest M. Halliday, a close friend who had been with the family when Eddie died, said that “such a blow might have crushed a lesser man,” but that MacNeal “sublimated his sorrow” in his scientific research on bacterial endocarditis.11 Physician, scientist, and medical officer Ward MacNeal would devote much of his career to trying to understand the terrible disease that had killed his son.12

Introduction

As army medical officer Ward J. MacNeal well knew, the miseries of disease have accompanied the miseries of war throughout human history. The conquistadores brought with them disease which devastated the New World; British colonial armies attempted to use smallpox against Native Americans in the eighteenth century; typhus plagued Napoleon’s armies; typhoid fever humiliated the American army during the Spanish-American War; and the effects of Agent Orange are a legacy of the Vietnam War. The First World War was no exception. As the war lengthened from months into years, many physicians stood alert to disease outbreaks among both military and civilian populations because, as American Expeditionary Forces (AEF) medical inspector Hans Zinsser wrote, “Typhus, with its brothers and sisters—plague, cholera, typhoid, dysentery —has decided more campaigns than Caesar, Hannibal, Napoleon and all the inspector generals of history.”1 Other physicians, however, were heartened by the absence of epidemics on the Western Front in the early years of the war, and expressed optimism that modern medicine had produced a new era. A Public Health Service (PHS) official, for example, observed in 1917, “Those pestilences once considered as the inevitable accompaniment of military movement have been shorn of terror by the hand of science.”2 He would soon be proved wrong. The influenza epidemic of 1918 killed more people in one year than the Great War killed in four. It ranks among the Justinian Plague of the sixth century A.D., which ravaged the ancient world; the Black Death of the fourteenth century, which killed as much as one-third of the population of Europe; and the epidemics that devastated the Indian populations in the Americas during the period of European conquest. As one of the deadliest pandemics in human history, the 1918 influenza sickened at least one-quarter of the world’s population, killing from 2 to 4 percent of those stricken, usually from the complications of pneumonia. “If the epi-

4

Introduction | 5

demic continues its mathematical rate of acceleration,” wrote an army epidemiologist, “civilization could easily have disappeared from the face of the earth within a matter of a few more weeks.”3 Influenza flooded hospitals with patients, closed schools and churches, killed millions of people throughout the world, and sent millions more to bed, pale and helpless for weeks. In the United States, an estimated 25 million people became ill and 675,000 died. The epidemic was so powerful that it created a dramatic, downward “blip” in life expectancy statistics in the United States, with both men and women losing about twelve years in 1918.4 Worldwide mortality estimates range widely from just over 20 million to 50 million. While University of Chicago bacteriologist Edwin O. Jordan’s 1927 estimate of 21 million provided the baseline for decades, more recently scholars have determined that as many as 17 million people died in India alone, increasing the estimate for global mortality to 40 or 50 million.5 The 1918 influenza virus was an unusual strain. Like the common flu, its morbidity rate (rate of sickness) was much higher than its mortality rate. But whereas the flu usually kills only the very weak in a population, the youngest and very oldest people, creating a “U-shaped” mortality curve, the 1918 virus was different. It produced a “terrible W” curve of high mortality for the young and old at the extremes of the demographic spectrum, with an unusual peak of mortality at its center, hence the W shape. The 1918 flu was deadliest for young adults ages twenty to forty, killing not only the weak, but also the strongest people in the population. Cemeteries in small towns and cities across the United States reveal the graves of these young adults who died in late 1918 and early 1919. Several political leaders, including AFL president Samuel Gompers and Senator Albert Fall of New Mexico, lost children to the flu, and at least three members of Congress succumbed, including Representative William P. Borland of Missouri, who died while touring the army camps in France. During the peace negotiations in Paris, the flu incapacitated many of the principals, including President Woodrow Wilson, who was ill for several days.6 But the pandemic killed few world leaders. Perhaps the most famous American to die of the flu was Randolph Bourne, age thirty-two, an intellectual and critic of the war. Another well-known influenza fatality was writer Katherine Ann Porter’s fiancé, an army lieutenant who nursed her when she had the flu but then died of the disease himself, “cutting her world in two” and inspiring Porter’s short story, “Pale Horse, Pale Rider.”7 Mary McCarthy’s young parents died of the flu, leaving her an

6 | Introduction

orphan and changing her world forever, as she relates in Memories of a Catholic Girlhood.8 Charles Drew, an African American physician whose improved methods of providing blood plasma saved many wounded soldiers in World War II, turned to a career in medicine after he lost his oldest sister to the epidemic.9 And when young art collector Duncan Phillips lost his brother to the flu, he commemorated his death by creating the Phillips Memorial Collection in Washington, D.C.10 Thus, in addition to the graves, the epidemic left a varied legacy as its survivors sought to reorder their lives in the wake of their loss. The origin of the flu has long been a mystery, and the responsible virus was not discovered and identified until 1997.11 Our best understanding is that a strain of influenza first appeared in March 1918 in the United States, in Kansas, sickening students at a school in Haskell and soldiers in Camp Funston near Fort Riley, and in Georgia, among soldiers at Camp Oglethorpe.12 The virus then traveled to Europe, probably with men on the troop ships, to the wretched conditions of trench warfare where it would thrive. That spring the flu struck thousands of soldiers but killed very few. After a summer lull, however, the flu became increasingly virulent and exploded in a worldwide pandemic in late August 1918, appearing simultaneously in Freetown (Sierra Leone), Brest (France), and Boston. It swept the United States, attacking military training camps, cities, towns, and rural communities.13 Soldiers reported sick with such recognizable symptoms—a quick onset of illness, very high fever, torpor, often a bluish cast to the skin, and a blood-producing cough—that the flu’s arrival in camps could be pinpointed to the day. The deadly strain of influenza arrived in Camp Devens near Boston on 12 September 1918 and in Camp Upton, New York, the next day. From there it moved west and south, reaching Camp Dodge, Iowa, by late September and Camp Wheeler, Georgia, by early October. Civilian communities were hit just as hard as influenza swept cities, towns, and rural areas alike. By early October the epidemic had penetrated practically every region in the country. In Europe, influenza attacked Allied and German armies with equal virulence, filling field hospitals and transport trains with weak, feverish men all along the Western Front. In October 1918, at the height of AEF’s military offensives in the St. Mihiel and Meuse-Argonne sectors, more American soldiers died in army camp beds than in the battlefields of France. By the War Department’s own account, flu sickened 26 percent of the army—more than one million men—and accounted for 82 percent of total deaths from disease.14 By mid-November, the flu subsided in Europe,

Introduction | 7

only to reappear in January and February 1919. This was the third wave that killed Ward MacNeal’s son Eddie, and while it was less powerful than the second, it was still deadly and spanned the globe. By mid-1919, the flu had probably infected all susceptible human material in the world and burned out. This book explores one aspect of this global disaster: the impact of the influenza epidemic on the American army during the war. In particular, it examines how army medical officers and other government officials responded to the crisis. Army medical officers stood at the center of the wartime epidemic, and their actions and experiences reveal the complex dynamics by which the American society and its government built a national army and waged war during the first quarter of the twentieth century. After dramatic medical advances in the prewar years, the government went into the war with unprecedented confidence in its ability to keep soldiers healthy. Public confidence in the health and welfare of the nation’s soldiers was vital to the government’s ability to conduct the war. After the war, a “lessons learned” army report concluded that soldiers’ belief that if wounded they would be well cared for was vital to the morale of the army and the nation. The converse, however, was also true. “Nothing perhaps affects the morale of the Army and nation more adversely,” warned the report, “than a feeling that the wounded are not being cared for and the dead are not promptly buried.”15 This would apply to the sick as well as the wounded. The influenza epidemic of 1918–1919 was not only a national trauma, then, but a professional disaster for physicians, especially army medical officers, and an experience in failure for the national government. Medical professionals did their best to save those stricken by flu and pneumonia, but without the virology and antibiotics that scientists would develop later in the century, they lacked the tools to control the epidemic. While they had recently gained control over a number of deadly infectious diseases, medical officers were helpless with regard to respiratory diseases, and knew it. This made their failure even more poignant. This book examines the impact of the influenza epidemic on the American army, its medical officers, and their profession through four major themes: the impact of infectious disease on the American conduct of the war at home and in Europe; the nature of military medicine and the special role of medical officers who served both the government war aims and the soldiers under their care; the government’s responsibility for the health and welfare of its soldiers; and the ways in which cultural values

8 | Introduction

and politics shaped medical policy and the historical memory of the epidemic. Regarding the first theme, this study reveals how the influenza epidemic was inextricably linked to the war. The epidemic was not merely a catastrophe at the margins of the war, nor an irritant in the otherwise compelling story of international violence and revolution. Influenza rather collaborated with the Great War. This book will argue that the war created the influenza epidemic by producing an ecological environment in the trenches in which the flu virus could thrive and mutate to unprecedented virulence. The influenza virus exploited conditions in military camps, battlefields, and trenches to transform from a common winter ailment dangerous only to the infirm, into a lethal disease that could sicken at least a quarter of all people it came in contact with and could kill even the very strongest. The resulting epidemic in turn impacted the war by striking down millions of soldiers of all armies and spreading disease and death to countries throughout the world. War and disease together thus produced a human disaster of global proportions. The influenza epidemic was especially disastrous for the United States because it overlapped entirely with the Americans’ war experience. The United States was not a major military player until late 1917 and was thus largely sheltered from the ravages of battle, material destruction, hunger, and the brutalization of society experienced by European nations during the first three years of the Great War. But the war experience changed the United States, accelerating powerful social and economic changes and extending the arm of the government into virtually every home in the nation. A second-order nation with a powerhouse economy before the war, the United States supplied the European powers, especially the Allies, with hundreds of millions of dollars worth of military supplies, weapons, and food, and later, millions of men. It emerged from the carnage a world power. The Americans’ brief military participation, however, meant that the influenza epidemic colored much of the American combat experience. Both were concentrated in September, October, and November 1918. Once it arrived in its deadly form in early September, the flu dramatically affected American war activities. Influenza hospitalized 25 to 40 percent of the men in U.S. Army training camps and killed almost thirty thousand of them before they could even go to France. Men carried the flu virus on board the troop ships, and many soon fell ill, toxifying the ships as they crossed the Atlantic. The epidemic struck the AEF during the climax of

Introduction | 9

the American military campaign, compromising the AEF’s performance in its largest campaign of the war, the Meuse-Argonne Offensive. During that operation, influenza clogged transportation lines along the battlefront, choked hospitals, killed thousands of soldiers, and rendered many more “noneffective”—unable to conduct their training or fighting missions. Army epidemiologist Haven Emerson later observed that when the influenza epidemic struck in September it coincided “with the period of maximum American Expeditionary Forces participation in combat” and was so powerful that it overwhelmed all other diseases. “In the mass of acutely sick men,” he wrote, “99 of every 100 were suffering from influenza or pneumonia.”16 The War Department later calculated that the army lost a staggering 8,743,102 days to influenza among enlisted men in 1918.17 The flu thereby depleted and demoralized troops, and distracted military and political leaders from fighting the war to combating disease. The second theme examines the unique position army medical officers occupied between the government and its citizenry, and their dual responsibilities for carrying out the Wilson Administration’s war aims and for protecting the health of the enlisted men and officers. This position produced several tensions: professionally, as physicians they were committed to the health of each individual, but as soldiers they were dutybound to the nation’s war aims and therefore charged with preparing young men to fight and perhaps die en masse for their country. While medical officers were responsible for enforcing War Department regulations and policing soldiers’ health and behavior, they also often lobbied their superiors for more resources and authority in order to improve health conditions for the soldiers. Politically, while medical officers reported and were subordinate to the army General Command and General Staff, they did not always agree with army policies. They therefore created tensions within the War Department when on occasion they went outside of the chain of command to appeal to elected officials and members of the public to change army medical policy. And finally, although medical officers did more than other officers to prevent war conditions from fostering disease, they were the ones who were put on the defensive by virulent epidemics and by soldiers’ families, elected officials, and military leaders who held them accountable for the sickness and death resulting from those outbreaks. Medical officers thus often found themselves caught between their oath to the army and the nation and the Hippocratic oath.

10 | Introduction

The third theme involves the dynamics within the national government as it assumed responsibility for medical care for its soldiers. During the war the government and its medical officers stood at the apex of their powers and responsibilities. The army was the most powerful arm of the wartime government, not only as a machine of war, but also as a bureaucracy responsible for the well-being of 4 million soldiers and their families. How the War Department and other federal agencies carried out these responsibilities reveals the dynamics between the American public and its government during war.18 Medical officers, equipped with new medical knowledge and technology to control many infectious diseases, did not hesitate to employ this knowledge to question and debate the War Department line command concerning training, transport, and medical authority in the army. In the larger government arena, members of Congress and the White House also sought to influence army medical policies through threats, persuasion, and legislation. And in the public forum, American citizens demanded government services and benefits for their soldier-sons and husbands and then held government agencies and officials accountable for these services. These various levels of negotiations meant life or death for thousands of men, guided the U.S. war mobilization effort, and helped shape postwar American medicine. The final theme concerns how cultural ideologies and political interests shaped the medical officers’ experience and their historical interpretation of events. The national government raised and commanded an army of young men in part by assuring them and their families that they would be well cared for and would fight in glory against the enemy. But the majority of American soldiers who lost their lives died in bed—killed not in combat by the powerful German army, but by a less glorious, unseen enemy. According to the War Department’s official figures, the 57,460 soldiers who died of disease outnumbered the 50,280 who died in combat.19 Thus, while the U.S. Army helped win the war and enjoyed the glory of victory, the medical officers stood impotent before a killer flu. Men like Ward MacNeal tracked the epidemic, cared for the sick, supervised exhausted medical staffs, and conducted autopsies on the dead. But despite a generation of progress, modern medicine could do little against the influenza and pneumonia that raked the army training camps and the AEF. To some it seemed a frightful throwback to the nineteenth-century plagues of cholera, typhoid, and yellow fever that devastated cities and armies. The flu epidemic thus damaged the army Medical Department’s hopes and promises of defeating the infectious diseases that traditionally

Introduction | 11

followed armies. For some medical officers, the catastrophe also threatened their confidence in their professional competence, manliness, and racial superiority, and challenged emerging views of the state as protector. When medical officer Percy Ashburn chronicled the army medical services after the war, he said of the epidemic, “It is a sad story, that of respiratory diseases, and Medicine sits bowed and humble when it is told.”20 Because of this humbling experience, many medical officers and other government officials became reluctant to recognize the epidemic as a meaningful event or to record it in the national memory.21 While some, like Ward MacNeal, would be personally changed forever, others in the profession who faced the destruction of influenza and pneumonia banished it from their memories.22 Many simply remained silent about the epidemic, not including it in their war discussions, speeches, memoirs, or reports of the war. Others, like Paul Woolley, a medical officer at Camp Devens, Massachusetts, began to represent the flu epidemic as an exception to an otherwise successful medical campaign: “Taken as a whole the incidence of disease, except during the epidemic of influenza and pneumonia, was what may be called normal.”23 Another medical officer serving on the other side of the Atlantic explained, “The absence of epidemics in this locality, aside from the two epidemics of influenza, made the amount of epidemiology practically nothing.”24 With “practically” no epidemics, medical officers fell silent about the flu. This approach, in turn, has led historians and others to dismiss the influenza epidemic as unimportant or even to ignore it altogether in their stories of the war. While the influenza epidemic of 1918–1919 has been the subject of much biomedical and epidemiological research, it inspired little historical attention. Historian Alfred Crosby, who wrote one of the few comprehensive works on the influenza epidemic in the United States, dubbed it “America’s Forgotten Pandemic.”25 Such silence about the influenza of 1918—such forgetting—has far-reaching and serious consequences. The tendency of medical officers, army commanders, and federal officials to downplay the role of the influenza epidemic in the Great War, and the impact of disease on military populations in general, has encouraged American complacency about the ability of medicine to control disease outbreaks during war. This book is intended to disturb that complacency. Ever since the Bible (Revelation, chapter 6) portrayed the Four Horsemen of the Apocalypse as the human disasters of war, famine, pestilence, and death, people have recognized the deadly relationship between war and disease.26 As one medical officer wrote, “It is well known that in

12 | Introduction

nearly all past wars preventable disease has killed more men than have perished from wounds.”27 This connection seems to have been lost, however, in the modern era due to both medical science’s increasing control over a number of diseases of war, and the professionalization of the practices of war and medicine. In the late nineteenth and early twentieth centuries, leaders in occupations such as the law, medicine, the sciences, and the military began to require would-be practitioners to undergo specialized education, acquire technical knowledge, meet licensing requirements, submit to the review of their peers, practice in specified institutions, and join exclusive organizations in their field.28 This process of professionalization promoted the compartmentalization of knowledge, tended to insulate practitioners from other professional communities, and protected them from the scrutiny of outsiders or lay people. Scholars studying the military and medical professions have either come from within or have conformed their investigations to the delineated professional boundaries. To put it bluntly, soldiers have studied war and physicians have studied disease, and few of them ventured into the other’s field of research. Only in the last few decades, for example, have lay people such as historians ventured into the history of medicine.29 Military physicians—medical officers—have occupied a uniquely overlapping profession of military medicine, but few scholars outside of medical officers themselves have undertaken to investigate the history of military medicine.30 The practice of history has compounded this separation of disease and war. Whatever their field of study, historians are bound by their primary sources—those produced during the period under study by people who experienced the events. Scholars therefore give special credence to historical accounts by contemporary experts who produced official reports, scientific papers, memoirs, or personal correspondence upon which historians rely for their research. If a contemporary army line officer neglected to report the presence of disease in his command, or a medical officer stated that the influenza epidemic was not a serious problem for the army, many scholars would take him at face value. But the historical record also includes spiking influenza and pneumonia mortality and morbidity statistics, pages and pages of hospital admissions lists for influenza, medical articles about dramatic clinical experiences with the epidemic, and brief but poignant letters or passages in memoirs about influenza. A closer look at these sources provides a more complete picture of the interaction between war and disease. It enables the historian to penetrate silences in the

Introduction | 13

historical record and can begin to explain long lapses in correspondence or diaries due to illness, or account for puzzling deficiencies in the written record. This book, then, seeks to reintegrate the phenomenon of war and pestilence that generated a human catastrophe of biblical proportions in the twentieth century. Katherine Anne Porter, a survivor of this catastrophe, sought to do the same. In her short story “Pale Horse, Pale Rider,” she evoked the Four Horsemen, in particular the pale one of death, and concluded her story observing, “No more war, no more plague, only the dazed silence that follows the ceasing of the heavy guns; noiseless houses with shades drawn, empty streets, the dead cold light of tomorrow.”31

1 Medical Heroes Medical Officers’ Confidence as They Prepare for War The health of the Army both at home and overseas has been excellent and [sick rates] lower probably than in any similar body of troops in the history of warfare. —Surgeon General William C. Gorgas

“I Haven’t the Least Doubt” In April 1918, Army Surgeon General William Crawford Gorgas received a letter from Major General Hugh Scott, commander of the Seventyeighth Division at Camp Dix in New Jersey, who was worried about disease in his camp. “I feel perturbed over the pneumonia and scarlet fever situation. . . . No one here seems to be able to give me a cause sufficient for the effects I see—the camp is as clean as a hound’s tooth.” He described the sanitation measures he had ordered in the camp and asked Gorgas to “come over to give us the once over and I will feel that I have done the best possible.” He closed his letter saying, “Until the best has been done I will feel uneasy.”1 Gorgas responded quickly, acknowledging the problem of pneumonia and taking the opportunity to recall a recent victory against disease. “It is now just like yellow fever before we used mosquito precautions,” he wrote, “we know perfectly well that we can control pneumonia absolutely if we could avoid crowding the men, but it is not practicable in military life to avoid this crowding.” He assured Scott, however, “I haven’t the least doubt that if you, tomorrow, could give every man in Camp Dix his own individual hut, that pneumonia would ease at once.” This, he explained, is what they did to successfully fight pneumonia among workers during construction of the Panama

14

Medical Heroes | 15

Canal. The surgeon general promised that he would visit Scott’s camp soon and said that “we have a number of the best scientists in the United States studying this question of transmission of pneumonia and may be [sic] we will be as successful with pneumonia in this as we were with yellow fever and malaria in the Spanish-American War.”2 This exchange between a worried general and a confident medical officer shows how medicine’s past victories shaped the Army Medical Department’s response to infectious disease during World War I. Army medical officers were elites among elites: officers among men, physicians among laymen, whites in a polyglot world, men in a gendered hierarchy, and professionals who believed they could wield the tools of modern science and technology to save lives and defeat disease. Gorgas felt proud and optimistic about the power of scientific medicine to fight disease and save lives. Although military mobilization created fertile ground for epidemics in army camps, Gorgas had “not the least doubt” that they could “control pneumonia absolutely given the right circumstances.”3 His confidence in his profession’s ability to control pneumonia in an era before antibiotics stemmed from advances in medical science that had generated powerful new vaccines and laboratory diagnostic techniques. These tools facilitated the early detection of disease in individuals, more effective treatment for some illnesses, and the prevention of others. The surgeon general’s response to Scott also shows that like many generals, Gorgas looked to past wars to prepare for World War I. He drew upon his successes in vanquishing yellow fever and malaria in Cuba after the Spanish-American War and in the Isthmus of Panama during the American construction of the canal there. Gorgas received international acclaim for those achievements, and his profession enjoyed reflected glory as the United States gained influence in the hemisphere. Gorgas’s optimism about the ability of scientific medicine to control disease also reflected medical officers’ sense of pride as members of a modern industrial nation that was stepping onto the world stage. With new scientific tools to fight disease, the medical profession took steps to consolidate its authority and power in society, and medical officers likewise sought to reinforce their status within medical and military professions.4 As war approached, they defined themselves in relation to other social groups by recruiting the elites among white, male physicians in the country and excluding women and African Americans from their ranks. They also assisted the War Department in screening American soldiers to ensure that only the strongest, healthiest men would become soldiers.

16 | Medical Heroes

This process, however, would also set the stage for tragedy. Gorgas and his colleagues’ past medical and military experience and painstaking screenings did not adequately prepare them or any other army personnel for modern industrial warfare and a daunting array of infectious diseases. The tropical diseases Gorgas confronted in Cuba and Panama would not menace the armies of World War I. Americans served not in tropical jungles, but in hastily constructed training camps and in cold and muddy trenches on the Western Front. The diseases that preyed most upon these soldiers were not transmitted by visible vectors such as mosquitoes carrying yellow fever and malaria or water contaminated with typhoid and dysentery. Instead, respiratory diseases such as measles and influenza attacked the army stealthily, borne on the air people breathed. These germs had no respect for social class or hygienic behavior, and most sanitary measures were powerless to stop them. Airborne respiratory diseases— first the measles, and then, lethally, influenza—would confound General Gorgas and thousands of medical officers and become their worst nightmare.

General Gorgas William C. Gorgas (fig. 1) was already a national hero when Woodrow Wilson appointed him army surgeon general on 6 April 1914. In 1903, Congress had recognized him with a special promotion for his work in Cuba, in 1907 President Theodore Roosevelt praised him publicly and appointed him to the Isthmian Canal Commission, and the following year the American Medical Association (AMA) elected him president. Several universities, including the University of Pennsylvania, Harvard, Brown, Johns Hopkins, and his alma mater, the University of the South in Sewanee, Tennessee, awarded Gorgas honorary degrees.5 The British government in South Africa called on Gorgas for advice on the control of pneumonia in the Rand mining district, and the Rockefeller Foundation consulted him on yellow fever in Latin America. He achieved further international recognition in 1914 when Oxford University awarded him an honorary degree of Doctor of Science. When Wilson named him surgeon general, he was at the top of his profession. Congress ratified his prestige with the unprecedented step of promoting him to major general in March 1915.6

Medical Heroes | 17

Fig. 1. William C. Gorgas, Surgeon General of the Army, April 1914 to October 1918. (National Library of Medicine, B 13205)

While Gorgas’s reputation was due to his record as a physician and sanitarian, his first love was the army. In fact, he became a physician so he could be a soldier.7 A Southerner, William Crawford Gorgas was born in Mobile, Alabama, in 1854. His mother was the daughter of the former governor and his father was a West Point graduate who served the Confederacy as a general in the Civil War. During the war, young Gorgas and his family lived in the Confederate capital of Richmond, Virginia, and afterwards, Gorgas pursued his father’s career by applying to West Point. When West Point refused him admission, he enrolled instead in the University of the South and then continued to medical school, graduating from Bellevue Medical College in New York City in 1879.

18 | Medical Heroes

In 1880 Gorgas joined the Army Medical Corps and finally succeeded in becoming an army officer. As a medical officer on frontier outposts throughout the West, he encountered the disease that would shape his life: yellow fever. Medical scientists did not know what caused yellow fever, but they did know that it killed 20 to 70 percent of its victims. This terrifying disease, however, was also the source of positive events in his life. Gorgas’s parents met when his mother fled to an army arsenal during a yellow fever epidemic in Mobile, Alabama.8 Gorgas too encountered his future wife during a yellow fever epidemic, in 1882 at Fort Brown on the Texas-Mexican border. Marie Gorgas opens her biography of her husband by describing how he cared for her when she was sick with fever. He soon fell ill too, and as they convalesced they fell in love—and, by surviving, together acquired permanent immunity to yellow fever.9 With this immunity, Gorgas and his wife began a lifelong association with the army and yellow fever, traveling the world to combat the disease. Gorgas’s professional breakthrough came during the Spanish-American War when the army sent him to Cuba in 1898 to run a yellow fever camp at Siboney. His patients included medical officer Victor C. Vaughan, later dean of the University of Michigan School of Medicine and president of the American Medical Association (AMA), who credited Gorgas with saving his life.10 After the war, Gorgas joined the army medical team assigned to clean up Cuba for the American occupation of the island. Yellow fever, however, was such a serious problem that the War Department appointed a board headed by Major Walter Reed to investigate the cause of the disease. After a series of dramatic and well-known experiments, in which volunteers exposed themselves to the bites of mosquitoes carrying yellow fever and thereby contracted the disease, Reed and the yellow fever board determined that the mosquito Aedes aegypti was the vector for yellow fever, carrying the disease pathogen from person to person. With this knowledge, Gorgas, as chief sanitary officer of Havana, launched a vigorous, effective sanitary campaign to rid Havana of mosquitoes, and in the following years yellow fever cases fell from well over one thousand in 1900 to none in 1902.11 Reed and Gorgas’s success brought them fame and enhanced the Army Medical Department’s prestige. The army surgeon general appointed Gorgas chief sanitary officer of the Panama Canal in 1904 with the mission to control the diseases that had driven the French from the project in the 1880s.12 Gorgas again enjoyed dramatic and indisputable success: in eighteen months, yellow fever

Medical Heroes | 19

disappeared from the Canal Zone. The last case was reported in May 1906.13 The site became so safe that Teddy Roosevelt traveled to Panama in November, returning home with high praise for Gorgas and other officials in Panama. In a special address to Congress, Roosevelt equated them with military heroes, “entitled to the same credit that we would give to the picked men of a victorious army.” The conquest of yellow fever would “stand as among the very greatest conquests, whether of peace or of war, which have ever been won by any of the peoples of mankind.”14 By eliminating mosquitoes from the environment, medical officers could banish or control the diseases they carried. Medical officer Reynold Webb Wilcox also lauded the Panama Canal achievement, telling the graduating class of the Army Medical School in 1915: “The sanitation of the Canal Zone, which made this feat possible, is an imperishable tribute to the Medical Corps of our Army.”15 Roosevelt, Gorgas, and their contemporaries believed that new scientific knowledge and technologies enabled American and European powers to extend their control and influence beyond their borders. Historians have shown how medicine facilitated imperialism and vice versa. Eric Hobsbawm, for example, argues that imperialism promoted the study of bacteriology and immunology because it provided incentives for white men to conquer the tropical diseases that they saw as inhibiting their occupation of colonial areas.16 Tropical medicine historian Warwick Anderson agrees, describing how physicians sought to resolve the problem of deadly fevers in colonies by controlling disease rather than requiring white colonists to adjust to their new environments.17 Gorgas’s victory over yellow fever therefore seemed to demonstrate that modern science could make the tropics the province of European civilization. Gorgas explicitly linked scientific progress with racial superiority and imperialism in his book, Sanitation in Panama. Claiming to have saved 70,000 lives, preserved the health of three times as many people, and saved $80 million in hospital costs, he compared the achievement to the discovery of the Americas.18 And in his 1909 presidential address to the AMA, “The Conquest of the Tropics for the White Race,” he described the control of yellow fever and malaria in tropical regions in racial supremacist and imperialist terms. “Advances in tropical sanitation in the last fifteen years,” Gorgas explained, “have shown that the white man can live in the tropics and enjoy as good health as he would have if living in the temperate zone.” The consequences of disease control were vast: “I dare to predict that after the lapse of a period, let us say, equal to that

20 | Medical Heroes

which now separates the year 1909 from the Norman conquest of England, localities in the tropics will be the centers of as powerful and as cultured a white civilization as any that will then exist in the temperate zones.”19 It might take centuries, but scientific medicine would enable “white civilization” to dominate the earth.

Scientific Medicine and Professionalization That William Gorgas’s career paralleled the emergence of modern medicine helps to explain the overweening confidence that he and other members of the medical profession had on the eve of the war. The medical profession and the Army Medical Department rode the crest of scientific and technological advances that reduced infant mortality and deaths from infectious diseases, and increased life expectancy. Sanitation measures such as municipal sewer systems and sand filtration of water drove cholera, dysentery and typhoid from the cities, and milk pasteurization reduced infant mortality and tuberculosis rates. Other diseases began to succumb to new medical practices stemming from germ theory—the concept that a specific pathogen caused a specific disease. Germ theory as described by Robert Koch in the 1880s promised new medical technologies that improved physicians’ ability to combat disease and accordingly increased their confidence in their powers.20 Physicians and community leaders at the New York Health Department had so much confidence in their abilities that in 1911 they declared: “Public health is purchasable. Within natural limitations a community can determine its own death rate.”21 New knowledge and technology also enabled physicians to professionalize the practice of medicine by increasing education requirements, standardizing medical practice, and controlling practitioners’ access to hospitals. In order to secure these developments, physicians’ organizations moved to increase their influence in society and politics. For example, by 1915 physicians’ groups had convinced most states to increase medical education curricula requirements and to institute medical examinations and licensure laws for the practice of medicine.22 Whereas armies of all eras had suffered from a variety of diseases, including yellow fever, malaria, typhoid fever, typhus, and dysentery, military medicine began to benefit from the new knowledge and technology. The identification of the typhoid bacillus, for instance, enabled medical officers to distinguish typhoid from other fevers and to detect the bacte-

Medical Heroes | 21

ria in water and food supplies. Antitetanus vaccinations became routine on the Western Front, and after scientists identified the body louse as the vector for typhus in 1906, medical officers instituted the antilouse bathing programs that became ubiquitous during the Great War. Thus, the new laboratory techniques and vaccines emerging from germ theory provided the medical community with tangible new powers over life and death. “Knowledge of preventive measures for preserving the health of the soldier has become so exact,” an army medical officer announced in 1916, “that, as an abstract proposition, in the case of most diseases it approximates mathematical certainty.”23 Armed with recent advances in scientific medicine, Surgeon General Gorgas was convinced that the old ratio of several times as many deaths from disease as from combat would have no place in modern warfare. After General John J. Pershing led troops into Mexico to punish Pancho Villa for attacking Americans, Gorgas expressed satisfaction with the army’s health record. His annual report for 1916–1917 noted that outbreaks of infectious disease among the troops had been “promptly checked,” and that “the physical vigor and the military efficiency of the various organizations at the close of the year was a matter of frequent comment and a subject of congratulation for all concerned.”24 Gorgas and other physicians sought to secure and extend such improvements in health to the nation at large. The surgeon general, for example, served on the board of the Life Extension Institute, which supported legislation to establish a national health department and national health policy in the belief that the government should use the knowledge of scientific medicine and technology to reduce disease and death for all the people.25 One member of the Life Extension Institute argued that human life no longer had a fixed length because disease and death could now often be prevented. “The world,” he wrote, “is gradually awaking to the fact of its own improvability.”26 At a time when medical research universities and teaching hospitals were just emerging, the Army Medical Department was at the forefront of many scientific advances. The army’s leadership in medicine demonstrated how the concentration of resources—medical literature and laboratories, trained researchers, access to various climates and diseases, and especially the availability of a homogeneous, largely compliant patient population of young soldiers—could promote scientific progress when confronted with specific problems. As early as the American Revolution, George Washington was the first commanding general to order

22 | Medical Heroes

mass immunization when in 1776 he ordered the inoculation of the Continental Army against smallpox.27 The army’s leadership continued in the early nineteenth century as army medical officers anticipated the U.S. Weather Bureau by collecting meteorologic data from army outposts, and in the 1840s when the army surgeon general produced the first nationwide report of public health statistics in a survey of the health of the troops.28 The army surgeon general created new national institutions such as the Army Medical Museum in 1862 and the National Library of Medicine, and in 1880 Surgeon General John Shaw Billings created the first catalog of medical publications.29 In the 1890s, another surgeon general, George Sternberg, wrote the first American textbook on bacteriology, and Fielding Garrison of the Army Medical Museum published one of the first textbooks on the history of medicine in 1913.30 In the early twentieth century, the army continued to produce heroes. Bailey K. Ashford, with the army in Puerto Rico, identified hookworm (uncinariasis) as the cause of debilitating anemia, and Carl Darnall developed the method of purifying drinking water with anhydrous chlorine.31 In 1909, Major Frederick Russell began immunizing volunteers in the army against typhoid, and after he demonstrated the vaccine’s effectiveness and safety, the army made typhoid immunization compulsory and reduced the typhoid rate from 243 to 4.41 per 100,000 in just three years.32 Typhoid vaccination was of particular importance to medical officers, one of whom described it as “the biggest single thing ever discovered in military hygiene” because, the officer explained, “it alone would probably save us a repetition of the anti-hygienic horrors of the Spanish War.”33 These horrors involved humiliating typhoid fever epidemics in 1898 among combat troops and men in the training camps that marred the Medical Department’s record of scientific success. Whereas only 385 American soldiers died in combat during that war, more than 20,000 soldiers contracted typhoid, and at least 1,500 men died.34 Camp Thomas at Chickamauga, Georgia, home to some 80,000 men, was the worst, with almost 10 percent of the men coming down with typhoid. Even William Gorgas, whose immunity to yellow fever enabled him to care for soldiers in Cuba who were stricken with that disease, soon fell ill himself with typhoid and was sent home to recuperate. Although typhoid was endemic in the United States in 1898, many people considered typhoid a disease of filth and poverty, caused by poor sanitary conditions and lax personal hygiene.

Medical Heroes | 23

An epidemic in the army, therefore, signaled the War Department’s failure to care properly for its men. The epidemic caused a furor in Congress and generated two government investigations. One, known as the Typhoid Commission, whose members were Walter Reed, Edward O. Shakespeare, and Victor C. Vaughan, determined that apparently healthy humans could carry and transmit the typhoid bacilli and that flies moving from latrines to food supplies spread the disease as much as polluted water did.35 The commission concluded that typhoid could be avoided with stringent sanitation measures but would not be eliminated without some form of immunization. The other investigation did not blame the Medical Department entirely for the epidemic either, noting that the War Department had not grasped the urgent need for sanitary efficiency and discipline and that the Congress had not granted sufficient funds.36 It recommended a number of reforms, including improved medical transportation and procurement systems, more medical personnel, and professionalization of the Medical Corps. These investigations to some degree vindicated the Medical Department, and the reforms improved its preparedness for the next war, but medical officers would long remember the humiliation of the scandal. Scores of young physicians who had served in the Spanish-American War held high office in the Medical Department or the army command during World War I. These included Gorgas, Merritte W. Ireland (his successor as surgeon general), Victor C. Vaughan (head of the infectious disease division during the war), Leonard Wood (Eighty-ninth Division commander and candidate for president in 1920), Jefferson R. Kean (War Department liaison with the Red Cross), and Bailey Ashford (director of the AEF medical school in France). These men would worry and work to ensure that this kind of disease outbreak—and public humiliation for their profession—would not happen again. General John Pershing’s memoir reveals that this was also on his mind as he prepared the army to join World War I. “The Medical Department’s plans constantly received my careful attention,” he wrote. “Most of the older officers remembered with something akin to horror the unsanitary condition of our camps at Chickamauga and elsewhere.” Everyone, Pershing remembered, “especially the medical men, were resolved that nothing like that should be repeated in our armies in the World War.”37 Given their memories of the typhoid debacle, the development of an effective typhoid vaccine increased medical officers’ confidence in their ability to control many of the diseases that plagued armies. As one medical officer told a University of California

24 | Medical Heroes

audience in 1916: “Our interest in typhoid is heightened by the fact that it is not only an important disease, but one that can and will eventually be obliterated.”38 In addition to obliterating disease, some medical officers sought to improve human beings themselves. Eugenics represented the apotheosis of the belief in the power of science to control disease and extend human life, and a series of university lectures on eugenics during 1912–1913 reveals these views. In one lecture, Victor Vaughan explained to his undergraduates at the University of Michigan that eugenics was part of a “broad scientific scheme for the uplift of the race.” This science of eugenics had negative and positive roles, the first “to prevent the multiplication of the bad stock, and the other is to encourage the replenishment of the good.”39 Vaughan and others offered a range of strategies for improving the American “stock,” from encouragement of “good” marriages, registries of birth defects and disabilities, and government monitoring of the health and behavior of families, to the segregation or sterilization of the people considered unfit for reproduction. Good stock did not require riches, Vaughan observed, but rather the absence of undesirable characteristics such as “alcoholism, feeble-mindedness, epilepsy, insanity, pauperism, and criminality.” He asserted that “all of these classes should be excluded from the list of those to whom is granted the privilege [of] . . . parenthood.”40 Another lecturer, Charles Davenport, suggested abandoning infant mortality programs so that children of the unfit would die.41 Vaughan’s pride became hubris when he lifted the eugenicist cum scientist to the level of a god, telling students: “By the process of evolution, man has grown to a degree of intelligence that makes him a coworker with the creator, and the future of the race is largely within man’s power to make or to mar, to illume or to darken, to fill with the joy of life or with the regret of having been born.”42 Both Davenport and Vaughan would later serve as medical officers during the war, and views such as theirs would shape the Medical Department’s interpretation of the influenza epidemic. As modern medicine saved more lives, it increased some physicians’ sense of self-worth to the point of being a “coworker with the creator.” Army medical officers were no exception to this story of progress and occasional hubris. One medical historian has written that the glory of the military medical profession was at an all-time high in 1918.43 Many civilian and military physicians considered medical and scientific progress inevitable. “Based on laborious study and active experience,” stated one se-

Medical Heroes | 25

nior medical officer proudly in 1917, “the Army Medical Corps has made steady and unfailing progress from the early days of the Revolution down to the time of recent sanitary triumphs of Sternberg, Reed, Gorgas and their contemporaries.”44 Woods Hutchinson, who served as an observer in the British medical service in 1916, had a more earthly measure. He reported that the British medical officer had become so successful in “almost wiping out disease” that “as a consequence he has become such a valuable part of the fighting force he has lost all the former immunities. . . . [and is] fired upon by the Huns, who count one doctor worth five hundred soldiers.”45

Recruiting and Excluding Physicians If, according to Hutchinson, the Germans believed that one British doctor was worth five hundred soldiers, Surgeon General Gorgas was concerned about another ratio—doctors to soldier-patients. As the United States edged toward war, he worried that the army did not have enough medical officers to care for a wartime fighting force. While the Medical Department was better equipped for World War I than it had been for previous wars, neither it nor the army as a whole was prepared for the colossal conflict an ocean away. In 1915, the regular army had only 440 medical officers, and the Medical Reserve and National Guard had only 2,750 total. Based on a calculation of seven medical officers for every thousand soldiers, an army of 2 million would need 14,000 medical officers. The War Department faced a daunting task in signing up enough medical officers to care for the thousands of young men streaming into training camps. Federal officials considered drafting physicians, but chose instead to rely on volunteers. The AMA estimated that 146,500 medical doctors lived in the United States, and as General John Pershing demanded more and more soldiers for the AEF it seemed the war might require mobilizing most of them. Some physicians responded to the need with alacrity, joining the Medical Corps before the United States even entered the war. They may have been inspired by patriotism, or angered by stories of German atrocities such as the torpedoing of the Lusitania, but for many, joining the war effort also provided a way to advance their professional and organizational interests.46 Rupert Blue, head of the Public Health Service (PHS), expressed an almost ghoulish excitement about the opportunities of war,

26 | Medical Heroes

noting “the wonderful way in which this war of wars is moulding the destiny of the entire medical profession.” Pointing out that “the practices of emergency surgery are being tried out on a scale so vast as to baffle the imagination,” he concluded that “when this war shall have ceased, the finest body of medico-sanitary soldiers that the world has ever seen will be returned to civil practice.”47 In that spirit, the Association of Military Surgeons launched membership campaigns, increasing its membership more than 50 percent during the war, from 4,384 in 1917 to 6,847 in 1918.48 In building up the Medical Corps, Gorgas personally recruited the elites of the medical profession to serve as leaders and mentors, bringing their medical prestige into uniform. He wrote a note to a cousin, Stanhope Bayne-Jones, a bacteriologist at Columbia, encouraging him to sign up for the Medical Reserve in 1915—and Bayne-Jones did.49 Gorgas also recruited advisers from the roster of prestigious physicians — Harvey Cushing, a pioneer in neurosurgery at Harvard; Simon Flexner of the Rockefeller Institute; William Welch, a leading bacteriologist at Johns Hopkins; and Victor Vaughan.50 For assistance, he also called on the Mayo brothers of the Mayo Clinic; George Crile, a leading surgeon from Western Reserve in Cleveland; and Hugh Young, a nationally known urologist. Several of these men gained access to policymaking at the highest levels of the war effort. American College of Surgeons president Franklin Martin won one of the seven seats on the Council on National Defense advisory board for himself and the medical profession, and recruited AMA president Frank Simpson, Gorgas, navy surgeon general W. C. Braisted, PHS surgeon general Rupert Blue, William Welch, and others to serve on the council’s General Medical Board (fig. 2).51 These “seats at the table” were important to the medical officers and ensured, as the Medical Department later noted, “that the importance of medicine to any war army we might create would not be overlooked, as was the case in the Spanish-American War.”52 With so many medical officers with national if not international reputations in their fields, Fielding Garrison, the army’s medical historian, noted that “the elite of our American profession flocked to the colors.”53 But not all medical men “flocked” to the colors. By November 1917 the War Department needed 20,000 medical officers, and according to the Military Surgeon, only 12,000 had enrolled. The problem was that some private practitioners were concerned they would experience material sacrifice and a loss of status when they entered government service.54

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Fig. 2. Executive Committee of the General Medical Board. Standing left to right: Frank Simpson, Victor Vaughan, William Welch; seated, left to right: W. C. Braisted, William Gorgas, Rupert Blue, Franklin Martin. (National Library of Medicine, B 13222)

One medical officer explained the problem: “We can never hope to build up our Reserve unless it is clear that in joining the Reserve Corps we are not committing an act that may uselessly imperil our well-being and that of our family.”55 In order to attract these reluctant physicians, the Medical Department not only mobilized the same values and images that regular army recruitment did—patriotism, national service, adventure, manliness, honor, courage, and “doing one’s bit”—but also emphasized the opportunities for research and professional advancement. It portrayed the army as an opportunity to practice medicine on an unprecedented scale and to gain experience not available in private practice. Medical officer H. C. Coe appealed to his colleagues’ sense of adventure: “Never before since history began have we had such an opportunity to render in full measure the service to humanity which has been the ideal of those who have not bowed the knee to Mammon.” Coe asked his colleagues, “Who of us would have missed the experience over here?”56 In addition to emphasizing nonpecuniary rewards, Gorgas sought to increase

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Medical Corps status by setting requirements for medical officer commissions that were higher than those for medical licenses in most states. Joining the corps would be an opportunity to serve with the best doctors in the world. Applicants had to be U.S. citizens between the age of twenty-two and fifty-five, graduates of an approved medical school, in possession of state licenses, “of good moral character and habits,” and they had to have at least one year in a postgraduate hospital internship.57 Medical officers also had to pass physical fitness and professional competency examinations designed to screen out unfit or incompetent applicants. Fit and well educated, the Medical Corps was also conspicuously white and male, unlike the army rank-and-file, which included thousands of African Americans as well as men from every ethnic group in the country. Although physicians of all backgrounds wanted to serve, the War Department prescribed racial, gender, and professional requirements that maintained the white, male, largely allopathic character of the cadre of physicians within the Medical Department. Even the shortage of medical officers in 1918 did not cause the Medical Department to recruit women or African American physicians.58 The War Department refused medical commissions to women despite repeated petitions from women’s groups, and while Gorgas enlisted the AMA and its JAMA to recruit physicians across the country, he did not use the African American physicians’ journal, the Journal of the National Medical Association (JNMA).59 The War Department’s efforts to exclude women and black men not only mirrored the racial and gender discrimination in American society, but also revealed how important a racial and gendered identity was to the largely white, completely male Medical Corps. The army had long excluded women physicians. Nurses were the only women in the Medical Department, and their status was not clear because members of the Army Nurse Corps did not have the same military rank or privileges as men in comparable positions.60 Although women physicians represented less than 3 percent of their profession in 1917—five to six thousand total—many of them wanted to serve in war.61 Immediately after Woodrow Wilson declared war on Germany in April 1917, Bertha Van Loosen, president of the Medical Women’s National Association (MWNA), the women’s equivalent to the AMA, cabled him to offer the services of her members.62 When the army demurred, the MWNA formed a committee to advocate medical women as officers in the Medical Reserve Corps. Surveying women physicians to identify those interested in

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wartime service, the committee found that 31 percent of those surveyed wanted to serve.63 Members of the MWNA lobbied their colleagues for support during the AMA annual meeting in June 1918. While AMA delegates did pass a resolution in favor of equal pay and rank for men and women physicians, they stopped short of full equality. “The very character of military service and women’s natural limitation for such service,” they explained, “must require wise discrimination in their employment in war work.”64 Women physicians in Colorado cited language in the National Defense Act of 1916 that restricted the appointment of officers to “citizens . . . found physically, mentally and morally qualified to hold such commissions,” and argued that the phrase qualified them for the Medical Reserve Corps.65 The Acting Judge Advocate General ruled against them, stating that there was no precedent for women to serve in the Medical Reserve; that soldiers were specified as “men” in other army regulations; that women could not physically serve in the war, and—especially significant in the matter of status and identity—that women could not be made officers because it would put them in a position to command men.66 Gorgas told the Colorado women that while he personally supported the women’s petition, he had to abide by the judge advocate general’s ruling. Secretary of War Newton Baker was less gracious, stating that he “did not approve of commissioning or enlisting women in the military service.”67 Baker, like the AMA delegates, believed that women physicians’ sex alone was reason to bar them from the Medical Corps. During the war, therefore, women physicians could participate in the war effort only as army civilian “contract surgeons,” working as sanitarians for army installations or as bacteriologists and pathologists in laboratories. Contract surgeons had few of the privileges medical officers had—no rank, no promotions, no bonuses or pensions, not even disability insurance. Still, fiftyfive women physicians served as army contract surgeons, eleven of them overseas. Female physicians also worked in philanthropic institutions, and some eighty women physicians, two of them African Americans, served overseas with voluntary organizations such as the Red Cross.68 One of the biggest objections to women physicians—the concern that a medical commission would put women in a position to command men —was also leveled against African American physicians. The argument seemed to require little explanation or reflection. Hugh Young, for example, a Johns Hopkins University urologist who directed the AEF venereal disease program during the war, remarked, “It seems to me that it

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was a mistake to allow a Negro to become an officer in the army,” because, he explained, “experience has shown that the average Negro soldier does not respect a Negro officer.”69 Thus, most World War I–era officers took for granted that women and black men could not command white men and thereby prevented them from joining the war effort. The issue of black male physicians was part of a larger debate within the army regarding black officers, and only 1,353 of the nearly 400,000 African Americans in the army during the war served as officers.70 African American physicians comprised fewer than 1.5 percent of the medical officers during the war. The National Medical Association (NMA) lobbied hard for more black physicians and officers, but the War Department resisted these efforts, declining for months to even discuss the issue with African Americans and their advocates. George E. Cannon, a black physician in New Jersey, recounted the process in the JNMA, observing that although the War Department issued an urgent appeal for medical men in the summer of 1917, it failed to assign two hundred of the estimated three hundred commissioned black medical officers to active duty. In addition, while the army transferred drafted white physicians to the Medical Corps, it would not do the same for drafted black physicians. “Race prejudice,” concluded Cannon, “was the obvious reason for such a policy.”71 He and other black leaders wrote letters to government officials, enlisted the help of U.S. senator David Baird of New Jersey and Emmett Scott, the secretary of war’s special liaison with the black community, to argue for more black physicians for the army. Scott told Baker that while African American physicians wanted to serve their country for reasons of patriotism, adventure, or professional opportunity, many were also worried about the fate of black draftees under the care of white army doctors.72 Although the Ninety-second Division, one of two black combat divisions, had black medical officers, white physicians cared for the thousands of black soldiers who served in army pioneer infantry and labor battalions both in the United States and Europe. “Colored medical men are willing and eager to serve men of their own color,” Scott advised Baker, and “colored soldiers as a rule prefer such medical care.”73 The War Department maintained, however, that it was “impossible to assign Negro medical officers to organizations in which the line officers are white.”74 This, Secretary Baker explained, was “an incident of service which the War Department could not remedy unless it assigned officers to places where they were not needed.” He regretted “that circumstances over which the Department had no control have made it impracticable to

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order colored professional men to active duty in a commissioned status in all cases where the applicants met the required qualifications.”75 The War Department did not budge from its position. It established a segregated training camp for black medical officers at Fort Des Moines, Iowa, and awarded medical commissions only to 356 of the 3,000 to 4,000 African American physicians in the country.76 One of these officers was Captain Clarence S. Janifer, a homeopathic physician, who served with the Ninety-third Division. General Pershing attached the Ninetythird to the French Army, and the French awarded Janifer the Croix de Guerre for his service.77 The majority of black soldiers served in the U.S. Army, however, and many officer training school graduates were assigned to serve in the Ninety-second Division. One of these officers, Dr. William Holmes Dyer, a medical officer, resented the myriad acts of race discrimination he encountered in the American army, but he welcomed his military role. “Here was the best blood of the Nation,” he wrote, “in that great school of the Soldiers, fitting themselves to be-come [sic] leaders of men in the army of a Nation.”78 Women and black physicians’ struggles for opportunity and recognition in the Medical Department demonstrated their energy and desire to serve in the war effort and revealed the degree to which white, male medical officers and their commanders defended strictly defined race and gender lines for their profession. Fighting for increased status within the army and the civilian world, medical officers took every opportunity to bar social “inferiors”—among whom they included women and African Americans—from joining their ranks. This process went to the core of the social order in the army.79

An Army Fit to Fight: Stratified and Segregated When American “doughboys” began to arrive in Europe in great numbers in the late spring of 1918, they presented a vivid image of the American arrival on the global stage—well fed, well supplied, and eager for combat. British nurse Vera Brittain was overwhelmed. “I pressed forward with the others to watch the United States physically entering the War, so god-like, so magnificent, so splendidly unimpaired in comparison with the tired, nerve-wracked men of the British Army.”80 An American physician in London similarly reported, “Medical man after medical man has commented with approval and even admiration upon the appearance of

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the American soldier, his alertness, activity, adaptability, and cheerfulness.”81 Many Europeans viewed the doughboys as big, strong, healthy men who could take the burden of the war from their bloodied, exhausted armies. But they saw only the most healthy portion of American manhood. The story was actually twofold: those men who made the grade and became soldiers were deemed the strongest and healthiest in the country, but the Selective Service also found that many of the millions of men brought under government scrutiny were physically unfit or diseased—not the stuff of a young, vigorous nation. The Selective Service touched almost every American household, registering more than 24 million men, examining 10 million, and producing an army of 4 million.82 The War Department, with medical officers as its agents, sought to recruit the fittest, strongest army for the United States. Civilian and military physicians participated in the screening process at every level. Many thousands sat on the Selective Service system’s 4,648 local draft boards, and almost 10,000 more physicians served on the medical advisory review boards that conducted physical examinations of registrants who were initially rejected for medical reasons.83 Local physicians examined recruits in every city, county, and Indian reservation in the nation, recording height, weight, and chest circumference, as well as orthopedic and medical information.84 Seventy percent of registrants received deferments because they were sole supporters of their families, held jobs considered vital to the war effort, or were considered unfit for military service. The 30 percent classified as suitable for military service were then medically examined, and the Selected Service rejected 30 percent of these as physically unfit for the army.85 Physicians enumerated fifty-five “diseases and defects” and found that in some areas one in five men had tuberculosis or venereal disease. Other ailments included epilepsy, goiter, underweight, and neurasthenia (nervous exhaustion). The Selective Service examinations shocked a nation that prided itself on its strength and vigor, as many people found the rejection of 30 percent of the recruits as physically unfit “appalling.”86 Observers offered a number of explanations for this ill health in American men. Some argued that industrialization and urbanization had replaced vigorous, healthful work outdoors with more sedentary employment in offices, factories, and stores. Charles Mayo noted, “our nation is becoming soft, dissipated and inefficient. From 25 to 50 percent of our youth from 20 to 30 years of age are physically defective from preventable causes.”87 But by screening out the unfit, the War Department believed it had produced the largest,

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healthiest, most fit army in the history of the land. President Wilson could thus write in the introduction to a book on the fitness of American soldiers, “No army ever before assembled has had more conscientious and painstaking thought given to the protection and stimulation of its mental, moral and physical manhood.”88 When all the recruiting and screening was over, the American army of 1917–1918, unlike the Medical Corps, represented the polyglot, ethnically diverse, and racially segregated nature of the roughly 100 million people in the nation. And the distinction between officers and enlisted men reflected the nation’s socioeconomic stratification. An estimated 20 percent of the draftees were foreign born and spoke at least forty-six languages. Perhaps 9 percent were not U.S. citizens.89 At least 5,700 Mexican aliens served in the war, as did some 12,500 American Indians.90 In addition to being ethnically diverse, one quarter of the draftees were illiterate or could not read English.91 Responding to these circumstances, the War Department created Americanization and English literacy instruction to integrate recruits into the army. Social reformers, confident in the value of social engineering and the power of expertise and public education, viewed the training camps as places to acculturate the recruits to the prevailing middle-class culture and to reinforce patriotism. The army accelerated acculturation by bringing together men from diverse regions and ethnic, racial, and religious backgrounds under the rubric of a dominant, nationally defined set of values, broadly cast as freedom and democracy.92 The War Department found, however, that it had to accommodate ethnic differences in order to recruit and manage the national army. The Selective Service, for example, produced posters in languages such as Ukrainian, Polish, Yiddish, and Spanish to appeal to immigrant populations, and welfare organizations in the training camps tailored their programs to meet the needs of different religious and ethnic groups. Late in the war, the War Department developed a “Camp Gordon Plan,” which called for each ethnic company to be led by a foreign-language speaking immigrant or second-generation officer.93 But despite such careful attention to ethnicity, race, bifurcated as either “white” or “colored” (meaning African American), stood as the most visible stratification in the army. The period 1890 to 1920 witnessed the nadir of postslavery race relations in the United States during which persistent poverty, sharecropping, disfranchisement, and Jim Crow segregation isolated most African Americans from mainstream white political and economic life.94 But for the country to go to war in Europe, it needed

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the support of all its people—including 10 million African Americans. Although some whites opposed training and arming black soldiers and others were loath to nourish black hopes for equality and full citizenship, Wilson’s War Department brought 400,000 African Americans into the war machine.95 Black Americans, who comprised 10 percent of the population, provided 13 percent of the draftees. At least 80 percent of them (compared to the roughly 30 percent of whites) served in labor units rather than combat units. But, as with black physicians, the War Department awarded few blacks commissions as army officers, and instead put white officers—including white medical officers—in charge of most black units. Yielding to pressure by black leaders, Secretary Baker did designate two out of a proposed eighty combat divisions for African American service, the Ninety-second and the Ninety-third, and kept them segregated from white units.96 The War Department thereby produced a mass army that reflected American society—ethnically and culturally diverse, socially stratified, and segregated by race and sex. The American army encoded the relative status of various groups in numerous ways. Like all armies, it was a creature of symbolism. The army uniform provided a material expression of this process, displaying a variety of emblems to signify the wearer’s identity and status. Stars and stripes indicated military rank and reflected class distinctions. Special patches and insignia represented skills and duties of the various service branches from lofty airmen to the lowly labor battalions. Army nurses, lacking military status, began the war without uniforms suitable for field work.97 Officers sported colored cords on their campaign hats and leather puttees or boots, while enlisted men wore no cords on their hats and struggled with cloth puttees wrapped tightly around their lower legs.98 In France, the Allied armies required all officers to wear the Sam Browne belt, a diagonal strap across the chest, to distinguish between the elite officer corps and enlisted men in any army.99 The War Department also decorated uniforms with badges for military campaigns, bars for terms of service, and medals for outstanding achievement, heroism, or wounds. These adornments proclaimed the social identity of the wearer, and new medical officers were often delighted to wear their uniforms. Hugh Young wrote how he and his companions were “all dressed fit to kill in our new uniforms” as they boarded their ship to France.100 Even the highly respected medical scientist, William Welch, who hated the idea of putting on a uniform, understood its importance. He knew that if he were to speak with authority to line

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Fig. 3. Staff officers, base hospital, Camp Jackson, South Carolina, July 1918. (National Archives, 165-WW-248-L-22)

officers on medical and sanitary war problems, “I really must get into a uniform.”101 The Medical Department worked carefully to maintain the distinctions of authority, power, resources, and status of medical officers within the huge, diverse institution and the broader American society. The Medical Department’s stratification by race, class, and gender appears vividly in army portraits of different groups of medical personnel at Camp Jackson, South Carolina. Figure 3 shows the Medical Corps of medical officers, all of them M.D.s, white, middle-class men, all wearing leather boots, posed in front of their barracks and so few in number that individuals may be identified in the photograph. Figure 4 shows the Nurse Corps, all white

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Fig. 4. Staff nurses, base hospital, Camp Jackson, South Carolina, July 1918. (National Archives, 165-WW-248-L-4)

women, standing in front of their “home,” not barracks, clothed in white dresses—more fashionable than practical—and in almost glowing, feminine contrast to the men’s khaki. The group photo of Hospital Corps personnel (fig. 5) included too many enlisted men to allow individual identification, and whereas the doctors and nurses are pictured with their quarters, the men are standing in the middle of a yard with no secure backdrop. None of the photographs includes a black face because the army was racially segregated.102

“The Task Is Great” Medical officers were keenly aware that their new scientific knowledge brought with it new responsibilities. They were not alone. Historian Nancy Tomes has shown how the germ theory and its scientific technologies and hygienic practices changed the American household in the late nineteenth and early twentieth centuries. As science increased middleclass women’s abilities to avoid disease in the home, it likewise raised their expectations about disease prevention. An illness in the family could humiliate a conscientious housewife. Tomes concludes that “for Victorian women, this new knowledge brought both a new sense of power and a heavy load of guilt.”103 Like Tomes’s housewives, medical officers sought

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to prevent disease before it happened. Military Surgeon, the army medical officers’ professional journal, recognized this relation by describing medical inspections as “essential to efficiency,” and explaining that “every housekeeper knows this, and it is the daily routine of all good ones to inspect their houses.”104 Surgeon General Gorgas was acutely aware of his medical officers’ responsibilities both to prevent disease and epidemics, and to treat illnesses and injuries. The physical welfare of the men in the army fell to them “from the time of their entry into active service until they are discharged.”105 The War Department’s record, including the victory over typhoid, gave him comfort. But these achievements also raised public expectations regarding health in the army and exposed the Medical Department to criticism. Twentieth-century Americans were not only accustomed to sanitary conditions, but demanded them from their government. As a writer in Outlook suggested in 1912: “Today we know that it is not ‘God’s will’ that children should die of diphtheria or young men be destroyed in the flower of their manhood by typhoid fever.” Instead, “We are inspired to work on toward the glorious ideal set for us by Pasteur when he said ‘it is within the power of man to cause all infectious disease to disappear from the earth.’”106 Conscious of the public’s expectations, the Military Surgeon cautioned, “The best way to show appreciation of the confidence which the people and legislators have bestowed

Fig. 5. Enlisted personnel, base hospital, Camp Jackson, South Carolina, July 1918. (National Archives, 165-WW-248-L-20)

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upon us is to demonstrate that high degree of efficiency which we have promised the nation.” And, the editors noted, “With this increased ability to accomplish comes a greater responsibility for accomplishment. The task is great.”107 Medical officers had science, prestige, influence, and access to power, and when the United States entered the war they also acquired the responsibility for millions of young lives.

2 Building a Healthy Army Government Control and Accountability This war begins with the medical officer possessed of no more authority than he had in 1898. Will his recommendations be as futile as they were then? —Victor C. Vaughan

Victor Vaughan—Officer and Physician Victor Vaughan, dean of the University of Michigan School of Medicine, veteran of the Spanish-American War, yellow-fever survivor, member of the Typhoid Commission, and proud advocate of modern medicine, began to warn the medical community and public officials about the dangers of infectious disease in army training camps as soon as the United States declared war on Germany in 1917. From his favorite forum, the Journal of Laboratory and Clinical Medicine, which he established in 1915, he warned that “the mobilization of raw, untrained men and their hurried transformation into effective soldiers have always been accompanied by marked increase in morbidity and mortality.”1 The camps acted like “drag-nets” for infections, and overcrowding and the recruits’ poor personal hygiene exacerbated the conditions. Vaughan called for more army medical personnel, more hospitals and quarantine facilities for sick soldiers, less crowded housing, and warmer clothing for healthy soldiers. He also advocated increased military rank and authority for medical officers, arguing that they needed to have additional authority to ensure healthy conditions for the soldiers.2 The War Department adopted some of these recommendations but rejected others, including increased rank for medical officers, arguing that implementation would interfere with the army’s urgent drive to France. Vaughan expected as much. “Medical officers will do their best and will present their recommendations to

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superior line officers,” he wrote in an editorial, “but they realize that these recommendations are likely to receive scant attention, and that the medical officer will be compelled to work under a heavy handicap.”3 The column was entitled, “Are We to Forget the Lessons of 1898?” Vaughan’s career, like that of William Gorgas, paralleled the emergence of modern medicine. Receiving one of the first Ph.D.s at the University of Michigan in 1876, he also earned an M.D. and remained at the university as a professor and epidemiologist. A medical officer in the Spanish-American War, Vaughan almost died of yellow fever, and then served on one of the commissions investigating the typhoid scandal of 1898.4 When Congress established the Army Medical Reserve as part of the postwar reforms, Vaughan was one of the first to sign up, and when the United States declared war in 1917, he and his five sons won officer commissions, all but one in the Medical Corps. Gorgas appointed him to head the army’s Division of Communicable Diseases in Washington, D.C.5 The War Department awarded him the Distinguished Service Medal for his war work, and he served as the first president of the Medical Officers War Veterans’ organization. Vaughan was proud to be an officer, but his primary identity was as a medical professional (fig. 6). He referred to himself as a “medical man” and entitled his autobiography A Doctor’s Memories.6 As a public health physician and advocate of eugenics, Vaughan believed that both an individual’s genetic makeup and physical environment determined one’s health. In describing his own life, he explained, “Heredity supplies the seed and this contains the potentialities of life. Environment conditions the growth, supplying the soil and all else concerned in the conversion of the potential into the actual.”7 Thus, Vaughan worked with Gorgas and others to maintain what he believed to be the genetically superior white, male, and professional makeup of the Medical Corps, and would also constantly urge the War Department leadership to provide adequate material resources and accommodations to protect the soldiers’ health. Vaughan’s war experience illustrates the tensions between the medical profession and the army line command. A medical officer assumed two roles during the war—one of physician caring for patients, and the other of military officer in service to the government. The two roles were often not compatible. The military physician could not always give the time, energy, and resources he believed necessary to properly care for an individual patient without jeopardizing the welfare of the larger mass of soldiers for which he was responsible. This tension between the needs of the indi-

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Fig. 6. Victor C. Vaughan. (National Library of Medicine, B 25090)

vidual and the needs of the army as a whole weighed especially heavily on medical officers during periods of intense combat or epidemic disease. Vaughan and his colleagues advocated Progressive Era tenets regarding the use of science and professional expertise to solve society’s problems during times of war as well as peace, and the government, they believed, was an appropriate institution to pursue these goals. The negotiation of specific policies, however, could be acrimonious as medical officers debated the General Staff on issues such as training and vaccination schedules for recruits, housing and transport facilities for the troops, and medical-resource allocations. Gorgas, Vaughan, and others consistently called for more material resources for the soldiers, and the army command and General Staff continually demurred, blaming the exigencies of war and the need to send an army of several million to France in a matter of months. The two groups seemed to be operating on different scales. Whereas medical officers worried about the health of the soldiers in their

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units, the War Department administration worried about winning the war in Europe. When medical officers found themselves the subject of public criticism after epidemic diseases broke out in the training camps in late 1917, they appealed to their political advocates outside the War Department for support.8 Controversies regarding the camp epidemics and Medical Department personnel thus pitted medical officers against the line command and General Staff, revealing deep rifts and power struggles between them and setting the stage upon which medical officers would later find themselves fighting influenza.

Dynamics of Power and Government Accountability As the nation went to war, its citizens witnessed a dramatic expansion of the federal government. Since the Revolution, Americans had been wary of centralized power, strong governments, and standing armies. During the Progressive Era (1890 – 1920), public officials and reformers had crafted only modest government instruments and a blend of public and private institutions to smooth the rough edges of industrial capitalism and address the problems generated by industrialization, immigration, and urbanization.9 Progressive reforms included the rationalization and bureaucratization of the fields of medicine and the military. For example, reformers sought to transform the army from a volunteer, locally oriented system of state militias to a professional, national institution, administered along the lines of modern businesses.10 In health care, progressivism accelerated the professionalization of the medical and nursing professions and produced a range of medical institutions such as state and local government health departments, health insurance programs, and hospitals.11 War mobilization again raised familiar issues concerning the role of government in regulating society, and given the country’s mistrust of big government, the Wilson administration and Congress instituted a veritable patchwork of public and private institutions to meet the war needs. The War Department augmented its operations with goods and services from other government agencies and private, voluntary organizations. In the training camps, for example, the War Department housed, fed, clothed, and trained the recruits, while the Public Health Service (PHS) assumed responsibility for health conditions in the areas around the training camps, the Young Men’s Christian Association (YMCA) provided English language and citizenship classes to immigrant and illiterate sol-

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diers, and voluntary organizations such as the Salvation Army, the Knights of Columbus, and the Young Men’s Hebrew Association provided social programs and recreation for soldiers in camps. Similarly, while the Army Nurse Corps administered nursing services throughout army installations in the United States and in Europe, the Red Cross provided most of the 21,000 female nurses for the military and organized fifty hospital units for the American Expeditionary Forces (AEF).12 As the government grew, proliferating new agencies and functions, so did public expectations about government performance and its accountability to the people who were footing the bill. The wartime army was the most powerful, highly visible, and rapidly growing arm of the expanding government. (The vast majority of the war was carried on by the army, which supplied 4 million men, with another 800,000 provided by the navy, the Marine Corps, and other services combined.)13 War mobilization brought millions of young men under the purview of the military establishment. No other bureaucracy had the authority to prosecute and execute its members for noncompliance with its rules. On their way to war men stopped at army training camps across the country, where the military turned civilians into soldiers; it issued them uniforms, trained them to march and fight, and melded a polyglot, diverse population of young men into a modern army. Wielding military authority as well as the public health powers of vaccination and quarantine, the Medical Department functioned as an integral part of the process and as a highly controlling, coercive agency. Government control and expansion was not a unidirectional process of the government acquiring power, but a dynamic of growing power with an evolving “social contract” and increasing social expectations about the government’s responsibility to its citizens.14 A democratic republic cannot successfully go to war without its citizens’ consent to finance the war and to serve in the military. As political scientist Bruce Porter writes, “In general, the voice of the people is heard the loudest when governments require either their gold or their bodies in defense of the state.”15 The U.S. government called upon its citizens to pay increased taxes, buy war bonds, work in war industries, volunteer in social welfare organizations, and most importantly, send their sons and husbands to risk death for their country. In return, Woodrow Wilson promised a war for high ideals (to “Save Democracy”) and assured people that the army would take good care of the soldiers, providing them with benefits and the best medical care available. Thus, the government employed the carrot and the stick

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with regard to soldiers’ welfare and found ways to reward and honor military service. The enlistment of four million men in the army—two-thirds of them through conscription—involved implicit reciprocal agreements between the government and the people. In this sense, as the War Department created an efficient army, it also acquired responsibility for soldiers’ health and welfare. The Military and Naval Insurance Act of 1917 signaled the Wilson administration’s grasp of the fact that as soldiers lost many of their freedoms and rights, the government acquired new responsibilities not only for the soldiers, but for their families. “When we draft the wage earner,” explained Secretary of the Treasury William McAdoo, when he proposed the legislation, “we call not only him but the entire family to the flag. . . . The wife and children, the mother, the father, are all involved in the sacrifice.”16 The War Department also provided soldiers with clothing, room and board, health care, and twenty-five dollars a month (with an additional eight dollars for foreign service), and required married men to allot half of their pay to their families, with the government contributing an equal amount.17 The government also provided death and disability benefits to soldiers’ survivors and optional additional life insurance of up to ten thousand dollars per soldier. While men had to pay for this benefit from their modest income, the programs represented an accommodation between the government and soldiers and their families. “It would be nothing less than a crime,” McAdoo told the Congress, “for a rich and just Government to treat its fighting men so heartlessly and to subject their dependent wives and children, who are unable to fight, to greater suffering than if they could fight.”18

Military Medicine and Control Despite his recognition of the human cost of war, McAdoo, like other government officials, tended to view the army as a mass entity—a national force—rather than a collection of individuals. The Medical Department was therefore responsible first for the corporate health of the army as a whole, and secondarily for the health of individual soldiers. For many new medical officers, just arrived from civilian society, military medicine’s collective approach would contrast sharply with the individual focus of private medicine with which they were familiar.

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As the army grew during the war, so did the Medical Department, from five to twenty-three administrative divisions, and from a strength of fewer than 10,000 people to over 300,000—larger than the entire prewar army. The number of medical officers increased from 2,000 to 30,000, nurses from 400 to 21,000, and enlisted men in the Hospital Corps from 7,000 to 281,000. Army hospital bed capacity increased tenfold from about 9,500 beds in 1917 to 120,900 beds at the Armistice.19 Still, despite its important role in the wartime army, the Medical Department accounted for only 7.5 percent of War Department personnel and less than 3 percent of total army war expenditures.20 It was but one of many army branches competing for resources, information, and authority to do its work. The department had several corps, each with different skills and duties. The most prestigious was the Medical Corps of physicians. In 1916 the Congress authorized seven medical officers per thousand men and expanded the Medical Reserve Corps to train civilian doctors for military service. The Dental Corps had one dental surgeon per thousand soldiers, and enlisted men who served as hospital personnel, cooks, and mechanics numbered five per thousand soldiers. Congress also authorized a Nurse Corps to staff hospitals and mobile medical units, and a Veterinary Corps to care for cavalry mounts, horse and mule trains, and other army livestock.21 In 1917 the War Department created a new Sanitary Corps to relieve medical officers from duties such as sanitary inspections, laboratory services, pharmacology, and hospital administration.22 Bacteriologist and medical historian Hans Zinsser, for example, served as a sanitary officer. Medical officers stood at a unique nexus of government control and societal expectations. As army officers, they had the administrative apparatus and authority to practice their medicine on thousands of men, but as physicians they felt responsible to individual patients. Like many others, civilian physicians suffered culture shock when they joined the army, losing many of their freedoms and rights and having to obey orders. They also soon learned that military medicine was not the same as civilian medicine.23 As Victor Vaughan told men at the medical officers’ training camp at Fort Benjamin Harrison, “You feel that you are not quite at home, and that possibly you are regarded as intruders.” He also pointed out that while in civil life both the physician and patient were “free agents,” that was not true in the military because “both are servants of the Government.”24 Newly commissioned medical officers had to adjust to a culture in which their primary role was military, not medical; their first duty to their

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country, not their patients. The army’s Medical Manual stated Medical Department objectives during war as twofold. The first priority was the “preservation of the strength of the Army in the field,” and the second priority was the care and treatment of the sick and injured in the field and in the home territory.25 The welfare of the army as a fighting body took precedence therefore over the care of the sick and injured. A commanding officer did not need to know who was sick or injured, only how many “effective” men he had to carry out his mission. The army calculated the “noneffective rate” of a given unit or camp as the number of soldiers per thousand who were unavailable for duty at a given time.26 This included men under medical care as well as men on leave or in disciplinary detention. Military medicine was thus practiced and evaluated at the aggregate level, not the individual level. It reduced soldiers to units in the war machine, with the goal of fighting the war of attrition by maintaining a large army in the field. Decisions concerning matters such as training schedules and troop shipments often placed military considerations ahead of health concerns. Army policy regarding the removal of the wounded from the battlefield illustrates this policy. One of the conundrums of military medicine was how to evacuate the wounded without depleting the fighting force. The speed of evacuation often meant the difference between life and death due to shock, blood loss, and infection, but it took two to four strong stretcher bearers to carry one sick or injured man off the field (fig. 7). Lieutenant George Strott, a battalion surgeon in the Second Division, described taking an injured soldier off the field during a battle in the Marne region in July 1918: “Three of us were carrying Cooper of my company in a blanket. I was at the feet with the other two going ahead with the other end.” Cooper, he remembered, had been shot in the leg, arm, and head. “We lost our hold on the blanket several times letting him slip to the ground.”27 This goal of quickly getting the wounded off the field of battle competed with that of maintaining the army’s fighting strength, and during a battle the fighting force came first. Medical Manual instructions on transporting the wounded required every medical station “from the firing line to the base” to classify the sick and wounded according to the nature and severity of their disabilities, “with a view to such disposition as will prevent any unnecessary depletion of combatant forces.”28 Officers in the line command often reluctantly detailed men as stretcher bearers, and at times assigned members of the unit’s band to the job. The Medical Department protested that the

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Fig. 7. Stretcher bearers in the AEF. (National Archives, 111-SC-21842)

musicians often lacked the strength for the work, pointing out that “music was of such value in maintaining the morale of troops that it was believed skilled musicians should not be subjected to the dangers attendant upon litter bearing.”29 Throughout the war, medical officers such as Jay Grissinger, chief surgeon of the Forty-second Division and then the AEF, requested a better medical transport system and wrote numerous memos recommending more litter bearers as part of the evacuation plan.30 But, as one medical officer put it, “from a cold military standpoint the care of the well and strong is more important than the care of the ill and feeble.”31 The influenza epidemic, however, would soon cause the ill and feeble to overwhelm the well and strong. Another heartbreaking problem of the war was that while many doctors viewed their professional mission as humanitarian—to heal the sick and wounded—the nations they served were in a war of attrition in which the army with the last man standing won. Regardless of their humanitarian ideals of lifesaving, medical officers had to take sides. Their primary job was to get the physically and mentally disabled fit to fight again. This could be excruciating for medical officers who saw themselves restoring

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men to life so that they could again risk death. But as an army medical textbook explained: “The services of physicians of higher rank in the army are to a large degree, rather for the command [i.e., the particular army unit] than for the individual.” The author explained that medical officers must promote the troops’ welfare “by collective general measures” and recognized that “this subordination of a patient’s interests is shocking to humanitarian and professional instincts and sympathies, but it is inevitable in the stern activities of war.”32 Gustavus Blech, a career medical officer, expressed concern about former civilian physicians’ inclination to “individualize” cases that attracted their pity or scientific interest. This, he argued, had no place on the field of battle, and could lead to “disastrous results for the wounded.” He assured his new colleagues, however, that “in medical institutions in the rear, the wounded are ‘patients’ rather than ‘soldiers,’” so that individual care was “not only possible, but obligatory.”33 Military medicine was similar to public health programs in its subordination of the interests and autonomy of the individual to the general good. The constitutional basis for public health regulation came under the “police power” of the commerce clause and its authority to promote the public welfare by restraint and compulsion.34 While private medicine often required patient consent, military medicine and public health could use coercion and state authority to protect the larger community. For example, the protection of a community against deadly disease by mandatory quarantine or vaccination outweighed the inconvenience or risks to the individual. With obedience to authority a central tenet of the military culture, the War Department had even more authority over its charges than public health departments, because in addition to requiring soldiers to submit to physical examinations, vaccinations, and medical procedures such as tonsil removal, it could court-martial men if they became sick with venereal disease or if they refused prescribed surgery. In one instance, the judge advocate general ruled that a soldier who refused to submit to surgery to repair a hernia was subject to court martial.35 Medical officers thus wielded great power over enlisted men. As gatekeepers, they determined who was physically qualified to get into the army and who could receive disability benefits when they got out. They determined who on any given day was fit for duty and who was not. They recommended and implemented measures to maintain the health and fighting efficiency of the men in their units and provided lifesaving medical and surgical care. Medical officers also policed soldiers to identify

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“malingerers,” those who “allege, counterfeit, exaggerate, create or conceal disease in a military environment.”36 Men might feign illness or injure themselves to avoid a duty or battle, or they might hide a malady to remain on active duty. Because malingering was a matter of medical opinion, medical officers at times resorted to tricking men into revealing their health or illness by viewing them through a peephole while undressing, or by putting them under anesthesia to move joints held immovable.37 They considered such efforts necessary to prevent fraudulent medical cases from clogging the medical system or damaging army morale. Another example of the control medical officers had over their patients was that unlike their civilian counterparts, they could recommend sweeping actions to prevent epidemics, such as moving entire army units out of an area if typhoid or cholera broke out.38 They could also experiment with human subjects. The Medical Department encouraged such research in the tradition of military medical triumphs and gave medical officers support for medical research.39 Army conditions facilitated the maintenance of uniform medical records, access to laboratories and support personnel for research activities, and the opportunities for travel to foreign countries where soldiers encountered new diseases. Training camps were ideal sites for such research because they not only contained a lot of men, but a lot of germs, too, and thus provided virtual laboratory conditions for medical officers to investigate the progress of various diseases and preventive measures in the population. For example, during the war, medical researchers inoculated 13,000 men at Camp Wheeler, Georgia, and 12,000 at Camp Upton, New York, with experimental vaccines, and men at Camp Devens participated in a dangerous measles experiment.40 Medical officer Isaac Brewer stressed the value of medical officers’ authority over the soldier in following research protocols because “his movements can be absolutely controlled.”41 Another medical officer detailed these advantages in an article entitled “The Possibility of Medical Research in the Military Service Because of Its Complete Control over Personnel.”42 Two enlisted men who worked in an AEF hospital noted that “if a physician or surgeon wished to experiment with a patient it was his privilege to do so especially if he was the war surgeon.” They accepted this situation because “the medical world should be greatly enriched through the knowledge gained by the army doctors.”43 War did, tragically, often increase the opportunities to gain knowledge. As one medical officer pointed out, “The opportunity for autopsies in the army is greater than in civil life.” Working at a camp hospital in the

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United States, he explained, “There is plenty of pathologic material for study and therefore, the chance to thoroughly complete the observations on a given problem is not blocked as it so often is in civilian hospitals.”44 In a similar spirit, surgeon George Crile reported that during his service with the British Medical Services, “amputations have accumulated so rapidly that one could realize the experience of a civilian lifetime in the course of a single battle and draw definite conclusions.”45 Medical experiments, autopsies, and amputations represent extreme examples of the government’s control over people’s bodies, but these practices and the more mundane activities of the Medical Department reveal a complex relationship between the government and its citizens. The amount of power medical officers and commanders had over the bodies of the men under their control made the War Department vulnerable to public and congressional criticism that the army was not caring properly for its soldiers. If medical officers exercised authority over hundreds, even thousands, of enlisted men, they also had to obey their superior officers and subject their medical judgment to military command. War Department regulations on medical services in the camps directed that a division surgeon— the medical officer for a division—“is charged, under the commanding general, with the general conduct and supervision of the Medical Department.”46 Thus, one of the sharpest conflicts in military medicine involved medical officers’ belief that they lacked the authority to carry out their duties. Medical officers from Surgeon General Gorgas on down complained that line commanders did not seek or ignored their advice on matters critical to the health and welfare of the soldiers. Some medical officers resented taking orders at all, especially from those they considered social inferiors—career army officers. The Military Surgeon exhorted physicians to obey military commands while recognizing that “the realization that they must merge their identity in the great medical war machine of which they become a part undoubtedly comes as a shock.”47 Medical officer Fielding H. Garrison explained to newly minted medical officers that “our relation to the Government is an absolutely impersonal relation. When one salutes the officer he is not saluting the man. . . . He is saluting his country’s flag which the officer represents.”48 And another medical officer observed, “Whatever our age or former position in civil life may have been, however superior we may feel ourselves to those of higher rank, socially or intellectually, it is not for us to argue or to question, but to obey.”49

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Health and Sickness in the Camps The training camps stood as powerful and visible expressions of the expanded federal government, and many Progressive reformers, army officials, and medical officers saw them as places to improve American society. As one contemporary noted, “For the first time in history a government looked beyond the machinery of fighting to the personal and moral welfare of the fighters.”50 In addition to giving English-language instruction, the army campaigned against venereal disease and educated recruits in the principles of personal hygiene. As the Medical Department explained: “Camp sanitation has advanced to a point where practically any site in this country . . . can be rendered healthful provided the necessary funds and labor are available for the purpose.”51 Medical officers hoped that the new knowledge and tools would enable them to reduce the ratio of deaths-by-disease to deaths-in-combat, thereby saving thousands of lives and avoiding the scandal of the typhoid epidemics of the SpanishAmerican War. The Japanese Army had reached a milestone during the 1907 Russo-Japanese War with fewer deaths by disease than by combat, and the Americans hoped to match their record.52 The Medical Department implemented an elaborate system of sanitation and preventive medicine that included measures such as smallpox and typhoid vaccinations (fig. 8); mosquito mitigation against malaria and yellow fever, such as screening barracks and other structures and eliminating bodies of stagnant water where mosquitoes might breed; water purification and sanitary waste disposal against typhoid, cholera, and dysentery; diets to prevent deficiency diseases such as scurvy and pellagra; personal hygiene inspections against dental disease and vermin; and periodic physical examinations to check for “carriers” of infectious diseases such as measles, mumps, or meningitis.53 Medical officers also examined men for cardiovascular ailments, conducted “foot surveys” to examine shoe fittings, and inspected mouths, skin, and genitalia monthly to detect venereal diseases. They treated men with curable ailments, quarantined those suspected of contagious diseases, and punished those who violated sanitary regulations. In his war memoir, Stretchers, Frederick Pottle provided one of the best descriptions of the first weeks in camp and the Medical Department’s efforts to prevent disease.54 Pottle, a college student when he enlisted in late 1917, served as a surgical assistant in the AEF, and after the war he became a professor of English at Yale. Like many civilians, the young Pottle

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Fig. 8. Inoculating troops at the Army Medical School. (National Archives, 165-WW-256-A-4)

felt he had lost his identity when he entered the army: “There is a sickening finality about enlistment, an extinguishing of one’s own personality as definite as through suicide. . . . To this is added an indescribable sense of degradation.”55 Reporting in the third person, Pottle recalled the “ordeal of vaccination and typhoid inoculation.” In this medical rite of passage, “the line pushed him forward irresistibly. . . . The recruit in front is white; as he moves up to the man with the needle he suddenly crumples up in a faint.” Pottle observed that the attendant showed no concern about the man who had fainted, and then it was his turn. “Our recruit’s arm is dabbed with alcohol on a swab of absorbent cotton. He passes a little beyond the man with the needle. He feels a sharp sting in the back of the arm; the needle goes in still farther. All over.” Pottle had survived. “It was not much, after all,” he admitted, “but he will dread it the second time just as much as the first.”56 Pottle reported the miserable, muddy weather at Camp Greenleaf, Georgia, in the fall of 1917–1918 and cold and drafty tents that “leaked like sieves.” Everyone had colds, and the whole unit was put under two

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weeks’ quarantine for spinal meningitis twice, in January and February. In March, Surgeon General Gorgas provided a happier memory when he inspected the camp. Pottle wrote of the visit with pride: “I see a line of about twenty officers, in the center a kindly-faced, smiling old man with a white moustache—General Gorgas. Beside him is a major whom I recognize from his pictures as Charles Mayo of the famous Mayo Clinic.”57 Pottle and his fellow recruits felt assured that their health was in the hands of the nation’s experts. Medical advances such as vaccinations and sanitation had brought many water- and insect-borne diseases under control, but respiratory diseases such as measles, pneumonia, and influenza had not yielded to systematic remedy. Medical officer Henry Nichols warned his colleagues not to focus only on intestinal and insect-borne diseases. His experience at a mobilization camp in Texas indicated that “epidemic lobar pneumonia is to be expected in large camps in the winter months, . . . respiratory, not intestinal disease will be the scandal of the World War.”58 Gorgas knew the danger, too. In 1917 he cautioned his medical officers, the War Department, and the public that pneumonia would be a problem in the camps during the winter: “We must now give renewed and most extraordinary attention to our precautions against ‘this greatest of all the captains of the men of death.’”59 But many medical officers believed that they did not have the resources and authority they needed to protect the health of Pottle and the other men in the camps. To a large degree they were right because much of that power resided with the General Staff and the line command. Cognizant of the public scrutiny they would face, medical officers knew they were up against difficult odds because disease thrived in mobilized armies. Medical officers complained that the general command did not consult them about the location of the camps and health care needs of soldiers, or if they did, disregarded their advice. As one put it, the recruits “were shifted from camp to camp by the thousands, taking with them such diseases as they were incubating, thus infecting all camps,” and once in the camps, “fatigue, exposure, and crowding made them easier victims for infections, and the infections came.”60 Throughout the war, Gorgas, Vaughan, and others recommended steps to prevent disease outbreaks, including reducing overcrowding in the barracks, gradually introducing trainees to military training so as not to stress new civilian recruits, and constructing detention camps for individuals exposed to infectious diseases and quarantine camps for the sick. The War

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Department’s response to their advice rarely satisfied them. For example, medical officers repeatedly called for the construction of observation camps for new recruits to monitor them for diseases before they entered training camps. After the war, the Medical Department noted that “no such detention camps were provided in the original plan of the cantonments,” and that after the War Department did approve such construction, they were never completed because “the signing of the armistice put a stop to this work.”61 As the medical officers feared, epidemics of measles, mumps, scarlet fever, meningitis, and pneumonia, seized the army in late 1917, and political controversies surrounding these outbreaks would set the scene for the flu of 1918. Measles was the worst. It arrived in training camps with the new recruits, and by November camps across the country reported epidemics of measles, often followed by deadly pneumonia. Camp Wheeler in Georgia had the highest hospital admission rate for measles in the nation, 534 per 1,000 men, more than 50 percent.62 Louis Duncan, a medical officer at the camp, reported the beginnings of a measles outbreak on 21 October 1917, complaining that “these draft men brought measles on every train.” Measles and pneumonia swept the camp, sickening men by the hundreds for ten weeks. Only after exposing all nonimmune men to the measles and after the sick had either died or recovered could Duncan report that “the conflagration had burnt out entirely.”63 The measles toll on the army included more than 48,000 hospital admissions, at least one million “noneffective days” among soldiers, and 30 percent of all 1917 mortalities, making it the leading cause of death in the army that year.64 Measles was not a surprise. It had plagued the Roman Empire and infected perhaps 6 billion people over the centuries.65 Although medical officers had not yet identified the measles virus, they knew that measles was highly infectious, transmitted among humans through the respiratory tract, and that, as with yellow fever, a single attack conferred lifetime immunity.66 The illness generally lasted fourteen days, unless it was complicated by pneumonia. Then it turned deadly. One in four pneumonia patients died. Survivors required weeks to recover. The measles was therefore dreaded in the army because, as Vaughan observed, “measles and pneumonia are so closely associated in military camps that it is well to consider them together.”67 Medical Department instructions for infectious diseases recommended segregating patients with different diseases in separate wards. A measles ward required the following: 1,000 cubic

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feet of air space per patient; screening of sheets or newspapers between beds to prevent the spread of germs; immune medical attendants (who had already had the measles); attendants equipped with gowns and face masks; daily disinfection; rigorous patient and ward hygiene; immediate removal of patients developing pneumonia to a separate ward; and retention of patients in the hospital for ten days after their fevers subsided.68 Medical treatment for measles included keeping the patient on a liquid diet, laxatives, aspirin for headache, and protecting patients’ eyes from direct light.69 These practices consumed a lot of material and personnel resources at a time when the War Department was desperately trying to get a welltrained and well-equipped army to France. The epidemics also slowed mobilization by rendering officers and enlisted men noneffective for weeks, interfering with training and transport schedules, and may even have contributed to the high American casualty rate in combat in France because illness at times curtailed the proper course of training.70 Epidemics could also undermine the nation’s ability to mobilize for war psychologically, because as the strong and fit young men, in the prime of American manhood, fell ill, people began to question the government’s ability to maintain health in the camps. Medical officers recognized the power of disease during war. As one medical officer noted, “The history of war has always been an history of epidemics.”71 Another remarked, “Whenever you mobilize and call to the colors a thousand men, you call with them at least twenty billion tubercle bacilli, ten billion typhoid, five billion pneumonia, and a couple of million dysentery germs.”72 They attributed measles deaths to the fact that many of the troops had come from southern, sparsely settled states and thus “included not only the generally immune city boys, but also vast numbers of rural lads who have never before been exposed to the [measles] infection.”73 But they also blamed material conditions. Victor Vaughan, for example, criticized the General Staff for rejecting the Medical Department’s recommendations to prevent epidemics. “Insufficient clothing, overcrowding in tents, barracks and hospitals, and lack of heat in the houses,” he charged, “have been potent in the development of the pneumonia among our soldiers, and for these deficiencies the medical corps is not responsible.”74 When the General Staff and line officers showed little interest in medical matters, the Medical Department used sanitary inspections as a lever to convince them to change their policies or practices.75 As the measles

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epidemic burned in the camps, Gorgas, accompanied by Vaughan and William Welch, personally inspected seven camps (Wheeler, Sevier, Bowie, Beauregard, Pike, Funston, and Doniphan) in November and December 1917. After each visit, Gorgas fired off pointed memos of his findings to the army chief of staff. From Camp Beauregard in Louisiana he recommended at least 50 square feet of floor space for each man, and that “no more men be sent to this camp until the division commander is prepared to care for them along the lines of the above recommendations.”76 From Camp Funston in Kansas, Gorgas called for quarantine and observation camps, charging: “Action now being delayed by post commander. . . . Urgent that action be taken at once.”77 The final report, as summarized by the Medical Department, attributed the measles and other epidemics to the susceptibility of new recruits to infected troops, as well as “overcrowding, lack of proper clothing, want of observation and detention camps, . . . and want of proper sanitary conveniences.”78 Gorgas and his colleagues implied that if the War Department would spend the required resources, it could prevent epidemics, even in nonimmune troops. The report would become a political football.

Congressional Investigations and Soldiers’ Welfare In November 1917, the Committee on Public Information (CPI), the government’s information bureau, presented a rosy view of the conditions in training camps, reporting, “General Sanitary Inspector in Report Shows That Health of Soldiers in Camp Averages Better Than That of Civilians.”79 Soon, however, trainees in many of the camps began to get sick, some of them were hospitalized with serious illnesses, and others began to arrive home in caskets, victims of infectious disease. Their families then began to write to their representatives in Congress and to Gorgas, Secretary of War Baker, and President Wilson, seeking information and demanding better care for their sons and husbands.80 One Michigan father asked his senator, Charles Townsend, for help after the War Department had refused to give him information about his son, who was in the hospital at Camp MacArthur, Texas, explaining that “no information will be furnished by any person in the military service which can be made the basis of a claim against the Government.”81 Outraged, Senator Townsend took the Senate floor with the letter in hand, objecting to any “attempts to measure the interest of the parent or the wife in the loved one by dol-

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lars.” He demanded that “the fullest possible information should be given the parents as to the health of their sons who are in the Army.”82 Some citizens leveled charges against the Medical Department, noting that measles was epidemic only in army camps, not civilian communities. Dr. S. S. Goldwater, chairman of the American Hospital Association and member of the Council on National Defense Medical Board, suggested that military hospitals were inferior to civilian hospitals.83 Marion Huffman, a druggist from Bellaire, Ohio, did the same, pointing out that “the mother and the pharmacist take care of the measles to perfection,” therefore, “does not it look ridiculous to report an extraordinary mortality from a minor disease.”84 Medical officers were painfully aware of the criticism. Medical officer Jay Grissinger remembered: “The civilian population was very sensitive and critical in the early days of the war as to the care which is being taken of the sick or injured soldier. . . . This confidence once lost is most difficult to regain.”85 Members of Congress were also sensitive to complaints about government neglect of soldiers in army camps, especially if the camps were in their districts or if the soldiers or their parents were constituents. Some visited the camps to see conditions for themselves, others used Gorgas’s inspection report to document the problems. After a trip to Camp Mills on Long Island, Representative Jeanette Rankin of Montana called for an inquiry into the camp hospital “where men from Montana and other Western States are quartered and where shocking conditions of sanitation and health are publicly reported to exist.”86 Members of Congress publicized their findings in the Congressional Record, and several put Gorgas’s inspection reports into it. One explained, “The people of this Nation and the Representatives of this House are entitled to all information regarding the condition of these camps. (Applause).”87 Representative Edwin Webb of North Carolina cited the Gorgas report after he had visited another camp, stating, “Here are more than 40,000 men, the pick and flower of the young manhood of this country, ready to lay down their lives.” After the applause subsided, he continued, “They do not want, and the Government of the United States has no right to ask the boys to die ignominiously like rats in a mud pen.”88 Congress formalized its concerns about health in the camps in December 1917 during hearings on the Wilson administration’s conduct of war mobilization.89 The hearings initially focused on supply shortages and problems with military procurement of small arms and ammunition. But on 19 December the New York Times gave Gorgas’s camp-inspection

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report a front page headline, “Gorgas Reports Troops at Camps Crowded, Ill-Clad,” and members of the congressional investigating committee immediately turned their attention to health issues.90 The next day Secretary Baker announced that the army had already complied with most of Gorgas’s recommendations, but the Gorgas report remained a powerful critique of the mobilization effort. Members of Congress were determined to find out what was going on in the army training camps and to change what was wrong. Wilson and Baker at first stiffly opposed any reforms and resented congressional interference with the war effort, but in mid-January, events converged to force them to act. Record low temperatures, food and fuel shortages, congressional support for legislation to create a special “War Cabinet” to manage the war effort, and the death from pneumonia in Camp Wheeler on 14 January of Representative Augustus Gardner of Massachusetts, the first member of Congress to join the army, brought events to a crisis point.91 At the same time, Senator George E. Chamberlain, Democrat from Oregon and chairman of the Senate Committee on Military Affairs, launched a critique of the Wilson administration’s conduct of the war, citing Gorgas’s inspection report, and charging that “the hundreds and thousands of young men who are dying in all of these encampments, [was] due to the inefficiency of the War Department itself.”92 Chamberlain ended his speech in the Senate reading letters from parents whose sons had died of disease in the camps. “If in his dying,” wrote one, “he is the means of securing better attention for the many boys that are yet to suffer and die in these camps, I shall feel that his death was not in vain.”93 When President Wilson tried to brush off the criticism, the New York Times reminded him “that this is not, after all, the Administration’s war; it is the people’s war, supported by their blood and treasure.” The Times scolded the president, “They have the right to be critical of the government’s war service, since they pay the cost and their criticism cannot, with safety, be disregarded.”94 Senator Chamberlain thereby thrust Gorgas and his Medical Department center stage in a high-stakes confrontation over the health of the nation’s soldiers. One member of Congress captured the dire nature of the conflict by telling his House colleagues, “If we have boys in the encampments who are being sacrificed, they ought to be sacrificed for the country and not by the country.”95 Congress summoned both Gorgas and Baker to respond to these charges, and their testimony revealed the rifts between them and between the Medical Department and War Department leadership they repre-

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sented. Some members of Congress took up the medical officers’ recommendations for more clothing, less crowding, and more medical personnel, while others defended the General Staff and line command and began to question the medical officers’ competence. Appearing before Congress on 25 January, Gorgas seemed to defer to the army hierarchy when he resisted blaming soldiers’ sickness and mortality on the general command’s failure to take his advice. On the other hand, he also appeared eager to have Congress intervene on his side against the General Staff. When asked why his recommendations to increase housing facilities at Forts Oglethorpe and Riley in order to prevent epidemics had not been acted upon, Gorgas responded, “I know of no reason except getting a decision on it from the General Staff.”96 To the question as to what caused the epidemics, Gorgas replied, “I think it was greatly increased by overcrowding,” and he showed the committee memos he had sent to the General Staff recommending 60 square feet of floor space per man in army housing.97 The New York Times summarized the hearing the next day: “Gorgas Ascribes Deaths to Haste,” reporting that “in its haste to answer the call from France and England the Government sent many young Americans to their death from disease, caused by over-crowding of cantonments and inadequate hospital and nursing facilities, General Gorgas testified.”98 This career army officer seemed to be questioning the judgment of his superior officers. Appearing before the Senate committee the following Monday, Baker defended the Wilson administration at the expense of Gorgas and his medical officers. In an extraordinary move, he disclosed that two medical officers had been tried and convicted by court martial in late 1917 for the deaths of recruits from pneumonia. The revelation humiliated the Medical Department. The courts martial had found both officers, Lieutenant John Dwyer at Camp Funston and Lieutenant Charles Cole at Camp Beauregard, guilty of neglect of duty, and had sentenced both physicians to dismissal from the army.99 The Camp Funston court convicted Dwyer for ordering extra duty for a private who reported sick to the infirmary instead of sending him to the hospital or to bed rest. The man died of pneumonia. The Camp Beauregard court martial convicted medical officer Cole for refusing to admit nine men with measles to a base hospital, sending them instead by mule-drawn ambulance to a regimental infirmary where two of the patients soon died. Despite the fact that the Medical Department had discharged the medical officers, Baker told the committee that he and Wilson had recommended imprisonment. “I want

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the country to know,” he declared, “that the lives and welfare and the illnesses of these soldiers are a responsibility which I will not permit to be dodged or handled in any cavalier fashion.”100 It was inappropriate for Baker to make these cases public because they had not been finally resolved, and unusual because the army generally eschewed publicity concerning court-martial trials. After Baker’s revelation, Gorgas requested permission to review the court-martial proceedings himself.101 While he was disturbed to see the department’s dirty laundry aired so publicly, there is no evidence that Gorgas attempted to defend either Cole or Dwyer. Secretary Baker also failed to acknowledge that Gorgas had already expelled a number of incompetent medical officers.102 Baker did know, however, the political sensitivity of the court martial of medical officers.103 The president, after all, had reviewed both cases. On one hand, convicting a doctor of neglect of duty could be interpreted as an insult to the profession; but on the other hand, Wilson and Baker realized that public confidence in the army’s treatment of the soldiers and their health were critical to the conduct of the war. There could be no doubt that soldiers received the best care possible; any infractions had to be punished severely. But instead of taking on the issues regarding housing, clothing, and hospitals in the camps, Baker suggested that some medical officers were not doing their job. When the men died of disease, his approach was to court-martial the doctors, not the generals. When Gorgas appeared before the House Committee on Military Affairs on 28 and 29 January, House members were rougher on him than the senators had been. One representative wielded a letter from a father whose son had died of pneumonia, which said, “My poor boy died, but he didn’t die for his country; he died for the want of care and nourishment.”104 Representative Ashton Shallenberger, Democrat of Nebraska, raised the issue of the court martial of medical officers and suggested an even harsher punishment than prison. “Have you ever tried shooting medical officers for neglecting their men?” he asked. “Have medical officers ever been executed for such things as that?”105 Gorgas responded carefully that he thought the court martial was the appropriate process for discipline. The House committee wanted to fix blame somewhere for the poor conditions in camps, and one representative finally succeeded. He asked Gorgas, “If there has been any lack of health conditions there, and any blame is attached to anyone, it would be chargeable to you, would it not?” and the surgeon general responded, “Yes.”106

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The congressional investigation may have been the worst professional experience either Baker or Gorgas had ever had. Gorgas felt the attacks keenly. He told his sister on 2 February, “Just at present I am having a pretty hard time. All my friends seem to have deserted me & everybody is giving me a kick as I pass by.”107 Baker at one point offered his resignation to the president.108 While he had accepted responsibility for many problems with war mobilization, he had also succeeded in deflecting blame for health conditions onto the Medical Department. The hearings identified medical officers, rather than the General Staff and the line command, as primarily responsible for the health (and sickness) of the recruits. By early February, the Wilson administration had regained control of the war effort, fending off the war council and munitions bureau proposals, and instead secured sweeping legislation called the Overman Act that created new executive powers to conduct the war.109 The Medical Department emerged from the congressional hearings both scarred and strengthened. The public attention on health conditions encouraged army officials to improve living conditions in the camps and increase the medical staff. While the Medical Department and its officers accepted responsibility for the army’s health conditions, Baker’s exposure of the court martial cases angered them. The Military Surgeon suggested indignantly that although the editors had not read the evidence in the cases, given the problem of malingering, Cole and Dwyer might have been justified in their diagnoses. Under threat of discharge for a mistaken diagnosis, they might as well let everyone who claimed to be sick go to the hospital. How, Military Surgeon reasoned, could medical officers detect soldiers feigning illness or injury if they were to be punished for overzealously carrying out this responsibility? “If medical officers are guilty of a military crime, they should be punished like other military officers, but if they are to be declared felons because of a mistake in diagnosis, who of us can escape?”110

War Department Tensions If medical officers resented their lack of control over health conditions in the camps, the General Staff resented the medical officers’ resort to external political influence to achieve their goals. Tension between the two

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groups persisted throughout the war, not only with regard to health policies and practices, but also in personnel matters concerning medical officers’ status and authority within the army. Three episodes in particular reveal the faultlines of power between the medical and military professions and their political advocates in the White House and Congress: the issue of increased military rank for medical officers, editorial policy at the Military Surgeon, and the reluctant retirement of Surgeon General Gorgas in the midst of the influenza epidemic. Medical officers took their frustration about their lack of authority to the core of power in the army hierarchy: they sought increased rank. Increased rank would give them more power and authority in relation to line officers; improve their status relative to physicians in other armies; increase their pay and benefits; and make the Medical Corps more attractive to civilian physicians. Or, as Victor Vaughan put it, “the higher the rank obtainable, the better the class of young physicians attracted to the corps.”111 When the United States entered the war, with the exception of Brigadier General Gorgas the highest rank for a physician was colonel, and only 3 percent of the Medical Corps held that rank; 68 percent of medical officers were either lieutenants or captains.112 Gorgas wanted access to the ranks above major for his medical officers and the rank of general for his most prestigious colleagues. As early as 1917, Gorgas had become concerned that American medical officers of the stature of his National Academy of Science physicians such as Harvey Cushing, Welch, and Vaughan would, as mere captains, be subordinate to English and French medical officers in the Allied forces who were colonels and generals. Franklin Martin, Gorgas’s friend and subsequent biographer, described the situation in urgent terms “as a distinct disadvantage and humiliation to the Americans.” Fortunately, wrote Martin, “Surgeon General Gorgas recognized the tragedy of this situation, and he was immediately stirred to aid us in adjusting it.”113 Gorgas took a contingent of medical leaders — Martin, Mayo, Welch, and Vaughan—to propose increased rank to members of the War College. After the college and Chief of Staff Peyton C. March failed to act on their proposal, they decided to go outside the chain of command, turning to their allies on Capitol Hill.114 There Gorgas worked with Senator Robert L. Owen, Democrat from Oklahoma and brother of medical officer William O. Owen, to draft the legislation. Senator Owen introduced the bill, S. 1786, a bill to provide advanced rank to army medical officers, in July 1917, before the training camps had opened. He told his colleagues

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that it was in the interest of “the health and the sanitary, medical and surgical care of our beloved young men we are sending to battle.”115 Gorgas did not immediately press for passage of the legislation, explaining at one congressional hearing, “we have to whip the Germans, and everything has to be secondary to that.”116 But given the measles and pneumonia in the camps and the ensuing criticism of the Medical Department, he and medical officers became less reticent to speak out and to go higher up the political hierarchy. “Because of the lack of enthusiasm in our behalf on the part of the secretary of war and the General Staff,” Martin explained, “the whole subject was presented to President Wilson, with a plea for his support.”117 They were rewarded on 5 March 1918 with a presidential letter of support for what was now called the “Owen-Dyer bill.” This time, lobbying began in earnest with the Medical Department enlisting support from the AMA.118 One of the most passionate arguments for the legislation came from Louis Livingston Seaman, M.D., of New York, whose letter supporting increased rank for medical officers was used by the AMA and Senator Owen in the legislative campaign. A former medical reserve officer, he laid out the issues of medical officers’ responsibility-without-authority for the soldiers’ health as a matter of life and death. “Shall the American soldier in the present war be sacrificed to preventable diseases, through red tape and the petty jealousies of line and staff officers . . . or shall he be allowed to retain his health under the most advanced science of the age?” Given the new faith in the ability of science and expertise to improve society, he argued, “Every death from preventable disease is an insult to the intelligence of the age. If it occurs in the army, it becomes a government crime.”119 Seaman reasoned that death from disease was a crime because of the government’s power over the soldier. “The state deprives the soldier of his liberty, prescribes his hours of rest, his exercise, equipment, dress, diet, and . . . if necessary [requires him] to lay down his life in defense of its honor.” He continued, “If wars are inevitable, and the slaughter of men must go on . . . then let our men be killed legitimately on the field, fighting for the stake at issue, not dropped by the wayside from preventable disease as we did in the Spanish-American War.” Given the new powers of medicine, “the greatest tragedy of war lies, not in the battle field [sic], but in the failure of a government to protect its guardians from preventable disease.” He believed the solution was to give the medical officer more authority to enforce sanitation and health measures for the troops,

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because “upon him devolves the duty of preventing disease, and his part in maintaining the effectiveness of the units makes him a most important factor in the Military Establishment.” Senator Owen put the letter in the Congressional Record.120 With this kind of excitement, Chief of Staff March summoned Martin and Gorgas to the War College to discuss their “pernicious activity in behalf of the Owen-Dyer bill,” but according to Martin, Gorgas made no apologies for lobbying and instead reiterated his case for the bill.121 He did not win over his superiors, because after Congress approved the Owen-Dyer language in the military appropriations bill, March threatened a presidential veto unless Gorgas dropped his demand for more generals. Although he was “much depressed” about the General Staff’s continued opposition to a measure he considered essential, Gorgas stood firm, and in a final, picturesque glimpse of medico-military political relations, White House physician Admiral Cary Grayson called Martin to advise him that the president would indeed sign the bill.122 Gorgas had gone around Baker and March and had won. The War Department, the Congress, and the leadership of the medical profession were willing to risk (or at least to bluff) delaying passage of the military appropriations during a war over the issue. Gorgas and his medical officers called the General Staff’s bluff and won their battle, but their willingness to use political influence further frayed relations between them. Secretary Baker soon revealed his wariness of the Medical Department in June 1918 when he wrote to the Senate Committee on Military Affairs regarding their invitation to Gorgas to testify at a hearing. “The opinion of the Department can only be expressed by the Secretary,” he told the committee chairman, explaining, “I have very definite beliefs about the relation of the Medical Department . . . and I should be very sorry indeed to have Congress proceed with any legislation affecting that relation without at least having an opportunity to consider my views on the subject.”123 Baker allowed Gorgas to appear before the committee, but it seems he did not trust the surgeon general to represent the War Department to Congress. Chief of Staff March heightened tensions when he removed Colonel John Van R. Hoff as editor of the Military Surgeon. Hoff, who had come out of retirement to edit the journal during the war, had written an editorial charging that the General Staff was not seeking appropriate medical advice because it had appointed two medical reservists instead of career medical officers to represent the Medical Department at its meetings.

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The General Staff must not really want medical advice, he suggested in the unsigned column, because while these men were “two of the most distinguished physicians in the world,” they knew little of military law and military medicine. Noting that the General Staff had told the medical officers they need not attend the meetings except when required, he commented snidely that one might infer that the General Staff was “ignorant of the fact that there are stupendous medico-military problems connected with war.”124 March immediately demanded to know who had written the editorial and within two days secured an official reprimand of Hoff from Secretary Baker, charging that the editorial “shows a complete disloyalty toward the legally constituted military head of the War Department and is calculated to produce friction in the military machine.”125 March then ordered Hoff back into retirement, relieved him from his post as Military Surgeon editor, and required the journal to print a statement indicating that “the article does not represent the opinion of the association,” adding, with a cut, “if that is the fact.”126 March’s intolerance for any challenge from the Medical Department was in line with his directive management style, but it also shows that issues concerning the welfare of the soldiers continued to be high stakes. His treatment of Hoff jarred the Medical Corps. The son of an army surgeon, Hoff was a decorated veteran, a founder of the Military Surgeon, and president of the Association of Military Surgeons, 1901–1902. He also loved the army. As one medical officer remembered, Hoff “realized, before the rest of us did, the incongruity of looking upon a Medical Officer as though he were different from any other Army Officer.”127 Believing that he had done his duty in writing the column, Hoff accepted his punishment but requested that a copy of his editorial be kept in his file.128 The blot on Hoff’s record did not endure, however. On 11 November 1919, the first anniversary of the Armistice, Secretary Baker removed the reprimand from Hoff’s record at his request. The Military Surgeon congratulated Baker on a “lordly action,” but the War Department’s discipline of a medical officer who loved the military culture had insulted the Medical Corps in 1918.129 Surgeon General Gorgas’s last days in the army also demonstrated the strained relations between the General Staff and the Medical Department. Historians generally state that Gorgas retired as surgeon general because he reached the customary retirement age of sixty-four. A close look at his diary during his last months in the army and letters he wrote to his wife, Marie, reveals that he was actually reluctant to go.130

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Gorgas was a reluctant administrator and preferred fighting disease in the field to working at a desk in Washington. For example, he took a leave of absence from the Office of the Surgeon General in 1916 to lead a Rockefeller Foundation trip to combat yellow fever in South America. When he returned, he discussed retirement with Baker, but dropped the matter as relations with Germany deteriorated and the nation prepared for war.131 As the war proceeded into 1918 and Gorgas’s sixty-fourth birthday and retirement date, 3 October, neared, Gorgas and Baker did not discuss his retirement. Instead, the secretary sent Gorgas on an inspection tour of the AEF. As he departed for France he wrote, “Never have gotten from Sec. Baker the information as to what my future is to be after my retirement on October 3rd. This is August 29th, so I will probably be retired while in France.” He added, “I do not understand why he makes such a secret of the matter.”132 Gorgas had hoped to be asked to stay on, and crossing the Atlantic with Baker, he looked for signs of his status. After Baker spoke highly of Gorgas during a speech on board the ship, Gorgas wrote that his assistant, Colonel Furbush, was “much elated. He feels sure now that the Secretary is going to continue me as surgeon general.” Gorgas was less sure, “The Secretary has not mentioned the matter to me. I think it queer that he is so secretive. I do not intend to say a word to him about it till he broaches the subject himself.”133 Still at sea figuratively and literally a few days later, Gorgas recorded, “Sec. Baker and I are getting along first-rate. He is an agreeable and attractive man. He has not yet given me an intimation as to what he is going to do with me after my retirement.”134 Perhaps Gorgas had forgotten his disputes with the secretary, but Baker had not. The suspense continued in France when Gorgas met Merritte Ireland, the AEF chief surgeon who would soon be his successor. “If Ireland knows anything about his future, he keeps it very quiet,” he told Marie, “On the contrary he talks as if he thought that I am to be continued as Surgeon General; constantly asks me to attend to this, that or the other thing when I get back—such things as only a Surgeon General can do.”135 Jefferson Kean, Ireland’s assistant, was intrigued that during a meeting on 21 September between Ireland and Gorgas, “We had a very pleasant evening, but no allusion was made to the fact that a new Surgeon General was due to be appointed two weeks from that date.” And, he noted, “Gen. Gorgas was carefully chaperoned by Col. Furbush.”136 Kean may have thought it odd that during a wartime meeting between two highranking medical officials and their assistants, men did not touch on such

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important issues as the future of the Medical Department or the people and politics of the job. The day before he was due to retire, Gorgas wrote to Marie, “I have heard nothing from the Secretary.”137 The next day, he was philosophical: “I retire today, being sixty-four years of age. This is a very fitting way to retire. In the battlefield of the greatest battle ever fought.”138 Gorgas learned his fate later that day. “When we got back to Bar la duc on the 3rd Col. Furbush found a paper which announced that Ireland had been made Surgeon General,” he told his journal. “Col. Furbush was much upset—he had expected that I would be continued.” Denying that he too was upset, he wrote, “I was not anxious to be continued as S.G. though I would have felt complimented at being asked.”139 But with some relief he told Marie that he had received a telegram from Baker “telling me to continue my investigation as long as I saw fit, and that as soon as he got to Washington he would issue an order placing me on active duty.” This, he assured her, “will cover the matter of full pay till I get back.”140 In addition to the inelegant end of Gorgas’s distinguished army career, it is curious that the War Department would change its leadership in the middle of a war—and in the middle of the influenza epidemic. Officials believed they had serious problems with the status quo. Removing the surgeon general risked destabilizing the Medical Department at a critical time, but given the controversies regarding medical officers’ rank and status in the army and the disagreements over health policies in the camps, it seems reasonable that Secretary Baker and Chief of Staff March were willing to take that risk. Less willing to fire a national hero, however, they let him retire, determined to take up medical issues with a new surgeon general. Gorgas’s run-ins with the War Department leadership had taken their toll on his appearance as well as his career. According to his cousin, Stanhope Bayne-Jones, at the time a medical officer with the Twenty-sixth Division, when Gorgas visited him on the Western Front, “I was happy to see him, but was distressed at his appearance.” He told his uncle, “He looks older and rather badly.” Perhaps, he suggested, “the work of the huge medical department that we now have must have been a big task for him during the last winter.”141 Gorgas, Vaughan, and other medical officers directly challenged army policies regarding sanitation, medical practice, and the treatment of soldiers, at times “going around the chain of command” to Congress and the president to advocate for their profession and for the care of the soldiers. Although they won the increased rank authority in the process,

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their political machinations angered the War Department leadership, which found ways to punish their audacity. In these confrontations, medical officers claimed professional expertise and competence in handling disease and injuries—provided they were given sufficient resources and support from the general command. The influenza virus, now feeding on the war, would soon undermine these claims.

3 Worst-Case Scenario The Influenza Epidemic of 1918 in the Camps We are inclined to boast that the age of pestilence has passed, but . . . I dare say that the world has never before known a pestilence more widespread, more intensive and appalling in its progress, or more destructive to life, than the epidemic of influenza which apparently came into being and grew in violence as the World War passed through its final stages. —Victor C. Vaughan

Two Spring Offensives By 1918, the world war was dragging on into its fourth horrible year. In 1914 a war of movement and territory settled into a war of attrition fought in an enormous network of filthy trenches. Chemical warfare emerged in 1915, and in 1916 the battles of Verdun and the Somme claimed perhaps a million lives, yet gained no territory for either side. In 1917, the French army mutinied, refusing to undertake any more offensive drives into German machine gunfire, Russia was in revolution, and, for Britain, the volunteer army of 1914 had become an army of conscripts drafted to feed a war of attrition their government might not be able to win. In fact, by early 1918 the Germans were gaining strength as the Russian Revolution and the subsequent Treaty of Brest-Litovsk ended the war on the eastern front and the Austro-German defeat of Italian forces at Caporetto similarly reduced the front in the south. These victories enabled the Germans to concentrate their troops and resources on the Western Front. On the Allied side, the United States officially declared war on Germany 6 April 1917, but would not become a significant military factor for another year. In January 1918, the Americans’ war mobilization accelerated, but General John Pershing’s American Expeditionary Forces

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(AEF) had less than 200,000 men, few of whom had completed their combat training. Spurred by congressional criticism of war mobilization, by May the War Department was finally transporting some 200,000 men a month to France, but Pershing’s army did not pass the one million mark or hold a significant portion of the 550-mile front until August.1 Therefore hoping to exploit the moment, on 21 March the Germans unleashed a powerful offensive across the Somme River with the goal of reaching Paris and defeating the Allies before the Americans could amass their army.2 As the Germans pursued their military offensive on the Western Front, the influenza virus launched its own offensive. In the spring of 1918, medical officers began to report a new virus emerging in the training camps at home and in battlefields in France. On 30 March, the chief medical officer of the Eighty-ninth Division at Camp Funston, Kansas, sent a worried telegram to the army surgeon general’s office in Washington: “Virulent secondary streptococcic pneumonia following epidemic pseudo influenza present. Many deaths influenza following immediately two extremely severe dust storms.”3 The officer asked the surgeon general to send an inspector to investigate the outbreak. That same week the Public Health Service (PHS) reported eighteen cases of influenza with three deaths among students at Haskell Institute, a school for Indians in Lawrence, Kansas.4 Surgeon General Gorgas and Captain Victor Vaughan, director of infectious diseases, received several other reports of outbreaks of “fever, type undetermined,” or “influenza” from training camps, including Fort Oglethorpe, Georgia. Medical officers there described the symptoms as headache, pain in the bones and muscles, marked prostration, high fever, as well as an occasional cough, rash, or nausea. Medical treatment for the flu included rest in bed, a light diet, aspirin for fever and pain, and keeping the patient warm, in hopes of preventing the onset of pneumonia. Recovery usually occurred after a few days.5 Across the ocean, Captain Ward MacNeal, epidemiologist at the AEF central laboratory in Dijon, was receiving similar memos that now document the emergence of the new epidemic. The first came from a medical officer at an army hospital in Bordeaux who reported the appearance on 15 April of an “epidemic of acute infectious fever, nature unknown.” Symptoms included “sudden onset with severe headache, backache, chilly sensations, general muscular soreness, prostration . . . temperature ranges from 102 F to 103 F or higher . . . inflammation of the upper respiratory tract and in about 10% of the cases a mild bronchitis.” The officer con-

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cluded that “this highly infectious disease clinically resembled influenza except for its short duration and absence of complications.”6 North along the coast, at St. Nazaire where the Americans had a major port, another medical officer reported a “small and rather mild epidemic of influenza,” involving fifty-four cases treated in the hospital during ten days in May.7 On the other side of France, Americans experienced similar outbreaks. Ambulance driver Guy Emerson Bowerman, Jr., serving with French troops near the Somme, recorded in his diary that on 28 May an epidemic kept him busy evacuating sixty men who had the “grippe.” In the American Forty-second Division, also with the French army in the Baccarat Sector of Lorraine, an enlisted man noted on 8 June, “An epidemic of grippe has hit the [sanitary] train and there is much sickness.”8 A Fortysecond Division general had to advise his superiors that a flu epidemic in his infantry brigade was rendering many of his men “sick and unfit for duty.”9 These reports on both sides of the Atlantic signaled the first wave of the influenza of 1918, emerging in army camps in the United States in March and April and in France during April, May, and June. While these spring flu outbreaks worried medical officers such as Gorgas, Vaughan, and MacNeal, they caused few deaths and received little public attention. The flu, after all, was a common illness that came during the winter season, and a few outbreaks in the camps was not cause for concern. Additionally, as more and more men left for Europe and the War Department began to release daily casualty lists to the newspapers, public attention turned from the soldiers’ welfare in the training camps to their fate in the trenches. Over the summer, however, the influenza virus would mutate into a virulent strain that demanded attention. The Great War and the influenza virus worked together in the training camps, on troop ships, and in the trenches on the Western Front to create a human catastrophe. The epidemic of 1918 is a powerful and deadly example of what a number of scholars have described as the complex interaction between the natural environment, human behavior, and disease pathogens.10 At many times in history, human social interactions have changed environmental conditions in ways that foster disease. The Great War was “social interaction” of colossal proportions, creating conditions that enabled the biological character of the influenza virus to take advantage of trench warfare and evolve into the most lethal flu in history. As Victor Vaughan observed, “It seemed that Nature gathered together all her strength and demonstrated to man how puny and insignificant he

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and his fellows are, with all his murderous machinery, in the destruction of his fellows.”11 The war and the flu collaborated in two ways: the war fostered disease by creating conditions in the trenches of France that some epidemiologists believe enabled the influenza virus to evolve into a killer of global proportions. In turn, disease shaped the war effort, by sickening one million American soldiers and diverting resources, personnel, and scarce human attention and energy from the military campaign. War and disease were inextricable. As a bacteriologist observed in 1917, “War is in a sense simply an incident which man foolishly permits to enter into that greater struggle with germ life.”12

The First Wave After the initial reports of influenza in March and April, the flu seemed to subside in the American army. The New York Times ran several stories in late June about an influenza epidemic in the German army and speculated about the degree to which it was affecting their fighting ability. The U.S. War Department, for its part, stated that although precautionary measures had been ordered, “the American troops have at no time shown any form of the disease.”13 But medical officers knew there was flu in the AEF. Louis C. Duncan, with the Second Division, had to struggle with the flu during the military operations at Chateau Thierry in late May. “Influenza was epidemic,” he wrote, and “when the troops started on the march many developed that disease and were unable to march.”14 Captain Samuel Bradbury, with the Eleventh Engineers, reported an influenza epidemic from 19 May to 3 July, during which 613 men were sick. He confined most to their quarters for an average of about four days, but he had to hospitalize twenty-two soldiers, one of whom died from pneumonia. Bradbury considered the incident worth writing an article about because of the “explosive nature of the epidemic, the comparative mildness of the disease and short duration of illness in each case, the absence of complications and yet the extraordinary manner in which the disease cut down the number of effectives.”15 This wave of the flu spread with surprising suddenness, weakened but did not yet kill its victims, and was therefore remarkable to only a few medical officers. In late May, the PHS picked up a report from Valencia, Spain, regarding “a disease of undetermined nature . . . characterized by high fever, to be of short duration, and to resemble grippe,” and similar cases were re-

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ported elsewhere in the neutral country.16 Although the belligerents in the war were less willing to reveal disease outbreaks in their armies, they experienced them just the same. French armies were evacuating 1,500 to 2,000 cases of flu to the rear per day in May, physicians in the Italian army reported flu epidemics in April and May, and the British had at least 30,000 cases in June.17 Although influenza typically came around in the winter, this outbreak was hitting in the late spring and summer. Like Samuel Bradbury, British medical officers from several camps in France considered the outbreaks significant enough to publish. Officers at one hospital reported more than 1,400 admissions with seven deaths from 21 June to 10 July, and in another hospital fifty people on the staff got the flu in one week.18 On the other side of the Western Front, the German high command was struggling to find replacements for the more than 900,000 casualties their army had sustained during their offensive drive, and, as the Times had reported, the flu was putting even more German soldiers out of commission. “Our army suffered. Influenza was rampant,” wrote German commander Erich von Ludendorff after the war. In his memoir he complained, “It was a grievous business having to listen every morning to the chiefs of staffs’ recital of the number of influenza cases, and their complaints about the weakness of their troops if the English attacked again.”19 But soon the flu abated. The mortality rate in American training camps dropped from double digits to 2.1 per thousand men in July and 2.3 per thousand in early September.20 Army medical officers remained vigilant, though, knowing that new trainees arriving in the camps from the draft were especially vulnerable to respiratory illnesses. The Medical Department made a number of recommendations to the General Staff on how to prevent further epidemics, including moderating the training programs to gradually introduce civilians to military life, increasing medical surveillance, and easing crowded housing. The department also issued a number of bulletins to medical officers and other personnel outlining measures to avoid disease outbreaks like those of the winter of 1917–1918. The Medical Department apparently assumed, however, that the flu itself had come and gone, because a 6 September memo did not even list influenza as a possible threat.21 But the flu had only temporarily disappeared. In mid-August, New York City health officials became concerned when a Norwegian steamer arrived in port with flu patients aboard. On 16 August the PHS told U.S.

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quarantine stations to inspect vessels from Europe for any cases of the “so-called Spanish influenza,” as it had first been reported out of Valencia, and to advise local health authorities of any cases.22 Such a notice was necessary because unlike typhoid, plague, cholera, meningitis, or smallpox, public health officials generally did not consider influenza serious enough to be designated a reportable disease. The chief surgeon of the AEF also received several ominous cables in August about flu epidemics in northern France. One reported “an epidemic of influenza followed by a very fatal type of pneumonia” in a French village, and another reported flu in a Thirty-sixth Division infantry regiment, at times followed by pneumonia which “seems to be a very fatal variety.”23 The PHS continued to issue warnings, provide information on the influenza, and in September began to publish weekly bulletins on the prevalence of influenza in the United States.24 Because the flu was highly contagious, transmitted through the air, with an incubation period of only a couple of days, efforts at quarantine and isolation were largely futile. Taking advantage of the conditions of the Great War, the flu virus had evolved from a bothersome disease that put men to bed for a few days to a plague that could render entire army units ineffective and kill millions.

The Second Wave Despite the PHS warning, the army’s first cases of the autumn influenza epidemic took the Medical Department by surprise. It struck first at Camp Devens, outside of Boston, on 8 September, “completely unheralded,” and medical officers diagnosed it definitively as influenza on 12 September.25 Within ten days, the base hospital and regimental infirmaries were overwhelmed with hundreds of sick trainees, and Camp Devens was in trouble. But because the federal government did not require physicians to report cases of influenza, Major Paul Wooley, the camp epidemiologist, did not advise Washington, D.C., for several days.26 Wooley’s subsequent report on the epidemic recorded the flu’s onslaught in terms of hospital admissions. The first two weeks of September began normally enough with admissions varying from thirty to ninety per day. But on Saturday, 14 September, more than five hundred flu victims showed up at the hospital, and for three days the next week the hospital admitted more than a thousand stricken soldiers every day. Through the rest of the month, daily admissions exceeded one hundred until the epi-

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demic subsided in October.27 Jane Malloy, the chief nurse at the hospital, described what the flood of patients looked like from the inside: “One day fifty were admitted; the next day 300, then the daily average became 500; into a 2,000 bed hospital 6,000 patients crowded.” She noted that “every inch of available space was used,” calculating that “three miles of hospital corridors were lined on both sides with cots.”28 Malloy also marveled that otherwise healthy young soldiers could fall so quickly to disease. Enlisted men working in the Camp Devens hospital were similarly appalled. Private Ralph Smith remembered that 374 patients died in just one night. Arthur F. Poole put it more crudely. “Men were dieing like flys [sic]; with the flu,” he wrote.29 Surgeon General Gorgas sent his most respected officers to investigate the flu outbreak at Camp Devens—Vaughan, William Welch, and Rufus Cole, an expert in respiratory diseases. On 25 September, they reported that “the situation remains grave and many more fatalities are expected before the epidemic has run its course.”30 They recommended sixteen measures to control the epidemic at Devens and other camps, the most drastic being the suspension of all transfers into or out of Devens until the epidemic passed. They also called for additional medical personnel, screening around hospital beds and dining tables to prevent contagion, and ultimately reducing the camp population by 10,000 to ease overcrowding and providing 50 square feet living space per man. But these measures could do little to delay the flu or cure the sick. Medical officers were acutely aware of their inability to help their patients. “I went to Camp Devens as soon as influenza was reported,” Vaughan later wrote, “and the realization of the utter helplessness of man in attempts to control the spread of this disease depressed me beyond words.”31 Scientific medicine failed them in the crisis. By the end of September, medical officers at Camp Devens had counted more than 14,000 cases of influenza—about 28 percent of the camp population—and 757 deaths.32 Others soon joined in their nightmare. Geographically, influenza swept from the northeastern seaboard south and west, following wartime transportation routes with its human hosts.33 It arrived in Camp Dix, New Jersey, on 18 September; Camp Funston, Kansas, on 20 September; Camp Kearney, California, on 27 September; and Camp Dodge, Iowa, on 29 September. Influenza did not hit Camps Wheeler and Greenleaf in the interior in Georgia until 11 October. The surgeon general’s office watched in horror as the annualized death rate in the training camps increased almost one hundredfold from 2.3 per thousand

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the week of September 13 to 206 per thousand the week of 11 October. The New York Times began tracking the death toll of the flu in the camps daily. The outbreak at Camp Devens formed a pattern repeated in army camps, hospital wards, and morgues across the country. (See fig. 9 for the alarming trajectory of overall army death rates from flu and pneumonia.) When the flu hit a camp, it exploded in a day or two, sending thousands to their beds. Hospital admissions would crest in two or three weeks, but pneumonia cases continued to increase for at least a week as the sicker patients developed complications. Camp Upton on Long Island, for example, hospitalized more than one hundred men every day for three weeks, from 15 September to 9 October. Admissions peaked at 483 admissions on 4 October. More than five hundred patients died at Camp Upton.34 After the climax of flu and pneumonia cases at a camp, the epidemic would subside slowly and disappear within four to six weeks. In the process, it cut a wide swath across the country. In twenty-six of the forty largest army training camps, at least one quarter of the soldiers reported sick with influenza and pneumonia, and eight of the camps had more than five hundred deaths.35 Figures in individual camps tell the same story. At Camp Meade, outside Baltimore, 27 percent of the 42,300 troops were hospitalized with the flu. The hospital had a capacity of about one thousand beds, but in just one day had to admit 875 flu patients.36 In Camp Sherman, Ohio, every third man reported ill. In Camp Syracuse, New York; Camp Dodge, Iowa; Camp Funston, Kansas; Camp Travis, Texas; and Camp Beauregard, Louisiana, more than half of the men were sick enough to be hospitalized. The division surgeon at Camp Beauregard reported 7,181 cases of influenza within two weeks, from 28 September to 10 October, explaining that “the experience at this camp as to morbidity and mortality is in line with the other camps affected by the disease.”37 Camp Beauregard did have one of the highest sickness rates in the army, but fewer deaths—294—than many other camps. Camp Dodge had 705 deaths, and officers at Camp Taylor, Kentucky, had to tell 768 families that their soldier had died.38 Medical staff as well as trainees fell ill. At Camp Cody hospital in New Mexico, seventy-five of the one hundred nurses got the flu, and five of them died.39 This influenza’s symptoms shocked medical officers. The usual flu gave patients a fever, chills, often a sore throat and cough, and myriad aches and pains. But this influenza was different. It could produce fevers of 105

Fig. 9. Graph of influenza deaths in the U.S. Army as a function of time, showing the explosion of deaths in mid-September 1918. (Leonard P. Ayers, The War with Germany: A Statistical Summary [Washington, D.C.: Government Printing Office], 127)

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and even 106 degrees Fahrenheit that made patients delirious or lethargic to the point of prostration. Patients bled from the nose and ears and coughed up bloody sputum, which one report described quite graphically as “foamy and bloody, and sometimes mixed so completely as to resemble tomato puree.”40 The flu rendered some patients incontinent and others nauseous. Medical officers found cyanosis, or blueness of the skin from lack of oxygen in the lungs, to be one of the most alarming symptoms. “One of the striking features of this epidemic is the blueness of the patient’s face,” wrote one medical officer. “All of them have red faces. . . . And a great many subsequently change from a red to a cyanotic shade. Indeed some of them are so red all over the body as superficially to resemble cases of scarlet fever.”41 A Scottish physician working at Camp Devens during the epidemic expressed his distress in a letter to a colleague in England. He began with the grim remark that Devens had nearly 50,000 men, “or did have before this epidemic broke loose.”42 The flu victims, he explained, came to the hospital with “what appears to be an ordinary attack of La Grippe or Influenza,” but which then developed into “the most vicious type of Pneumonia that has ever been seen.” Within two hours of admission, they had “mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face until it is hard to distinguish the coloured men from the white.” Then, “it is only a matter of a few hours until death comes, and it is simply a struggle for air until they suffocate.” It was horrible, he told his friend. “One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies sort of gets on your nerves.” Doctors and nurses were among the dead, and a separate barracks had been designated as the morgue. Deaths averaged about one hundred per day, and “it would make any man sit up and notice to walk down the long lines of dead soldiers all dressed up and laid out in double rows.” He asked his friend to write to him with news other than the epidemic, because all he and his colleagues talked about was pneumonia. “We eat it, live it, sleep it, and dream it, to say nothing of breathing it 16 hours a day.” Army pathologists were also shocked by their findings of the flu’s impact inside a victim’s body. Autopsy reports consistently remarked on the livid appearance of the lungs—normally light and airy, they were now sodden and distended, filled with a frothy, bloody liquid. The disease seemed to continue to attack even after death. Pathologists described how, when they moved a body to do an autopsy, “a foamy, blood-stained

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liquid ran from the nose and mouth when the head was lowered.”43 Physicians performing autopsies at Camp Devens described influenza pathology as unique, characterized by “the intense congestion and hemorrhage” of the lungs.44 Cole and Welch observed one such autopsy, and Cole noted that Welch, an experienced pathologist, “turned away from the blue, swollen lungs with wet, foamy, shapeless surfaces [and] became excited and nervous, saying, ‘this must be some new kind of infection or plague.’” Commented Cole, “It was not surprising that the rest of us were disturbed, but it shocked me to find that the situation, momentarily at least, was too much even for Dr. Welch.”45 Flu was also “too much” for other army personnel. A general who was deeply disturbed by the sight wrote, “The autopsies disclosed a flaming red lung of the victims, a pathological condition seldom seen before or since then,” adding “I hope the world will never see another flu epidemic.”46 Sergeant Arthur Warner, drafted into the army from Connecticut, served in the 151st Depot Brigade at Camp Devens. He recalled how, during the epidemic, he had to take fifty men to the base hospital so they could “move bodies that were being brought in by ambulances.” He had to send some men back to barracks because they “couldn’t stand this gruesome task.”47 The epidemic was not confined to military communities, but hit cities, towns, and rural areas equally hard.48 Although the epidemic in the United States most likely originated in military installations—at Camp Funston in March, then Camp Devens in September—it soon spread throughout the country. From its arrival in Boston and the attack on Camp Devens the week of 7 September, influenza swept across the country, reaching virtually all regions by the week of 5 October. On 16 October, the New York Times reported that influenza had reached epidemic proportions in “practically every State in the country.”49 The impact was similar to that in the training camps. Wade Hampton Frost, a PHS epidemiologist, collected data from ten cities showing an average influenza sickness rate of 28 percent, comparable to that in the training camps. Civilian rates ranged from a low of 15 percent in Louisville, Kentucky, to 21 percent in San Francisco and 25 percent in Baltimore to 53 percent in San Antonio, Texas—similar to the worst sickness rates in the training camps.50 This penetration into all corners of the country gave the influenza the power to actually reduce the life expectancy statistics for Americans by about twelve years for the year 1918.51 Some people believed that the camps were foci for the epidemic, but another PHS epidemiologist, Edgar Sydenstriker, pointed out that this

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may have been only because the army had better records and reported flu outbreaks earlier than civilian communities. He bemoaned the “incomplete and inaccurate morbidity reports among the civil population,” and said he had to rely instead on mortality figures to calculate the impact of the epidemic. Studying data from 118 communities, he estimated that deaths from influenza and pneumonia ranged from 2.7 percent to 4.6 percent, similar to death rates in many army camps.52 When influenza struck, it paralyzed many communities. Public health officials closed schools, government offices, stores, and theaters in order to prevent the spread of the disease and because of the lack of workers due to illness. Given the wartime emergency, war industries and mines continued production, but in some locations, influenza so depleted the labor force that factories had to suspend operations. Influenza also undermined army training and transport plans, and began to take a toll on war mobilization. Congress took notice. As the flu spread along the eastern coast, Senator Henry Cabot Lodge of Massachusetts exclaimed, “The epidemic is stopping the war work in the States.”53 The House and the Senate held weekend hearings and immediately passed legislation to provide one million dollars to the PHS to fund additional personnel, public education, and data-gathering activities to fight the epidemic.54 President Wilson signed the bill into law on 1 October. Congress did not provide additional funds to the War Department, assuming that war expenditures could cover fighting the flu, but it did establish an emergency medical reserve of physicians for the PHS, and provided relief to the territories of Alaska and Puerto Rico for costs they incurred in fighting the flu.55 In the end, the U.S. War Department tabulated a record of 791,907 hospital admissions for influenza, and estimated that some 26 percent of the army—or about one million men—got sick.56 It exploded in the AEF in France about a week later than it did in the United States. The highwater mark for deaths in the United States came the week of 4 October, with 6,160 officially recorded deaths, and in the AEF, the week of 11 October, during the height of the American Meuse-Argonne campaign, with 1,451 reported deaths from flu.57 It appeared that the flu was less widespread in the AEF than in the training camps in the United States. One army report set hospital admissions for influenza at 167 per thousand in the AEF compared to 361 per thousand in the U.S. camps.58 This may have been because many of the men in France had been exposed to the flu

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during the spring epidemic and because of the poor record-keeping practices in the AEF. Although sickness rates varied from location to location and from camp to camp, in general, when the virus attacked an army unit, approximately 75 percent of the population had immune systems that could fend it off and did not fall ill. In the other 25 percent, however, the individuals’ immune system was defenseless and they got the flu. For them, the influenza could render the body open to a number of secondary infections and complications that could kill. The most common was pneumonia, which was responsible for most deaths—the War Department recorded 99.4 percent of “all the deaths charged to influenza” as “due secondarily to pneumonia.”59 About one quarter of all flu victims developed pneumonia, which killed one-third to one-half of all its victims.60 Pneumonia infection occurred when an individual’s defense system broke down because of poor living conditions or other stresses, or in this case, an especially virulent pathogen. Once established, pneumonia involved inflammation of the lungs and was characterized by fever, cough, chest pain, and difficulty in breathing. An influenza attack could lead to other deadly complications such as empyema, the consolidation of purulent matter (pus) in the lungs. Medical officers treated empyema in various ways, including periodic aspiration of the infected matter with a needle, surgical excision and draining, or at times the removal of ribs from the infected region.61 Other complications in the lungs included pulmonary emphysema and gangrene of the lungs, the latter of which was almost always fatal. Influenza could also result in serious ear infections, spinal meningitis, or infections in other vital organs such as the kidneys or the heart.62 The relationship between tuberculosis and influenza was unclear to many physicians. Whereas deaths among tuberculosis patients in several army hospitals increased during the epidemic, one medical officer observed that tuberculosis patients in his hospital had a lower rate of influenza than his hospital staff.63 Some medical officers speculated that tuberculosis developed in some patients as a complication of influenza, but the Medical Department concluded that “it seems very improbable that any great number of cases of tuberculosis owe their origin to the influenza epidemic.”64 The Medical Department also recorded fifty cases of acute endocarditis, the heart disease that killed Eddie MacNeal. Heart failure was one of the dangers of pneumonia, one medical officer explained. He recommended giving

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pneumonia patients digitalis to get them through the crisis because “the virulence of the toxins is very great, and the hearts early show signs of giving out.”65 While medical personnel in the United States did not experience the rush of wounded soldiers from the battlefield as did their AEF counterparts, as the flu struck their camps many of them felt as if they were at war (fig. 10). The Scottish physician at Camp Devens observed that the morgue had “long lines of dead soldiers all dressed and laid out in double rows,” which, he figured, “beats any sight they ever had in France after a battle.”66 Mary E. Hallock, a head nurse in a hospital ward at Camp Dodge, Iowa, described her ordeal as if it had been a pitched battle. Camp Dodge, it turned out, had the most “noneffectives” of all the camps, with a stunning 775,151 man-days lost to disease.67 As at Camp Devens, Camp Dodge’s hospital was flooded with flu patients, many of them delirious from fevers of 104 or 105 degrees. Hallock needed help from the camp’s trainees because of the nursing shortage during the epidemic. Every evening the camp staff would send some trainees to the hospital, and, according to Hallock, their job was “to stand by the side of the bed to keep the patients in bed because they were delirious.” She also required clergy because “we had to get a minister or rabbi or a priest to come and comfort them in their delirium—about them dying.” Remembering the epidemic sixty-five years later, she said, “It’s just a nightmare to me even today.” When asked if she had seen as much death as if she had gone to Europe, she replied, “Well, I couldn’t have worked any harder because I worked from 12 to 14 hours every day.” When asked why she joined the organization called Veterans of World War I instead of the women’s auxiliary, Mary Hallock said simply, “I am a member of the Veterans because I am a veteran.”68

Weak Medicine Medical officers tried a variety of measures to prevent the influenza and pneumonia from getting a grip on their soldiers in the first place. One strategy was to educate the soldiers themselves on how to avoid contagion. In late September, the Surgeon General’s Office released a bulletin on “How to Strengthen Our Personal Defense against Spanish Influenza,” with twelve suggestions, including avoiding crowds, covering the mouth and nose when sneezing, personal cleanliness, fresh air, warmth, and

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Fig. 10. Emergency hospital during influenza epidemic, Camp Funston, Kansas. Note the alternating head and foot arrangement of the beds intended to lessen contagion. (National Museum of Health and Medicine, Armed Forces Institute of Pathology, NCP 1603)

proper eating of good food.69 The army flyer circulated widely in both the military and civilian communities. Camp Jackson in South Carolina, for example, distributed 50,000 instruction cards to camp inmates, and the Colgate Company published the memo in the New York Times, stressing the bulletin’s prescription for dental cleanliness.70 Camp commanders and medical officers took various other steps to fight the epidemic. An inspection report from Camp Funston, Kansas, illustrates what the officers at one camp did.71 The camp was under quarantine, and only the relatives of the seriously ill could enter, wearing masks. The camp commander put many men in canvas tents to alleviate overcrowding and arranged cots with head and feet alternating in the hope of preventing contagion. In some barracks, beds were cubicled with tent canvas hung between them or arranged alternately head to foot to prevent contagion between patients. The camp also encouraged ventilation in the living quarters by promoting open windows and fires in some

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buildings. It suspended all assemblies except the YMCA movies, in which men sat in every other seat. The dining staff boiled the dishes after use and banned common drinking cups. Medical officers conducted sick call twice daily to identify the sick and, like Mary Hallock, recruited enlisted men to take care of the sick. Although the Medical Department stated that the camp was handling the epidemic in a satisfactory manner, the health inspector made nineteen additional recommendations for improvement. These included removing all cases of influenza from the barracks to the hospital, providing 100 square feet of floor space for all flu cases in the hospital, screening dining tables so that men sitting on either side of the tables did not infect one another, and providing the camp with thirty more nurses and two more medical officers with laboratory training and equipment. The inspector also recommended keeping soldiers off duty until ten days after their temperature had returned to normal in order to avoid relapses. Once people became sick from a flu virus with a secondary bacterial infection in this era before antibiotics, there was little physicians could do. The Medical Department could provide little guidance regarding the best treatment for influenza other than keeping patients warm, providing them with fresh air, feeding them well and often, and fending off signs of pneumonia. Medical officers tried a range of methods to treat the flu and pneumonia ranging from experimental vaccines, to mouth and nasal sprays, to emetics and enemas, none of which worked.72 Nurses often gave patients with high fevers alcohol baths to cool them down. Theda Schulte, a nurse at Camp Mills, fed honey to her pneumonia patients every two hours, so that “almost all the honey on Long Island was collected and sent to us.”73 Corporal John McQueen, a clerk at Camp Devens serving as an orderly during the epidemic, used Old Crow whiskey and aspirin—not only for his patients, but for himself as well. He remembered how after five days of tending a ward without nurses, the physician McQueen was working for “made me take my first drink of whiskey to keep going.” That physician, he added, “was very capable.”74 Medical officers at Camp Dodge set the epidemic period at 20 September to 20 October. They tracked the origin of the flu in the camp to two men who arrived on 12 September who quickly became ill and were hospitalized, one of them dying of pneumonia. The flu spread from there, attacking 12,000 of the 33,000 people in the camp. When the flu struck, the hospital commander asked the Red Cross for help in getting supplies,

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and J. R. Steward, a volunteer with the Red Cross, was startled by the long list so urgently handed to him. At end of the first day, however, he had purchased and delivered the following supplies to the hospital: “500 wash basins, 25 laundry baskets, 3,200 suits winter pajamas, 1,400 bars Ivory soap, 24 foot tubs, 38,500 paper drinking cups, 150 pair blankets, 30 sheets of Wall Board, 12 dozen hot water bottles, 12 dozen ice bags, 2 gross tooth brushes, 40,000 paper napkins, 1 gross clinical thermometers, 300 brooms, 300 mops, 200 camp stools, 800 bed slippers, 5,000 paper bags, 72 urinals, 72 bed pans, several hundred sheets and pillow cases.”75 Steward’s report notes that the hospital had 2,200 regular beds, but at one point had nearly eight thousand patients—most of them, he proudly stated, on beds provided by the Red Cross. J. R. Steward’s shopping list and the myriad other measures the camps implemented demonstrate the enormous demands the epidemic made upon material and human resources. Some camp commanders took additional steps to fight the epidemic. Army officials at Camp Taylor, Kentucky, canceled all passes and furloughs and kept the trainees confined to their barracks, guarded by military police to keep them from leaving the camp and spreading disease.76 Alarmed at the hundreds of relatives rushing to the camp to care for their sick sons, husbands, or sweethearts, camp commander Marshall Crowder barred family members from entering the camp unless they had received word of impending death of a soldier at the camp. This measure did not prevent cross infection, however, and family members often caught the flu themselves. The Mayfield Daily Messenger in Kentucky reported that Mrs. Richard Martin died of the flu after visiting her husband at Camp Taylor.77 At Camp Dix, General Scott, who had written to Surgeon General Gorgas about the measles epidemic, prohibited the sale of near beer, soft drinks, pie, and other foods. While the general did not claim that these products harbored or spread the flu, he apparently did not want to leave anything to chance, so he issued the order “as a radical move . . . to reach every possible source of infection.”78 Other commanders were simply overwhelmed. At Camp Grant, Illinois, Colonel Charles B. Hagadorn, a West Point graduate and career officer who had served in Russia and the Panama Canal Zone, was acting camp commander when influenza struck. He worked hard to control the epidemic and was troubled when more than five hundred soldiers died of pneumonia under his command. Although Camp Grant’s sickness rates and death rates were no worse than other camps and better than some,

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on 7 October, even as the epidemic waned, he committed suicide with a pistol wound to his head. Fellow officers later told reporters that Hagadorn had been showing the strain of the epidemic.79 Try as they might, medical officers could do little to stem the influenza epidemic, and army camps in the United States averaged at least 20 to 30 percent sick rates. Bad as they were, these figures probably understated the impact on the army’s effectiveness because they captured only those soldiers who reported sick and received medical attention. Army investigators, for example, found that some regimental physicians did not send soldiers to the hospitals unless they had temperatures over 101 degrees Fahrenheit.80 Many stricken soldiers may have just stayed in bed with or without knowledge or permission of their commanding officers. Others may have gone home when they got sick, either with leave or AWOL. “One of the boys played wise and got sick while he was home, his mother being ill,” Charles Johnston, a soldier at Camp Funston wrote home in early October. “He is down with pneumonia, so will have a prolonged visit while home. Think I will try that when I come home, eh!” And several days later Johnston reported, “There have been hundreds of boys taken A.W.O.L. since [the camp was] quarantined.”81 In a similar case, an Indiana sailor wrote that when a buddy did not return from shore leave, officers prepared to charge him with desertion until he was located in a Chicago hospital with influenza.82 The situation became so bad that in October the War Department ordered the investigation of all absentees from government service, reminding commanding officers that they were required to report all cases of illness.83 Regardless of the exact numbers, veterans of the epidemic remembered the bodies. Some seemed to have encoded the epidemic numerically to remember how bad it was. Private Wright Stevens recalled, “I think there were about 100 flag draped caskets every day or so.”84 John McQueen remembered that 875 men died at Devens in one month, and that twentythree undertakers handled the deceased inside a circus tent. Put in charge of men convalescing from the flu, McQueen wrote, “I found 181 sick men laying on straw beds. Two blankets—no pillows—no sheets. No medical supplies.”85 Aaron Glicksman of Chicago, a trainee at Camp Jackson, was put in charge of two hundred men in a flu ward because of the nursing shortage. He remembered losing “about 125 men daily” at the height of the scourge.86 Medical student Carl Dragstedt gained pathology experience at Camp Mills, New York, doing “8 to 14 autopsies every day during Oct., Nov., and Dec. 1918.”87

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The influenza and pneumonia of 1918 shocked medical officers and soldiers alike. It rendered strong, healthy men powerless and struggling for breath; it distorted and saturated the lungs of those it killed; it rendered helpless professional physicians of great skill and knowledge; it consumed an enormous amount of army resources; and it killed in such great numbers that images of sick and dead bodies and coffins stayed with the survivors for the rest of their lives.

The Evolution of a Killer Influenza was a stealthy virus, invisible to its hosts, and it traveled with soldiers as they moved to and from their homes, training camps, battlegrounds, and hospitals. Spreading along rail and shipping lines, modern steam power enabled it to move across vast expanses to reach new, unexposed populations and avoid burning out, killing all susceptible hosts and thereby dying itself. Its short incubation period, sudden onset, and distinctive symptoms enabled public health officials to track its course day-to-day across Europe and the United States.88 As it traveled the world, medical personnel began to give the disease an identity and to name it. Some called it the “Three Day Fever,” others “The Grippe,” or “Grip,” and others “knock-me-down fever.” The British referred to it as the “Flanders Grippe” or “Epidemic Catarrh,” and the Germans coined the cacophonous name, “Blitzkatarrh.” But given Spain’s early candor about its influenza problem, many people began to call it the “Spanish Grippe,” “Spanish Flu,” or, as author Richard Collier later dubbed it, “The Plague of the Spanish Lady.”89 Familiar with the consequences of influenza, army medical officers also knew how ignorant they were regarding the origin and control of the disease. Despite modern germ theory, they could not identify the disease pathogen or “germ” that was causing the epidemic. Some believed that bacteria they often cultured from patient’s tissues, Pfeiffer’s bacillus, was the cause, and even used it as a diagnostic tool.90 But researchers soon realized that it was actually producing only the secondary pneumonia, not the flu. In November 1918, Victor Vaughan acknowledged, “We are compelled to conclude that it has not been proved that the Pfeiffer bacillus is or carries the virus of the disease we know as influenza.”91 Flu viruses would not be isolated until 1933, and scientists are only today unraveling the origin of the 1918 epidemic and the cause of its lethality.92 During the

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epidemic, its cause remained a mystery. Medical officers and other physicians compiled an enormous amount of clinical evidence and epidemiological data about influenza and pneumonia attempting to understand the pandemic. The Index Catalogue, the Army Medical Library catalog of medical articles published throughout the world, listed more than fifteen hundred titles on the influenza epidemic in 1919 alone.93 As with all epidemics, scientists wanted to know where the influenza came from and debated whether it began in the United States, Europe, or the Far East, that is, China or Russia. Most quickly dismissed rumors that German spies brought the influenza to the United States on a U-boat.94 Medical officers realized that the “Spanish flu” was a misnomer, more the result of the lack of censorship in Spain than the absence of the flu in other countries.95 Ward MacNeal and University of Chicago bacteriologist E. O. Jordan theorized that the epidemic began in France among the Allied troops in the spring.96 Victor Vaughan, Hans Zinsser, and others made a more convincing argument that the flu epidemic began in the United States in the spring of 1918.97 Vaughan suggested that while the flu was endemic in many countries, emerging every winter, in March 1918, “influenza seemed to pass from the sporadic to the epidemic stage, [with] many camps reporting increases at this time.”98 More politically sensitive writers declined to take sides in the flu-origin argument. Victor Vaughan’s son, Warren T. Vaughan, suggested instead “multiple foci,” explaining, “we cannot, with the information at hand find any one locality in which the disease was prevalent sufficiently ahead of the pandemic . . . so that we might determine accurately the site of origin.”99 The Medical Department also sought to have it both ways, asserting that influenza appeared “in both Europe and America so nearly at the same time as to render its transference from one area to the other very unlikely.”100 With this approach, no one country deserved “blame” for the flu. Medical officers agreed much more on the nature of the 1918 influenza, especially that they had never seen anything like it. Even their clinical descriptions contained dramatic language. “The disease was a veritable plague,” wrote physicians from Camp Dix. “The extraordinary toxicity, the marked prostration, the extreme cyanosis and the rapidity of development stamp this disease as a distinct clinical entity heretofore not fully described.”101 George Soper, a New York epidemiologist who had done the public health sleuthing on the “Typhoid Mary” case and who joined the Sanitary Corps for the war, wrote, “Rarely before in the history of war has an infection exhibited a more explosive character or has

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so large a proportion of troops been infected in camps under conditions of abundant shelter and food and freedom from the strains and anxieties of conflict.”102 Medical officers treating patients at Camp Upton, New York, wrote that as they walked through their pneumonia wards that held as many as nine hundred patients, “The memory of this sight will haunt for life the minds of those who saw it.” They described their “horror at the frightfulness of the sight of the hopelessly sick and dying and at the magnitude of the catastrophe that had stricken wholesale the young soldiers prepared to face another enemy but helpless before this insidious one.”103 They saw the flu as not only deadly but unjust. At a more detached level, medical officers’ observations and data revealed four alarming characteristics about the epidemic. The first is that although they could not identify the pathogen causing the epidemic, many observed that the disease came in three waves.104 The first mild yet widespread wave of flu emerged in the American training camps and the AEF in spring 1918, the second and most deadly wave in the fall prevailed from September to November 1918, and the third wave, deadly but less widespread in the United States, appeared in the first quarter of 1919.105 Some medical officers speculated that these waves were the result of some sort of change in the pathogen that enabled it to become more virulent. “On purely biological grounds,” wrote Hans Zinsser, “it is entirely logical to suppose that infectious diseases are constantly changing, new ones are in the process of developing, and old ones being modified or disappearing.”106 Other medical officers corroborated Zinsser’s view. Men at an AEF hospital observed that outbreaks of flu among their patients “tended to be progressively more severe both in character and extent,” which they attributed to “increasing virulence acquired by the infecting agent.”107 Another medical team observed, “The chief difference between the disease in the fall and that in the summer however is that in the fall a large number developed broncho-pneumonia with a high rate of mortality.”108 Researchers at Camp Dodge theorized that the pathogen increased in virulence as it passed through successive hosts. “We were impressed with the idea that after long passage through many individuals the organism thus transmitted from one person to another may have gained in virulence,” they wrote.109 But because they could not conceive of the mechanism causing the transformation, medical officers’ ignorance of the epidemic’s cause remained profound. When epidemiologist Joseph Siler, director of the AEF laboratory at Dijon, organized a November 1918 conference to examine the flu and its complications, he posed the

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most basic questions: “Is it a clinical entity? Is it a pathological entity? Is it an entity from an etiological standpoint?”110 The second characteristic medical officers identified was that the flu was highly contagious and struck quickly with little warning. One AEF medical inspector cited its “extreme contagiousness,” and two others noted, “it is probable that practically all susceptible human material in infected camps suffered from an attack of the disease.”111 After the war the Medical Department concluded that literally every soldier was exposed to influenza, so that “26.6 percent of men in military service contracted some form of this disease. . . . 73.4 percent, while equally exposed, escaped infection.”112 Many medical officers used “explosive” to describe the arrival of influenza. As George Soper wrote, “Stated briefly, the influenza has usually occurred as an explosion.”113 Victor Vaughan similarly observed that “no other disease spreads so fast” and that “influenza may be nearly explosive in character.”114 An AEF medical officer noted, “The suddenness of the onset was so acute that patients could, as a rule, tell the hour they were taken sick.”115 Soper agreed, stating, “The patient can often tell the exact moment of his attack.”116 The third factor that impressed medical officers was that this flu was a killer. The new strain of influenza was so virulent that it caused many serious complications, especially acute infections of the lungs—pneumonias. While the overall case mortality rate for influenza was low (2 to 4 percent) compared to some other infectious diseases of the time, the very high sickness rates and the mortality from pneumonia meant that a lot of people died (fig. 11). Moreover, medical officers were amazed that unlike normal flu, which was typically fatal only for the very old and the very young, this one was most deadly for the strongest people—the cream of American manhood that they had vetted for the army. “The influenza, or ‘flu’ cases were the worst of all,” observed John Garret Nelson, a medical officer in an army hospital in Toul. “Men in apparently splendid health and perfect physical condition were suddenly desperately ill, and many of them dead in less than forty-eight hours.”117 This penchant for killing young adults was the fourth flu characteristic medical officers identified. Young adults aged twenty to forty had the highest death rates in the epidemic, forming a “terrible W” mortality curve. That is, a plot of mortality versus age had the usual peaks at the young and old ends of the age scale, but also produced an unusual peak in the middle118 (fig. 12). As Victor Vaughan observed, influenza, “like war, kills the young, vigorous, robust adults.”119

Fig. 11. Pie chart of deaths by disease in the U.S. Army, 1917–1919, showing that almost 84 percent were due to pneumonia. (Leonard P. Ayers, The War with Germany: A Statistical Summary [Washington, D.C.: Government Printing office], 126)

Fig. 12. Graph showing the “terrible W” age distribution of influenza deaths. (Jeffrey K. Taubenberger, “Seeking the 1918 Spanish Influenza Virus,” ASM News 65 [7 July 1999], Figure 1)

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Given the largely all-male army, the Medical Department did not track sex differentials in influenza and pneumonia rates. Civilian epidemiologists did, however, and came up with mixed results. Frost, for example, reported sickness rates slightly higher among females than males, whereas Jordan found sickness rates higher for males.120 All researchers agreed, however, that influenza and its complications killed young people, both men and women, in unprecedented numbers. This last characteristic especially baffled medical officers. Why had influenza become so lethal for young adults in the fall of 1918? Some theorized that the flu was changing with the war. MacNeal wrote that “a great pandemic of pestilence has followed in the wake of war,” and speculated that “the conditions for its incubation probably bear a relation to the great war and the altered living conditions dependent upon it, but the relation is far from clear.”121 Overwork, overcrowding, exposure to wet and cold, bodily discomfort, loss of sleep, and alcoholism, he suggested, reduced troops’ resistance to disease in the trenches and throughout the AEF. The Boston Medical and Surgical Journal compared the mild first wave of influenza with “the severe epidemic now in progress,” and speculated, “Is it possible that there was a direct relation between these outbreaks?”122 Indeed, since then, medical researchers have tried to understand this “relation” between the flu and the war. Scholars have several theories regarding the genesis of the 1918 influenza virus. Some involve the transmission of new influenza virus strains from animals to humans, others the evolutionary biology of the virus itself. Those advocating the animal transmission theory observe that in the time intervals between epidemics, flu viruses reside in animals (swine or avian “reservoirs”). These viruses can become particularly deadly when they reenter the human population either by jumping from an animal host to human host, or by combining with a more benign human flu virus.123 The animal-reservoir theories explain circumstances that could produce a pathogen against which many humans were defenseless, but they cannot explain how or why the flu became so virulent between the spring and fall of 1918, or why it targeted young adults. The evolutionary biology theory is able to address these questions and therefore provides a more satisfactory explanation. Scientists now believe that the flu virus generally infects the host’s respiratory system and reproduces itself by replicating in the body and shedding into the air, seeking new hosts via the lungs. This replication peaks within two days of infection, and lasts only about six days, after which

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little of the virus is shed.124 Proponents of an evolutionary biology approach consider the 1918 influenza in its historical and social context rather than as an isolated biological entity. They theorize that as the influenza virus moved from host to host, person to person, it went through a series of mutations that produced a particularly deadly strain.125 Evolutionary biologist Paul Ewald in particular provides an integrative explanation of the 1918 virus by asking what was different that year to allow the virus to become so lethal. He stresses that the evolutionary process involved natural selection as well as random mutation. According to current scientific knowledge, in 1918 as now, flu viruses mutated continually in hosts around the world. Not all of these mutations were winners. For example, if a virus evolved to such great virulence that it killed its host before the host exposed and infected new ones, the virus would die with the original host, and “burn out.” Only a few mutations improved the virus’s competitive position. Most did not increase its viability, were therefore not selected, and did not survive. Ewald argues that trench warfare created crowded and chaotic living conditions that enabled an especially aggressive and deadly virus to gain unprecedented strength. It did this by continuously bringing the virus into contact with new hosts—young, healthy soldiers—in which it could reproduce. In other words, the difference in 1918 was the trench life on the Western Front. Medical officers’ observations of 1918 show the flu changing and becoming more virulent during the war. Ewald’s theory of the evolution of the flu virus provides the mechanism to explain how this occurred. The flu virus, he argues, evolved to take advantage of the crowded conditions and constant movement of people in and out of the trenches. Ewald introduces the concept of a “cultural vector” whereby people and vehicles spread the virus from an infected population to a new population. He describes this as “attendant-borne transmission,” because troop transports and medical evacuation services removed sick men from the trenches to hospitals behind the lines, and carried to the trenches men not yet exposed to the virus.126 In one example, an army hospital with a 360-bed ward for influenza patients received and passed along 824 people in a 24hour period. The army replaced these soldiers, Ewald points out, by delivering 824 others to the trenches. As soldiers became ill, the army quickly replaced them with “fresh” troops so that the population was always a mix of infected soldiers who were not yet ill, but could be shedding the virus, and not-yet-exposed soldiers. The military needs of trench

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warfare thus kept the flu from burning out. As Ewald explains, “Soldiers in the trenches were grouped so closely that even immobile infecteds could transmit pathogens. When a soldier was too sick to fight, he was typically removed from his trenchmates. But by that time trenchmates often would [already] have been infected.”127 Ewald also cites studies on how human physiology, tissue characteristics, and fever and immune responses differ with age, and might therefore allow the flu virus to behave differently in hosts of different ages. As the cultural vectors continuously fed unexposed young bodies to the flu virus, the virus improved its ability to reproduce in the soldiers, that is, it selected for young adults, producing the “W” mortality curve.128 Ewald thus presents a plausible argument that the Great War and the epidemic did not occur coincidentally — instead, war conditions evolutionarily caused the influenza epidemic. Americans’ accounts of life and transit on the Western Front document these conditions. A classic doughboy complaint embraced both the transport and crowding problems: train travel in France crowded them like animals—the boxcars were marked, “8 horses or 40 men.” William Livergood of Pennsylvania, a mechanic with the Eightieth Division, was one to know. His job was to procure horses for the Allied army, and he spent a lot of time in trains. On the way to buy the horses in June 1918, he writes, “There were 40 of us put in a Frog [French] box car about half as large as our box cars” (fig. 13). He and his colleagues then managed to take about two train loads of horses a week back to the coast of France for the American divisions newly arriving. “It sure is awful to be a tramp I tell you,” he wrote in his diary, “We got a lot of travel out of it. We were all over northern and western France dozens of times.” His commuting came to an end, however, when he got the flu on 10 July, and became so sick that he was hospitalized for eight days.129 That was just the kind of situation medical officer Samuel Bradbury worried about with the men in the Eleventh Engineers under his care. In early June five men came down with the flu in one company of 250 men. Commanders then moved the unit to a new location with twenty-two men to a freight car, on a trip that took thirty-six hours. A week later, ninety-eight men, or 40 percent of the company, came down with the flu. “The railway journey,” he concluded, “with the men crowded into box cars, had considerable influence in the increase of the infection in all companies.”130 Private Arthur Hoehn understood this process back in the United States. A pharmacist working as a guard at Fort Oglethorpe, he remembered that during the epidemic,

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Fig. 13. Troop train in France showing the crowded conditions on transport systems during the war. (U.S. Army Military History Institute, Carlisle, Pennsylvania, C. G. Krekel Collection)

when he took buddies to sick call or the hospital, they were often so weak he had to carry or hold them up, and had to “have him cough in my face,” for the whole trip.131 When they were not on crowded trucks or trains, thousands of soldiers huddled together in the more than 5,000 miles of trenches that riddled the 550-mile Western Front from the North Sea to the border of Switzerland. Soldiers on both sides of no-man’s-land dug and tunneled into the earth for protection from machine gun, sniper, and artillery fire. Over the years, the Western Front became a world unto itself where soldiers cooked, ate, slept, tended to their equipment, and tried to survive artillery barrages and enemy raids. Deep and narrow trenches and dugouts offered the most protection for the least digging. But the attending mud, filth, miserable weather, poison gas, rats, and lice promoted infectious diseases such as typhus, trench fever, typhoid, and dysentery. Al Ettinger, of the famous “Fighting Sixty-ninth” regiment, described his first home in the trenches, a dugout that accommodated fifty men 40 feet underground. “At the trench level entrance to the dugout, woolen blankets were kept saturated with water as protection against gas. Going down the stairs, we entered

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a large room with bunks, three tiers high around the sides,” he wrote. “It was an eerie feeling down in that dugout.”132 To relieve soldiers from the filth and horror of the trenches, most armies cycled their combat units for a week or two at a time through the front lines, the rear lines, and then entirely back from the combat zone—a fine mixing of infected men and new hosts for a predatory virus. Ettinger described the constant movement of men in the trenches. His regiment rotated in three units so that each spent two weeks at the front and one week resting behind the lines. Father Patrick Duffy, chaplain to Ettinger’s unit, recorded that to leave the front, the Sixty-ninth marched 10 kilometers to the rear. Duffy remembered that “we found a tremendously large fleet of camions driven by the little Chinks whom our fellows now call the undertakers, because they associate them with death and burials.”133 As these French colonial troops from Southeast Asia drove ambulances carrying the sick and wounded from the front, as well as troop transports carrying in replacements, no one imagined they were transporting the flu virus and fresh hosts as well. The crowding and the continual transport of men in and out of the front lines allowed the flu virus to become as powerful a force as any weapon in the war. The Western Front was even more malignant than historians have thought; men in the trenches were literally fighting germs and Germans.

4 Fighting Germs and Germans Influenza in the American Expeditionary Forces The tricks of marching and of shooting and the game called strategy constitute only a part—the minor, although picturesquely appealing part—of the tragedy of war. They are only the terminal operations engaged in by those remnants of the armies which have survived the camp epidemics. —Hans Zinsser, Major, Sanitary Corps

Epidemic in a War of Attrition Colonel Jefferson Kean, deputy chief surgeon of the American Expeditionary Forces (AEF) and chief army liaison with the American Red Cross, was one of the few army officers who tracked infectious disease across the AEF. A medical inspector during the Spanish-American War and Walter Reed’s first yellow fever patient, he knew the power and danger of infectious disease.1 His war diary created a telegraphic record of the development of the influenza epidemic in France. In late May, he noted the first wave of the flu, “Mild epidemic of ‘three-day-fever’ since April 15th, causing no deaths.”2 In June he made only one entry regarding disease in the AEF. Then on 7 July, “Epidemic of ‘three-day fever’ at an end.” On 9 August, however, Kean recorded, “Small outbreaks of ‘three-day-fever’ again appear, the Pfeiffer bacillus being found; character becomes more virulent.” Sometime later he returned to add an ominous notation to this entry: “Influenza.” On 17 August, Kean noted, “Influenza increasing and becoming more fatal.” The following excerpts show the pace of his diary accelerating as he witnessed a developing crisis.

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4 September: Influenza appearing again, with severe pneumonia. 18 September: Sudden and serious increase in influenza-pneumonia; most extensive at Le Mans; with several hundred cases and thirty deaths. Reported also in French Army and among civilians. 28 September: Influenza increasing and spreading rapidly; 1700 cases reported at Brest. Total in A.E.F. Sept. 1–25, 11,910 cases. 6 October: Influenza and pneumonia have increased by thousands of cases. Case mortality of pneumonia, 32 percent. The situation is very serious. 11 October: Pneumonia mortality this week 45.3% 19 October: No improvement in influenza situation in A.E.F. 26 October: Influenza and pneumonia decreasing. New cases fallen off seventy-five percent. 2 November: Influenza-pneumonia declining. 7 November: 9.3 percent of A.E.F. in base or camp hospitals. Total non-effective rate reached 10.22 percent. . . . Influenza steadily decreasing; little of it on arriving transports. On the day of the Armistice, 11 November: “Sick rate has fallen to 9.98 percent.” And finally, 12 December: “Sick rate down to 7.46 percent. Influenza epidemic near its end.” Kean’s diary records the evolution of the first wave of influenza, from a “mild epidemic” in April into August’s “more virulent” strain to the “very serious situation” of the second wave in September and October. The sick rates he used to track the progress of the epidemic went to the heart of the struggle in the Great War. It was a war of attrition, where the winner would be the one with the last soldier standing. The point was not how many of the enemy an army killed or wounded, but how many men an army could field the next day. Replacement troops were key. The German strength had been seriously depleted by the 900,000 casualties of the spring offensive, and the Allies hoped that the German losses, combined with the arrival of one million Americans by August 1918, would tip the balance. Disease outbreaks that killed soldiers or rendered them ineffective, however, could seriously jeopardize the numbers game. Hospitals became a battleground where medical officers fought to keep as many men in the field as possible. Some historians have argued that because the influenza hit all belligerents with equal ferocity—civilians and the military—that it did not affect

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the outcome of the war.3 The flu did strike everywhere. Wartime censorship and poor record keeping obscure the actual situation, but millions of people became sick and many of them died throughout the world. About 225,000 civilians died in Britain. In France, the British Expeditionary Force recorded 313,000 cases of influenza in 1918, a rate of 15 percent, although the medical services believed that their records for influenza were incomplete.4 The French lost 135,000 civilians and 30,000 soldiers in the epidemic.5 In Germany, an estimated 225,000 civilians also died of the flu, and the German army recorded more than 700,000 cases of influenza, with morbidity rates ranging from 16 to 80 percent in various units.6 In the United States, Americans had a similar experience with the epidemic, with millions of civilians falling ill and as many as 675,000 dying. For the American army, however, unlike the Europeans, the influenza epidemic overlapped almost completely with the war. Few American soldiers experienced the German march through Belgium in 1914, the battles of Verdun or the Somme in 1916, or even the German offensive in the spring of 1918, but everyone experienced the flu epidemic. Only a few AEF combat units had participated in military operations in the spring and summer of 1918. Pershing did not field an entire American army until September when 550,000 men fought in the St. Mihiel offensive on 14– 16 September, and 1.2 million served in the Meuse-Argonne campaign beginning 26 September.7 The flu virus that had exploited war conditions to acquire new and lethal powers would now play a key role in the AEF’s greatest battles. Bursting upon the AEF in France about a week later than it had in the training camps, the second wave ran its course in about eight weeks, from roughly 15 September to 15 November. On 18 October, the AEF chief surgeon reported that “influenza and pneumonia continue to prevail in all parts of the A.E.F.”8 The flu was so powerful that it became for the moment the only disease of war. During the epidemic, medical officers diagnosed few soldiers with wartime’s perennial diarrhea and dysentery.9 And influenza even outnumbered combat casualties. According to one War Department report, whereas in 1918, 227,000 soldiers were hospitalized for battle wounds, including 71,400 men injured by mustard gas or other chemical weapons, and 144,000 for gunshot and artillery shell wounds, half again as many AEF soldiers—340,000—were hospitalized for influenza.10 Such horrifying figures brought infectious disease once again center stage in War Department politics and revealed the conflicting missions of military medicine—protecting the health of

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individual soldiers and providing a fighting force for war. Influenza struck the AEF as the army reached its peak strength and hit troops the hardest at the height of their military engagement.

Getting across the Ocean Transoceanic ships had long been transporters of deadly pathogens, bringing new sources of infection to the Americas since the time of Columbus. One of the first functions of the new federal government in the 1790s was to screen ships coming to American ports for disease and to quarantine any suspicious vessels or passengers.11 Ships not only brought germs to new environments, but the usually crowded conditions on board also provided excellent environments for disease to spread throughout a ship’s crew and passengers. Medical officers believed that such crowding on troop transports was “the most menacing insanitary condition” in the army, worse even than crowded housing in the camps.12 But given the shortage of ships and the pressure to get men to France, crowding was inevitable. Chief of Staff Peyton March decided from the beginning to use the navy transport service as a ferry, not as a transatlantic passenger service, so that men were closely packed, often sharing bunks in shifts (fig. 14). For example, as a passenger ship, the USS Leviathan had a capacity of 6,800, but the navy, which was responsible for transporting the army to France, used it to carry almost 11,000 soldiers.13 Although at the height of the epidemic the navy abandoned double bunking, crowding and the lack of ventilation on many ships remained a problem. The Medical Department later reported that despite medical officers’ reports of overcrowding on the ships, “the complement of the troop [sic] assigned was steadily increased in nearly every instance.”14 Faced with such crowding, medical officers screened men for sickness in the embarkation camps to prevent pathogens from getting on the ships in the first place. Still, with a short incubation period (twenty-four to forty-eight hours), the flu virus managed to board many ships with soldier-hosts. “Each and every inmate of the ship, as far as we know,” observed a medical officer on the USS President Lincoln, “may be the carrier of some pathogenic germ, which may find suitable conditions for its growth and development in the nearest person.”15 He may have been speaking of Ivan Farnworth, a soldier from Utah. Drafted in 1918, Farnworth trained for three months in California, and

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Fig. 14. Bunks aboard a troop transport ship. (National Archives, 111-SC37123)

then traveled by train across the country on his way to France. After arriving at Camp Mills, the embarkation camp in New York, he got the flu. Admitting to a form of malingering (in this case, hiding an illness), he told the story of how he got by the Medical Department’s screening process. After someone put him into a shed with other sick men, a physician came by to stick a thermometer under his tongue. “I was burning up with a fever,” he said, “but I just rolled the thermometer up on top.” Farnworth wanted to stay with his unit. “Our captain was turned back,” he remembered, “and he cried like a little child. He felt so bad that he couldn’t go over with the troops. He got turned back on account of the flu.” So, Farnworth said, “I just rolled that thermometer up on top of my tongue.” The physician suspected a fever, so when it did not register on the thermometer, he got a new one. Farnworth foiled him again. The puzzled doctor asked, “You are sick, aren’t you?” and Farnworth replied, “No, I feel fine.” And to the inquiry as to why his face was so red, Farnworth said, “It is always red. I just have a naturally red face.” He thus finessed the

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medical screening, but could not get on the ship alone. He needed his buddies. “Those kids just covered me up with their overcoats and carried my stuff on to the boat. . . . Then we went to France.”16 The Medical Department could not prevent him from boarding his ship with his flu germs. Traveling on a slow boat, he had recovered from the flu by the time he arrived in France, and his germs had most likely infected other hosts. Once the troops were on the ships, medical officers continued to examine them, isolating the ill from the rest of the population or, when possible, transferring them to home-bound ships for appropriate care.17 When army nurse Mary Dobson got the flu, she spent her entire voyage in the ship infirmary. Her ship was to sail on 29 September 1918. “In the morning I was really sick and had a very bad sore throat. But got on the boat and next morning they sent me to the infirmary,” she remembered. “I was there ten days with very little care because there was only one nurse for about twenty girls, all with influenza.” Her symptoms included “terrific pain all over your body, especially in your back and your head, and you just felt as if your head was going to fall off.” She also remembered a terrible odor in the ship’s infirmary. “I never smelt anything like it before or since. It was awful, because there was poison in this virus.” Eighty people died on her ship, but the navy did not bury them at sea. “We were on a southern route and it was very hot,” noted Dobson, so “they had to take all the food out of the refrigerator and put bodies in.”18 Events on board other troop transports during September 1918 show that Dobson’s experience was not unique. For example, the George Washington reported 550 cases of flu on board by its second day at sea, and seventy-seven deaths before the ship arrived in Brest, France.19 In another instance, even before the USS Wilhelmina departed for France on 23 September, medical officers removed fifty-two of its 2,400 passengers to an army hospital because they had flu. The medical officer on board, Robert Ivy, remembered that the fleet surgeon decided nonetheless against delaying the trip on account of sickness. New cases of flu developed every day of the journey, however, and by the time the ship arrived in France, 465 passengers, or 20 percent, were sick and fourteen had died en route. Ivy recalled that during the crossing they watched another ship in the convoy, President Grant, bury at least twenty bodies at sea, “owing to a shortage of coffins.”20 The story of the great transport ship Leviathan is one of the most dramatic and well-known stories of the damage wrought by the flu as the

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troops crossed the Atlantic. It struck many of them even before they were aboard the ship. As E. W. Gibson, an officer with the Fifty-seventh Pioneers, marched with his men to the ferry boats to Hoboken Harbor and the Leviathan, they “were falling out of the ranks, unable to keep up.” Army ambulances and trucks followed to pick up those fallen from the flu. Like Farnworth, many wanted to stay with their colleagues, so they “threw their equipment away and with determination tried to keep up with their comrades.” Not everyone succeeded, though, because once on board, officials took off one hundred more before sailing.21 The Leviathan left the port on 29 September with more than 11,000 people on board. Despite the medical screening, by the end of its first day at sea, seven hundred men were sick, and more fell ill every day. A navy report described the night of 1 October aboard the Leviathan as “a true inferno reigned supreme.” The report warned that “the conditions during the night cannot be visualized by anyone who has not actually seen them,” but then painted the picture. It described how sick men were spitting and vomiting without restraint, and “pools of blood from severe nasal hemorrhages of many patients were scattered throughout the compartments, and attendants were powerless to escape tracking through the mess.” The medical personnel gave their patients water and fruit, but these too soon ended up on the floor, so that “the decks became wet and slippery, groans and cries of the terrified added to the confusion of the applicants clamoring for treatment.”22 When it arrived in Brest on 8 October, the Leviathan carried at least two thousand passengers with the flu or pneumonia, and the bodies of seventy who had died during the crossing. Another fourteen would not make it off the ship alive after landing, and several hundred other Leviathan passengers died in AEF hospitals.23 Pershing’s chief of staff, James Harbord, remembered that when the Leviathan arrived at Brest, the camp’s commanding officer, Colonel Butler, “sent his own regiment down the four miles to the wharf, and between five in the afternoon and midnight they carried those . . . men on improvised stretchers to the Camp.”24 The image of a regiment carrying two thousand stretchers over four miles through the night illustrates the power of the flu to consume army resources—stretchers, men, beds, time, and morale.

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The Flu and Army Politics The Medical Department, like the rest of the War Department, bifurcated power between the surgeon general’s office in Washington, which had jurisdiction over the camps in the United States, and the chief surgeon of the AEF, who controlled medical operations and policies in France. The two branches joined ranks, however, on issues such as preventive health measures, housing density, and rank and authority for medical officers. The issue of troop transport to France severely tested the War Department’s challenge to balance measures to control the disease with the need for the rapid enlistment, training, and transport of recruits to France. During the influenza crisis, the Medical Department was in transition between surgeons general because Secretary Baker had pushed Gorgas into retirement, and his replacement, Merritte Ireland, would not arrive in Washington until late October. One of Gorgas’s deputies, Brigadier General Charles Richard, served as acting surgeon general in the interregnum. Despite his temporary status, Richard was not timid and mobilized the Medical Department to respond to the epidemic. Upon receiving the report of Vaughan, Welch, and Cole on the flu at Camp Devens, Richard issued a warning to the Medical Corps that influenza was epidemic, and “No disease which the Army surgeon is likely to see in this war will tax more severely his judgment and initiative.”25 His office peppered Chief of Staff March and others with daily memos making recommendations on the epidemic and distributed numerous bulletins to army personnel throughout the country on managing influenza and pneumonia.26 On 19 September, Richard warned March that influenza could break out on the troop ships. Acknowledging that “the military situation may demand that troops move without interruption, and this office recognizes that military necessity must govern in the last analysis,” he advised against taking troops from infected camps until the epidemic was over in their region.27 March approved this recommendation, which at the time affected only a few training camps. The next week, Richard told him that “a most serious situation exists at Camp Devens,” and that influenza had hit at least ten large camps and was continuing to spread. “Epidemic influenza,” he warned, “has become a very serious menace and threatens not only to retard the military program, but to exact a heavy toll in human life, before the disease has run its course throughout the country.”28 He recommended canceling all draft calls for registrants destined for infected camps and minimizing transfers between camps.29 While the

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War Department instructed camp commanders to reduce crowding and increase medical personnel, it halted only some of the new draft calls, so that in late September new trainees were still entering flu-ridden camps. Only the Provost Marshall’s subsequent cancellation of the October draft finally eased pressure on the camps.30 By the time the arrival of sick and dead soldiers in France got General Pershing’s attention, the epidemic had reached the highest echelons of the War Department and enveloped two monumental personalities—March, at the head of the army bureaucracy in Washington, D.C., and Pershing, AEF commander-in-chief in France. As intelligent, ambitious, West Point–trained officers with overseas experience, neither had doubts about his own abilities. The president and secretary of war had given them such unprecedented authority and freedom—Pershing to conduct the military campaign, and March to reorganize and manage the War Department to meet the demands of the war—that each believed himself the principal commander of the wartime army. In the rush to build the AEF, the two generals’ imperious personalities soon clashed, and relations between the War Department and AEF headquarters deteriorated. Conflicts ranged from issues as trivial as the Sam Browne belt (March wanted to abolish it as a waste of leather, Pershing to retain it as a sign of rank; Pershing won), to how many divisions the AEF would field.31 Baker adjudicated individual issues but did not clarify who was in charge until August 1918, when he determined that the chief of staff had authority over both the War Department and the AEF and held rank and precedence over all other officers in the army.32 By late September, Pershing’s office joined the Surgeon General’s Office in sending daily communications on the epidemic to March. For example, on 26 September, the day the AEF launched its Meuse-Argonne offensive, Harbord wired news of “a great number of cases of severe influenza and pneumonia and consequently many deaths among troops recently arriving in France.”33 In another cable, Harbord, who was familiar with the Medical Department’s recommendations to March, wrote: “Presume . . . that quarantine recommended is being enforced.”34 By the first of October, the AEF reported, “Influenza severe type epidemic throughout France and in A.E.F. complicated by septic rapidly fatal type of pneumonia.”35 Pershing demanded more medical personnel and supplies, more hospital space aboard ships, and a one-week quarantine of troops before transport. Richard used one of these cables in a memo of 1 October to March, noting that “if infected troops continue to arrive in

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France it will add greatly to the burden already heavy of caring for sick and noneffectives with the present shortage of medical personnel and equipment.”36 He then recommended reducing the capacity of troopships by at least one-half and reiterated his proposal of a one-week quarantine of all troops prior to embarkation. March disapproved the request, implying that rigorous preboarding physical screening procedures were sufficient to control the epidemic. Richard responded immediately: “It is impossible for medical officers to state with any degree of safety that any particular command is free from infection, or that it may safely embark on troopships for overseas service.” With that warning, he upped the ante dramatically, recommending that “all troop movements overseas be suspended for the present, except such as are demanded by urgent military necessity.”37 Richard was willing to suspend war mobilization to protect the health of the soldiers. He forwarded the communication to the General Staff and reminded them of March’s earlier disapproval of their quarantine proposal, but March still rejected a quarantine at embarkation ports. The controversy soon reached the White House. Perhaps in response to entreaties from the Medical Department, President Wilson sent for March to ask why he refused to stop shipments of men during the epidemic. According to March, the president “named a doctor of national reputation who was close to the White House as among those taking this stand.”38 March recited the army’s screening precautions and pointed out correctly that sick rates in some training camps were not much better than on the ships. He also invoked the exigencies of a war of attrition, pointing out “the psychological effect it would have on a weakening enemy to learn that the American divisions and replacements were no longer arriving.”39 He told Wilson that troop shipments should not be halted for any reason, and Wilson deferred to his judgment. “When symptoms of the disease were made manifest,” March summarized, “I adopted the policy of reducing the packing-in process by 10 per cent. I declined, however, to stop the shipment.”40 March and Wilson had no intention of stopping U.S. participation in the war. The “packing-in” policy had a price. Vice Admiral Albert Gleaves, chief of the naval cruiser and transport force, concluded that “the Spanish Influenza Epidemic taxed the resources of the transport medical departments to the utmost.”41 Calculations of how many American soldiers died while crossing the Atlantic vary. Gleaves estimated that 8.8 percent of the troops transported became ill with influenza and 5.9 percent of

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them—or 789 people—died at sea.42 Alfred Crosby’s tabulation of the Stars and Stripes reports on the number of men who died at sea and in hospitals within five days of arriving in France estimates the figure to be at least four thousand.43 Pershing saw the influenza epidemic’s interference with the conduct of the war before March did, and as the epidemic intensified, he called for more medical equipment and personnel.44 He increased the pressure on March in a confidential cable on 12 October: “Inadequate hospitalization facilities becoming more critical. . . . Situation so serious that it merits immediate attention and exhaustion of every possible effort to get this material and personnel to us at once.”45 The week ending 11 October recorded 6,160 American soldiers dying of the flu and pneumonia in France.46 Whereas March the mobilizer was loath to let a disease slow down the shipment of men to France, Pershing the field commander knew that sick soldiers were no help to him. When Pershing needed 90,000 replacement troops for his Meuse-Argonne campaign, March could provide him with only 45,000 because of the epidemic. He advised Pershing on 23 October: “Epidemic has not only quarantined nearly all camps but has forced us to cancel or suspend nearly all draft calls. . . . Only a few thousand replacements for November are in service.”47 March told the AEF commander, “If we are not stopped on account of influenza . . . you will get the replacements and all shortages of divisions up to date by November 30.”48 The conflict between the army’s responsibility to maintain the health of American soldiers and the Wilson administration’s desire to win a war of attrition at all costs once again stood at the center of government war policy. The army’s leadership negotiated medical policy, weighing the merits of amassing an army in France quickly against risking infectious disease aboard crowded ships. The General Staff, headed by March, favored executing the war with dispatch, while the Medical Department counseled preventive measures that would slow mobilization. When medical officers used their political contacts and exploited divisions within the War Department to advance their views, it exacerbated the already strained relations with the General Staff. After the war, some medical officers blamed the General Staff for the AEF hospital bed shortage. “The American E. F. hospitals could have taken care of the sick and wounded among the troops,” one report charged, “if there had been only a normal number of sick aboard incoming convoys.”49 Medical officers, however, lauded Pershing, because, according to Surgeon General Merritte Ireland,

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“it was only through his unwavering support that we were able to complete the organization we had and to carry out our work to a successful termination.”50 For his part, Pershing implied that the War Department policies had promoted the epidemic because “large numbers of cases were brought in by our troop ships.”51

The Meuse-Argonne Offensive General Pershing perhaps understood that disease had delivered a serious blow to the AEF during its most important military operation. The Meuse-Argonne Offensive (26 September to 11 November 1918) lasted forty-seven days, engaged 1.2 million soldiers, and consumed as much artillery fire as the Union army had used during the entire Civil War. The Meuse-Argonne accounted for the lion’s share of American battle casualties, allowed Wilson to claim a military role in defeating the Germans, and also became the battle by which posterity would judge American military abilities for a generation. The Meuse-Argonne campaign began poorly however, stalling after just four days and causing Allied commanders and historians to question the abilities of Pershing and the American doughboys. “The period of the [Meuse-Argonne] battle from October 1st to the 11th,” wrote Pershing, “involved the heaviest strain on the army and on me.”52 That strain was due not only to enemy opposition and the challenges of military logistics along the Western Front, but also the unseen virus that was depleting the AEF ranks, damaging morale, and interfering with AEF operations. The Meuse-Argonne campaign coincided completely with the influenza epidemic, taking place during six of the eight most intense weeks of the epidemic. Alexander N. Stark, chief surgeon of the First Army, which bore the brunt of the battle, wrote, “Influenza so clogged the medical services and the evacuation system, [and] rendered ‘ineffective’ so many men in the armies that it threatened to disrupt the war.”53 Were the Americans incompetent soldiers or were they just sick? Consideration of the staggering illness among the troops and the stories of people who experienced the epidemic at the front or behind the lines reveals the various ways in which the influenza epidemic shaped the American war experience. As American soldiers faced the enemy across no-man’s-land, a virus strengthened by war conditions also attacked them from within.

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The Meuse-Argonne was the Americans’ contribution to a final Allied offensive along the Western Front to drive the German army out of France. American combat divisions had fought in several Allied operations, but now Pershing had enough troops to field a completely American army. An independent American military campaign would give President Wilson a firmer stake in the war so he could shape the postwar world and would enable Pershing to prove American military prowess. The AEF’s first major battle was at St. Mihiel, 14–16 September, where it pushed a weakened German army several miles back from its entrenchments. The next campaign was Meuse-Argonne. Pershing planned a ninedivision offensive to the west of the Meuse River into the Argonne Forest designed to penetrate the main German defenses in only two days. He launched his attack early on 26 September. William Holmes Dyer, medical officer with the Ninety-second Division in the Argonne Forest, and one of the few black physicians serving as medical officers, was there. He heard “the most terrific bombardment of the war,” which began the night of 25 September and continued for thirty-six hours. “The old woods in which we were trembled as if by earth quake, the flashes of the cannon lighted up the inside of our tents and our ears were deafened.” Wounded soldiers soon streamed into a nearby evacuation hospital, but in Dyer’s camp, “in this wet, filthy woods many of our boys became ill from the dampness, cold and exposure causing me much work and worry caring for them.”54 The campaign, however, did not go as planned. American divisions soon sustained tremendous casualties or became bogged down in massive traffic jams in their supply lines. After four days of battle the army had incurred 35,000 to 45,000 casualties without reaching the main German positions. Casualties so depleted combat divisions that Pershing reduced the authorized strength of divisions by four thousand men each, roughly 20 percent, and broke up several divisions to supply replacements to the others.55 On 1 October he halted the campaign, admitting that his plan had failed. Allied generals were dismayed and disgusted, and Georges Clemenceau called for Pershing’s replacement.56 Assessing the early days of the Meuse-Argonne, historian Donald Smythe writes “whether because of incompetence or by its own command and logistics problems or both, the First Army was wallowing in an unbelievable logistical snarl.” It was, he says, “as if someone had taken the army’s intestines out and dumped them all over the table.”57 Smythe also describes a worn, weary,

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and depressed Pershing, who may have had the flu. At one point during those first days of October, Pershing broke down as he drove toward the front, sobbing his dead wife’s name and saying he did not know how he could go on.58 Americans were finally learning the bloody realities of trench warfare long known to the Europeans. After relieving several of his top commanders and calling for replacement troops, Pershing renewed the offensive on 4 October, but the going was still rough. During September and October 1918, the AEF endured monthly casualty rates higher than any during the Civil War or World War II.59 Military observers also estimated that there were 100,000 American stragglers—almost 10 percent of the combat force—wandering behind Allied lines. The problem was so bad the army command increased military police surveillance to restore order among the military units.60 Eventually, the Americans did break the German lines, defeat their army, and help bring about the Armistice. But the Meuse-Argonne had been costly for the Americans. It claimed 17,647 soldiers killed, 69,832 wounded by bullets or artillery fire, 18,864 gassed, 2,029 shell-shocked, and 68,760 with medical problems, mostly the flu.61 Historians have long debated the value of American participation in World War I and how well the AEF performed. Most agree that the prospect of a seemingly endless supply of fresh, well-fed, and wellequipped troops joining the Allies demoralized Germans and tipped the balance in the war of attrition. They do not agree, however, on the quality of American military performance. Some European historians all but ignore the AEF. British historian John Keegan, for example, devotes fewer than ten pages to the Americans in his 426-page The First World War, and Lyn MacDonald ends her story of the German spring offensive in early April before most Americans even arrived.62 American historians at first took their lead from Pershing’s Pulitzer Prize–winning memoir of the war which put a positive light on AEF performance, but more recent scholars are critical of Pershing and his army.63 Some believe that the AEF almost lost the Meuse-Argonne campaign, while others attribute American failures to the inexperience of the troops, logistical confusion, and flawed military leadership.64 According to David Trask, “The most important service of the AEF was to appear in France,” and, he adds, only the Armistice saved it from severe criticism.65 He blames the paralysis during Meuse-Argonne to poor tactics, loss of the element of surprise over the Germans, American inexperience, and the logistical tangle behind the lines. He ignores the role of disease, however. Paul Braim suggests that

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Pershing began to lose his sense of judgment and perspective during the Meuse-Argonne, achieving victory only at the cost of improperly trained soldiers’ lives. Critical of Americans’ habitual unpreparedness for war, he concludes, “The losses should have served as a lesson of the price of military unpreparedness. That lesson was not learned.”66 The experience of the AEF in World War I demonstrated another lesson unlearned by many —the powerful role disease plays in war.

Influenza and Its “Effect on Effectives” On 22 October, Brigadier General George Van Horn Moseley sent a memo to James Harbord, AEF chief of staff, outlining the influenza epidemic’s “effect on effectives.” Moseley reported that the AEF flu rates dropped slightly the week before, but that the mortality rates from pneumonia were increasing. He warned that troop convoys could bring in more men with influenza and pneumonia, that the AEF could not evacuate all the sick to hospitals because of a shortage of hospital trains, and that hospital beds were in short supply. “Moreover,” he concluded, “the shortage of personnel will make it impossible to give the very large number of patients now being cared for the care which it is desirable that they should receive.”67 Although some historians acknowledge the existence of influenza and pneumonia in the AEF during the final months of the war, few have examined the meaning of the epidemic during the Meuse-Argonne campaign beyond increasing the casualties and the need for replacements.68 Memos such as General Moseley’s suggest that the epidemic had a widespread impact on the American conduct of the war, and a closer look at the AEF performance in France in September, October, and November 1918 reveals that influenza seriously depleted troop levels, consumed scarce transportation and medical resources, probably contributed to the problem of stragglers during the Meuse-Argonne campaign, damaged troop morale, and made many people very sick and weak for a long time. Each of these factors requires further explanation.

Depleted Troops The AEF may have been more depleted by noneffectives due to flu than official figures indicate. American record keeping in France, for example,

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was imperfect at best for several reasons. First, the army training camps and the AEF counted the sick differently. While the training camps recorded all soldiers who reported ill, the AEF recorded only those hospitalized. An orderly serving in an AEF hospital remembered that during the epidemic, “the influenza rate was so high that the camp hospital was overcrowded and refused all men who did not have at least 104 degrees of temperature.”69 Often medical officers had to confine men to their quarters and did not record them as hospital admissions.70 Second, it was more difficult for AEF medical officers to keep track of the soldiers in their units than for their counterparts in the United States because of the constant movement of troops in France, transfers of individuals from unit to unit, and other confusions of military operations.71 In just one example, in late September men of the Eighty-fourth Division were billeted in twenty-one villages in an area spanning 30 miles.72 Such dispersion would hamper division commanders’ ability to keep track of their men, sick or well. Pershing complained to Harbord about poor medical record keeping. “The Medical Department has handled its men well so far as [medicine] is concerned,” he said, “but they lose track of men absolutely.”73 And finally, many soldiers went to great lengths to avoid going to army hospitals and sought to take care of their sicknesses themselves. From a dugout in the Argonne Forest, William Conklin, with the 308th Medical Detachment, wrote home that “when a small influenza epidemic broke out I found my hands full.” Soldiers from two companies were nearby and “the men all wanted to keep away from the hospital if they could. I had to depend on very rough and ready treatment.”74 British soldier Robert Graves recounts in his war memoir how he went AWOL for several days when he got the flu.75 Such underreporting hid the severity of the situation from the AEF commanders, who received reports as low as 220,000 cases, or only a 10 percent morbidity or sickness rate in the AEF.76 The Medical Department’s official record of 791,907 hospital admissions for influenza represents the lowest possible number of cases, about 20 percent of the 1918 American army. Another postwar assessment made the staggering statement that one million of the two million in the AEF “came into the hands of the Medical Department: roughly 775,000 through disease and 225,000 through injury.”77 Morbidity rates, then, rather than absolute numbers, provide a more accurate view of the impact of the epidemic on the AEF. The navy recorded 40 percent morbidity among its men, and individual AEF units reported sick rates of 20 to 40 percent or higher.78 The

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Medical Department estimated that about 26 percent of the army got sick, and Secretary Baker wrote that “one out of every four men had influenza.”79 These official assessments of the flu’s impact mean that one million soldiers in the four-million-man army within the United States and Europe may have fallen ill with the flu within a matter of weeks. In September, for example, the Eighty-eighth Division was training and fighting with the French army in the Alsace region. The division surgeon reported that “on September 20 extensive epidemic of influenza began,” and within a week 2,254 cases were reported in the division of 18,000. The flu continued in the division into October, with a total of 6,845 cases reported, more than 30 percent of the division. Because the Eighty-eighth was deployed at the front, medical officers noted that, “most of the patients were of necessity treated in billets,” with officers often giving up their accommodations for the most severely ill patients. Medical officers recorded a total of 1,041 pneumonia cases, but noted “there is every reason to believe that the actual number of cases was larger.”80 The division’s mortality rate for pneumonia cases reached an alarming 45 percent the week of 19 October.81 The worst day was 14 October, when eighty men in the division died from the disease. The epidemic interfered with operations, and the medical unit reported that “during the period covered by the epidemic the training of the sanitary troops had to be decreased.”82 Responding to an urgent inquiry from a superior officer wondering why he had not responded to an earlier request for information, the chief surgeon had to report that “the delay has been due to the fact that we are still in the midst of the epidemic of influenza and its concomitant pneumonia.” He guessed that a quarter of the division—five thousand men— were sick, “altho this estimate is probably below rather than above.”83 Battle casualties and disease required Pershing to restore division strength with replacement troops. The Twenty-sixth Division, one of the most experienced combat divisions in the AEF, for example, sustained eight thousand casualties in October—about a third of the division. Other divisions were down to only five thousand combat infantry apiece, forcing the American commander to reduce AEF rifle company strength from 250 to 175 men.84 Pershing also planned to break up divisions newly arrived in France to reinforce others, but finding healthy soldiers as replacements was not easy. For example, when medical officer William L. Moss investigated the epidemic in the Eighty-sixth Division to assess its suitability to provide replacements, he found a divisional sickness rate of about 35 percent, with influenza rates as high as 73 percent in some of

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the 250-man companies. He recommended that only units with no or very little illness be moved to the front.85

Consumed Transportation and Medical Resources Although AEF medical services were equipped to handle disease as well as combat wounds, the magnitude of the epidemic overwhelmed them. An early War Department plan called for hospital beds for 25 percent of the troops and a later one specified hospital capacity for 15 percent of AEF troops, but in the fall of 1918 army medical services actually had beds for only about 11 percent of AEF troops.86 Thus a 20 percent sick rate could tax medical resources, and the flu’s impact was felt throughout the AEF’s complex network of medical stations and transportation lines.87 Stretcher bearers represented the furthest extension of medical services into the battlefield. It took two to four men to carry one stretcher, depending on availability of labor, the men’s strength, and the difficulty of the terrain. At the battlefront, the stretchers brought casualties to dressing stations where medical personnel conducted triage. There they identified malingerers and separated patients into groups of moderately wounded, seriously wounded, gassed, contagious sick, noncontagious sick, and psychiatric cases. They treated the slightly wounded or mildly shell-shocked soldiers, dressed wounds, splinted broken bones, in some cases conducted surgery on the wounded, and provided food and warmth for those men able to return to their units. Stretchers or ambulances transported other men to field hospitals that moved with the combat divisions and were often close to the lines. The more serious cases were stabilized, then sent to hospitals farther back from the lines. The AEF designated specific hospitals for different kinds of cases—a hospital at Revigny, for instance, received influenza patients. First Army chief surgeon Alexander N. Stark wrote that during the Meuse-Argonne campaign, influenza “engulfed the First Army . . . and for a time it appeared as though its ravages would seriously affect military operations by overwhelming the sanitary formation.”88 He and his staff handled the flu at the front lines by “triaging all affected with signs of the disease as carefully as the wounded were sorted out, masking all affected, and transporting the uncomplicated cases in ambulances carrying no other class of patients to hospitals at Revigny set apart for this disease.” They also sent “those evidencing the slightest signs of pneumonia to a special hospital hastily established at Brizeau village,” and

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kept well, unaffected soldiers in the open air as much as possible. “While this menace,” wrote Stark, “did not stop the operations, it slowed them perceptibly.”89 A key function of field and evacuation hospitals was to identify “nontransportable patients,” who were too injured or sick to be moved. These included “those with hemorrhage, aspirating chest wounds, severe abdominal wounds, partial traumatic amputation, and deep shock.”90 They soon added pneumonia patients. Early in the epidemic, some medical officers discounted the seriousness of influenza and treated patients only after they had attended to soldiers with battle wounds. Neglected flu patients, however, often developed pneumonia, and an AEF epidemiologist warned that “the extreme contagiousness of the disease and its intimate relations with pneumonia is not fully appreciated throughout the A.E.F.”91 A medical officer working at a base hospital remembered that soldiers with the flu transported by ambulance from the front often died en route or within a few hours of reaching the wards.92 Another recalled that epidemiologists at his hospital soon “became convinced that influenza cases stood transportation very poorly, and that pneumonia occurred with much greater frequency in patients that were transported even comparatively short distances.”93 Convinced of the danger of transporting flu victims, Hugh Young, AEF urologist, became enraged when an army physician ordered the transfer of his brother-in-law to an evacuation hospital. The man soon died of pneumonia, and Young charged the officer with neglect of duty. “He was, I felt, directly responsible for my dear brother-in-law’s death.”94 With this kind of concern, on 12 October, at the height of the epidemic and in the midst of the Meuse-Argonne offensive, the AEF chief surgeon informed medical officers that “moving a case of pneumonia to make room for a battle casualty may kill the pneumonia patient and not aid the wounded, and the practice should not be tolerated.”95 The practice of holding flu patients at the front, however, overloaded the advanced medical units at the same time they were receiving battle casualties. Famed surgeon George Crile, working in a mobile hospital near the front lines in the Argonne, saw the impact of flu patients there. “Everything is overflowing with patients,” he noted in his diary. “Our divisions are being shot up; the wards are full of machine gun wounds. There is rain, mud, ‘flu’ and pneumonia. Some hospitals are overcrowded, some are not even working.”96 Staffing was so desperate, he complained, that “an ophthalmologist was in charge of these hundreds of

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cases of desperate pneumonias that are dying by the score.”97 Similarly, Richard Derby, Second Division medical officer and son-in-law of Theodore Roosevelt, noted the division medical services were “taxed to the utmost in keeping our field hospitals cleared, and ready to move with the advance.” As the Second moved into the Argonne, sickness “claimed many more victims than did the machine-gun bullet. The evacuations amounted to four or five hundred a day, of which only a fifth were battle casualties.”98 The flu could also put medical personnel out of commission at the very time they were needed most. William Estes, a surgeon working in an evacuation hospital near the front and responsible for repairing wounded soldiers, was hospitalized with influenza for several days during the Meuse Argonne offensive.99 The epidemic overwhelmed AEF medical personnel just as it did their counterparts in the training camps back home. On 22 October, more than 140,000 patients occupied AEF base hospital beds, 21 percent over the normal capacity of 116,000 beds, and on 5 November, there were 142,000 patients for 138,000 beds.100 At the local level, an army hospital in Bordeaux reported that during the Meuse-Argonne offensive their hospital overflowed to a peak of 4,235 patients compared to a normal capacity of 3,000.101 A medical officer at the laboratory at Dijon noted a dramatic increase in the demand for autopsies during the epidemic.102 Traffic jams and delayed transport created some of the worst problems of the Meuse-Argonne campaign, and the flu complicated the situation by flooding the system with febrile men and their caretakers. More than onethird of the 151,000 evacuations by train to hospitals behind the lines during the Meuse-Argonne operation were for disease, and the Medical Department reported “there never were enough ambulances for evacuation.”103 Thus, the influenza epidemic took thousands of healthy men from the AEF rank and file, filled the ambulances and trains, and overwhelmed AEF medical personnel and resources. A nurse serving in the Argonne in early November captured the scene at the front. Her hospital had no lights after dark, no water for two days, and endured intermittent German air attacks, but the sick and wounded continued to come. She wrote home that “hundreds and hundreds [were] pouring in here from another sector suffering from influenza and pneumonia.” Supplies were dangerously scarce, she said: “Imagine having 280 medical patients and six medicine glasses, no cups or bowls available.” She, five other nurses and two corps men cared for flu patients by keeping them warm with food, hot drink, and wool socks (fig. 15). “Our results are splendid with

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Fig. 15. Flu ward in AEF camp hospital no. 45, Aix de Bains, France. (National Library of Medicine, A 6721)

all but those seriously ill with pneumonia, on arrival,” she concluded. “I never want to see another case of pneumonia following influenza, it is a dreaded disease that is filling our A.E.F. cemetery fast.”104 From the stretcher bearers to the military cemeteries, the influenza epidemic overwhelmed army resources.

Stragglers Both the War Department and historians have bemoaned the image of nearly 100,000 stragglers—almost 10 percent of the combat force— wandering behind the American lines. A War Department memo on straggling dated 21 October blamed the problem on a lack of discipline among officers and soldiers, noting that many stragglers hid in the woods or dugouts along the former no-man’s-land. It recommended that “skulkers” found straggling for the second time should be “tried by court martial and sentence of death imposed upon them.”105 What War Department officials failed to consider, however, was that many of these men may not

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have been cowards or incompetents. The sudden onset, high fever, and extreme prostration of influenza may have contributed to the straggling phenomenon on the Western Front. Acting Surgeon General Richard, for example, advised that while most patients recover in three to four days, they are “entirely incapacitated for duty while the attack is at its height.” He also noted that “after a little practice, influenza patients can very often be detected by the peculiar, expressionless aspect of the face.”106 George Soper described the flu patient as “wholly incapacitated for exertion. He lies curled up and can hardly be roused for food.”107 Private Elton Mackin, whose Marine unit formed part of the army’s First Division, witnessed as much during the Meuse-Argonne. “Losses had been heavy,” he wrote, “some were due to battle . . . but most were caused by sickness, dysentery and flu.” Not everyone reported their illness to their commanders or medical officers, and Mackin observed that “men, weakened, sought a place of fancied shelter in the brush. They sometimes wrapped a sodden blanket around them and slept. And in sleeping they died.”108 Al Ettinger, a messenger for the Forty-second Division, remembered that during the Meuse-Argonne, “at least half of the men had severe colds; some could hardly drag themselves around.”109 Ettinger escaped the flu himself, but was seriously gassed during the battle. Unconscious for three days, he awoke to find himself hospitalized with flu victims. The flu was so devastating that medical personnel apparently mistook a man rendered unconscious by poison gas for a flu victim. On the Western Front men overcome with high fever may have become disoriented, accidentally separated from their units, or may have fled from the trenches or battlefield to wait out their fever in some abandoned building or shell hole. Decades after the war, John Voorheis, a veteran of the Seventy-seventh Division, sent a telling message to a comrade during a division reunion. “A special hello to Paul Segal for saving my life (from flu) in the old bay barn.”110

Morale One of the most important elements in an efficient fighting force is high morale, whereby soldiers have confidence in their mission and their commanders, are willing to fight with and for their comrades in arms, and are assured that their families are faring well at home. Military historian James Seidule argues that poor health, including the flu, damaged AEF morale and contributed to the Americans’ tactical problems and inferior

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performance on the battlefield. “The flu sapped the strength and the morale of everyone in the AEF,” he explains, and influenza “combined with malnutrition, inadequate clothing, and lack of sleep to create thousands of soldiers who suffered from combat exhaustion. . . . The result was an ineffective army with low morale.”111 Seidule points out that among other factors, disease undermined unit cohesion because men evacuated for sickness rarely returned to their original units, and instead were assigned to units of strangers, and the soldiers in the original units wondered about the fates of their comrades sent to the hospital who never returned.112 Many soldiers also worried about their families and lovers at home. Harry S. Truman served as captain of an artillery unit in the Thirty-fifth Division during the war. When he heard about the influenza epidemic in his hometown, according to biographer David McCullough, he “became so alarmed he hardly knew how to contain himself.” Truman’s sweetheart Bess, her brother Frank, and two other friends all had the flu. Even after he learned that they were recovering, he continued to worry. “Every day nearly someone of my outfit will hear that his mother, sister, or sweetheart is dead,” he wrote home. “It is heartbreaking almost to think that we are so safe and so well over here and that the ones we’d like to protect more than all the world have been more exposed to death than we.”113 Another soldier who had not received mail from his family and friends wrote home, “I do worry about the mail considerable, and sickness at home makes it worse.”114 Similarly, when Edward Hodgson, with an artillery battery fighting in the Meuse-Argonne, learned in mid-October that his sixteen-year-old brother, Lawrence, had influenza, he wrote home, “I hope Lawrence is better for I know he must need lots of care when he is sick.”115 He did not know that several other members of his family in Delaware were also ill and that Lawrence would die. Instead, he reflected, “What kept me going was seeing the moon. I knew that the same moon connected me to something good—to home, to Delaware. It saved me, probably, until the flu really knocked me out.”116 Influenza struck Hodgson shortly before the Armistice, and he was so delirious and weakened that it was days before he realized that the war had ended.117

Prolonged Incapacity Edward Hodgson’s case of flu incapacitated him for weeks. Mortality and morbidity rates alone, therefore, fail to encompass the scope of

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influenza’s debilitating effect on the army. The influenza virus and pneumonia made some people very sick and needing care for a very long time. The experiences of three American soldiers show that even when they were out of bed, they functioned below par for months. Harry Pressly, a law student from Nebraska, served as a military police officer in the AEF. Stationed in the port town of Brest, he began to feel poorly in mid-September 1918. At first he stayed in bed at his barracks, but on 26 September went to the hospital with a temperature of 104 and severe chills. There he remembered overhearing an orderly say he would not survive more than two days. When he did recover enough to write, he related his experience to a friend back home, sparing her few of the details. “Most of the boys there in that ward had the flu, and a great number of them went West [died] while I was in the room,” he explained. The men in the ward would know when someone was near death “because a curtain would be brought in, placed around the bed, and not long after, the poor fellow would be carried out on a stretcher, and you knew he had passed on.”118 The first time Pressly tried to get out of bed he was so weak he fell to the floor. When he did leave the hospital after ten days, he wrote home that “this letter will be very short, but will take more time and exertion than any I have written from France.”119 A month later he reported, “I am feeling better I think, . . . I got to spitting up blood yesterday and today so called on the doctor. He examined me with the stethoscope (lungs and heart) and couldn’t find anything wrong.”120 The medical officer told Pressly that as long as his temperature was normal, he was okay, but to have it taken daily as a precaution. Pressly did recover, but very slowly. When he went to see President Wilson’s arrival in France in December, he complained, “As my chest has remained sore, since I had the flu, it was quite hard on me. . . . I can hardly breathe this evening.”121 In January, he reported that he weighed 118 pounds, down from his usual 142. And in March 1919 he told his friend, “I have a bad cold, and my chest is so sore tonight. . . . It has been that way ever since I had the flu.”122 Hospitalized on the first day of the Meuse-Argonne campaign, Harry Pressly was weakened for at least six months. Ambulance driver Russell Dale was in the action at the Meuse Argonne, evacuating the wounded—or “blessies” as he called them—from advanced posts at the front to hospitals behind the lines. On 10 October he wrote to his parents in Indiana that he had come down with “the grippe” and was feeling rotten. “I was chilling like everything, and had fever, and every bone in my body ached.” He returned to camp where

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“the cooks made my bed for me right beside the kitchen stove, and corporal ‘Sox’ Gray, the Section doctor, fixed me up some dope.” Sleeping by the camp stove did not help, however, because “somehow the chills just ran up and down my backbone all night. So that this morning I’m feeling about as rotten as ever.” His commanding officer suggested he go to the hospital, so, he told his parents, “Guess I’ll do it, for I’m only a nuisance around camp, and it’s hard for them to take care of me.” With a reassuring “don’t worry about me . . . . If I was home, you’d just put me to bed on chairs till I got well,” he went off to the hospital. Only then did Dale appear on the AEF medical record books, and four days later he was out of the hospital. “I had this Spanish influenza that is so prevalent over here. I’m feeling all right now, though I’m still a trifle weak from being in bed so long.”123 Because of the flu, Dale could not transport the sick and wounded from the front during the offensive, but instead consumed transport and medical resources himself. He became a liability rather than an asset to the AEF. William Schira, of Ohio, was an orderly in Base Hospital 53 near Langres when the epidemic hit. His war-and-flu experience alternated between his role as a hospital worker and his turn as a hospital patient. On 18 September his hospital received several hundred patients, including eighteen German prisoners. Assigned to guard the prisoners, he wrote in his diary, “I believe I have the Gripp. I ache all over and have a high fever and a bad cold in my lungs.” He guarded the prisoners two more days but noted, “I am sick as a dog.” The next day he reported to sick call and was hospitalized, as were several of his friends. At first Schira appreciated the rest. “I am having a nice time in the Hosp. The nurses are very good to me.” He soon became bored, but “my temperature rose again this afternoon and I am real sick. They put me to bed and I darn’t get up for anything.” After more than a week in the hospital he was “disgusted,” comparing his case to combat casualties. “Some men have their arms off, some their legs, and they are all badly shot up. They are all from Verdun Front. I am lying to the Doctor and trying to get out of Hosp. But I am really not able.” He was also worried. “Another man died in this Ward this morning from pneumonia,” he told his diary. Discharged on 3 October, Schira immediately began working, but admitted, “I am so weak I can hardly stand up.” An orderly in a pneumonia ward, he had responsibility for forty-five patients, some of them delirious with fever. He had a temperature, too, but resisted going to bed until it reached 102 degrees. Returning to the hospital, he admitted his fear of pneumonia. “I don’t

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want 6 feet of France to sleep in.” This time he fought for his life. A nurse told him through his delirium that he “was flirting with the undertaker,” and he began to think about his girlfriend, Anna. “They are giving me Aspirin, Quinine, Strychnine, Glycerin, Digitalis,” he observed. After another week in the hospital, Schira was again released on 22 October and returned to working nights in the wards. He looked so bad, though, that the nurses offered to do his work and put him to bed in the ward. On 6 November he wrote, “I have worked almost day & night for the last week and was sick all the time.” He was again hospitalized, “Now this makes 3 times. . . . I am disgusted with my condition.” He stayed in the hospital until the Armistice, and hoped every day to be released. On 13 November he sneaked out of the hospital to attend his unit’s celebratory banquet, with a “good spread,” but admitted “I didn’t eat much.” With that demonstration of strength, he was again released from the hospital on 15 November, and went back to the wards. This time he stayed out of the hospital as a patient until he contracted scarlet fever in April.124

The Epidemic Wanes By mid-October, influenza had swept through many of the training camps, leaving a large number of trainees who had either had the flu or would be unlikely to get it. The Medical Department figured out that it could avoid or at least minimize influenza on troop ships by transporting men who had already had the flu or had been exposed to it and were therefore likely to be immune.125 Upon adopting this practice, after midOctober the army experienced little influenza and pneumonia en route to France. By the end of October the flu was receding from many parts of the AEF, too. James Harbord lauded March’s new policy on 26 October, cabling Washington that health conditions were improved “due to efficacious preventive measures taken in United States.”126 On 2 November, March could announce that only seventy-three men in a group of 25,000 troops landing in Europe had influenza.127 But influenza and pneumonia had already taken a heavy toll on the army, the AEF, and on Pershing’s performance during their most important operation. Healthy Americans might have done better. And if a major American contribution to the war was to provide more bodies to a war of attrition, an epidemic that consumed those bodies compromised the American mission. Influenza’s impact on the AEF’s performance

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would color how Americans both within and outside the army assessed it for the next generation. The AEF defeated the Germans at Meuse-Argonne, and the Allies declared victory on 11 November. But thousands of American soldiers did not live to celebrate the victory. One of them was Rhode Islander Henry Muenzel, who served with a machine gun battalion during the Meuse-Argonne operation. After days of fighting, he fell ill and was hospitalized in Langres. Muenzel died of pneumonia on 24 October. Josephine Finch, one of the nurses who attended him, wrote to his mother to describe the circumstances of his death. He had died about noon, she said, and “I do not think that he realized he was dying and he did not leave any message as I know of.” She explained, “He had something like convulsions during the night and the following morning when I came on duty he was very sick, but would understand you when you spoke to him; about noon he passed away quietly.”128 Muenzel, like so many others, had lost his life to war and disease.

Back Home After President Wilson appointed AEF chief surgeon Merritte Ireland to be the new army surgeon general, Ireland asked Jefferson Kean, who had recorded the progress of the flu in his diary, to return to Washington with him as his principal assistant. As the men crossed the Atlantic in late October, however, they could not escape the flu. “Our voyage to New York was uneventful,” Kean wrote, “except that we both picked up influenza. I had a temperature of 104, and was hardly able to dress to go ashore, but said nothing for fear of being held up by the Ship Surgeon.” (Kean, like so many other officers and enlisted men, resisted joining the sick rolls.) When his brother-in-law, a physician, met him at the dock, he “took charge of me and carried me off to his apartment to be put to bed.” The hospitals apparently were full of flu patients. Kean got out of bed on Armistice Day, and two days later went to Washington “weak and miserable, but happy to be home.” According to Kean, “Gen. Ireland’s attack was less severe,” but eager to begin his new job, Ireland “did not stay in bed long enough and was very miserable for several weeks.”129 Ireland and Kean, then, both began their new jobs of overseeing the demobilization of the wartime Medical Department “miserable” from the flu. Ireland, as government spokesman for the army’s health, presented a more favorable view of the situation. Upon arriving at the port in New

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York, he told reporters that “the American Army in Europe is the healthiest that the world has ever seen, and the morale of the entire force leaves nothing to be desired.”130 The wounded men, he remarked, regardless of whether they were drafted or regulars, made no complaints, and few soldiers were dying of the flu because they led “healthy outdoor lives.” Ireland added that although there was a shortage of doctors, nurses, and some supplies in army hospitals in France, as the Times reported, “this matter was being attended to.” The surgeon general told the Times, “The American Army demanded the best of medical and surgical care and comfort, and was getting it.” He most likely put this positive “spin” on the AEF medical situation because the nation at war would tolerate nothing less. After the Armistice, the pandemic receded from the front pages of the newspapers, giving way to stories of doughboy homecomings. Military medical personnel almost immediately began to record their war experiences. In true Progressive fashion, on 30 October the Medical Department ordered camp and divisional medical officers to prepare reports on the influenza and pneumonia epidemic from each camp and army station.131 But what would these official reports say? How would the Medical Department explain the catastrophe to the public? Given pronouncements such as Surgeon General Ireland’s about the health of the army and their own dashed hopes of protecting soldiers from disease, medical officers writing the medical history of the war would find it difficult to incorporate into their collective memory a pandemic that had been completely out of their control.

5 Postmortem The Trauma of Failure, 1918–1919 Necropsy 2920. Patient entered Base Hospital No. 17 on September 12, 1918, having been in France for one week. He had been sick at landing and had been riding in a baggage car for several days. He died Sept. 12 at 11:50 p.m. —Ward J. MacNeal, AEF Division of Laboratories

Necropsy As Surgeon General Merritte Ireland fought off his case of the flu and faced reporters in the Port of New York, medical officers cared for the sick and sought to stem the spread and the death toll of the influenza epidemic in France. Epidemiologists such as Ward J. MacNeal at the AEF’s central laboratory in Dijon stood at the center of the storm, bearing the brunt of the army’s responsibility for investigating the epidemic in the American Expeditionary Forces (AEF). MacNeal received the first reports of the “fever of unknown origin” in the spring of 1918, traveled to the sites of several flu outbreaks in AEF camps during the spring and summer, watched the virus mutate to its lethal form by August 1918, and then compiled the record of the flu’s destruction in the AEF. He wrote the first comprehensive medical account of the epidemic in the AEF, which was published in a medical journal and thereby incorporated into the official medical history of the war.1 Alarmed by their patients dying so quickly under their care, medical officers were appalled by their postmortem examinations. In 1918 army medical officers conducted thousands of autopsies, investigating 92 percent of the deaths in hospitals in August and September, and 85 percent of the deaths in October.2 The purpose was to “secure proper records of causes of death of American troops in France, and specimens of scientific

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value for the Army Medical Museum”3 (fig. 16). One AEF pathologist, for example, performed sixty-seven autopsies on flu victims in just two weeks in October. M. W. Lyon, Jr., at Walter Reed Hospital, conducted more than fifty autopsies during the epidemic.4 MacNeal’s report, like many on the influenza, included autopsy observations that often revealed the tragedy of an individual’s death. For example, Major H. E. Robertson reported: Necropsy 5002: Patient had a slight cold on Saturday, October 5, but took dinner with friends on that date. He was admitted to American Red Cross Military Hospital No. 1 from the Hotel Meurice at 6 p.m. on October 7 in a dying condition; died October 8 at 8:30 a.m. Duration of illness was therefore about 60 hours.5

And from Captain Arthur U. DesJardins: Necropsy 3456: Patient was admitted to Evacuation Hospital 2 on Oct. 16, 1918, with diagnosis of acute influenza; temperature 103 F.; pulse, 116. . . . October 17, the temperature rose to 104 F., . . . remained above 104 F., at times reaching 105 F; respirations increased to 50. . . . Death Oct. 20, 1918 at 11:30 p.m., four days after admission.6

Physicians like Robertson and DesJardins could do little more for their patients than monitor the progression of the disease. The autopsy reports revealed intimate and powerful images of the flu’s destruction, whereby the lungs—in a healthy person, pink, light, and air-filled—became bloody and sodden. MacNeal summarized the findings: “As a rule, all lobes of both lungs were involved, both lungs large, dark, heavy and firm. On section, the cut surfaces were very moist, dripping a bloody frothy fluid; . . . the whole process in the lungs might be designated as an example of massive, pseudo-lobar form of bronco-pneumonia, of a very malignant type.”7 Medical officers at times found gangrene or pockets of purulent matter in the lungs of the deceased and some compared the damage to that wrought by poison gas. These physicians experienced the flu epidemic with an intensity shared by few others.8 MacNeal and hundreds of other medical officers were not pinned down in the trenches by artillery fire or forced to go “over the top,” but they did fight in the front lines against the killer flu virus in the hospital wards and saw its destructiveness on the autopsy table. When the gov-

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Fig. 16. Postmortem room, base hospital, Fort Riley, Kansas. (National Archives, 165-WW-250-O-11)

ernment enlisted American soldiers to Save the World for Democracy, it assumed the role of the protector of the soldiers’ health. Medical officers acted as the agents of this protector. Although they knew better than anyone the dangers of infectious disease in the army, and did their best to prevent and control the epidemic, they reckoned with the influenza to little avail. In the aftermath, they were responsible for the postmortem on the influenza epidemic both literally, as they examined the bodies of the deceased, and figuratively, as they reported to the War Department and the American people the army’s record in protecting the health of its soldiers. The epidemic undermined their pride and confidence in being able to conquer disease and protect the men in their care. Medical officers also labored behind the lines as “noncombatants,” and some of them felt like second-class citizens in a war where the “real men” fought on the battlefield. Military surgeons struggling to save soldiers wounded in battle were still in some way fighting the enemy, but medical officers caring for flu patients experienced both professional and personal failure in their inability to protect the men from disease. These postmortem experiences

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could be excruciating for medical officers who operated within a military culture that did not consider them true warriors. Throughout the Great War, soldiers, their families, social groups, Congress, and government agencies negotiated policies concerning soldiers’ health and the care of the sick and the dead. As the war took more and more soldiers’ lives, the government and its citizens also sought to give meaning to their sacrifice, honoring them as heroes from the fields of war. Death by disease threatened to compromise that meaning, however. When thousands of soldiers died of disease—even more than died in combat—the influenza epidemic undermined the view of the state as protector. For medical officers, the flu was a frustrating and humiliating story of helplessness at a time when they, like all soldiers, were being tested by war.9

The Army and the Public When Americans joined the army in 1917 and 1918, volunteering or submitting to the draft, they committed themselves to possible injury or death to advance the nation’s interests and war aims. Modern warfare required mobilizing an entire nation, not just the military, and created an unprecedented connection between the U.S. government and its citizens. In order to maintain public support for the war, the Wilson administration assured its citizens that the war was being conducted well and that national resources, including American lives, were being used responsibly. During the influenza epidemic, thousands of worried parents and wives, journalists, business leaders, and elected officials flooded the White House, Congress, and War Department with letters and telegrams concerning their sons’ and husbands’ care. The correspondence shows the extent to which citizens held the government accountable for its policies and conduct during the war and the health crisis. Kate Hathaway of California, whose two nephews were serving in the war, sent Secretary Baker a special recipe for a sickroom disinfectant. “I am willing that they should face death in this war for democracy,” she told him, “but I can keep silent no longer because of the possibility of an unnecessary death on a lonely cot.”10 Members of the public requested information and offered theories about the cause of the epidemic. The New York City health commissioner asked what the army was doing to protect the civilian population around

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the camps from the epidemic, and a Prudential Insurance Company statistician wired the surgeon general’s office requesting data on the number of influenza cases and deaths in the troops in the United States in order to gauge the extent of the epidemic.11 Other correspondents suggested that the flu was the result of a peculiar order of the planets, contamination in chewing-gum factories, contagion from aliens (especially Germans), and people scattering germs along the Canadian border with Montana. The Surgeon General’s Office responded respectfully to these letters, usually advising that “there is no information in this office at this time that would support your suggestion. However, due consideration will be given to the matter.”12 Mothers sent special treatments for pneumonia, seeking to help the government help their sons. When a Czech woman in Ohio whose son was in the army sent in a letter and a recipe for a poultice for pneumonia, the War Department intelligence office translated her letter from the Czech in order to respond to her properly.13 Some members of Congress made pointed allegations of mismanagement in the camp hospitals. Representative Isaac Sherwood of Ohio wanted to know what was being done to prevent the spread of influenza in the army, and Senator Joseph Frelinghuysen of New Jersey asked if the inoculations the army administered increased the mortality rates from flu.14 In October 1918, two members from Kansas complained of the lack of medical personnel at the Camp Funston hospital. Senator Charles Curtis forwarded a letter alleging that “boys have died in Camp Funston without having any attention at all from an Army Doctor or an Army Nurse,” and Representative Jouette Shouse of Kansas telegraphed a demand for more nurses for the hospital.15 Curtis and Shouse both expressed an understanding of the exigencies of the epidemic, but Shouse called for “unusual steps in order that mothers of boys at Funston may know that the government will do all possible to care for their sons.”16 The Medical Department responded with assurances that staffing was adequate, that all patients were receiving care, and that the epidemic was abating. In some cases, government officials changed policies in response to citizens’ complaints. In the wake of the measles and pneumonia epidemics in the camps in late 1917, Congress increased payments to families of deceased soldiers, provided for the embalming of the bodies of dead soldiers, discontinued burial at sea of soldiers who died in transport, and encouraged the War Department to communicate more promptly and fully with families about soldiers’ casualties and illnesses.17 For example, the

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House Committee on Military Affairs heard testimony on a bill to “render possible the return of the bodies of our soldier dead to their home burial grounds in sanitary and recognizable condition.”18 Concern for the dead continued after the war as different groups formed the “Bring Home the Soldier Dead League” and “The Field of Honor Association” to debate whether to keep men buried in American cemeteries in France or to bring them home. In a politically astute move, Secretary of War Baker decided to let the families make the delicate choice themselves. The War Department ended up repatriating more than 45,000 Americans buried in Europe to cemeteries in the United States, including 2,400 flu victims from the Army of Occupation buried in Germany.19 Government officials such as Baker understood the political importance of treating soldiers well—alive or dead—in order to maintain popular support for the army. Medical officers were especially sensitive to public criticism, ever mindful of the humiliating typhoid epidemic during the Spanish-American War. Sighed Military Surgeon, “There is probably no organization which is a fairer mark for the shafts of public comment than one of those which are organized under federal control and which have, as the essence of their being, the support of the taxpaying citizen.”20 When faced with rumors that patients in army hospitals were poorly fed and clothed and that the physicians played poker, the Medical Department started a series of hospital papers for hospital personnel and nearby communities. The intent was “to combat such ridiculous and harmful stories,” explained medical officer Alexander Powell. “It did not take the Medical Department many months to realize that it not only had on its hands thousands of sick and wounded soldiers,” he explained, “but it also had the great American public—and the public required the most careful and tactful handling.”21 The most sensitive issue was the death of U.S. soldiers.

Dying for the Government Nation-states must mobilize their citizenry to support national goals, and in wartime this requires honoring the dead for their sacrifice for those goals. Historian Cecilia O’Leary has demonstrated that merely establishing a state is not sufficient in itself to create a nation, but that political leaders must use the imaginative process to mobilize the masses in order to unite disparate communities and social divisions behind a national vi-

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sion.22 In this context, then, dying for one’s country took on a significance beyond an individual death and came to represent the citizenry and the meaning of the war. A soldier’s dignity in death carried dignity for the nation and justified the war aims. The Great War formed a crucible for American nationalism in which the government and its citizens negotiated the definitions and meanings of national war aims, sacrifice, and individual honor. The U.S. government, like other war states, therefore convinced people to die for it by fostering mythologies about heroic sacrifice, and by creating medals, memorials, ceremonies, and national holidays that give meaning to and justify war. Some of the most powerful writing on World War I reveals how people tried to make sense of their war experience. Many of these writers portray the horrors and brutality of trench warfare: the life with rats, lice, and mud in the trenches; the hours and days of artillery barrages; the fruitless if not senseless infantry attacks against fortified machine guns; the agony of mustard gas and of gas gangrene; and the obscenity of a war of attrition measured not in land or treasure, but in the number of dead. Writers such as Vera Brittain, Sigfried Sassoon, and John Dos Passos spent a lifetime trying to make sense of these sights and sounds and experiences; other people never could.23 Nations appointed commissions to honor the dead and commemorate the war, to console the public, and to interpret the war experience in terms of glory and purpose rather than horror and tragedy. Historian George Mosse explains, “The aim was to make an inherently unpalatable past acceptable, important not just for the purpose of consolation but above all for the justification of the nation in whose name the war had been fought.”24 Honoring the dead and making sense of their sacrifice may have been even more difficult for the United States than for European countries because the national interest in the war was less clearly defined, because the war exacerbated ethnic, racial, and class divisions in the country, and because many Americans took pride in the society’s antimilitary tradition.25 The government therefore had to impart meaning to the war that surmounted these obstacles. The Wilson administration succeeded in rallying much of the nation to the War for Democracy, but the need to explain the war dead remained. This was made even more difficult by a war of attrition that troubled soldiers, citizens at home, and army commanders alike.26 Many military commanders could not accept attrition through death in the trenches because it seemed passive and unwarriorlike compared to a war of motion and cavalry charges. Military losses to disease

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must therefore have been even more painful to accept and more difficult to glorify. The United States had one final problem in making sense of the war dead: its ratio of deaths-from-disease to deaths-from-combat was worse than the other belligerents. Warfare presented many ways to die. The most glorious was to be killed in action against the enemy (KIA), or to die of combat wounds, while other soldiers died in accidents, were murdered or killed themselves, and still others were executed for crimes. More than half of the American dead, however, had succumbed to disease.27 This was more than in any other army in the Great War. Compared to the American ratio of roughly one combat death to one death from disease, in the French army six to seven men died in combat for every one who died of disease, and in the British and German armies the ratio was almost ten to one.28 While this was due as much to the short time the AEF was in the trenches as it was to the death toll of the flu epidemic, the data nonetheless humiliated the Medical Department. The situation led Victor Vaughan to parse the figures in an almost unintelligible manner at the first meeting of the Medical Veterans of the World’s War: Fortunately, notwithstanding the epidemic of influenza and pneumonia, notwithstanding that our death rate jumped from August, 1918, to October, 1918, to nine times the former rate, the death rate in August was less than 5 or about 5 percent of the annual death rate per 100,000, and it jumped to 47: notwithstanding that, we have come out of this war with the lowest annual death rate of any army that ever engaged in any war in recent times, in so far as we have any statistical data.29

Regardless of the cause of death, the state endeavored to honor its soldiers alive and dead. It awarded medals and ribbons to declare the government’s gratitude; promptly answered its mail from soldiers’ families to show the government’s interest in each soldier; compensated soldiers’ families for their loss; and commemorated their sacrifice with national cemeteries and ceremonies. Army Regulations and the Medical Manual spelled out in detail the procedures for reporting casualties and deaths and for handling the deceased soldier’s body and personal effects. Given “the unavoidable cruelties that war inflicts,” wrote one officer after the war, “we try to make up now in the prompt and efficient care of our wounded and sick and in our orderly and decent burial of the dead.”30 Government practices included tagging and registering the dead, notify-

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ing the family, embalming the body if possible, clothing the deceased in a proper uniform, and even taking photographs of the graves for the families. The War Department created the Graves Registration Service in May 1917 to catalog and bury the American dead, charging it with a “sacred obligation” whereby “the graves of American Dead should be perpetually honored and cared for.”31 The Graves Registration Service also prohibited burying men alone because “every isolated burial endangers the loss of a soldier’s body, and such a menace to the comfort of bereaved friends must be prevented at all hazards.”32 The army accorded each deceased soldier or nurse a funeral with military honors when conditions permitted. The individual’s rank rather than the cause of death governed the funeral procedure. Abraham Lincoln had long ago demonstrated at Gettysburg the power of the war dead and the national cemetery to give meaning to the human sacrifice of war.33 American national cemeteries presented a mixed message regarding the soldiers who died for the Wilson administration’s stated purpose of war for democracy. In Arlington National Cemetery, for example, although Civil War graves had not been segregated by race, during World War I cemetery managers set aside a section for “colored enlisted” men.34 This was not the practice in American cemeteries in Europe, however. In an AEF stratified by rank and class and segregated by race and sex, in death, officers and enlisted men, blacks and whites, and men and women were buried together and accorded equal space and resources.35 The same was true for cause of death—soldiers and nurses who died of influenza or another disease were buried right alongside men who had been killed in combat. In the Great War, American soldiers died as heroes, serving the nation and its ideals, whether going “over the top” to attack the enemy, fleeing the front lines, or suffocating on a lonely army cot. Congress also authorized War Risk Insurance benefits for death or disability “in the line of duty” regardless of the cause of death. Racial discrimination did prejudice the distribution of death and disability awards, and social and moral qualms withheld benefits to army patients with venereal diseases and many who were “shell-shocked,” but there is little evidence that the government discriminated against those who died of other diseases rather than in combat.36 By 1920, the Treasury Department had awarded more than one-half of the 105,050 death benefits for death by disease.37 Still, the military cult of manliness, action, and honor emerged in many subtle and not-so-subtle ways to valorize combat service and death in

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combat over death from disease.38 In the first place, the government paid soldiers who served overseas an increased monthly salary. It also gave soldiers and army nurses a gold chevron for the left sleeve for every six months they served overseas with the AEF, whereas war service at home was recognized with a silver chevron. The War Department awarded a gold “wound stripe” for the right sleeve for every time a soldier was wounded (not for each wound—soldiers unfortunately often sustained several wounds at a time), but reserved the Purple Heart for individuals wounded in action under “meritorious” circumstances.39 Frank Holden remembered that reporters considered Sergeant John B. White, who had five wound chevrons from having incurred sixty-three wounds on his body on five occasions, “a worthy rival of Sergeant York.”40 (American Sergeant Alvin York attacked a German machine-gun nest during the battle of Meuse-Argonne, killing twenty-five Germans and capturing 132 more and their guns. The government awarded him the Medal of Honor for his courage and accomplishment, and Hollywood immortalized him in 1941 when Gary Cooper played the title role in the film, Sergeant York.) The army did not, however, reward people for surviving lethal illness. Evelyn Raymond Schneider, a nurse who withstood measles, diphtheria, and scarlet fever while she served in Camp MacArthur in Texas, did not receive a stripe for her sleeve.41 When an army chaplain dedicated a cemetery at an American hospital in France, he cited the men who had died on “bloodstained, crater-pocked battle fields.”42 The war dead, in other words, were always the “fallen,” not the suffocated, and their deaths recalled images of blood, not bloody lungs. The War Department required medical officers to certify each death by reporting the identity and rank of the deceased, and the date, time, place, the cause of death and whether the injury or disease occurred “in the line of duty.”43 The Manual stated that “all diseases or injuries from which an officer or enlisted man suffers while in the military service of the United States may be assumed to have occurred in the line of duty,” unless they occurred before enlistment, while the man was AWOL, were self-inflicted, or were the result of willful neglect or immoral behavior, the latter referring largely to venereal disease.44 Thus, Major Jay Turnbull reported the death from pneumonia of Private Morley Banks of the 805th Pioneers, in October 1918, by noting that “death occurred in line of duty. Death was not result of soldier’s misconduct.”45 Regardless of the cause of a soldier’s death, commanding officers were responsible for notifying a soldier’s nearest relative of his death.46 In

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France, Captain L. G. Tighe, a battery commander in the Eighty-eighth Division, which had been hit hard by influenza, had to write letters to numerous families whose sons died of the flu. To Mrs. Lucy J. Hill in Dunnegan, Missouri, he said, “I want to write to you and give all the explanation and condolence possible,” and his two-page, single-spaced letter was a testament to the commanding officer’s respect for his men and for his duty to communicate with the family. Tighe first tried to explain the influenza epidemic to Mrs. Hill, noting that the flu itself was not dangerous, but that the complication of pneumonia could be. “This is what happened to your son Charles and it came so fast and with such little warning that the best medical aid that there was could not save him.” Tighe assured her that her son died quietly and “without agony,” and recounted his funeral at the American cemetery in Clermont, attended by the chaplain, a regimental band, and members of his unit. He then eulogized Charles Hill as a soldier and a man and framed his death as a sacrifice to an honorable cause. “This war has been a horrible thing,” he began, “at times we ask ourselves whether it is all worth while but there must be a reason for it and we must feel proud, very proud of men like your son, Charles.” Charles and others had done their very best, and “have died in the service of their Country in the most glorious and noble way that it is possible for a true American citizen and an honorable American soldier to die.”47 Charles Hill died in an army hospital bed many miles behind the front lines, but to his commanding officer and his mother, he was a war hero. Some families sought details about their loved one’s last moments and the circumstances of his death, and commanding officers, as well as medical officers, nurses, army chaplains, and volunteers with the welfare agencies responded. After James P. Working died of pneumonia at Camp Dodge, his parents missed his shaving kit in the personal effects the army sent home. Correspondence shows that one of Working’s officers tracked the kit down and sent it to the bereaved parents.48 Army chaplains Father Patrick Duffy with the Forty-second Division and Gustav Stearns with the Thirty-second Division spent much of their time ministering to the sick and dying, helping them write their last letters home, and presiding over funerals.49 William G. Hickey, regimental chaplain for Captain Tighe’s unit, wrote letters to Mrs. Hill and other parents describing their son’s funeral. His letters often included poetry or Bible verses and enclosed “a small piece of ribbon that was around the flowers placed on the casket and the grave.”50 Such correspondence between army officers and parents reverberated across the country during the epidemic.

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These army correspondents invoked images of heroism and the purpose of the war to justify a soldier’s sacrifice and to ease his family’s pain. Officers also at times sought to hide the chaos of a fighting army that may have lost track of its men, or the fact that an artillery shell had left no trace of a man’s body, or that a wounded soldier had been left in the field for hours or days. Some veterans told of parents who were grateful that the government had returned their son’s body to them, when they knew that the man had actually been blown to unidentifiable bits by an artillery shell. Others told of men summarily executed on the front lines for cowardice or insubordination whose families were told simply that they had been “killed in action.”51 It was easier for families to learn the details of a soldier’s death when they were still in the training camps. Friends and family often traveled to the camps to be with trainees who became sick. A Red Cross volunteer at Camp Dodge remembered seeing in the visitor’s house “parents to whom the sad news must be broken of the death of a dear one before their arrival, or the impending death of the one they sought.” And, he continued, “in the wards were more relatives beside the cot of a dead or dying boy, still and stunned by the suddenness of it, or grief stricken and inconsolable.” He saw one mother “on her knees beside her boy, holding his hands while he passed away.”52 In some cases parents brought charges of neglect or incompetence against the Medical Department, complaining that their sons did not have adequate medical care. The parents of Private Robert Melton, who died of pneumonia at Camp Funston, reported his physician, medical officer Louis W. Shreiber, for curtailing the time Mrs. Melton spent with her son. The army investigated, but cleared Schreiber of any misconduct charges.53 In another instance, a former army medical officer wrote a book alleging Medical Department incompetence in the death of his brother-in-law at Camp Morrison in Virginia.54 Most of these cases absolved the Medical Department, but they illustrate the degree to which families held the government responsible for soldiers’ welfare. They also suggest that the death of a son in the battlefield—no matter how horrible—was easier for many families to endure than a death in a hospital bed. Representative S. D. Fess of Ohio declared during the measles epidemic that no glorified war rhetoric could hide the “record of sickness and death of our youth called to the colors who have thus paid the penalty of national inefficiency before ever having the honor to be shot in defense of their country’s honor. The country,” he warned, “will demand an account.”55 Death in combat was certainly easier to explain.

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Warriors Dying in Bed War has always meant early death for young men, but the ideology and customs shaping how a society views these deaths change over time. No one planned on dying of disease in the army. The image of sacrifice was one of death in battle or KIA. When Theodore Roosevelt dedicated a memorial to the dead of his Rough Rider regiment of the Spanish-American War, he noted without irony their “supreme good fortune of dying honorably on a well-fought field for their country’s flag.”56 Thus, despite government policies that sought to treat the dead equally, many people, including soldiers, distinguished between the soldiers who died in battle and those who died of disease. This process can be seen in several ways: how war memoirs emphasized combat experience over daily life and rarely mentioned disease; how Americans honored and glorified death in combat but rendered invisible death by disease; and how people venerated warriors but held “noncombatants” such as medical officers in lower esteem. War memoirs often tell tales of the battlefield that overshadow the duller life behind the lines and between battles. The majority of a soldier’s experience in the war was boring, however, involving long marches and train rides, endless waiting in the trenches or behind the lines, and the routine tasks of life in the army. These activities may not make for compelling reading (or brisk book sales), but their omission obscures the role of sickness in the lives of many military personnel. The Medical Department reported that in 1918 alone more than 2.8 million officers and men required hospitalization or treatment in quarters for illness, and that sickness accounted for an astounding 40.6 million days lost in the army.57 Sick soldiers, however, have no place in most World War I narratives. Other than the legendary discussion of “cooties” at the front (which focused more on the lice than on the typhus or trench fever they could transmit), there was little discussion of sickness in general or the flu epidemic in particular. Few Forty-second Division memoirs, for example, discuss the ravages of the influenza beyond suggestive passages. Lawrence Stallings’s 400-page memoir made but three references to the flu. He noted that the Germans suffered from it, that in October his division had 11,000 cases per week (more than 40 percent morbidity), and finally observed that the AEF had special sheds “where the influenza patients had been removed from incoming transports to recover or die.”58 While these observations suggest significant or even shocking events, Stallings did not discuss them. He did not say who was sick, what the army did for them,

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or what impact the epidemic had on the unit and on the troops’ morale. Similarly, influenza patients populated the ward where medical personnel had taken Al Ettinger after being gassed, but he wrote little about the epidemic. And while Father Duffy made a point to observe and record the death of each man in his regiment, he wrote paragraphs describing how individuals died in combat but merely mentioned the names of the men who died of disease.59 Louis L. Collins, who later became lieutenant governor of Minnesota, was one of the few Forty-second Division memoirists to give much attention to influenza and its victims.60 Unitwide histories also valorized death in combat over death by disease in several ways. One was the manner in which they recorded war casualties. A history of an artillery regiment in the war completely omitted deaths from disease on the casualty list, thus rendering them invisible, but included the names of men wounded in combat and even those killed or wounded “by accident.”61 A Thirty-second Division Roll of Honor listed all those who died in the war from combat or disease, but provided photographs only of officers who were killed in action.62 Even the Medical Department ordered its casualties by cause of death. The department’s list of medical officers, nurses, and enlisted men who died in the war placed those who were killed in action at the head of the list, and those who died of disease at the end.63 Death from the flu carried subtle and traumatic meaning for medical officers, soldiers, and their families because in addition to KIA being more honorable, only “weaklings” died in bed of a fever. Surgeon Harvey Cushing remarked on the death of his friend, British medical officer and poet Thomas McCrae, “a soldier from top to toe—how he would have hated to die in bed.”64 Another medical officer said of the soldiers who died of disease, “How disappointed they were not to have been up on the front, and, if death was necessary, not to have died on the field of battle. This is to me the saddest part of our hospital work.”65 Harry Everett Townsend, an army combat artist, observed that the hospitals were overflowing with men with the flu during the Meuse-Argonne battle. “It’s a hard death for one who has come so far, thinking at the worst, to die fighting the Hun,” he said.66 Some soldiers even felt the need to defend disease victims. The Dooins’, an army hospital newspaper in France, wrote of the death of Private Henry E. Montague from pneumonia following influenza in December 1918. “Montague was only twenty, but he fought hard. It is quite as difficult to fight Pneumonia as to fight Huns, and far less inspiring.”67

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Many medical officers considered caring for the sick much less exciting than repairing the wounded. Harold Barclay, a surgeon at an army base hospital, had no desire to “take care of a lot of uninteresting sick,” and tried repeatedly to get transferred. “I want to get into the real thing and be with real men, and not sitting around here just taking care of sick people,” he wrote.68 As neurosurgeon Harvey Cushing endured an undiagnosed illness during the late fall of 1918, he mused that physicians were often stricken with that which they studied, “accordingly, I should be in hospital with ‘G.S.W. skull’ [gunshot wound to the head] rather than with this. It would have been more appropriate and more interesting to watch.”69 Cushing’s dark humor suggests his embarrassment at being bedridden with a medical ailment instead of a battle wound. Army nurses were the only Americans who could die in bed glorified as heroes because they died while fulfilling their socially prescribed gender role—making the ultimate sacrifice while caring for men.70 Most of the nurses who died in the war succumbed to disease, and when conditions permitted, the army buried the women with full military honors. The New York Times reported one funeral of a young nurse (unnamed) who had died of pneumonia after caring for influenza patients in an army hospital in California with the headline, “Nurse Who Died on Duty Buried Like a General.”71 Army Nurse Corps superintendent Dora Thompson noted the “beautiful solemnity” of a military service, so that “much of the sting of loss is gone; one feels so keenly the joy of service in the supreme sacrifice.”72 In a book commemorating the nation’s war dead with individual portraits, soldiers who died in the war numbered twenty to a page, whereas each deceased army nurse received a full-page portrait (fig. 17). The nurses’ white uniforms and caps and the soft-focus of the portraits enhanced the sanctified effect.73

Nurses and Other Noncombatants Medical officers’ inability to control the flu epidemic undermined their confidence in their professional abilities. “Do not flatter yourself that what you did had any effect,” one epidemiologist told his colleagues during the epidemic. “If you came out well, you play in luck—that is all there is to it.”74 Another team of medical officers admitted, “In view of our death rate . . . we can scarcely make great claims for this treatment.”75 Such failure during a national crisis was intolerable for many medical

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Fig. 17. Portraits of a nurse and soldiers who died in World War I. (W. M. Haulsee, F. G. Howe, and A. C. Doyle, Soldiers of the Great War [Washington, D.C.: Soldiers Record Publishing Association, 1920])

officers, especially at a time when they had to wrestle with the environment of wartime hypermasculinity.76 Their role as healers paled next to the virile heroes of armed combat. Medical officers served not as warriors, but as “noncombatants” similar to female nurses and male laborers. They thus had to fend off the prevailing, value-laden wartime dichotomies of combat versus noncombat, homefront versus battlefront, soldier versus “slacker.” The Military Surgeon reflected this concern with

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regard to the low rate of physician enlistment: “It is unthinkable that there is hesitancy because of physical fear,” it protested. “we have the best of testimony that the medical officers in the present war are brave even to rashness and we pride ourselves upon the fact that courage is a time honored attribute of the followers of Aesculapius.”77 In the military culture, combat experience proved to be the path to advancement and respect in the military. While many medical officers were

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proud of their roles as professionals and scientists, most were denied the path to glory in war. “No medical officer can acquire fame in war,” William Gorgas told Victor Vaughan, “but every medical officer has the opportunity to do good.”78 The AEF, like other armies along the Western Front, cultivated a contempt for those not on the front lines. Some men conflated “noncombatants,” such as the soldiers who worked in army offices, medical personnel who tended to the sick and wounded, or the black stevedores who loaded and unloaded the ships, with women, children, and men unqualified for military service at home.79 Marine Elton Mackin, for example, remembered how his buddies derided the men in the Services of Supply (SOS) in which the Medical Department served. Asking a colleague in the trenches if he had teased a German, the other soldier said, “Nobody kids those birds—nobody but those slacker bastards in the SOS! They don’t know any better.”80 The secretary of war rewarded combat experience when he promoted AEF chief surgeon Merritte Ireland to be the new army surgeon general over Robert E. Noble, who had stayed in Washington to serve as Gorgas’s deputy. As a senator told Ireland, “On account of your distinguished services in France with the fighting forces the equation was settled in your favor rather than in Gen. Noble’s favor.”81 In a less important case, when medical officers in Boston formed a club after the war, they limited membership to “those who have served in the advanced zone in the recent war” and named it the Eclat Club, after the French word for shrapnel.82 Medical officers resisted the sobriquet of “noncombatant.” A man serving with the British Medical Services observed, “The division of the troops into two categories—combatant and non-combatant . . . is a wholly artificial arrangement.”83 Medical officers, he pointed out, often had to withstand enemy shelling and the hardships of the trenches. Percy Ashburn, a medical officer who served in Washington, D.C., during the war, wrote, “Only half of the army got abroad at all. . . . To the A.E.F. was the glory; to the man at home quite as hard work and disappointment.”84 Medical officers sought respect not only as physicians but as men. Army morale officer E. L. Munson sought to contradict the view of medical personnel as noncombatants by noting that the percentage of medical corps deaths was higher than for other branches of service.85 On an equally morbid note, another medical officer boasted, “The mortality of the army surgeons in the different battles has been fully as high as that of the infantry.”86 Thus, asserted the Military Surgeon, “When [medical officers] have won their spurs at the front under exactly the same condi-

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tions as any other soldier and the same risks, they have a right to demand the same rewards, not because their skill and efficiency as surgeons are increased thereby, but because they have won by soldier service.”87 In order to demonstrate their manliness, many medical officers spurned the relative safety of service in hospitals behind the lines or in the United States and lobbied the army command for assignment to combat units. Stanhope Bayne-Jones, Gorgas’s cousin, first got Surgeon General Gorgas to send him to France, and then used his connections to transfer out of the laboratory at Dijon to a combat division. Once in the Twentysixth Division, he grew a mustache.88 Richard Derby, Theodore Roosevelt’s son-in-law, resisted being promoted to a staff job, choosing to stay with the Second Division. “The Division,” he believed, “was the unit that did things . . . . [Promotion] had no attraction for me, and . . . as long as I was young and tough and strong I would stay with a division.”89 Enlisted men had similar concerns. Chester C. Nash, Jr., a cook at an AEF hospital, confided to his diary that while being in the army was a wonderful experience, “I would prefer to get into a man’s unit, get out of this baby affair. Then I might be a real man.”90 But medical officers wielded scalpels, not bayonets, and rarely went “over the top.” So, although the War Department awarded Distinguished Service Medals and Distinguished Service Crosses to medical officers for their war service, none received the most coveted decoration, the Medal of Honor. The government reserved that for “heroic acts.”91 The epidemic damaged medical officers’ masculine and professional pride. Thousands of soldiers died despite the fact that the Medical Department had carefully screened the “weaklings” and “unfit” from the army. The best physicians in the land, vetted by the Medical Department, stood helpless as the healthiest people in the country succumbed to flu and pneumonia. “Let us look on the failures,” wrote one medical officer. “A great lesson has been learned as to what it is useless to do.”92 Navy physicians were similarly abject. For example, two medical officers published a paper on the flu which they wrote “not with any claim for acceptance or originality,” but in hopes “that in the light of totally negative or confusing reports some seemingly unopened direction may be presented along which to further extend our efforts to clarify the etiology of the recent conflagration.”93 Losing soldiers in combat to enemy fire was tolerable, because the blame lay with the enemy—the Germans killed the American soldiers. But when men died of disease, medical officers had only themselves to blame. To make it worse, some people credited the

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nursing care they received—in other words, female nurses, not doctors— with saving their lives. The war had exaggerated gender distinctions as men took up weapons to fight on the battlefront while women stayed behind to tend to the homefront. Medicine, a largely gendered profession, was completely segregated by sex in the army: doctors were men and nurses were women. These distinctions became sharper to medical officers as they shared with nurses the second-class status as noncombatants. Although male orderlies worked in army hospitals, “the term male nurse is a misnomer,” a medical officer observed. “A man can not be a nurse any more successfully than he can be a mother.”94 As the physicians of the Medical Corps created and defended a privileged position for themselves by barring nonwhites and women from their ranks, they worked equally hard to distinguish themselves and their skills from nurses, believing they possessed more powerful knowledge and technology. Although army nurses crossed over gender lines when they entered the theater of battle, they remained subordinate to army physicians. The nursing profession had emerged in the nineteenth century to comport with women’s gendered sphere, and Florence Nightingale promoted women as medical professionals by claiming their “natural” role as caregivers and promising their subordination to male doctors.95 As one nurse declared, “Woman possesses qualities which naturally make her superior to the average man for this important work, which,” she added, “stands second to the medical profession itself.”96 The influenza epidemic threatened this relation because it rendered male physicians helpless and empowered female nurses in a time of crisis. Physicians and nurses alike knew that traditional nursing care—warmth, good food, bed rest—provided the best and only effective treatment for influenza and a preventive against pneumonia.97 Allowing pneumonia patients to rest also enabled their lungs to clear. Nursing, not medicine, saved lives. Furthermore, while medical officers were responsible for keeping the soldiers from getting sick in the first place, nurses did not have this responsibility. They stepped in when the soldiers became sick— in other words, when the doctors had failed. A telegram from General Pershing to Washington headquarters in early October encapsulated the crisis regarding the status relation between physicians and nurses. He wired that influenza was epidemic among the troops, and “in all probability conditions will not improve but will grow worse during the winter.” He needed more medical personnel, but: “Request 1,500 members of Army Nurse Corps, item M1181 W, to be sent to France as an emergency

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requirement at the earliest practicable date. . . . Cancel an equal number of Medical Corps replacements requested for October and November.”98 At the height of the epidemic, Pershing wanted to replace doctors with nurses. While the influenza epidemic was an experience in failure for many physicians, it was often a triumph for nurses because the two groups measured their successes differently. Historian Nancy Bristow has argued that nurses found personal and professional satisfaction during the epidemic because caring for patients met their standards of womanhood. Male physicians, however, she notes, “measured themselves against the heroic masculine standards of medicine, and in the face of the epidemic often experienced both personal and professional disillusionment.”99 The epidemic gave female nurses the opportunity to offer their skills to the nation. As army nursing superintendent Dora Thompson told a nurses’s convention, “The heroic self-sacrifice and fidelity to duty shown by the nurses is without parallel, as no great epidemic such as this has swept over the country since the world has had the blessing of graduate nurses.”100 Another nurse, Mary Beard, exclaimed, “With such a spirit animating us all, there is coming to the nursing profession a broadening, a growth, a development so great and so good one hardly dares to imagine its possibilities.”101 The epidemic even convinced the army to drop its ban on employing African American nurses in the training camps. Aileen Cole Stewart went to Camp Sherman, where she was sworn in the day after the Armistice. She remembered that while the surgeon general had at first said it was “not feasible” to employ black nurses, “in 1918 the Red Cross called us up because of the flu epidemic.” All of her patients were flu victims, and “people were dying everywhere. It was dreadful. The country was just devastated.”102 Although Camp Sherman did not segregate the hospital, Cole and her colleagues did live in segregated housing. (Racial integration in the army was limited; the War Department did not call African American doctors to serve in the camps during the epidemic.) Medical officers continually defended their status as superior to army nurses, and most were vigorously opposed to the nurses’ effort to acquire military rank. When Congress established the Army Nurse Corps in 1902, it denied nurses the privileges of rank despite the fact that they needed rank to clarify their authority, professional education, and skill over enlisted men in the hospital wards. Army nurses renewed their demands for rank when the United States entered the war, but Congress

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rejected it in the face of Medical Department opposition.103 Negotiations continued after the war when army nurses and their supporters launched a well-funded national lobbying campaign to bring the issue before the Congress.104 This time, with the ratification of the Nineteenth Amendment in 1920 establishing national women’s suffrage and the support of some army officers (most quotably Pershing, who told a congressional committee that “if we would give nurses guns, we would not need to give them rank”).105 Congress approved rank for nurses. The new law provided for only “relative rank,” however, stating that members of the Army Nurse Corps “shall have authority in and about military hospitals next after the officers of the Medical Department.”106 Medical officers thus retained dominance in the power relation between male and female officers. Surgeon General Ireland had to resist one final challenge to parity for nurses, though, rejecting a proposal that the gold bars indicating rank be made of gold lace for nurses.107

The Third Wave Despite the November 1918 armistice, the war and the flu were not over for everyone. Many Americans had to stay in Europe because troop ships had been returned to commerce and were not available to take people home quickly. Pershing had also formed another army. The AEF’s Third Army joined the Allied Army of Occupation and moved into the Rhineland to ensure the terms of the Armistice and keep pressure on the Germans during the treaty negotiations. As the training camps at home hastily emptied, many of the two million soldiers languished in France until the spring and summer of 1919. Soldiers and medical officers alike fell prey to a third wave of influenza which swept the world: another wave of death and failure. The third wave was not unexpected. Medical scientists were familiar with cycles of flu outbreaks, and Jay Grissinger, Third Army chief surgeon, was prepared: he had requested 5,000 hospital beds for the 240,000-man army. When the commanding general approved only 2,100 beds, Grissinger went over his head to the army chief of staff and got his 5,000. “The soundness of our calculation,” he later wrote, “was abundantly proven during the early months of 1919 when an outbreak of respiratory disease was encountered.”108 But even if expected, the third wave of influenza seemed especially cruel because it killed people who had survived the war.

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As one officer remarked, “Perhaps nothing touched the hearts of the American people more than did the deaths of those who had survived strenuous training, an ocean voyage fraught with peril, enemy shells, and disease, only to succumb to illness after all warfare was over.”109 Medical officer William Dyer had to watch a patient, Private Ben Eggleston, die of pneumonia aboard the Aquitania on 27 February 1919, just two days before the ship landed in New York.110 During the first three months of 1919, the Third Army hospitalized more than 31,000 men. While only 13,000 of these had respiratory illnesses, 90 percent of the deaths were from the flu and pneumonia. In the Forty-second Division, 30 percent of one regiment fell ill with the flu, and Frederick Pottle’s evacuation hospital had seventeen deaths during the first week of January.111 The epidemic prompted a spate of medical bulletins, inspections, and a special investigation of respiratory disease in the Army of Occupation, none of which shed new light on the problem.112 Medicine was as ineffectual as during the first and second waves, but AEF medical services seemed, if anything, a little more frantic. A Third Army bulletin issued during the epidemic warned medical officers and line commanders that “sick casualties only differ from battle casualties in that they are largely preventable,” and “sickness is not a dispensation of Providence, but usually a breach of discipline and sanitary offense.” The bulletin ended ominously: “Epidemics do not occur in well regulated companies,” suggesting that any outbreaks signified incompetence or laxity on the part of the medical and line officers in charge.113 Bed rest, alcohol baths, and aspirin could not prevent Clair F. Pfennig from getting pneumonia. Pfennig, an engineer with the Twenty-ninth Engineers, managed to avoid the first and second waves of influenza, but on the last day of the year he reported to sick call with a temperature of 104.8 and was sent to army Base Hospital No. 216 with four others from his unit. He would not leave the hospital for six weeks. His war diary for the period contains little more than daily weather observations and notes on the trajectory of his illness. The first week he noted his temperature and the alcohol baths nurses gave him to reduce his fever. One day he suggested his delirium, writing, “Little crazy head.”114 After three weeks, Pfennig was able to get out of bed for fifteen minutes, but several days later was “not as well.” After a full month in the hospital, he could be “up all day,” and in the fifth week he ate at the mess for the first time.115 During his confinement in the hospital, one of Pfennig’s friends died and another recovered. The hospital discharged Pfennig himself on 17 February

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1919, and after that he made few comments in his diary about his physical condition. Pfennig may have needed to recuperate for some time, though, because he sailed home with a “casual company,” units the army used to gather sick and injured soldiers to evaluate their fitness for return to duty. When influenza reappeared in the army in Germany, Congress was much less interested than it had been in October 1918. In February 1919, an Alabama senator presented a resolution from his state’s legislature calling for additional funding to investigate and eliminate influenza, and an Ohio representative took the floor of the House to inquire about what the Public Health Service (PHS) was doing to prevent a recurrence.116 When other members of Congress introduced bills to fund an investigation of the epidemic, Secretary Baker said he welcomed a study because a solution to “the problems concerning the cause and methods of prevention and control of the pneumonias, influenza, and allied diseases . . . is the most urgent one confronting public health authorities today.”117 But in early 1920 the Senate approved only one-tenth of the funds requested, reducing support from $5 million to only $500,000.118 There was little interest in fighting the flu after the war. Questions regarding health conditions in the army did arise briefly in Congress in January 1919, but soon fell silent. If members of Congress were not getting complaints from servicemen’s families, they were less inclined to investigate. When a New York congressman complained about the treatment of a pneumonia patient at Walter Reed Hospital, New York colleague and decorated war veteran Representative Fiorello La Guardia headed off his challenge. He took the House floor to defend the Medical Department, armed with the results of an investigation of the case that absolved the hospital of neglect. He stated, in a non sequitur, that while he had no personal experience with Walter Reed, “The medical department of our service overseas come out of this war with a 100 per cent perfect record.”119 Congress and the public’s inability to sustain interest in one of the worst plagues in human history may be attributed to several factors. First, the fact that the influenza attacked civilians and soldiers alike blunted criticism of the army. People could not charge the army with neglect as they had with the measles and pneumonia outbreak in the winter of 1917–1918. Second, the War Department seemed more skillful in handling crises. For a while, a scandal threatened with regard to health conditions at the port of Brest on the west coast of France through which one

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million men passed to return home.120 During the epidemic, a high-ranking medical inspector stated, “The condition in which our troops are arriving is pitiful and the lack of provision for their welfare at the so-called rest camp thoroughly unsanitary, inadequate and distressful.” He warned, “These conditions would create a serious scandal in the United States and would cause American people to go wild with resentment.”121 The War Department defused the problem with what amounted to a public relations campaign, including praise on conditions in Brest by General Pershing, a navy chaplain, and Mary Roberts Rinehart, a former nurse and well-known mystery writer.122 AEF chief of staff James Harbord sent Rinehart, who had two sons in the military, to Brest with instructions to telegraph what they expected to be her favorable findings regarding conditions in the camp to Washington. “She is patriotic and sympathetic, as well as gifted and charming,” wrote Harbord, and “her cablegram was widely published at home and fulfilled its purpose.” According to Harbord, the strategy worked. “No more unfavorable press notices condemned Brest and Pontanezen Barracks after her disinterested testimony was released,” he wrote, with some pride.123 Another reason Congress and the public’s concern about soldiers’ health waned was that as more and more men left the army and came home, health conditions in the camps became less important to the nation. Americans and their representatives turned away from the war and the outside world with dizzying speed. The Wilson administration dismantled the public and private apparatus that had supported the war effort and demobilized the army. The speed of demobilization was breathtaking. In November 1918, the army stood at more than 4 million men, but by 1920 it was just over 200,000.124 The final reason for Congress’s lack of interest in the epidemic was that war news gave way to news of revolution in Europe, race riots in the United States, the Red Scare, President Wilson’s role in the Paris peace talks, and the Senate debate of the Treaty of Versailles and the League of Nations. The electorate even shifted gears, rejecting the political party that had led the nation in war. Voters put the Republicans in control of Congress in 1918, and then elected a Republican president in 1920. Despite the personnel cuts, the Medical Department fared well in the reorganization process. Surgeon General Ireland was even able to maintain a separate promotion system for medical officers, complaining that the Medical Department “suffered very seriously” under the General

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Staff.125 “That is the cruel thing about all of this,” he stated. “If the Medical Department is not efficient, if the sick are not cared for, or if the sanitation of a command is not carried out as it should be, the Medical Department is going to be held responsible and is going to be blamed.”126 Congress placed controls on the General Staff and allowed the Medical Department to retain its own promotion system.127 The postwar Congress did spend months investigating the army and the conduct of the war, but paid little attention to the impact of infectious disease outbreaks. Even the investigations of Medical Department practices focused on discharge policies and the treatment of patients in three hospitals, not epidemics.128 Members of Congress and scores of witnesses from the War Department and other communities had no criticisms of the Medical Department’s conduct during the influenza epidemic. It was as if it had not happened. In this political climate, medical officers and other army officials began to minimize the role of infectious disease in the military.

Turning Away from Failure William Gorgas, in his last assignment as surgeon general, inspected the AEF medical services. In September and October 1918, he toured the forces from combat units on the front to the hospitals in the rear. Although he was with the AEF during the height of the influenza epidemic, he mentioned the flu only once in his fifty-page report, focusing instead on the evacuation and treatment of the wounded and the shell shocked, and sanitation in hospitals. The report was classified until 1986, but Gorgas invoked the judgment of the American people as he reported on the Medical Department’s care of the soldiers. He told the secretary, “I would not hesitate to assure any wife, mother, or sister that her husband, son, or brother, when wounded in France, would receive the very best professional and nursing care.”129 In his initial report to the Secretary of War and Congress on the operations of the American Expeditionary Forces, General Pershing did not mention the influenza epidemic.130 His final report characterized health in the AEF as “marvelously good,” noting “only two diseases have caused temporarily excessive sick rates, epidemic diarrhea and influenza, and of these influenza only, due to the fatal complication pneumonia, caused a serious rise in the death rate.”131 Gorgas and Pershing thus chose to handle the influenza in the AEF with virtual

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silence. Their failure to acknowledge the role of the epidemic in the war may be attributed to their desire to make a positive accounting to their leaders and the American people, as well as their interest in avoiding a discussion of something that was beyond their control. But the omission created a misleading view of the American war experience. Clues as to why Gorgas ignored an epidemic that was sickening thousands and killing hundreds of men in the army appear in a statement he made earlier in the war: “No other branch of the Army is nearer the hearts of the people in time of war than the Medical Department.” Gorgas felt keenly his department’s responsibility to the American people, and warned that while parents whose sons were killed in battle may reconcile themselves, “if they have reason to fear that their sons have been neglected when sick or wounded, they develop a spirit of bitterness for which there can be no antidote.” He acknowledged that “there is no consolation when [a mother] has reason to believe [her son’s] death unnecessary, or that his health was not guarded by every known agency.”132 The influenza story did not inspire confidence in the American government or medical establishment. Shortly after the Armistice, an American Medicine editorial expressed dismay at the “extraordinary indifference on the part of the public” regarding the influenza epidemic. “Why does not the public ask ‘Who started the epidemic?’” the journal inquired. The writers hoped only to “[arouse] the public to a livelier interest in its own welfare, and to stir those in authority to a keener sense of their great responsibility.”133 Similarly, Military Surgeon published numerous scientific articles on influenza and pneumonia and in 1920 called for more examination of the meaning of the epidemic to the profession. Likening the task of fighting disease to that of Sisyphus rolling the rock up the mountain, the journal listed the canon of medical science victories, but observed “while we were congratulating ourselves on our accomplishment, we came to reckon with the plague of Influenza.”134 But physicians and government officials alike probably felt relief when it became apparent that few people—including members of Congress—were inclined to raise questions about the flu. Medical officers’ inability to control the epidemic represented both personal and professional failure, and they, more than any other government officials, would have to admit to Americans that they could not protect their soldiers from death by disease. It was tragic that thousands of soldiers had to die of influenza and pneumonia on army cots, but it was equally tragic that medical officers, already laboring under the sobriquet

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of “noncombatant,” had to preside over their deaths. It was clear who had killed men in combat—the Germans—but who had killed those who died of disease? Medical officers had used all of the tools available to them to combat influenza and pneumonia, to little avail. They had not been able to control the health environment of American soldiers or control the influenza and pneumonia that attacked their patients. They would, however, be able to control their story of war and epidemics.

6 “Except for the Flu . . .” Writing the History of the Epidemic Any one interested in preventive measures, and wishing to demonstrate the efficiency of modern methods would be glad to pass this disease in silence. —Lieutenant Colonel Mazyck Ravenel

The New Surgeon General The responsibility for writing the history of the successes—and failures— of military medicine during the Great War fell to army surgeon general Merritte Ireland, and any account would include reports on the influenza epidemic in the army at home and abroad. But the meaning of the flu epidemic was not self-evident to Ireland, his medical officers, or anyone else, and was in many ways mysterious; an event and an experience needing explanation.1 Ireland’s approach to writing this history is revealed in a speech he gave to an influential audience, the American Medical Editors’ Association, in April 1920, eighteen months after the Armistice. In his speech, “Plans for Reorganizing the Medical Department of the Army,” Ireland asked the editors to support his proposals to Congress for funding to recruit physicians to the army, to construct an army medical center, and build a new Medical Reserve Corps.2 Ireland warned that physicians were not joining the army in great enough numbers. Although the Medical Corps of army physicians shrunk from a wartime strength of more than 30,000 to 1,700 in 1920, even this smaller corps had a 50 percent vacancy rate.3 He called for more rapid promotion, civilian internships in army hospitals, a recruitment program “to induce young physicians to consider the army as a career,” and federal funds to co-locate the Surgeon General’s Library, the Army Medical Museum, and a medical

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school on one campus with Walter Reed Hospital. Ireland, however, had little to say of medical war heroism, the fight for democracy, or the patriotism of his profession. Nor did he mention the influenza epidemic. His speech was about bricks and mortar and military pay—tame for a man who had commanded medical operations on the winning side in the largest war the country had ever known. The surgeon general, it seems, had adjusted his rhetoric to the postwar, postepidemic world. Merritte Ireland had seen many of the world’s military “hot spots” as he advanced through the ranks of the Medical Department (fig. 18). The son of a civilian physician, Ireland pursued his father’s profession but chose a military path, serving, like his predecessor William Gorgas, as a medical officer in army posts in the American West.4 During the SpanishAmerican War, he was stationed in Cuba and afterward traveled to the Philippines for American military action there. After a long stint in Washington, D.C., Ireland went to Fort Sam Houston Hospital in Texas to treat the sick and injured from the Punitive Expedition in Mexico. There he met General Pershing, who, favorably impressed, made him assistant chief surgeon of the American Expeditionary Forces (AEF), promoting him to chief surgeon in April 1918. Later that year, Pershing again advanced Ireland’s career by recommending him to succeed Gorgas as surgeon general. Pershing later wrote that several senior medical officers, “each of whom might with good reason have been a candidate himself,” had asked him to do so.5 Remarked one medical officer, “Honest, brave, with a keen sense of humor and just enough wrath to make him perfectly delightful, General Ireland was the embodiment of everything that made me love the Army of the United States.”6 Although Ireland, like Gorgas, had a rich and successful army career and the respect of his colleagues, he operated in a different historical context. While he was a war hero and wore the army’s Distinguished Service Medal, he did not share Gorgas’s popular image as medical hero. He functioned more as a government official. As surgeon general in the postwar era, from October 1918 to May 1931, Ireland built the army medical center at Walter Reed, received many honors, and served as president of both the American College of Surgeons and the Association of Military Surgeons. But he presided over a smaller, less prestigious and less powerful agency than Gorgas and correspondingly projected a more circumscribed vision. Gorgas was an internationalist who rose to fame conquering disease in the tropics, while Ireland took the reins of the army medical services as it endured one of the worst plagues in human history.

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Fig. 18. Merritte W. Ireland, Surgeon General of the Army, 1918 to 1931. (National Library of Medicine, B 15392)

Gorgas headed an agency in ascendancy that embraced the nation’s medical profession and fought a war for democracy. Ireland assumed office as the country demobilized and turned away from the army, the government, and international affairs. As his purview diminished, he directed his vision internally to husband Medical Department resources and medical officers’ status during a time of retrenchment. Still, Ireland had to reckon with the legacies of the Great War. The Medical Department’s history of the war became the vehicle for forming an understanding of the war and influenza epidemic, the bricks and mortar of history that provided a foundation for the national memory of the epidemic of 1918–1919. If medical officers could not control influenza

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and pneumonia, they could control the history. As they wrote the story of the influenza epidemic, they chose images and values that were acceptable and meaningful to the War Department and the public, and that would put them and their profession in the best light. Scholars have shown how physicians and other elites during the early twentieth century interpreted epidemics in order to maintain the status quo by blaming or scapegoating certain social groups for disease outbreaks.7 Medical officers were no exception. While they accepted that much about the epidemic remained a mystery, many embraced medically or scientifically unsupportable explanations that better satisfied their social and psychological needs. They began to shift their analysis of disease causation from material factors such as living conditions and overcrowding—things the army could control—to factors it could not control, such as an individual soldier’s personal characteristics, especially race. In this process they employed familiar concepts of white supremacy and black inferiority in an effort to reassign blame for the disaster and avoid government responsibility. Given that there was little “good news” about the flu epidemic, medical officers also chose to dismiss the epidemic as a meaningful medical or military event. “Had the pandemic of influenza which swept over the world in 1918 been avoided,” Merritte Ireland said, almost wistfully, in a speech in 1922, “the total number of lives taken by disease during the World War would have been insignificant compared to that which obtained during the previous wars.”8 Medical officers thereby recast themselves from medical heroes to agents of the government, and their explanation of the influenza epidemic in the army established the ways many Americans would remember—or forget—the flu.

A Medical History of the World War After the war, the War Department proposed a standing army of 500,000 and universal male military training, but Congress embraced the traditional American view that a standing army threatened democracy and authorized instead an army of 280,000 and enhanced the role of the National Guard.9 In 1922, Congress further reduced the size of the army to 175,000, and for the next fifteen years army strength hovered in the mid130,000s.10 The Medical Department fell from a strength of 281,341 in November 1918 to 12,973 in 1921.11

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Although the Medical Department lost resources, personnel, and status after the war, it undertook a massive, public enterprise to create a written record of the department’s accomplishments, to make “a contribution to medical science,” and to stand as a “monument” to those who served in the Medical Department.12 Surgeon General Gorgas had authorized the project during the war and his staff toured the training camps and the AEF to instruct medical officers how to keep and record histories.13 The Medical Department followed the example of the British history of the medical services during the Crimean War and the American Civil War’s Medical and Surgical History of the War of the Rebellion, and sought to keep up with the European nations that were writing their own medical histories of the Great War.14 Medical officers writing the Medical Department in the World War had access to the latest medical literature concerning influenza. The 1919 Index Catalogue contained more than fifteen hundred titles of articles about influenza published in English, German, French, Spanish, Italian, and Dutch.15 The medical literature ranged from autopsy reports in a single hospital, to an analysis of the progress of the flu across the country and the world. The Medical Department had also generated its own literature with reports on the flu from medical officers throughout the service. Noted one physician, “No malady, perhaps, has ever been investigated so intensively and from so many different points of attack in an equal length of time.”16 Ireland’s project culminated a magnum opus of Great War medicine, The Medical Department in the World War (hereafter, MDWW), which comprised fifteen volumes, published from 1921 to 1929.17 One of the only branches of the U.S. Army to complete its history of the war, the Medical Department’s history was a high profile effort requiring dedicated federal funding and political support from organizations like the American Medical Association (AMA).18 The first three volumes described Medical Department administration and finance, volumes 4 to 8 reported on the medical services infrastructure, mobilization, and field operations; volumes 9 through 14 summarized the army’s experience with disease and combat injuries; and the final volume provided statistics on the physical characteristics, diseases, and injuries of the men in the army. In true Progressive fashion, the influenza epidemic was well documented, appearing in four places: volume 4 on sanitation and disease prevention in the camps and ports; volume 6 on army epidemiologists; volume 9 on communicable diseases; and volume 12 on the pathology of

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respiratory diseases. The Military Surgeon called the history a “stupendous and laborious task,” and another reviewer called the project “a monumental contribution to medical literature, which for years to come will be a book of reference for physicians throughout the world.”19 Ireland assumed the role of primary author, medical officer Charles Lynch served as editor in chief, thirty civilian and army physicians sat on the editorial board, and many others, some leaders in their field, wrote the various chapters. The project went through a rigorous editing process whereby the surgeon general’s staff edited the chapters and then sent it to the General Staff for review. Over the years, the General Staff required a number of changes before the secretary of war approved the MDWW for publication.20 Such an editorial process was not new. Long before the war, the surgeon general’s board of publications reviewed medical officers’ scientific papers or speeches for “facts of value to the enemy, erroneous or inaccurate statements, grammatical and typographical errors, errors in taste and judgement, florid self-praise,” as well as “abusive statements, or any other sins of omission or commission which might reflect upon the Medical Corps or the Medical Reserve Corps.”21 The authors of the MDWW thus wrote their history within layers of historical precedent, scientific medicine, general staff oversight, and public expectations of army medicine’s ability to care for soldiers ravaged by war and disease.

Material versus Biological Causes Medical scientists have long debated whether a person’s heredity or material environment plays a greater role in increasing the risk of disease or the severity of illness.22 As Progressive-era medical scientists incorporated germ theory into their views, they shifted from the view that environmental conditions (i.e., poor sanitation, “bad air,” poor housing) generated sickness, to a more focused effort to identify specific germs that caused disease. This approach did not reject public sanitation as key to preventing disease, but it did emphasize people’s bodies as carriers of infection and thereby employed preventive methods of vaccination, quarantine, and isolation of the sick to control disease. The heredity/environment debate continued as physicians and public health officials discussed whether social reform or identifying ever more disease-causing pathogens was the more effective way to improve health conditions. Because the army was responsible for the soldiers’ environmental conditions—hous-

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ing, clothing, sanitation, diet, medical care—deficiencies in these areas could render the state vulnerable to charges of neglect. Medical officers were acutely aware that the big killer in the epidemic was not influenza but the pneumonia that could follow. “Without exception the deaths from this respiratory epidemic have been due to secondary pneumonia,” wrote medical officers at Camp Custer, and others at Camp Wheeler reported that “there was practically no mortality from influenza. All the fatal cases dying of a complicating pneumonia.”23 To the confusion and frustration of medical scientists, pneumonia, unlike typhoid or measles, could be caused by many pathogens—bacteria, viruses, fungi, even an injury to the lungs during an operation.24 Pneumonia could also be either a primary or secondary disease, meaning that it could be the first disease a patient contracted, caused by a bacterium such as the pneumococcus or streptococcus, or it could be a complication of another illness such as measles or the flu, developing after the primary ailment broke down a patient’s immune defenses. These pneumonias (except postoperative ones) could be contagious. Medical officers knew that secondary pneumonia could develop when the flu patient did not receive proper care and nourishment, and here the role of living conditions became a matter of life and death. As the MDWW noted, the only effective treatment was “rest in bed, warmth, rest, and a light, hot diet.”25 AEF sanitary inspector Hans Zinsser wrote, “It was clearly demonstrated that perhaps the most important thing from the patient’s point of view is to hospitalize him as soon as the first symptoms appear.”26 Medical officers at Camp Logan in Texas believed that early hospitalization helped them prevent pneumonia and death, because “statistics show that our base hospital admission rate was the highest in any camp in the United States and that our death rate was the lowest.”27 Good care—putatively under the control of medical officers—could save lives. But war conditions, troop travel, training camps, and the trenches were not conducive to good medical care. Medical officers faced a deadly situation beyond their control. The authors of the MDWW did not, however, elaborate these problems, but rather emphasized other factors over material ones. For example, although factors such as age or length of service were of greater significance in determining who would suffer the most from influenzal pneumonia, medical officers often invested race with greater explanatory power, even in the face of ambiguous or contradictory evidence. The MDWW volume on communicable diseases states that in addition to

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disease rates by troop strength, hospital admissions, deaths, and noneffectiveness, the “the incidence of the diseases considered is given geographically and by race.”28 (Authors of the various MDWW volumes included some women but apparently no African American officers or physicians.)29 Their history of the Medical Department during the war reveals how racialist theories, used to explain disease, clouded their understanding of the causes of death from pneumonia and compromised the development of effective public policy to control it.

Housing and Clothing Members of Congress had criticized the War Department in the winter of 1917–1918 for crowded housing and inadequate clothing for soldiers, and throughout the war medical officers stressed the importance of sufficient material resources to soldiers’ health. In his 1918 annual report, Gorgas said that many of the deaths from disease could have been prevented “if the country and the department had been willing to purchase that advantage by delaying the calling and training of the soldiers until thoroughly satisfactory arrangements for clothing, housing, and caring for them had been matured.”30 When he toured army camps in late 1917, Gorgas, in Progressive manner, measured the square footage in the barracks and tents, and recommended 50 square feet of floor space per man. “Whatever the original cause of the epidemic,” he later explained, “these evils are accentuated by the crowded conditions of the camp.”31 At one point, AEF medical officers objected to a general order allowing only 20 square feet of floor space per man. When headquarters issued a subsequent bulletin providing for a minimum of 40 square feet, one medical officer observed in disgust that the order “was emasculated by the words ‘where possible.’”32 At Camp Humphreys in Virginia, Lieutenant Colonel I. W. Brewer found that the incidence of influenza increased with the density of population in the barracks. He noted that one regiment, which had about 78 square feet per man, had only a 2.5 percent flu rate, whereas another regiment with 45 square feet per man had an incidence of 26.7 percent, ten times as high.33 Floor space presented a simple and measurable factor to evaluate and compare health conditions across camps. In the same spirit, Acting Surgeon General Richard had been insistent, if unsuccessful, in reducing crowding on troop ships. In the postwar analysis, however, the crowding issue seemed to disappear. The MDWW provided little discussion of housing; the extended sci-

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entific discussion of respiratory disease devoted less than two pages to housing in an article of more than one hundred pages.34 While citing Brewer’s study and “a definite relation between the degree of crowding and the amount of respiratory infection,” the authors did not explicate housing conditions, include any charts on floor space per soldier, or compare disease rates between men in barracks and those in tents.35 This information existed, though, because during the war the surgeon general’s office routinely requested such data from army units. Even though medical officers often identified race as a factor contributing to disease rates, they did not examine the impact of racial segregation on disease transmission. Brewer’s study included a map showing incidentally that black units were housed separately from much of a camp, but did not explore how segregated housing and transportation might have protected them from infection from the larger camp.36 Medical officers also showed no cognizance of the (perverse) opportunities that racial segregation afforded them to track the impact on disease transmission of what amounted to virtual quarantines. For example, medical officers at one AEF camp characterized merely as “interesting” the fact that after commanders prevented African American soldiers from observing a YMCA performance inside the tent and made them watch it standing on the outside, none of them contracted influenza.37 Many medical officers worried that insufficient clothing promoted pneumonia. “We have found regiments as for instance 54th Pioneers,” warned Hans Zinsser at the height of the influenza epidemic, “where the men have only one blanket apiece, where over two hundred of them have no overcoats and where they have only one set of light underwear.” He reminded the AEF chief surgeon that “the question of sufficient clothing and covering at night is perhaps the most important single factor in the prevention of pneumonia in the front area.”38 In his report on the October 1918 flu epidemic in the Eighty-eighth Division, the chief surgeon noted that “under orders of the War Department on departure from the United States men were limited to one uniform, summer underwear, one blanket and an overcoat. On arrival at the port of debarkation in France the overcoats were taken from the men.”39 The MDWW, however, fell silent on the relationship between clothing supplies and pneumonia rates. The Medical Department may have declined to pursue the issues of crowded housing and inadequate clothing because they could do little about army living conditions during wartime. As William Gorgas observed after the war, “It is difficult to convince people in authority of the

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evils of overcrowding and the sanitary advisability of segregation [of the sick from the well].”40 The Surgeon General’s Office noted that in the AEF, control of the environment for the “sake of prevention of disease” was severely limited by “restrictions of transportation, the insufficiency of structural material and labor to build shelter, and by the difficulty of getting enough fuel to heat living places and to dry clothing, and enough water of pure quality to provide sufficient facilities for body cleanliness and the washing of clothes.”41 Victorian housewives would have been frustrated, and medical officers certainly were. But as soldiers serving a nation at war they could not openly criticize the army and their superior officers without risking charges of insubordination, court martial, or a scandal. They therefore turned to factors less under their control that lent themselves to endless analysis and speculation: the offending pathogens and the bodies of the soldiers themselves.

Bacteriology The Golden Age of Medicine and medical discovery was the era of bacteriology, not virology.42 While scientists could see bacteria with microscopes, they could only theorize the existence of much smaller, less visible, viral pathogens. They would not identify specific disease-causing viruses until the 1940s, and therefore had neither the knowledge nor the technological tools to identify the flu virus. Many scientists were hampered by a mistaken belief that Pfeiffer’s bacillus, which they often found in flu patients’ bodies, caused influenza. Others theorized a causative organism they could not see, calling it a “filterable virus.” The term stemmed from observations made in experiments carried out by army researchers that fluid taken from an infected person and put through a filter of unglazed porcelain (fine clay) could still infect a person or animal with the same disease.43 But researchers failed time and again to reproduce the flu experimentally, and after the war the cause of the influenza epidemic remained a mystery. “No organism has proved to be the cause of the clinical disease influenza,” stated the MDWW, recognizing that their ideas of the disease were “perhaps more confused than clarified as a result of the numerous and varying reports of clinical and laboratory investigation.”44 Although unsure of the causative agent, medical officers felt more confident that they knew how flu was transmitted. Vaughan expressed the prevailing view that droplets emitted by sneezing, spitting, or coughing

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spread influenza, as did hand-shaking or using contaminated eating implements: “Influenza is not transmitted through the air for long distances. . . . It is transferred from man to man either directly or indirectly; either by direct contact or indirect contact.”45 Medical officers therefore debated such factors as the merits of washing dishes with boiling water to kill germs.46 In the wake of the germ theory, scientists eagerly rejected theories of “miasma” or “bad air” causing disease, and were therefore slow to grasp the concept of airborne transmission of disease pathogens. “There is to-day substantial agreement that the disease is transmitted from individual to individual, rather than by aerial convection,” the MDWW explained. “The known facts of the matter may all be explained without recourse to the theory of spread by the air.”47 Thus medical scientists dropped the view that the air itself could cause illness, and adopted one whereby people could spread disease with visible, germ-laden droplets produced by sneezing or coughing that could travel only a short distance through the air. This view encouraged many people to use face masks and screening around beds even though these were actually largely ineffective against viruses which, unlike “droplets,” could indeed travel through the air and permeate fabric. Given the army’s success with typhoid inoculation, medical officers frantically sought a vaccine or serum to protect soldiers against flu or pneumonia and injected thousands of soldiers, rabbits, rats, and other hapless animals with fluids taken from sick patients hoping to find a cure or prophylactic. Medical officers at Camp Merritt injected two dozen patients suffering from empyema with a vaccine made from their own strep bacteria in order to produce antibodies to the infection, and at the Yale Army Laboratory six volunteers inhaled a substance filtered from the lung tissue of people who had died of pneumonia.48 Neither inoculation proved effective against pneumonia. Medical officers also administered experimental vaccines against pneumonia to thousands of soldiers at Camp Wheeler in Georgia and Camp Upton in New York, and although pneumonia rates among vaccinated men may have been lower, the results were inconclusive.49 When some researchers promised vaccinations against influenza, the Public Health Service (PHS) and the AMA warned against unrealistic expectations. “Nothing should be done by the medical profession that may arouse unwarranted hope among the public,” the Journal of the American Medical Association advised, because failure would “be followed by disappointment and distrust of medical science and the medical profession.”50

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Thus frustrated by the failure of bacteriology and pathology to tell them what caused the disease, medical officers turned to analyzing the demographic characteristics of the epidemic, that is, using a soldier’s age, length of service, and race to explain susceptibility to the flu.

Age and the “Terrible W” Most medical observers recognized the “terrible W” demographic curve of the flu victims. One civilian researcher calculated that more than 60 percent of the deaths were among persons between twenty and forty years of age.51 But although data on age were readily available to the army, with millions of young men in the ranks, the Medical Department provided little analysis of age differentials in morbidity and mortality rates. Army researchers could have parsed the age data any number of ways to learn, for example, if flu or pneumonia impacted any specific age cohort, say ages twenty-three to twenty-five, more than another. The MDWW, however, passed quickly over the age factor, devoting only onehalf of a page to it, stating that army data showed “nearly the same relations between the age groups as those published from civilian sources.”52 But “nearly” was an equivocation. PHS statisticians reported that death rates were uniformly lower in the twenty to forty years of age cohorts in the civilian sector than in the army. While the army reported a death rate of 14.2 per thousand people twenty-five to twenty-nine years of age, Edgar Sydenstricker found a rate of 10.1 for that age group in Baltimore, and another PHS researcher, W. H. Frost, reported a rate of 10 per thousand for ages twenty-five to twenty-nine in nine cities across the nation.53 Such figures could embarrass the army, create a public relations problem, or even spur more congressional hearings. Considering the relative civilian and military rates, former surgeon general William Gorgas told an audience of life insurance presidents that “our death rate from influenza has been about five times as large in the army as among the civil population in New York City,” and this ratio was later cited by New York’s public health commissioner.54 The War Department may have minimized the importance of age as a factor in the flu for fear of perpetuating such comparisons. Department officials preferred to point out that influenza attacked civilian and military communities equally and often blamed civilians for disease in the army, the most common case being the threat of venereal disease from civilian women near the camps.55

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Length of Service The length of time a recruit had been in military service provided another politically sensitive factor that influenced flu and pneumonia rates. Medical officers had long known that new army recruits had high sick rates. At Camp Lee in Virginia, for example, 77 percent of the deaths from flu and pneumonia in the camp were among men with less than three months in the army.56 Victor Vaughan and his colleagues identified “the recruit, strange to camp life, unused to cold, unaccustomed to severe physical exertion, as the one primarily responsible for sickness in the American army.” This, they noted, “was the experience in the winter of 1917–1918. It was the experience during the influenza epidemic.”57 Even before the epidemic, some medical officers argued that overly rigorous training of recruits in their first weeks broke down their immune systems and made them susceptible to diseases. “In the present war,” charged a medical officer with the Seventy-ninth Division, “many physically fit and robust individuals who have come from sedentary occupations in civil life, have been wrecked in so far as the army is concerned.”58 He recommended a plan of progression by easy stages to physical tasks. Earlier in the war, Gorgas, Vaughan, and others had advocated detention camps to observe new recruits for communicable diseases and allow them to adjust to the army routine. The MDWW did conclude that 60 percent of more than 34,446 deaths in the army camps from influenza and pneumonia occurred in soldiers with less than four months of service, and that “this relation is the most clean cut of any found among the factors influencing the comparative rates of the camps.”59 The MDWW history, however, failed to employ the epidemiological data to advance wartime arguments for the need for detention camps to monitor new recruits for disease. By the end of the war, the War Department had completed construction of only a few detention camps. Highlighting this factor might have raised questions about army practices that placed new recruits at risk.60

Ethnicity As they downplayed material factors such as housing or clothing, many medical officers stressed biological factors—an individual’s susceptibility or immunity—as important factors affecting disease rates. According to Vaughan “the greatest single factor in the prevalence of disease in certain camps and their absence in others has been the natural

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susceptibility of the men.”61 Individual immunity and susceptibility provided a way to shift the explanation for disease causation from the army and its policies to the bodies of soldiers. Medical officer George Soper reinforced the link between disease and identity, stating: “The war has proved most useful as a teacher of the fundamental principles of disease control. It has shown more clearly than ever that it is persons and not things that are to be feared.”62 Surprisingly, the War Department minimized ethnicity as a factor in disease susceptibility. Progressive Era medical scientists had been identifying immigrants as sources of dangerous diseases for years, and some, including eugenics advocates, wanted to shield white, native-born Americans from contamination by foreigners.63 They believed that dirty and impoverished foreigners brought diseases, such as typhus, cholera, or the “Spanish Influenza.” Public health officials routinely monitored the impact of immigration on the nation’s disease rates and often broke out sickness rates by ethnic groups. For example, one public health officer wrote that “we know that the Jewish stock acts favorably on our mortality curves, while the Irish stock acts unfavorably,” and others argued that the presence of “foreign stock” in the United States increased the death rate from various causes.64 In a massive analysis of data from the medical screening of army recruits inelegantly entitled Defects Found in Drafted Men, statistician Albert Love and eugenicist Charles Davenport categorized for the Medical Department various “defects” according to the soldiers’ racial and social characteristics.65 The Americanization program in the training camps was, of course, predicated on the “problem” of ethnic diversity in the army. Army officers sometimes used ethnicity to explain behaviors. For example, officers studying malingering believed that Eastern Europeans were more prone to malingering than “Americans,” and intelligence officers evaluating soldiers’ morale reported the ethnic background of each man suspected of disloyalty.66 But such ethnic parsing and distinctions are absent from Medical Department documents and analysis. Even in divisions such as the Seventy-seventh, where soldiers spoke dozens of languages, medical officers rarely recorded a patient’s ethnic background. Stressing ethnic differences within the army was perhaps not a good strategy for the Wilson administration, which demanded national unity behind the war effort. But medical officers also had another tool to explain disease: race.

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The Army, Race, and Disease In a huge army including men from literally every region, culture, and class background, the Medical Department chose to emphasize race— defined as “white” and “colored” or “negro”—in its analysis of disease causation and susceptibility. Three factors shaped this process: one, the need to downplay ethnic and regional divisions within the army; two, American racism and an effort to reinforce white supremacy at a time when the enlistment of African Americans in the military challenged the manhood of some whites; and three, the desire to satisfy the pressures to blame someone for the flu and pneumonia epidemic and to deflect blame for the epidemic from the army. In volume 9 of the MDWW, which covered numerous communicable diseases from anthrax to yellow fever, race is one of the most prominent and consistent factors of epidemiological study, comparing rates between “white” and “colored” men.67 This had not always been the case. In 1917 the Medical Department examined disease rates by class, explaining, “In military statistics it is customary to divide the Army into two groups, the commissioned officers and the enlisted men and noncommissioned officers.”68 The War Department annual report for 1918 continued this practice because “officers by their greater knowledge and income are better able to protect their own health.”69 The report also charted pneumonia rates by a patient’s state of birth and the location of the camp, concluding that men from the rural South were more susceptible to pneumonia than men from the urban North.70 After the war, however, the Medical Department greatly reduced its use of the officers/enlisted men and regional comparisons, and instead emphasized racial incidence. But using race as a primary analytical tool camouflaged other relevant factors and obscured a more accurate understanding of how army policies and practices could promote death and diseases in the ranks. According to Medical Department figures, in many cases African American soldiers had lower admissions rates to army hospitals for influenza than whites, but higher pneumonia mortality rates. In the training camps, the annual admission rates in October 1918 were 198 percent for whites and 158 percent for blacks, while death rates were 9.5 percent for whites and 11.1 percent for blacks. (These percentages mean that if the October rates continued for an entire year, on average the army would admit white soldiers to the hospital about twice a year, and black soldiers about 1.5 times a year.) In the AEF the same month, white admissions

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were virtually the same as black admissions, 39 percent and 40 percent, respectively, but whites had a lower death rate, 3.3 percent to 5.0 percent. Such data suggest that blacks were not more susceptible to influenza than whites but did show a higher rate of pneumonia. This was most likely due to the fact that when blacks contracted the flu they received medical care inferior to that of most whites. The correlation of disease rates with membership in a certain group did not necessarily indicate a causal relationship; that is, a racial group did not necessarily have a high rate of disease because of its race but because of other adverse factors that correlated with race. This scientific racism reflected the race prejudice and segregation of the country as a whole and confused medical scientists’ understanding of the nature and cause of many infectious diseases. Medical scientists in the army, however, conflated correlation and causation, even when it was not scientifically supported. The delineation of races between black and white is biologically meaningless in the first place, given the centuries of racial mixing in the United States. Medical officers also considered race even when the African American population in a camp was small. Camp Devens, for example, reported death rates by race even though there were no African American men in the camp in 1917, and blacks never comprised more than 9.3 percent of the camp population.71 Differential disease rates among population groups are rather the result of different material environment conditions and/or the different historical experiences of a particular population sharing a gene pool that renders them more or less resistant to diseases.72 For example, recruits already exposed to measles and mumps in childhood did not get these diseases in the training camps. In a more recent example, the sickle cell trait has long been thought to be a genetic characteristic of black people—of Africans and African Americans. The sickle cell provides resistance to malaria but can also cause a serious blood anemia. Genetic research has revealed, however, that this is a historical and regional trait connected to a population’s residence in areas where resistance to malaria becomes a selected characteristic. Therefore, some groups of people in the Middle East and Mediterranean, not considered “black,” have the sickle cell trait, while people of African descent who have lived for generations outside the tropics do not carry it.73 Skin color is not the determining factor. Race, however, did matter when racial discrimination limited soldiers’ access to adequate living conditions and medical care. Black soldiers most

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likely had higher pneumonia rates because their living conditions were inferior to whites, because many were often reluctant to go to sick call and to consult white medical officers, and because they had difficulty getting the proper medical attention and nursing care that could prevent pneumonia.74 On the other hand, race prejudice enabled medical officers to blame African Americans for sickness in the ranks. White officer Colonel Albert Kellogg, for example, implied as much in his description of black stevedores who worked in a wartime port: “The men were of ‘the poorest’ mental and physical caliber. A very high percentage appeared at sick call each morning.”75 Most medical officers thus did not connect material conditions and social practices with disease rates, and instead employed the concept of racial susceptibility to explain why the disease came into some camps or why the disease rates were so high. Racial susceptibility presented for most white physicians a simpler, more acceptable explanation than the lack of resources, and deflected attention from army policies. This was of course not unique to the Medical Department, but a reflection of the prevailing racism of the time. A postwar U.S. Army War College survey of white officers on “The Use to Be Made of Negroes in the U.S. Military Service” reveals that to a man the respondents believed that African American soldiers were slow to learn, obedient, not ready to be officers, and best kept in labor units.76 Army doctors thus gravitated to one of the strongest and most familiar stereotypes in American society to explain illness and death—African American inferiority and white supremacy. Even if it did not explain the epidemic, race was useful to the army and gave comfort to its medical officers. The War Department and medical officers were tapping into a long debate on racial susceptibility to disease. In the early twentieth century the vast majority of African Americans lived in the South and endured miserable living and working conditions, white racism and violence, and poor medical care.77 African American death rates from syphilis, malaria, and pneumonia were often two to three times higher than for whites, and life expectancy was significantly lower. In 1896, eugenicist Frederick L. Hoffman of the Prudential Life Insurance company published an influential report, Race Traits and Tendencies of the American Negro, and attributed his statistics to “scientific” evidence that blacks were congenitally defective and ill-suited for freedom. “Gradual extinction,” he wrote, “was only a question of time.”78 African American leaders vigorously

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countered this view, arguing that blacks suffered from inferior economic, social, and political conditions.79 Black physicians reasoned that “germs have no color line,” so that disease could attack whites and blacks equally, and therefore it was in whites’ self-interest to improve black health. The most powerful rebuttal came from Charles V. Roman, an editor of the African American physicians’ Journal of the National Medical Association. He went to the heart of the matter, charging in 1917 that “the greatest difficulties confronting us from a sanitary and hygienic standpoint arise not from the physiological weakness of the colored man but from the psychological strength of the white man.” Shifting the blame for poor health among African Americans from black bodies to white minds, he argued, “The white man’s immunity to fact is a more destructive force than the colored man’s susceptibility to disease. A diseased mind presents more serious problems than a frail body.”80 Roman also editorialized that “conduct and condition, not race, are the determining factors in disease and death.”81 Although he was clearly describing a crucial dynamic of disease and human society, his views did not penetrate to the army’s Medical Department. During and after the Great War, views such as Hoffman’s prevailed. Mobilization drew a large population of blacks into the army and into industrial centers and thus into the purview of Northern white physicians and public health officials. Some viewed the army as a grand laboratory to test scientific theories regarding race. In 1916, for example, Military Surgeon published a four-part series on army medical statistics in which medical officer Weston Chamberlain sought to confirm the work of Hoffman and others, concluding that “the higher mortality among negroes is in part, at least, a purely racial difference, and not due entirely to unfavorable sanitary conditions.” The army experience supported this view because, he argued, “the housing, clothing, feeding, and most other hygienic factors are identical for the white and colored soldiers.”82 The JAMA applauded a similar study by medical officers Love and Davenport because “the white and colored troops live under equally good sanitary conditions and are examined with equal diagnostic skill.”83 But if equality between the races was the official position, army conditions were in fact not “separate but equal” in the racially segregated army. White and black units did different work, traveled separately, often lived under different conditions, had different diets, and had different expectations regarding access to medical care. Medical officers rarely considered ways to

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equalize the housing, diet, or exercise to control black/white comparisons. Instead, they merely asserted that conditions for the races were the same. In one case, a medical officer at Camp Devens asserted in the first paragraph of a memo that black recruits “were housed in the Depot Brigade under exactly the same conditions surrounding the white recruits who arrived on the same date from New England,” but later in the same memo stated that two battalions of black troops “have not had the most favorable living conditions.”84 African American units in the training camps and in France did not enjoy conditions on a par with those provided white divisions. Army hospital wards, especially in the training camps, were often, though not always, segregated by race. The Office of the Surgeon General, for example, sent out a memo in March 1918 on “Separation of White and Colored Patients,” advising medical officers “to arrange for the care of white and colored patients in separate ward or separate rooms, so far as possible.”85 With only a few African American nurses serving in the training camps very late in the war and about 350 African American doctors, the majority of black patients were under the care of white health personnel, which may at times have led to inferior health care. The racially segregated training camps often had different housing arrangements for black and white soldiers; in some cases, blacks were housed in tents while whites lived in barracks.86 Emmett Scott, Secretary Baker’s adviser for African American affairs, received so many complaints about conditions that he sent Charles Williams, of the Hampton Institute, to do a survey of conditions for black trainees. Williams summarized his findings in his memoir: “For the Negro soldiers it was at times exceedingly difficult to secure what was necessary. When there was a shortage they were the ones to suffer.”87 Even the food provided white and black soldiers was not “identical.” A study of the army rations allocated to men at camps Grant, Dodge, and Funston over four months revealed that the 366th Infantry of the Ninety-second Division, one of the two black combat divisions, received less protein and fewer calories than the white units, even though they were on the average taller and heavier than the whites.88 In France, medical officers in the Ninety-second Division reported dismal sanitary conditions in their camps. In August, sanitary inspector J. S. White found that the men needed warmer clothing, chlorinated water, and better sewage disposal, and again in November he reported that they

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“lacked most of the primary creature comforts so necessary to secure efficiency and prevent a lowering of resistance to disease.”89 Another inspector attached a floor plan to his report to emphasize that an old tannery where a black regiment was housed was largely “uninhabitable and in the event of an epidemic of Influenza or Pneumonia breaking out, there would be a holocaust.”90 Private Robert Stevens of Louisiana, with the 803rd Pioneers, a black unit that fought in the Meuse-Argonne, remembered, “We did not have enough changing clothes. When we started to fight in France we stayed in the same clothes for days. At the end of the war some clothes were so dirty and lousy they had to be cut off.” Food was short, too, he wrote, “Our rations ran out. We had to forage food from dead Germans.”91 Stevens also remembered that when several hundred men in his regiment were sick with pneumonia, the unit had only one medical officer. African-Americans in France served in labor battalions loading and unloading ships, building roads, cleaning up camps, and burying the dead, often in very unhealthy conditions. Medical inspectors criticized the black stevedores’ living conditions in Brest, reporting, “There was scarcely enough water for drinking and cooking purposes. The supply was insufficient for bathing, and there were no bathing facilities.”92 During the epidemic, stevedores in Brest who coaled the troop ship Leviathan for five days endured bad weather, long hours, and then slept in the same bunks recently vacated by debarking troops, many of whom had had the flu.93 Inspectors at Brest reported “too many insanitary conditions to enumerate,” and advised that each unit be given a half day off each week to bathe and do their laundry. “This recommendation,” they wrote, “was denied on the ground that time could not be spared.”94 Military expediency outweighed soldiers’ health. “The troops of all races were housed, clothed, fed, and officered with the same painstaking care,” wrote Surgeon General Ireland after the war. “Consequently their relative susceptibility to infectious diseases was not influenced by extraneous economic circumstances.”95 But contrary to Ireland’s assertion, black and white soldiers were not “officered” equally. White command of black soldiers was the most sensitive issue concerning African Americans in the army, and black leaders protested this throughout the war.96 Some white officers admitted their inexperience for command. John Richards, assigned to the Ninety-third Division, wrote, “I had the typical Northern feeling that only a Southerner could work with (black soldiers).”97 He then described his experience with a litany of

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racist stereotypes of African Americans as servile, naive, lazy and childlike, and concluded that “black still turns naturally to white for leadership, just as on the Southern plantation the slave turned questioning eyes to the planter.”98 Another white officer with the Ninety-third wrote that “many of us were greatly disappointed when we found ourselves assigned to this regiment.”99 When urologist Hugh Young, in charge of the AEF venereal disease program, visited the Ninety-second Division medical services, “to my surprise,” he wrote, “I found them all Negro doctors, lieutenants and captains.” As he advised them on how to control venereal disease in the division, he said, “I talked very frankly about the unsurmountable barrier between the two races.”100 Such racism pervaded the army command. White Marine Al Ettinger believed that racism in the American army was worse than in the French. “The 92nd had to cope with the prejudice of the American general staff, as well as the Germans,” he wrote, “whereas the 93rd Division had been assigned to the French Army, which fully appreciated their services and didn’t have that kind of prejudice.”101 William Dyer, a black medical officer with the Ninety-second Division, would have agreed with Ettinger. He was absolutely amazed by a division announcement during the battle of Meuse-Argonne that African American medical aides would be used to handle the mustard gas cases “because the Negro is less susceptible than the whites.” “Why,” asked Dyer, “is the Negro less susceptible to Mustard gas than the whites? No one can answer.”102 White physicians often attributed the higher rate of pneumonia among African American soldiers to racial susceptibility and therefore accepted such rates as normal. For example, when AEF headquarters conducted an inquiry regarding the high sick rates in a Ninety-third Division unit at Brest, the white medical officer reported that the rates were not too high, “considering that this is a colored organization and that respiratory diseases are more prevalent during the winter months, especially in colored troops.”103 Another officer reported that a “colored battalion arrived [in France] practically 100% sick,” but explained that “they are cotton-field negroes from the South, and are extremely poor physical specimens.”104 In this context, medical officers could feel less responsibility for high disease rates among black soldiers and less pressure to address problems. Medical officers’ racialist explanations for disease took several forms. Some implied that black troops brought flu and pneumonia into a camp or that an outbreak started in a black unit. A medical officer reporting

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from Camp Upton in New York stated that “it is probable that if these infected negroes could have been kept out of Camp Upton pneumonia would have contributed a comparatively unimportant part in the camp morbidity.”105 Paul Woolley at Camp Devens wrote that “many of the blacks were harboring the pneumococci.”106 Other medical officers assumed racial susceptibility without examining or testing for it. When pathologists at Camp Taylor in Kentucky found a lower incidence of flu among black soldiers than among whites, they provided an anatomical explanation that “the rarely obstructed upper air passages [nasal sinuses] of the negro afforded a good defense against lodgment of micro-organisms.”107 The sixty-page report, however, which included measurements and analysis of almost every organ of the flu victims’ bodies, recorded no data on the dead soldiers’ noses or facial configurations, nor did it report how many of the 126 autopsies were conducted on blacks and how many on white soldiers. The pathologists did not reach their conclusion from scientific evidence, nor did they investigate the influence of other relevant factors on disease rates such as segregated housing and work details. When evidence contradicted medical officers’ assumptions, they ignored or discounted it. In a case where blacks had lower complication rates from flu and pneumonia than whites, medical officers did not attribute it to black vigor or white susceptibility, but simply called it “striking.”108 Medical officers downgraded the quality of information regarding African American soldiers, suggesting that “the figures are probably not as satisfactory as for the whites.”109 The MDWW dismissed the importance of social or army medical practices: “It is possible that the colored recruit was slower on the average in reporting his illness, but inasmuch as the total figure is practically the same as that of the white the more probable explanation would seem to be that when attacked, the colored man averaged a more severe case than did the white man.”110 Not all medical officers made racial generalizations.111 One officer recognized that different disease rates could be due to different treatment by officers, and that “the colored men are more susceptible, possibly because they keep up and about longer and come under treatment late. Their complaints may be disregarded by officers who think them shirking.”112 Warren Vaughan wrote that “any comparison of race morbidity or mortality, to be of value, must be based on the observations of individuals living in the same climate, in the same domestic environment, and in similar age distribution,” but noted that this was “practically impossible” because “even in the military forces many factors are at play.”113 Some officers

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said little about race. Ward MacNeal’s report on the flu in the AEF noted only “both whites and colored troops were attacked,” and a report on influenza at Camp Dodge stated, “The proportion of negroes contracting the disease was just about the same as for the whites.”114 Other medical officers noted the racial makeup of their camp populations but did not employ race as a factor in disease incidence.115 W. G. MacCallum, a pathologist for the army during the war, for example, did not state the race of his autopsies although he worked in camps with large African American populations, Fort Sam Houston in Texas and Camp Dodge in Iowa.116 After the influenza epidemic, medical officers found themselves in an intolerable vise between their responsibility for the lives of American soldiers and their helplessness in the face of an uncontrollable epidemic during war. In writing the medical history of the war, they chose to emphasize race and minimize other factors such as ethnicity, or factors such as material conditions, age, and length of service that were more significant to disease incidence. They did this not only as medical scientists but as government officials accountable for the health of the soldiers. The stakes concerning their performance were high, and Merritte Ireland understood this. He told an audience in 1919: “There is no nation on the face of the earth which demands such a high standard of care for its sick and wounded soldiers as does the United States,” and, he added, “no administration could survive which does not meet the demands of the nation in this respect.”117 How, then, to tell the story of the flu? It was not the story of medical heroes or great achievement, such as Reed and Gorgas conquering yellow fever in Cuba and Panama, nor was it a struggle against such a clear enemy as German machine guns and artillery. The Medical Department’s effacement of material conditions and preference for racial analysis reinforced the politics of race and inscribed white supremacy on the medical history of the war, and thereby chose a narrow path of racial determinism to explain disease. In doing so, they missed an opportunity to better understand how improved material conditions could have saved lives from pneumonia and how army policies could foster as well as prevent disease.

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The Army, the War, and American Medicine The crucible of war and epidemic created a military medical experience that officers and soldiers would never forget. Some of the most competent physicians in the country served in the military during the war. Victor Vaughan liked to point out more than a third of the nation’s approximately 142,000 physicians served.118 In addition to standing among the most competent and influential physicians in the profession, veteran physicians gained valuable credentials. The state of California, for example, recognized an honorable discharge from the army or navy medical corps as equivalent to the state’s medical certification examination.119 Many veterans rose to the top of their profession after the war: Hans Zinsser wrote a definitive textbook on bacteriology; Stanhope BayneJones became dean of the Yale Medical School; Jefferson Kean edited Military Surgeon from 1924 to 1935; and medical officers held high-profile positions at the New York department of health and the PHS.120 Some men even served in World War II. Albert Love helped plan the medical history for that war, and others, including Bayne-Jones and Joseph Siler, served as epidemiologists. War medicine imparted new medical knowledge to thousands of physicians and nurses and shaped medical science and practice in many ways. Medical officers improved blood transfusion technology, accelerated the development of plastic and reconstructive surgery, promoted research on wound shock, improved the treatment of wound infections, created the new medical specialty of aviation medicine, and identified the phenomenon of shell-shock.121 The war gave many physicians from rural areas their first encounter with the routine use of diagnostic laboratories, X-ray technology, and medical specialties such as pathology and otolaryngology, which encouraged the establishment of commercial laboratories and group practices after the war.122 In contrast to the inability of medicine and sanitation to prevent the influenza epidemic, advances in war surgery increased the prestige of surgery after the war.123 As the president of the American Surgical Association told the 1919 conference, “The traumatic surgery of this war has constituted a tremendous vivisection experimental laboratory in which not mice, nor rabbits, nor guinea-pigs, nor dogs have been subjects of experiments, but human beings, the choicest young men of the civilized world.”124 Such experience gave surgeons like George Crile new insights regarding when and how to operate on wound patients

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in shock.125 With X-ray technology to assist in extracting shrapnel and bullets, blood transfusion, tetanus antitoxins, and improved hospital administration, military surgeons dramatically increased a wounded soldier’s chances of survival. The Carrel-Dakin treatment of debridement (cutting away of dead tissue), irrigation of the wound, and daily bacteriological testing to show the wound free of infection before final closure allowed many men to avoid gas gangrene and amputation of infected legs and arms. The excitement of war surgery and the seemingly miraculous abilities of army surgeons to save the lives of wounded men also elevated surgeons and the operating theater above the sanitarian and his quotidian medical inspections. For surgeon Hugh Young it was almost as exciting as combat. Brought up in a family of war veterans, he wrote, “For many years I was grievously disappointed that I could not follow in their footsteps . . . but the surgical amphitheater is a perpetual battle ground and therefore more than compensates.”126 Some nurses agreed. Helen Dore Boylston told her diary, “I’m operating at night again. This time with Major Crabtree. I love working with him. When he operates, things really happen.”127 After the war, many nurses who served with the AEF left public health work for the glamour of hospitals.128 The war left a mixed legacy regarding the U.S. government’s involvement in health care. On the one hand, veterans’ hospitals, death and disability benefits, and the Veterans’ Bureau increased the government’s role, and on the other hand, the postwar revulsion toward government control of society ended the drive for national health insurance.129 Epidemics have often generated reforms: smallpox in the Continental Army spurred the first mass inoculation; cholera, typhus, and typhoid during the Crimean War prepared the ground for the professionalization of nursing; and typhoid epidemics in the Spanish-American war led to reforms in the U.S. Army. But the influenza epidemic of 1918–1919 inspired little social reform. The failure of internal medicine and sanitation to prevent epidemics may even have accelerated the decline in the status of internal medicine relative to surgery and the eclipse of broad public health agendas in the postwar society. The war and the influenza epidemic may also have given impetus to a movement called the New Public Health, which emphasized the education of the individual in order to change behavior rather than broader reforms to improve the environment and eliminate the causes of disease. In

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its most liberal guise the New Public Health dispersed the benefits of medical science to all people, but it also allowed a withdrawal from social reform. In the postwar atmosphere of retreat from big government and retrenchment in international affairs, physicians as a class retreated from the political and social engagement of the Progressive period and chose to pursue public health surveillance and education instead.130 The army promoted this shift with its emphasis on health education and systematic physical examinations of recruits and soldiers. During the influenza epidemic, for example, the surgeon general’s bulletin, “Rules to Avoid Respiratory Diseases,” largely governed personal behavior, such as covering one’s mouth while sneezing or coughing, and even breathing through one’s nose rather than mouth. Such instructions suggested that it was up to the individual soldiers to stay healthy, even if the army did not properly clothe or house them. The War Department published the rules throughout the army and in newspapers such as the New York Times.131 Soldiers apparently learned these lessons well. Responding to a postwar YMCA essay contest on the question, “Home, Then What?” several soldiers described what they had learned regarding personal hygiene and public health. “We learned that filth and disease are the greatest enemies known to mortal man,” wrote Private Joshua Lee in his second-prize entry. He avowed that “as U.S. troops entered hundreds of French villages and cleaned them up so will discharged soldiers return to every corner of America and apply the laws of sanitation.”132 In this way, many soldiers adopted values and personal hygiene practices that survived their departure from the army and government control.133

Memorializing the Flu After the war, an army general lamented, “What a record we might have had without our pneumonia scourge is one of those things governed by the awful if. That blasting [sic] epidemic was a big blot on our escutcheon.”134 While the origin and exceptional virulence of the 1918 pandemic remained a mystery, its devastation was evident to all. The Medical Department and its MDWW presented the flu as an aberrant event and thereby shaped how the epidemic would be remembered. Shifting their analysis of disease susceptibility and causation from material to racial factors allowed the Medical Corps to evade responsibility for the epidemic. More importantly, their dismissal of the significance of the flu

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as a medical event framed the epidemic as an exception to modern medical experience and thereby maintained unshakeable the belief in the progress of modern science and American medicine. As Surgeon General Ireland had planned, the MDWW tome stood as a memorial to medical officers’ accomplishments and contributions during the war. The Medical Department also became a primary architect of the nation’s memory of the influenza epidemic of 1918; medical officers’ response to the “big blot” on their escutcheon also began to shape the historical silence on the epidemic. William Gorgas did not live to shape that memory. After leaving the army, he joined a Rockefeller Foundation program to fight his preferred foe, yellow fever. He and his wife, Marie, sailed to England on his way to Africa, but in London he suffered a stroke and died within weeks on 3 July 1920. He died a hero, with the king of England awarding him a knighthood as he lingered in a hospital bed. Upon returning home, Gorgas’s body lay in state in Washington, D.C.135 The U.S. government buried him in Arlington Cemetery along with other victims and heroes of war, and in this way honored his service. In October 1918, having survived the flu on her trip across the Atlantic, army nurse Mary Dobson was immediately put to work at an army hospital in Savenay, near the port of St. Nazaire, caring for flu patients under the assumption that she would now be immune. “It was raging there,” she said, “half of these men we were nursing had been brought in straight off the boat. We had a big ward full of boys dying, a lot them.” Many of her patients would never make it to the battlefield, succumbing instead to the flu. “They just died within twenty-four hours after they got there.”136 One of the things that troubled Mary Dobson the most, though, was all of the funerals for the dead. “The cemetery was just up the hill and every morning you could hear the bugle blowing as they buried the bodies. It was gruesome. It really was.”137 Most AEF soldiers and nurses took at least one walk to the hastily constructed American cemeteries in France to say farewell to a friend or to honor those who had lost their lives in the war. Many war memoirs and unit histories contain photographs of fresh graves and cemeteries (fig. 19). The World War I cemeteries in France bear the names of the great battles, “Flanders Field American Cemetery,” “Somme American Cemetery,” “St. Mihiel American Cemetery,” “Meuse-Argonne American Cemetery,” but none are named after the diseases that helped to populate them. These cemeteries, like those across the United States, contain headstones of enlisted men, officers, and nurses who died of the flu and pneumonia during World War I.

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The graves demonstrate that the power of disease can equal or exceed that of human warfare. They also represent the government’s recognition of the sacrifices of war. We will not fully understand the meaning of that sacrifice until we embrace the total experience of war—death by disease as well as death in combat.

Fig. 19. Cemetery at U.S. Base Hospital No. 3, Vauclaire, France. (National Library of Medicine, A 02655)

Conclusion Memory and the Politics of Disease and War Common soldiers, our kind, never get to know the why of things. We only have the pictures from our memories, and what the politicians tell us—afterward. —Private Elton Mackin

Roscoe Vaughan On 19 September 1918, twenty-one-year-old Private Roscoe Vaughan reported to sick call at Camp Jackson, South Carolina, feeling achy and feverish.1 Medical officers promptly hospitalized him along with eightytwo other soldiers that day. Influenza had reached the camp only the day before and followed the familiar pattern. It swept the camp quickly, sending 1,000 men to the hospital the first week, and ultimately sickened more than 10,000 of the 38,000 men in the camp.2 Influenza cases peaked after four weeks, and pneumonia cases peaked a week later. Medical officers at Camp Jackson implemented a special treatment program for respiratory diseases, holding sick call twice a day to examine the men for influenza and other illnesses and sending anyone with a temperature over 100 degrees to the hospital.3 Despite their efforts, however, more than four hundred people died, including five nurses caring for the soldiers.4 Private Vaughan was one of the unlucky ones who got pneumonia and became desperately ill. Within a week, on 26 September, the day Pershing launched the Meuse-Argonne campaign, the young man died. Captain K. P. Hegeforth performed an autopsy, describing the recruit as a “fairly well developed, well nourished man measuring five feet ten inches.” He then excised a piece of Vaughan’s sodden lung, preserved it in formaldehyde and wax, and, in accordance with instructions from the Office of the Surgeon General, sent it to Washington for analysis and cataloging at the

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Army Medical Museum. Hegeforth was participating in the Medical Department’s scientific program to identify and preserve examples of the myriad diseases and wounds of war. Almost eighty years later, in 1995, Jeffrey Taubenberger, a scientist at the museum, now called the Armed Forces Institute of Pathology, was looking for a research project in which he could use a recently developed process called polymerase chain reaction (PCR), which multiplied small bits of DNA into quantities large enough for scientists to read. The tissue samples from the 1918 flu epidemic warehoused at the institute presented the perfect material for his project. Taubenberger and his laboratory technician Ann Reid then used PCR to analyze a number of the tissue samples. After several unsuccessful attempts, in 1997 the bit of Roscoe Vaughan’s lung that Captain Hegeforth had sent to the museum yielded the genetic code of the killer flu, which Taubenberger and Reid identified as influenza virus type A, H1N1.5 The government and its medical officers had been good stewards of the physical tissues preserved from that epidemic, literally maintaining ownership of the influenza virus through the century. As custodians of the memory of the influenza epidemic, however, their stewardship has been less steady.

The Final Act A majority of the most able physicians in the country served in the military during the war. Their story regarding the influenza epidemic is a tragedy in three parts. First, a generation of scientific medical discoveries promised to control many infectious diseases and gave medical officers an inflated sense of their ability to prevent or cure disease, encouraging overly optimistic public expectations of the army’s good health during World War I. Second, the influenza epidemic exploded these expectations and delivered an experience in failure to army physicians who could do nothing to prevent the flu or to treat the deadly pneumonia that often ensued. And third, in the wake of this fall from confidence, medical officers began to discount the significance of the epidemic as a medical event. This book has described at length the first two acts: medical officers’ pride and confidence in their profession and themselves; and the impact of the influenza epidemic on the American war effort and military medical services. The third act, medical officers’ and others’ dismissal of the flu as a significant event, requires more explanation.

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The influenza epidemic’s most important, if enigmatic, legacy has been its reinforcement of the government’s and the society’s reluctance to acknowledge the deadly role disease often plays in war. As a nation memorializes past wars, it defines the values and images under which succeeding generations will enter the next conflict. This process is crucial because a modern nation-state must rely on all of its people and resources to wage war. Memories help people make sense of the present, but they also incorporate and reinforce class, race, gender, and power relations that determine what is remembered (or forgotten), by whom, and to what purpose.6 As people have written war stories and official reports of wars, they have often effaced human suffering, reflecting the military’s tendency to downplay the fact of injury as a product of war.7 This tendency is especially apparent with respect to the story of disease in war. If it is difficult for a government to tell the whole story of how war puts soldiers in harm’s way against an armed enemy, it is even more difficult to describe how war and huge armies foster diseases that the military establishment may be unprepared to fight. Americans turned away from the influenza epidemic of 1918–1919 for several reasons. First of all, the influenza epidemic had to compete with a lot of other “history” during the war era. Belligerent nations had sent 60 million men to the field of battle, and had killed between 9 and 10 million soldiers, injured twice that number, and killed at least 5 million civilians as well. The war severely damaged the British Empire and ended four European monarchies—Germany under Wilhelm II, the Austro-Hungarian Empire, the Ottoman Empire, and Russia under the tsar. The Great War also unleashed revolution across Europe, destroyed European economies, brought to the world stage a rich and newly powerful United States, and laid the foundations for fascism and the Second World War. Modern states with their industrial arsenals and mass armies generated a horrific war of attrition that measured victories not by traditional military goals of land or treasure, but by which side could kill the most men. This process was so terrible and profound that some historians argue that it hastened the end of nineteenth-century Western optimism, idealism, and belief in the steady progress toward the perfection of society, and gave rise to much of the alienation, hatred, and violence of the twentieth century.8 These truly momentous and traumatic developments demanded attention. Many people who had been traumatized by the war and the epidemic may have sought to forget those painful experiences. If, like Katherine

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Ann Porter’s world, their personal worlds had been broken in two by the death of a loved one, they may not have wanted to look back. In a public vein, scientific medicine’s inability to conquer the influenza epidemic may have spurred a national amnesia. It was not a story that people of the Progressive Era and the Age of Modern Medicine wished to be reminded of. When journalist Terra Ziporyn examined the portrayal of three different diseases (diphtheria, typhoid, and syphilis) in popular scientific periodicals from 1870 to 1920, she found that reporters preferred covering success in combating disease to reporting failure. “Medical science,” she explained, “apparently interested the American public only when it suggested the possibility of progress.”9 New York Tribune reporter Heywood Broun’s book on the war, a collection of his columns, illustrates her point—none of them mention the flu despite the fact that it killed more American soldiers than the Great War’s battles put together.10 Influenza produced no heroes. Compared to the Armistice and the Allied victory in Europe, influenza was no success story. The War Department and its medical officers were not the only ones reluctant to discuss the epidemic.11 In the vacuum of public interest, and amid the distractions of peace talks, revolutions in Europe, and demobilization and riots at home, Congress gave the influenza epidemic only brief attention. They and the American people left the issue of the flu epidemic to the medical profession, who gained “ownership” of its memory by default.12 Medical officers throughout the army began to portray the experience as exceptional. And with the complicity of millions of soldiers and citizens, many traumatized by both war and disease, they were to a large degree successful. Epidemiologist George A. Soper proffered a breathtaking understatement in his observation that “had it not been for the pneumonia, the pandemic would not have attracted much attention.”13 Secretary of War Baker followed suit, stating, “Had this great pandemic not occurred, the disease rate and the death rate from disease in the Army would have continued as it was throughout most of the war period—far lower than the normal disease and death rate in the United States.”14 The president of the American Medical Association, Alexander Lambert, took the same perspective. “If the death-rate from pneumonia is subtracted from the total death-rate from disease in the army at home and abroad, it is only 2.2 which is apparently less than the death rate of the men in civil life.”15 These and many similar constructions suggest that medical officers preferred not to discuss the flu; their experiences with it did not comport

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with their self-image as powerful, successful professional physicians and patriots. In this mode, Victor Vaughan stated flatly in his autobiography, “I am not going into the history of the influenza epidemic.” Dismissing it with one, horrifying sentence, he wrote: “It encircled the world, visited the remotest corners, taking toll of the most robust, sparing neither soldier nor civilian, and flaunting its red flag in the face of science.”16 But if Vaughan and his colleagues did not tell the story, who would? Perhaps Private Elton Mackin was right when he observed that common soldiers had to wait to learn their history from officers and politicians.17

The Importance of Numbers But ignoring the influenza epidemic had public policy consequences. It obscured the nature of the war in Europe and at home—the deadliness of disease pathogens as well as human warfare—and helped to create a flawed foundation upon which to formulate future army plans. Recognition of the effects of the influenza epidemic, for example, might have explained a mystery that came before the Congress in early 1919. Elected officials from Kansas alleged that improper supply and leadership of the Thirty-fifth Division resulted in high casualties during the Meuse-Argonne battle. Representative Philip P. Campbell introduced a resolution calling for a congressional investigation, and Governor Henry J. Allen testified before Senate and House congressional committees in support of the resolution.18 Allen asked the committee to investigate why adequate ammunition and supplies were not provided the division, because if it had, “we could have saved half of these casualties.”19 Throughout four days of hearings the discussion focused on the violence of the combat and the division’s difficulties in providing medical care to the wounded. While several witnesses said the division evacuated seven thousand soldiers during the first days of the battle, the influenza epidemic that was raking the American Expeditionary Forces (AEF) during the battle was invisible. The only mention appeared when the division commander, General Peter Traub, stated that “in five days and nights 7,000 wounded passed— wounded, sick, gassed, and exhausted—all cases handled by [division chief medical officer] Col. Turck.”20 Although Traub noted that “no organization in the world can handle all the unforeseen problems that come up in a battle,” he never mentioned the epidemic as a complicating factor. Secretary Baker ignored the influenza, too, even though it could have

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explained what he believed to have been inaccurate data. He told the House committee that whereas the Thirty-fifth Division received more than 10,600 replacements, the number killed in action and died of wounds to 1 November was only 827. Baker distrusted the numbers, stating, “I have not here the list of minor casualties, but apparently the number of 7,000 lost is an overestimate of the whole number.”21 However, the typical 25 percent sickness rate during the epidemic in a division of 20,000 to 25,000 could have accounted for the evacuation of 7,000 men. The committee decided against an investigation, perhaps impressed by General Traub’s testimony. As Traub praised his men—“There was never a finer body of men anywhere furnished by any country”—committee members applauded.22 The hearings demonstrated that the War Department and its critics alike failed to come to terms with how the influenza epidemic added to the casualty rate and exacerbated transportation and supply shortages, which in turn resulted in more casualties. The portrayal of war casualty statistics also shaped the subsequent understanding of the consequences and meaning of the war. Leonard Ayres of the Russell Sage Foundation in New York served as chief statistician for the War Department during the war and produced the definitive statistical record of the war. He calculated 116,000 American deaths in World War I, 43 percent (50,280) of which were in battle, 50 percent (57,460) due to disease, and 7 percent (7,920) to accidents and other causes. He defined battle deaths as those “killed in action and died of wounds,” and recorded a total of 79,610 AEF deaths from battle, disease, and accidents.23 Some medical officers, however, simply deleted the epidemic from medical history. When statistician Albert Love considered average army hospital admission rates for future wartime plans, he noted that 1918 was the best year because there were so many men in the camps, but then calculated, “If the epidemic influenza months September and October are excluded, the average daily admission rate to hospital and quarters for the year was 3.50 per 1000.”24 But by excluding the epidemic he effaced the relation between disease and war. A Prudential Insurance statistician also cut the epidemic from a study of American mortality rates in 1921 when he tracked improved rates for eight infectious diseases in Philadelphia by “comparing the period 1868–72 with the period 1915–20 (exclusive of 1918).”25 The War Department’s official record of the war, The Order of Battle, listed battle casualties only, including 50,475 battle deaths. It failed to report the more than 29,000 who died of disease and other causes, such as

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accidents and suicides, in the AEF.26 Following this approach, a 1919 Senate document on the cost of the war stated that 50,000 men were killed in battle. Although this report calculated various costs of the war, including shipping tonnage, loans to belligerent nations, and damage to civilian property during the war, it failed to mention the war cost of 57,000 deaths from disease. It reduced the army death toll by more half.27 Given reports such as these, historians like Martin Gilbert record the American death toll in the war at 48,000, less than half of Ayres’ original 116,000, obscuring the role of influenza in war and the sacrifice of the soldiers who succumbed to that powerful enemy.28 Such figures portrayed a war unrecognizable to men like medical officers Ward MacNeal and Victor Vaughan, or battery commanders such as H. G. Tighe, who witnessed the destruction of the epidemic firsthand.

Forgetting the Flu As it faded from the historical record, the epidemic seemed also to disappear from the national memory. Many physicians who wrote about the impact of the war on American medicine and public health failed to acknowledge the epidemic at all, focusing instead on the technical and administrative improvements more fitting to their notion of the progress of scientific medicine.29 State and territorial health officers did not put the flu epidemic on their 1919 annual conference agenda and Public Health Service (PHS) surgeon general Rupert Blue did not mention it in his opening address to them, speaking instead on the war, idealism, PHS war work, and an antimalarial campaign.30 Hans Zinsser, a professor of bacteriology at Columbia University and editor of the Journal of Laboratory and Clinical Medicine, served as an AEF sanitary inspector during the epidemic. But in his famous book, Rats, Lice, and History, which examined epidemics during war at length, he devoted only a few sentences to the flu epidemic of 1918.31 Historians have followed the lead of their subjects and taken their cue from the medical officers and their contemporaries in framing the epidemic as exceptional. In 1957, for example, a historian of government science wrote, “With the exception of its futile efforts to check the influenza epidemic, the record of medicine in the war was so outstanding that it introduced a new era of warfare in which the diseases that had once ravaged armies and civilians alike were kept under control.”32 And

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more recently, medical historians have stated, “Except for the terrible worldwide influenza epidemic of 1918, disease claimed far fewer men in World War I than had historically been the case in other wars.”33 Alfred Crosby’s 1976 book on the epidemic, America’s Forgotten Pandemic, was one of the few books on the epidemic until recently. Perhaps inspired by the AIDS epidemic and concern about new, emerging human pathogens, several books and documentaries are now bringing the flu in the United States into new light.34 Despite its deadliness, most military and medical histories mention the epidemic with only a sentence or two or ignore it altogether. Such well-known historians of World War I as Martin Gilbert, A. J. P. Taylor, John Keegan, and Hew Strachan mention the epidemic only in passing.35 Among American authors, Paul Fussell does not remember the flu in The Great War and Modern Memory, David Kennedy devotes but a couple of lines and a footnote to the flu in Over Here: The First World War and American Society, and Harvey A. DeWeerd, in President Wilson Fights His War: World War I and the American Intervention, provides a chart that records 62,000 deaths from disease but does not mention the influenza epidemic in his text.36 More recently, a number of historians have acknowledged that influenza interfered with the American execution of the war but have failed to explore the military, political, or psychological consequences of the disease.37 Medical historians have also given short shrift to the influenza epidemic. Paul Starr, in The Social Transformation of American Medicine, makes no mention of the epidemic, and James Cassedy’s Medicine in America gets the date of the epidemic wrong, placing it after, not during the war.38 Even military medical historians accord the flu little respect. One author dismisses the flu with one sentence, while another states unequivocally (and inaccurately): “In World War I the American Expeditionary Forces suffered no major epidemic problems.”39 Richard Ginn’s history of the army medical service corps relegates the epidemic to asides in sections on entomology (in a footnote) and X-ray technology.40 Thus, following the cues from hundreds of war memoirs and official medical histories that efface the role of disease in war, historians have relegated the worst epidemic in modern history to the sidelines of human memory. While historians have not “remembered the epidemic,” historical memory itself has become an important and rich theme in the historical literature on the Great War. In their fine studies of soldiers in the British army during the war, Paul Fussell and Ilana R. Bet-El stress the importance of the routines of daily life in shaping the soldiers’ war experience

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and the meaning and memories they took from the war, but they fail to mention the experience of disease.41 Scholars who examine the commemoration of the war dead imply that all were victims of combat and weapons, rarely including the devastation of disease to soldiers and their families.42 Adrian Gregory examines the role of silence itself in commemorating the war, as nations began to observe “moments of silence” to honor the war dead. He does not, however, examine the role of silence about aspects of the war.43 That silence deserves study. Historians must now develop an expanded view of war memory to encompass disease— not only the influenza epidemic, but disease in all wars and its impact on soldiers and their families, medical officers and nurses, and line officers and the army high command. The influenza epidemic demonstrated that human intelligence and technology could not always predict and control disease. But the lesson of 1918 did not endure. Although the army did establish an epidemiology board during World War II, citing the flu epidemic, a number of textbooks on military preventive medicine published during that war failed to discuss respiratory illness or mention influenza. For example, Medical Diseases of War mentioned influenza only as a misdiagnosis for paratyphoid or trench fever, and a 1941 symposium on war medicine published fifty-seven papers, most of which were on war surgery, a few on nutrition, but none on respiratory diseases.44 Such silence about the influenza epidemic was more than a mere omission from the history of the Great War —it clouded the historical record of human disease and death and undermined public health education efforts to prevent infectious disease. Silence about deadly epidemics meant that the public was not fully educated about the risks of disease in their daily life and that Americans were not prepared to understand that their soldiers may die of disease as well as of wounds of war. To portray the influenza epidemic as exceptional was in one sense reasonable because it was extraordinary. But to dismiss it as exceptional and therefore not worth remembering was dangerous, as the next war would show. During World War II, the Medical Department saw a much more favorable deaths-from-disease to deaths-from-combat ratio. Only 5 percent of the more than 300,000 army deaths were from disease.45 Morbidity, however, was another story. The vast majority of army hospital admissions were due to disease—almost 15 million of 17.5 million. Medical officers had become better at saving lives of the sick, but still struggled to prevent disease outbreaks. Malaria and other tropical fevers in particular

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crippled U.S. military forces in the Southwest Pacific. In one case, malaria rendered the entire Thirty-second Division deployed in Papua noneffective for four to six months, and two-thirds of the men showed clinical symptoms of malaria for ten months. Not until the army high command —General Douglas MacArthur, a veteran of the Meuse-Argonne—ordered line officers to adopt antimalarial measures could medical officers reduce the debilitating morbidity and noneffective rates.46 In this way, ignoring or dismissing the role of disease in war set the stage for another human tragedy. Will an influenza epidemic like that of 1918 happen again? Evolutionary biologist Paul Ewald makes the argument that the influenza of 1918 will not recur because humans will not re-create the same historical and ecological circumstances of trench warfare that enabled the virus to mutate as it did that year.47 Other writers point out that even under similar circumstances, antibiotics would now reduce the mortality from pneumonia.48 We do know, however, that soldiers, physicians, medical knowledge, governments, and disease will once again meet in war, and that infectious diseases will both yield to and resist control by medical officers. Americans should expect their military to prepare for nature’s deadly surprises—not only biological warfare, but biology, too. In one of his first essays after the Great War, military medical historian Fielding Garrison described war as a “biological phenomenon beyond the control of man,” part of the “painful evolution of man himself from his low prehistoric estate as an animal to his present civilized state.”49 He then compared the war to the influenza epidemic, citing British physician F. G. Crookshank: “Both were biological phenomena, of remote, multiplex or undecipherable causation, arising suddenly, and nowise preventable by merely deciding or wishing that such things should not be.”50 Garrison anticipated the Medical Department’s wish that the flu had never happened. He also knew that ignoring a disease does not make it go away. Silence about the role of infectious diseases in war can only breed arrogance about our scientific powers and render us more vulnerable to the next epidemic and its deadly mysteries. We maintain that silence at our peril.

Notes

notes to the prologue

notes to the introduction

1. Biographical information on MacNeal comes from the Ward J. MacNeal Papers, American Society for Microbiology Archives, Baltimore, Maryland (ASM). I am grateful to archivist Jeff Karr at the ASM for providing me with information for this story. 2. MDWW, vol. 2, 203. 3. MacNeal, “The Influenza Epidemic of 1918,” AIM (June 1919): 660. 4. Hans Zinsser, “The Etiology and Epidemiology of Influenza,” Medicine 1 (1922): 278. 5. MacNeal, “The Influenza Epidemic of 1918,” AIM (June 1919): 660. 6. Ward J. MacNeal to Director of Laboratories, AEF, 13 October 1918, RG 120, Entry 2839, Box 1, NARA. 7. Ward J. MacNeal, “The Influenza Epidemic of 1918 in the American Expeditionary Forces,” manuscript, RG 120, Entry 2119, Box 5560A, NARA. 8. MacNeal, “The Influenza Epidemic of 1918,” AIM 23 (June 1919): 666. 9. Ward J. MacNeal to Director of Laboratories, AEF, 27 December 1918, RG 120, Entry 2119, Box 5560A, NARA; and MacNeal, “The Influenza Epidemic of 1918,” AIM 23 (June 1919): 657–88. 10. Ruth MacNeal McEvoy, “Ward J. MacNeal,” undated, Ward J. MacNeal Papers, ASM. 11. Ernest M. Halliday, “Memorial Service for Dr. Ward J. MacNeal,” Ward J. MacNeal Papers, ASM. 12. Anne Blevins to Jeff Karr, 5 August 1996, Ward J. MacNeal Papers, ASM; and Ruth MacNeal McEvoy to Jeff Karr, 25 July 1996, Ward J. MacNeal Papers, ASM. For an example of this work, see Ward J. MacNeal and Anne Blevins, “Bacteriological Studies in Endocarditis,” Journal of Bacteriology 49 (June 1945): 603–10.

1. Hans Zinsser, Rats, Lice, and History (1934; New York: Bantam, 1971), 113. 2. William Colby Rucker, “The Influence of the European War on the Transmission of the Infections of Disease, with Special Reference to its Effect upon Disease Conditions in the United States,” MS 40 (March 1917): 258. 3. Victor C. Vaughan, quoted in Richard Collier, The Plague of the Spanish Lady (New York: Atheneum, 1974), 266. 4. Andrew Noymer and Michel Garenne, “Long-term Effects of the 1918 ‘Spanish’ Influenza Epidemic on Sex Differentials of Mortality in the USA,” in Howard Phillips and David Killingray, eds., The Spanish Influenza Pandemic of 1918 – 1919: New Perspectives (New York: Routledge Press, 2003). 5. Edwin O. Jordan, Epidemic Influenza: A Survey (Chicago: American Medical Association, 1927), 229; I. D. Mills, “The 1918–1919 Influenza Pandemic: The Indian Experience,” Indian Economic and Social History Review (1986): 1–40; K. David Patterson and Gerald F. Pyle, “The Geography and Mortality of the 1918 Influenza Pandemic,” BHM 65 (June 1991): 4–21; and Howard Phillips and David Killingray, “Introduction,” in Phillips and Killingray, eds., The ‘Spanish’ Influenza Pandemic of 1918 – 1919. Many writers continue to refer to the epidemic as the “Spanish Flu,” but I refrain from doing so because the term is inaccurate and because it perpetuates the mistaken notion that the disease was from the “outside” and was therefore alien to an otherwise healthy United States. 6. Alfred Bollet, Plagues and Poxes: The Rise and Fall of Epidemic Disease (New York: Demos Publications, 1987), 123 – 29; and Alfred Crosby, America’s Forgotten Pandemic: The Influenza of 1918 (Cambridge: Cambridge University Press, 1989), 171–200. 7. Katherine Anne Porter, “Pale Horse, Pale

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192 | Notes to the Introduction Rider,” in The Collected Stories of Katherine Anne Porter (New York: Harcourt, Brace, Jovanovich, 1979). 8. Mary McCarthy, Memories of a Catholic Girlhood (New York: Harcourt, Brace and World, 1957). 9. Spencie Love, One Blood: The Death and Resurrection of Charles R. Drew (Chapel Hill: University of North Carolina Press, 1996), 102. 10. Marjorie Phillips, Duncan Phillips and His Collection, rev. ed. (New York: W. W. Norton, 1982), 59–60. 11. For an account of this process, see Ann H. Reid, Thomas G. Fanning, Thomas A. Janczewski, and Jeffrey K. Taubenberger, “Characterization of the 1918 ‘Spanish’ Influenza Virus Neuraminidase Gene,” Proceedings of the National Academy of Sciences 97 (2000): 6785 – 90. See also Gina Kolata, Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It (New York: Farrar, Straus, and Giroux, 1999). 12. PHS, Annual Report, 1918, recounted an outbreak of “influenza of severe type from which 3 deaths resulted” at Haskell, Kansas, March 30, 1918 (Washington, D.C.: Government Printing Office, 1918), 268; Victor C. Vaughan, “An Explosive Epidemic of Influenzal Disease at Fort Oglethorpe,” JLCM 3 (June 1918): 560 – 64; Victor C. Vaughan and George T. Palmer, “Communicable Diseases in the National Guard and National Army of the United States during the Six Months from September 29, 1917 to March 29, 1918,” JLCM 3 (August 1918): 676 – 79; Crosby, America’s Forgotten Pandemic, 19; and Phillips and Killingray, The ‘Spanish’ Influenza Epidemic, 5–6. 13. Pyle, The Diffusion of Influenza; and Crosby, America’s Forgotten Pandemic, pt. 2. 14. MDWW, vol. 9, 66 – 69, and 126; and Leonard P. Ayres, The War with Germany: A Statistical Summary (Washington, D.C.: Government Printing Office, 1919), 125–26. 15. United States Army American Expeditionary Force, “Report of the Superior Board on Organization and Tactics,” unpublished report, 1919, MHI, 101. 16. MDWW, vol. 6, 1103. 17. WDAR, 1919, vol. 1, pt. 2, 2026 and 1448. A note about statistics: Exact death rates and sickness rates for the influenza epidemic in the army are virtually impossible to determine for several reasons relating to the chaos of war and the way the War Department kept its medical records. First, army physicians diagnosed and admitted patients who probably had

influenza under various diagnoses. One table in the WDAR, 1919, for example, cited “broncho-pneumonia, lobar pneumonia, influenza uncomplicated, influenza with broncho-pneumonia, influenza with lobar pneumonia, influenza with other complications, other respiratory diseases” (vol. 1, pt. 2, 2026). The Medical Department recognized this problem and often aggregated its statistics, but this has made it difficult if not impossible to determine the actual number of true influenza cases. Second, the army aggregated most statistics either yearly in its annual reports, or for the war period, as in the fifteen-volume history, The Medical Department in the World War, so it is difficult to ascertain specific figures for the most destructive period of the flu epidemic, the second wave that occurred in the last quarter of 1918. Third, while the Medical Department kept detailed records on disease rates in individual training camps and in the aggregate in the United States and its territories, records for the AEF in France are much less coherent. Belligerent armies were of course loath to reveal their sickness and noneffective rates, and the constant movement of personnel and equipment to and from Allied army installations in England and France and across the fields of battle frustrated efforts to keep careful records of disease rates for individual military units. The office of the AEF surgeon general ordered both periodic and special reports throughout the war, and these reports and inspections provide information for the AEF as well as anecdotes regarding disease outbreaks in specific army units and army hospitals. As this book will show, sickness rates and death rates from influenza were most likely higher than official records indicate, but I have taken a conservative approach to statistics, largely relying on War Department figures as provided in the annual reports, the MDWW, and in Leonard P. Ayres, The War with Germany: A Statistical Summary (Washington, D.C.: Government Printing Office, 1919). 18. Julie Greene, Pure and Simple Politics: The American Federation of Labor and Political Activism, 1881 – 1917 (Cambridge: Cambridge University Press, 1998), 13; and Charles Bright and Susan Harding, “Processes of Statemaking and Popular Protest: An Introduction,” in Bright and Harding, eds., Statemaking and Social Movements: Essays in History and Theory (Ann Arbor: University of Michigan Press, 1984). 19. Ayres, The War with Germany, 123. 20. Percy M. Ashburn, A History of the Medical Department of the U.S. Army (Boston and New York: Houghton Mifflin, 1929), 320.

Notes to Chapter 1 | 193 21. William MacNeill has written that “the people affected, the medical class and the professional historians all tried to forget. No-one had much to be proud of.” Quoted in Eugenia Tognotti, “Scientific Triumphalism and Learning from Facts: Bacteriology and the ‘Spanish Flu’ Challenge of 1918,” SHM 16 (2003): 110. 22. Alfred Crosby argues in America’s Forgotten Pandemic that the influenza epidemic left a permanent influence on individuals in society rather than at the level of organizations and institutions (p. 323). My argument is that medical officers’ and government officials’ collective “forgetting” of the flu was an act of collective and institutional memory. 23. Paul Woolley, “Report on Epidemic and Infectious Diseases in Camp Devens, Mass.,” JLCM 5 (October 1919): 35. 24. Major Ralph G. Stillman in Raymond Shiland Brown, Base Hospital No. 9, A.E.F.: A History of the Work of the New York Hospital Unit (New York: N.p., 1920), 217. 25. Crosby, America’s Forgotten Pandemic. 26. I am grateful to Fred Anderson for helping me develop the ideas in the following paragraphs. 27. P. W. Huntington, “Transmissible Disease in War,” New York Medical Journal 104 (8 July 1916): 62. See also Friedrich Prinzing, Epidemics Resulting from Wars (Carnegie Endowment for International Peace; Oxford: Clarendon Press, 1916); David John Davis, “Bacteriology and the War,” Scientific Monthly 5 (November 1917): 385 – 99; Lloyd L. Smith, “The Diseases of War: Their Prevention, Control, and Treatment,” CSJM 15 (December 1917): 487 – 91; Hans Zinsser, Rats, Lice, and History (New York: Little, Brown, 1935); Justina Hamilton Hill, Silent Enemies: The Story of the Diseases of War and Their Control (New York: Commonwealth Fund, 1941); and Ralph H. Major, Fatal Partners: War and Disease (Garden City, N.Y.: Doubleday, Doran, 1941). More recent views include William H. McNeill, Plagues and People (Garden City, N.Y.: Anchor Press/Doubleday, 1976); and Jared Diamond, Guns, Germs, and Steel: The Fates of Human Societies (New York: W. W. Norton, 1997). A skeptical view of the relation between war and disease is in Roger Cooter, “Of War and Epidemics: Unnatural Couplings, Problematic Conceptions,” SHM 16 (2003): 283–302. 28. On professionalization, see Brian Balogh, “Reorganizing the Organizational Synthesis: Federal-Professional Relations in Modern America,” Studies in American Political Development 5 (1991): 119 – 72; Jeffrey Berlant, Profession and Monopoly: A Study of

Medicine in the U.S. and Great Britain (Berkeley: University of California Press, 1975); and John Ehrenreich, “Introduction,” in John Ehrenreich, ed., The Cultural Crisis of Modern Medicine (New York: Monthly Review Press, 1978). 29. Charles E. Rosenberg, “Introduction: Why Care about the History of Medicine?” in Explaining Epidemics and Other Studies in the History of Medicine (Cambridge: Cambridge University Press, 1992). 30. Roger Cooter, “War and Modern Medicine,” in W. F. Bynum and Ray Porter, eds., Companion Encyclopedia of the History of Medicine, vol. 2 (London: Routledge Press, 1993), 1536; and Mark Harrison, “Medicine and the Management of Modern Warfare,” History of Science 34 (December 1996): 379. 31. Porter, “Pale Horse, Pale Rider,” in The Collected Short Stories of Katherine Anne Porter, 317.

notes to chapter 1 Epigraph is from William C. Gorgas, “Report of the Surgeon General,” WDAR, 1918, 332. The report covered the period January 1917 through June 1918. 1. Hugh Scott to William Gorgas, 28 March 1918, “Pneumonia, Camp Dix,” RG 112, Entry 31, Box 44, NARA. 2. William C. Gorgas to Hugh L. Scott, 10 April 1918, RG 112, Entry 31, Box 44, NARA. 3. Gorgas to Scott, 10 April 1918, RG 112, Entry 31, Box 44, NARA. 4. Jeffrey Berlant, Profession and Monopoly: A Study of Medicine in the U.S. and Great Britain (Berkeley: University of California Press, 1975). 5. Biographical information on Gorgas comes from John M. Gibson, Physician to the World: The Life of General William C. Gorgas (Durham, N.C.: Duke University Press, 1950); Marie C. Gorgas and Burton J. Hendrick, William Crawford Gorgas, His Life and Works (Garden City, N.Y.: Doubleday, Page, 1924); and Franklin H. Martin, Major General William Crawford Gorgas (Chicago: Surgical Publishing Company, 1924). 6. CR, 63rd Cong., 3rd sess., 4 March 1915, H 5510. 7. Gibson, Physician to the World, 212. 8. Joseph F. Siler, “Major-General William Crawford Gorgas,” American Journal of Tropical Medicine 2 (1922): 162. 9. Gorgas and Hendrick, William Crawford Gorgas, 1. A prophylactic vaccine for yellow fever was not developed until the 1930s.

194 | Notes to Chapter 1 10. Victor Vaughan, A Doctor’s Memories (Indianapolis: Bobbs Merrill, 1926), 346–55. 11. Mary C. Gillett, The Army Medical Department, 1865–1917, Army Historical Series (Washington, D.C.: Center of Military History, United States Army, 1995), 249. 12. Gillett, The Army Medical Department, 263 – 78; Weston Chamberlain, Twenty-five Years of American Medical Activity in Panama, 1904 – 1929: A Triumph of Preventive Medicine (Mount Hope, C.Z.: Panama Canal Press, 1929); and William C. Gorgas, Sanitation in Panama (New York: D. Appleton, 1915). 13. Chamberlain, Twenty-five Years of American Medical Activity in Panama, 14. 14. Theodore Roosevelt, “Special Message Concerning the Panama Canal,” 60th Cong., 2nd sess., CR, 17 December 1906, 458. 15. Reynold Webb Wilcox, “The Medical Corps in Peace and War,” MS 37 (July 1915): 3. 16. Eric Hobsbawm, The Age of Empire, 1875–1914 (New York: Vintage Books, 1989), 251. On tropical medicine and imperialism, see Gillett, Medical Department of the Army, 201–306; Warwick Anderson, “Immunities of Empire: Race, Disease, and the New Tropical Medicine, 1900 – 1920,” BHM 70 (Spring 1996): 94 – 118; Marcos Cueto, “Sanitation from Above: Yellow Fever and Foreign Intervention in Peru, 1919–1922,” Hispanic American Historical Review 72 (1992): 1 – 22; Ken De Bevoise, Agents of Apocalypse: Epidemic Disease in the Colonial Philippines (Princeton, N.J.: Princeton University Press, 1995); and David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in NineteenthCentury India (Berkeley: University of California Press, 1993). Paul Weindling argues that bacteriology promoted European imperialism, in “A Virulent Strain: German Bacteriology as Scientific Racism, 1890 – 1920,” in Waltraud Ernst and B. Harris, eds., Race, Science and Medicine, 1700 – 1960 (London and New York: Routledge, 1999), 218–24. 17. Warwick Anderson, “Disease, Race, and Empire,” BHM, Spring 1996, 65. 18. Gorgas, Sanitation in Panama, 292. 19. W. C. Gorgas, “The Conquest of the Tropics for the White Race,” JAMA 52 (19 June 1909): 1969. 20. Nancy J. Tomes and John Harley Warner, “Introduction to Special Issue on Rethinking the Reception of the Germ Theory of Disease: Comparative Perspectives,” JHMAS, January 1997, 7 – 16; Nancy J. Tomes, The Gospel of Germs: Men, Women, and the Microbe in American Life (Cambridge, Mass.:

Harvard University Press, 1998); Ronald L. Numbers and John Harley Warner, “The Maturation of American Medical Science,” in Judith Walzer Leavitt and Ronald L. Numbers, Sickness and Health in America: Readings in the History of Medicine and Public Health, 2nd ed., revised (Madison: University of Wisconsin Press, 1985), 113 – 25; and George Rosen, A History of Public Health (expanded edition; Baltimore: Johns Hopkins University Press, 1993). 21. Hermann Biggs, 1911, cited in Evelynn Maxine Hammonds, Childhood’s Deadly Scourge: The Campaign to Control Diphtheria in New York City, 1880 – 1930 (Baltimore: Johns Hopkins University Press, 1999), 221. 22. Samuel L. Baker, “Physician Licensure Laws in the United States, 1865 – 1915,” JHMAS 39 (1984): 192; James Burrow, Organized Medicine in the Progressive Era: The Move toward Monopoly (Baltimore: Johns Hopkins University Press, 1977); and Rosemary Stevens, American Medicine and the Public Interest (New Haven: Yale University Press, 1971), 55–131. 23. Edward L. Munson, “The Education of Line Officers and Sanitary Efficiency,” MS 39 (November 1916): 535. 24. War Department, “Report of the Surgeon General,” WDAR, 1917, 350. 25. U.S. Congress, Senate, S. 6049, A Bill to Establish a National Department of Public Health, 61st Cong., 3rd sess. (1910); and Manfred Wasserman, “The Quest for a National Health Department in the Progressive Era,” BHM, Fall 1975, 353–80. 26. U.S. Congress, Senate, Sen. Doc. 419, National Vitality: Its Waste and Conservation, 60th Cong., 2nd sess. (1909), 635. 27. Elizabeth A. Fenn, Pox Americana: The Great Smallpox Epidemic of 1775 – 82 (New York: Hill and Wang, 2001). 28. John F. Fuller, Thor’s Legions: Weather Support to the U.S. Air Force and Army, 1937–1987 (Boston: American Meteorological Society, 1990), 1 – 3; and Rose C. Engleman and R. J. T. Joy, Two Hundred Years of Military Medicine (Fort Detrick, MD: Historical Unit, U.S. Army Medical Department, 1975), 1–5. 29. Wyndham D. Miles, A History of the National Library of Medicine: The Nation’s Treasury of Medical Knowledge (Bethesda, Md.: National Library of Medicine, 1982), 16, 61, 325; and War Department, Surgeon General’s Office, Index-Catalogue of the Library of the Surgeon-General’s Office (Washington, D.C.: Government Printing Office, 1880 – 1961).

Notes to Chapter 1 | 195 30. George M. Sternberg, A Manual of Bacteriology (New York: William Wood, 1892); Fielding H. Garrison, An Introduction to the History of Medicine (Philadelphia: W. B. Saunders, 1913); and Engleman and Joy, Two Hundred Years of Military Medicine. 31. Bailey K. Ashford and Igaravides Pedro Gutierrez, Uncinariasis (Hookworm Disease) in Porto Rico: A Medical and Economic Problem (Washington, D.C.: Government Printing Office, 1911); and Carl R. Darnall, “The Purification of Drinking Water for Troops in the Field,” MS 22 (1908): 253–85. 32. Gillett, The Army Medical Department, 348–49. An earlier effort to immunize soldiers in the army in 1904 failed. See W. D. Tigertt, “The Initial Effort to Immunize American Soldier Volunteers with Typhoid Vaccine,” Military Medicine 124 (1959): 342–49. 33. C. C. McCulloch, “Military Hygiene,” Medical Record (2 June 1917): 947. 34. Vincent J. Cirillo, “Fever and Reform: The Typhoid Epidemic in the Spanish-American War,” JHMAS 55 (October 2000): 363 – 97; and J. T. H. Connor, “‘Before the World in Concealed Disgrace’: Physicians, Professionalization and the 1898 Cuban Campaign of the Spanish American War,” in Roger Cooter, Mark Harrison, and Steve Sturdy, eds., Medicine and Modern Warfare, The Wellcome Institute Series in the History of Medicine (Amsterdam: Rodopi B. V., 1999). 35. Walter Reed, Victor C. Vaughan, and E. O. Shakespeare, Report on the Origin and Spread of Typhoid Fever in the U.S. Military Camps during the Spanish War of 1898, 2 vols. (Washington, D.C.: Government Printing Office, 1904). The Commission published three different reports; the one commonly cited is the final report of 1904. 36. U.S. Congress, Senate, Report of the (Dodge) Commission Appointed by the President to Investigate the Conduct of the War Department in the War with Spain, 56th Cong., 1st sess., Senate Doc. 221; Gillett, The Army Medical Department, chapter 7; and Stanhope Bayne-Jones, The Evolution of Preventive Medicine in the U.S. Army, 1607–1939 (Washington, D.C.: Office of the Surgeon General of the Army, 1968), 123–46. 37. John J. Pershing, My Experiences in the World War (New York: Frederick A. Stokes, 1931), 175–76. 38. Frederick P. Gay, “The Contribution of Medical Science to Medical Art as Shown in the Study of Typhoid Fever,” Science 44 (28 July 1916): 113. 39. Victor C. Vaughan, “Eugenics from the Point of View of a Physician,” in Lewellys F.

Barker et al., Eugenics: Twelve University Lectures (New York: Dodd, Mead, 1914), 57–58. On eugenics, see Frank Dikötter, “Race Culture: Recent Perspectives on the History of Eugenics,” AHR 103 (April 1998): 467 – 78; Daniel Kevles, In the Name of Eugenics: Genetics and the Uses of Human Heredity, 2nd ed. (Cambridge, Mass.: Harvard University Press, 1995); and Martin S. Pernick, “Eugenics and Public Health in American History,” AJPH 87 (November 1997): 1767–72. 40. Vaughan, “Eugenics from the Point of View of a Physician,” in Barker, Eugenics, 60. 41. Charles B. Davenport, “The Eugenics Programme and Progress in Its Achievement,” in Barker, Eugenics, 1–14. 42. Vaughan, “Eugenics from the Point of View of a Physician,” in Barker, Eugenics, 61. Emphasis added. 43. Roger Cooter, “Of War and Epidemics: Unnatural Couplings, Problematic Conceptions,” SHM 16 (2003): 298. 44. C. C. McCullough, Jr., “The Coat of Arms of the Medical Corps,” MS 41 (1917): 145. 45. Woods Hutchinson, The Doctor in War (Boston: Houghton, Mifflin, 1918), vii. 46. Paul A. C. Koistinen, Mobilizing for Modern War: The Political Economy of American Warfare, 1865 – 1919 (Lawrence: University Press of Kansas, 1997), chapter 7; and Ronald Schaffer, America in the Great War: The Rise of the War Welfare State (New York: Oxford University Press, 1991). 47. Rupert Blue, “Proceedings of the 25th Annual Meeting, October 7 – 10, 1917,” MS 41 (November 1917): 518. 48. MS 43 (December 1918): 680–81. 49. William Gorgas to Stanhope BayneJones, 17 June 1915, Ms. C155, Stanhope Bayne-Jones Papers, 1870–1969, Box 8, NLM. 50. “Officers and Members of the Academy, November 20, 1918,” Proceedings of the National Academy of Sciences 4 (1918): vii–viii. 51. Franklin H. Martin, Fifty Years of Medicine and Surgery (Chicago: Surgical Publishing Company of Chicago, 1934). 52. MDWW, vol. 1, 82. 53. Fielding H. Garrison, An Introduction to the History of Medicine (Philadelphia: W. B. Saunders, 1921), 811. John S. Barry describes the prestige of these men in The Great Influenza: The Epic Story of the Deadliest Plague in History (New York: Viking, 2004). 54. Stephen Skowronek, Building a New American State: The Expansion of National Administrative Capacities, 1877 – 1920 (New York: Cambridge University Press, 1982), chapter 4; and Samuel Huntington, Soldier

196 | Notes to Chapter 1 and the State: The Theory and Politics of CivilMilitary Relations (New York: Vintage, 1964). 55. Henry Page, “Civil Physicians and National Defense,” MS 40 (April 1917): 394. 56. H. C. Coe, “Sacrifice,” MS 43 (September 1918): 344–45. 57. MDWW, vol. 1, 789–90; JAMA 70 (13 April 1918): 1100; and “An Imperative Appeal for Medical Officers,” CSJM 16 (June 1918): 275–77. 58. Mary Roth Walsh, Doctors Wanted, No Women Need Apply: Sexual Barriers in the Medical Profession, 1835–1975 (New Haven: Yale University Press, 1977); and Ellen S. More, Restoring the Balance: Women Physicians and the Profession of Medicine, 1850 – 1995 (Cambridge, Mass.: Harvard University Press, 1999). 59. On AMA activities during the war, see MDWW, vol. 1, 574–80. 60. On army nurses, see “The Army Nurse Corps,” MDWW, vol. 13, pt. 2; Mary T. Sarnecky, A History of the U.S. Army Nurse Corps (Philadelphia: University of Pennsylvania Press, 1999); and Susan Zeiger, In Uncle Sam’s Service: Women Workers with the American Expeditionary Force, 1917–1919 (Ithaca, N.Y.: Cornell University Press, 1999). 61. The U.S. Census of 1910 reports that 84 percent of women physicians were white, native born; 12 percent were white, foreign-born; 4 percent were African American; and less than 1 percent were Native American, Asian, or of other racial or ethnic origin. 62. Ellen S. More, “A Certain Restless Ambition: Women Physicians in World War I,” American Quarterly 41 (December 1989): 638. In 1917 the AMA did not exclude women but did bar black physicians from membership. 63. Kimberly Jensen, “Women, Citizenship and Civic Sacrifice: Engendering Patriotism in the First World War,” in John Bodnar, ed., Bonds of Affection (Princeton, N.J.: Princeton University Press, 1996), 145–46. 64. Jensen, “Women, Citizenship, and Civic Sacrifice,” 147. 65. Kimberly Jensen, “The ‘Open Way of Opportunity’: Colorado Women Physicians and World War I,” Western Historical Quarterly 27 (Autumn 1996): 341–42. 66. War Department, Opinions of Judge Advocate General, vol. 1, 1 April 1917 to 31 December 1917 (Washington, D.C.: Government Printing Office, 1919), 126–27. 67. Kimberly Jensen, “Uncle Sam’s Loyal Nieces: American Medical Women, Citizenship, and War Service in World War I,” BHM 67 (1993): 685.

68. Jensen, “Uncle Sam’s Loyal Nieces,” 679–80. 69. Hugh Young, A Surgeon’s Autobiography (New York: Harcourt, Brace, 1940), 361. 70. Gerald W. Patton, chapters 1–4 in War and Race: The Black Officer and the American Military, 1915 – 41 (Westport, Conn.: Greenwood Press, 1981); and Mark Ellis, Race, War, and Surveillance: African Americans and the United States Government during World War I (Bloomington: Indiana University Press, 2001), 74–101. 71. George E. Cannon, “The Negro Medical Profession and the United States Army,” JNMA 11 (January–March 1918): 21. 72. For examples, see editorial, “The World War — What Does it Mean? How Does It Apply to the Afro-American?” JNMA 9 (October – December 1917): 195 – 97, and C. V. Roman, “The War — What Does It Mean? What Should We Do? JNMA 11 (January – March 1918): 41–42. 73. Emmett Scott to the Secretary of War, 10 December 1917, RG 107, Entry 96, Box 2, NARA. 74. R. B. Miller to Senator David Baird, 21 October 1918, printed in JNMA 11 (JanuaryMarch 1918): 23. 75. Cannon, “The Negro Medical Profession and the United States Army,” 28. 76. Herbert M. Morais, The History of the Negro in Medicine (New York: Publishers Company, 1967), 111; and MDWW, vol. 7, 262–76. See also Louis T. Wright, “The Negro Doctor and the War,” JNMA 11 (October–December 1919): 195–96. 77. Frederick M. Dearborn, ed., American Homeopathy in the World War (New York: Globe Press, 1923), 298. 78. William Holmes Dyer, “War Time Diary of Dr. William Holmes Dyer,” unpublished manuscript, Lincoln Public Library, Lincoln, Illinois. I am grateful to Adele Logan Alexander for providing me with a typescript of the diary. 79. Ava Baron, “Gender and Labor History: Learning from the Past, Looking to the Future,” in Ava Baron, ed., Work Engendered: Toward a New History of American Labor (Ithaca, N.Y., and London: Cornell University Press, 1991); and Joan Wallach Scott, “Gender: A Useful Category of Historical Analysis,” in Gender and the Politics of History (New York: Columbia University Press, 1988). 80. Vera Brittain, Testament of Youth (1933; New York: Penguin Books, 1978), 420–21. 81. “Our London Letter,” Medical Record 94 (10 August 1918): 251.

Notes to Chapter 1 | 197 82. Leonard P. Ayres, The War with Germany: A Statistical Summary (Washington, D.C.: Government Printing Office, 1919), 13– 19. 83. Order of Battle, vol. 3, pt. 1, 374. 84. For a description of these examinations, see Albert G. Love and Charles B. Davenport, Physical Examination of the First Million Draft Recruits: Methods and Results, Office of the Surgeon General, Bulletin No. 11 (Washington, D.C.: Government Printing Office, 1919); U.S. Congress, House of Representatives, Committee on Military Affairs, “Army Appropriations Bill, 1919” (7 December 1917), 1178 – 79; and Clarence Cole, E. W. Loomis, and Eugie A. Campbell, “A Report of Physical Examination of Twenty Thousand Volunteers,” MS 43 (July 1918): 45–65. 85. WDAR, 1919, vol. 1, pt. 1, 80–81; and pt. 2, 1431–32. 86. Edward H. Beardsely, A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth-Century South (Knoxville: University of Tennessee Press, 1987), 133. For “appalling,” see “The ‘Health Rate’ of a Nation,” JAMA 72 (1 February 1919): 346; and Harry D. Orr, “Examination of Recruits for the Army and Militia,” AJPH 7 (May 1917): 485–88. 87. C. H. Mayo, “Medical Service in the United States Army,” St. Paul Medical Journal 19 (December 1917): 351. 88. Woodrow Wilson, “Special Statement,” in Edward F. Allen, Keeping Our Fighters Fit for War and After (New York: Century, 1918). 89. Nancy Gentile Ford, Americans All! Foreign-Born Soldiers in World War I (College Station: Texas A&M University Press, 2001); and William Bruce White, “The American Military and the Melting Pot in World War I,” in Peter Karsten, ed., The Military in America from the Colonial Era to the Present (New York: Free Press, 1980), 301–12. 90. Figures on these groups vary in the literature. I have used those from a study by Thomas A. Britten, American Indians in World War I (Albuquerque: University of New Mexico Press, 1997), 59–60, and 198, n. 28. 91. U.S. Congress, House, 66th Cong., 1st sess., House Report 423, “Enlistment of NonEnglish-Speaking Citizens and Aliens,” 27 October 1919, 1. 92. Nancy Bristow makes this argument powerfully in Making Men Moral: Social Engineering during the Great War (New York: New York University Press, 1996), especially chapters 1 and 2. See also Cecilia Elizabeth

O’Leary, To Die For: The Paradox of American Patriotism (Princeton, N.J.: Princeton University Press, 1999). 93. Ford, Americans All! 67–87. 94. Leon F. Litwack, Trouble in Mind: Black Southerners in the Age of Jim Crow (New York: Knopf, 1998); Neil R. McMillen, Dark Journey: Black Mississippians in the Age of Jim Crow (Urbana: University of Illinois Press, 1990); C. Vann Woodward, Origins of the New South, 1877 – 1913 (Baton Rouge: Louisiana State University Press, 1971); and Joel Williamson, The Crucible of Race: Black/White Relations in the American South since Emancipation (New York: Oxford University Press, 1984). 95. Marvin Fletcher, The Black Soldier and Officer in the United States Army, 1891–1917 (Columbia: University of Missouri Press, 1974), 67–68; Arthur E. Barbeau and Lorette Henri, The Unknown Soldiers: Black American Troops in World War I (Philadelphia: Temple University Press, 1974); and Ellis, Race, War, and Surveillance. 96. Jennifer D. Keene, Doughboys, the Great War, and the Remaking of America (Baltimore: Johns Hopkins University Press, 2001), argues that the War Department’s accession to segregation in the army illustrates the power of the “citizen soldier” to negotiate with the government. I think she overstates her case, however, because most government officials were segregationists, anyway, and were including African Americans only in response to political pressure from African Americans and their advocates. See preceding note. 97. MDWW, vol. 13, pt. 2, 302–5. 98. Jonathan Gawne, Over There! The American Soldier in World War I: The Illustrated History of the American Soldier, His Uniform, and His Equipment (London: Greenhill Books, 1997); and War Department, Manual for the Medical Department, United States Army (Washington, D.C.: Government Printing Office, 1916) (hereafter Medical Manual), 30–31. 99. William K. Emerson, Encyclopedia of United States Army Insignia and Uniforms (Norman: University of Oklahoma Press, 1996); Gawne, Over There! 11; and Frederick Palmer, Newton D. Baker: America at War (New York: Dodd, Mead, 1931), 410 – 12. 100. Hugh Young, A Surgeon’s Autobiography (New York: Harcourt, Brace, 1940), 268. 101. Simon Flexner and James T. Flexner, William Welch and the Heroic Age of American Medicine (New York: Viking Press, 1941;

198 | Notes to Chapter 1 Baltimore: Johns Hopkins University Press, 1993), 375. 102. On black nurses, see Darlene Clark Hine, “The Call That Never Came: Black Women Nurses and World War I, an Historical Note,” Indiana Military History Journal 8 (January 1983): 23 – 27; and Hine, Black Women in White: Racial Conflict and Cooperation in the Nursing Profession, 1890 – 1950 (Bloomington: Indiana University Press, 1989). 103. Tomes, The Gospel of Germs, 67. 104. Editorial, “The Medical Inspector,” MS 43 (July 1918): 69. 105. WDAR, 1917, 338. 106. Earl Mayo, “Our New Attitude toward Disease,” Outlook, 20 July 1912, 635. 107. Editorial, “Ability and Responsibility,” MS 39 (July 1916): 69.

notes to chapter 2 The epigraph comes from Victor C. Vaughan, “Are We to Forget the Lessons of 1898?” JLCM 2 (May 1917): 589. 1. Victor C. Vaughan and George T. Palmer, “Communicable Diseases in the National Guard and National Army of the United States during the Six Months from September 29, 1917, to March 29, 1918,” JLCM 3 (August 1918): 635–36. 2. Victor C. Vaughan, “Measles and Pneumonia in Our Camps,” JLCM 3 (January 1918): 248 – 57; and “An Explosive Epidemic of Influenzal Disease at Fort Oglethorpe,” JLCM 3 (June 1918): 560 – 64; Vaughan and Palmer, “Communicable Diseases”; and Vaughan and Palmer, “Communicable Disease in the United States Army during the Summer and Autumn of 1918,” JLCM, July 1919, 587–623, and August 1919, 647–86. 3. Victor C. Vaughan, “Are We to Forget the Lessons of 1898?” JLCM 2 (May 1917): 589. 4. Biographical material on Vaughan is from Horace W. Davenport, Victor Vaughan: Statesman and Scientist, Historical Center for the Health Sciences Monographs, no 4. (Ann Arbor: University of Michigan Press, 1996); Victor Vaughan, A Doctor’s Memories (Indianapolis: Bobbs Merrill, 1926); and a commemorative issue of the JLCM 15 (June 1930). 5. Vaughan, A Doctor’s Memories, 406. 6. Victor C. Vaughan, “A Medical Man’s Opinion Concerning Universal Military Training,” JLCM 5 (March 1920): 407 – 9, and A Doctor’s Memories. 7. Vaughan, A Doctor’s Memories, 1. 8. The army General Staff were the officers charged with administration of the army for

the War Department, and the line command were the officers within the army hierarchy with command over the various combat and support units of soldiers. 9. On Progressive reform, see Martin Sklar, The Corporate Reconstruction of American Capitalism, 1890 – 1916 (Cambridge: Cambridge University Press, 1988); Barry D. Karl, The Uneasy State: The United States from 1915 to 1945 (Chicago: University of Chicago Press, 1983); Stephen Skowronek, Building a New American State: The Expansion of National Administrative Capacities, 1877 – 1920 (New York: Cambridge University Press, 1982); and Bruce D. Porter, War and the Rise of the State: The Military Foundations of Modern Politics (New York: Free Press, 1994). 10. On Progressive reforms in the army, see Ronald J. Barr, The Progressive Army: U.S. Army Command and Administration, 1870 – 1914 (New York: St. Martin’s Press, 1998); Skowronek, Building a New American State; Samuel Huntington, The Soldier and the State: The Theory and Politics of Civil-Military Relations (New York: Vintage, 1964); Peter Karsten, “Armed Progressives: The Military Reorganizes for the American Century,” in Peter Karsten, ed., The Military in America from the Colonial Era to the Present (New York: Free Press, 1980); and Jack Lane, Armed Progressive: General Leonard Wood (San Rafael, Calif.: Presidio Press, 1978). 11. On Progressive reforms in medicine, see Rosemary Stevens, American Medicine and the Public Interest, updated ed. (Berkeley: University of California Press, 1998); and Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), 79–289. 12. Benjamin S. Warren and Charles F. Bolduan, “War Activities of the United States Public Health Service,” PHR 34 (6 June 1919): 1243 – 68; and Henry Pomeroy Davison, The American Red Cross in the Great War (New York: Macmillan, 1919). 13. Leonard P. Ayres, The War with Germany: A Statistical Summary (Washington, D.C.: Government Printing Office, 1919), 13. 14. Historian Jennifer Keene has written that “citizen soldiers” in the U.S. Army played a “critical role” in shaping that institution during World War I. She also argues that veterans of the war provided the impetus for passage of the GI bill during World War II because they believed that soldiers had a “social contract” with the government. See Jennifer D. Keene, Doughboys, the Great War, and the Remaking of America (Baltimore: Johns Hopkins University Press, 2001). 15. Porter, War and the Rise of the State, 10.

Notes to Chapter 2 | 199 16. U.S. Congress, 65th Cong., 1st sess., Senate Doc. 81, W. G. McAdoo, “The Duty of a Just Government,” 15 August 1917, 4. 17. The Military and Naval Insurance Act, approved on 6 October 1917. See Treasury Department, Bureau of War Risk Insurance, Military and Naval Insurance; and Military and Naval Compensation Claims as a Result of the World War, 30 June 1919 (Washington, D.C.: Government Printing Office, 1920). 18. McAdoo, “The Duty of a Just Government,” 3. 19. Order of Battle, vol. 3, pt. 1, 248. 20. Order of Battle, vol. 3, pt. 1; and Ayres, The War with Germany, 131–33. 21. National Defense Act was approved 3 June 1916 (39 Stat. L., 166); Owen, Legislation Relating to the Medical Corps of the U.S. Army, 49–59; and Tobey, The Medical History of the Army, 34–36. 22. War Department General Order No. 80, 30 June 1917; and Richard V. N. Ginn, The History of the U.S. Army Medical Service Corps (Washington, D.C.: Office of the Surgeon General and Center of Military History, United States Army, 1997), 57–88. 23. Roger Cooter, “War and Modern Medicine,” in W. F. Bynum and Ray Porter, eds., Companion Encyclopedia of the History of Medicine, vol. 2 (London: Routledge Press, 1993), 1536–73; Howard Levy, “The Military Medicinemen,” in John Ehrenreich, ed., The Cultural Crisis of Modern Medicine (New York: Monthly Review Press, 1978): 287–300; Mark Harrison, “Medicine and the Management of Modern Warfare,” History of Science 34 (December 1996): 379 – 410; and Roger Cooter and Steve Sturdy, “Of War, Medicine and Modernity: Introduction,” in Roger Cooter, Mark Harrison, and Steve Sturdy, eds., War, Medicine and Modernity (Stroud, England: Sutton, 1998), 1–21. 24. Victor C. Vaughan, “The Responsibilities of the Medical Profession in this War,” MS 41 (December 1917): 656. 25. Medical Manual, 179. The Medical Manual issued in 1916 was used throughout the war, MDWW, vol. 1, 855–56. 26. See for example WDAR, 1919, vol. 1, pt. 2, 1448–49, and 1463–64. 27. George Strott, “The Medical Department of the United States Navy with the Army and Marine Corps in France in World War I,” http://perso.club-internet.fr/batmarn2/ltstrott.htm. 28. Medical Manual, 202, paragraph 628; and MDWW, vol. 8, on transportation and triage. Historian Richard Ginn’s explanation of the differences between the French and

American evacuation systems helps to elucidate this policy: “There is a fundamental doctrinal conflict between quickly clearing the battle field versus conserving the fighting strength. The French gave primacy to the latter (and perhaps to a humanitarian impulse) by fielding a sophisticated surgical capability early in the evacuation chain. That option assumed greater survivability and faster return to duty through the earlier use of sophisticated treatment. However, it was elected at the expense of providing combat commanders a faster tempo of combat operations through a more quickly cleared battlefield and small logistical tail in the forward area. The U.S. doctrine struck a good balance in World War I, handling the question with good sense and within the limits of the technology available at the time.” Ginn, The History of the U.S. Army Medical Service Corps, 54, n. 31. 29. MDWW, vol. 8, 888. 30. Jay W. Grissinger, Medical Field Service in France (Washington, D.C.: Association of Military Surgeons, 1928); and J. W. Grissinger, “Report on Organization and Activities of the Medical Department of the Third Army of the American E.F.,” April 1919, RG 120, Entry 977, Box 1, NARA. 31. Joseph H. Ford, quoting Jefferson Kean in Ford, Details of Military Medical Administration (Philadelphia: P. Blakiston’s Son, 1918), 6. 32. Ford, Details of Military Medical Administration, 6. 33. Gustavus M. Blech, “The Part of the Medical Department in Maintaining Military Morale,” MS 48 (June 1921): 640–42. 34. Robert D. Leigh, Federal Health Administration in the United States (New York: Harper and Bros., 1927), 30; and Frank J. Goodnow, “Constitutional Foundations of Federal Health Functions,” AJPH, August 1919, 561–66. 35. War Department, Opinions of Judge Advocate General, 1918, vol. 2 (Washington, D.C.: Government Printing Office, 1919), 152–53; and “Refusal to Submit to Surgery,” JAMA 70 (May 1918): 1544. See also General Order 29, 26 March 1918, War Department, General Orders and Bulletins, 1918 (Washington, D.C.: Government Printing Office, 1919). 36. Pearce Bailey, “Malingering in U.S. Troops, Home Forces, 1917,” MS 42 (March 1918): 261–75. See also MDWW, vol. 7, 848– 57; Ford, Details of Military Medical Administration, 531–51; Tom A. Williams, “Malingering and the Simulation of Disease in Warfare,” MS (May 1921): 520 – 33; Joseph Catton, “Malingering: Its Diagnosis and Significance,”

200 | Notes to Chapter 2 CSJM, November 1917, 458–61; and “Malingering,” MS 48 (December 1919): 706–17. 37. Bailey, “Malingering in U.S. Troops,” 271–74. 38. William C. Gorgas, “Health Problems of the Army,” AJPH 7 (November 1917): 937. 39. William C. Gorgas, “Clinical Research in United States Army Base Hospitals,” MCNA 2 (September 1918): 313–14. 40. Russell L. Cecil and J. Harold Austin, “Results of Prophylactic Inoculation against Pneumococcus in 12,519 Men,” JEM 28 (July 1918): 19 – 41; Russell L. Cecil and Henry F. Vaughan, “Results of Prophylactic Vaccination against Pneumonia at Camp Wheeler,” JEM 29 (1 May 1919): 457–83; P. F. McGuire et al., “Protection Afforded by Anti-Pneumococcus Vaccination against Respiratory Infections,” MS, November 1921, 559–65; and letter from F. Russell to men at Camp Devens, RG 112, Entry 31, Box 84, NARA. On the experimental nature of the pneumonia vaccine, see Harry M. Marks, The Progress of Experiment: Science and Therapeutic Reform in the United States, 1900 – 1990 (Cambridge: Cambridge University Press, 1997), 60–70. 41. Isaac W. Brewer, “The Control of Communicable Diseases in Camps,” AJPH 8 (February 1918): 124. 42. William S. Dow, “The Possibility of Medical Research in the Military Service Because of Its Complete Control over Personnel,” MS 56 (February 1925): 131 – 32. Although army researchers usually stated that soldiers who participated in medical experiments were volunteers, this was not always the case. During the early twentieth century, military personnel had the right in principle to refuse to participate in medical experiments, but incentives such as cash payments and better duty assignments raised questions about pressures on volunteers. See Susan E. Lederer, “Military Personnel as Research Subjects,” in Encyclopedia of Bioethics (New York: Macmillan, 1997), 1774–76. 43. Guy R. Moore and Rexford B. Cragg, “Reminiscences of a ‘Buck’ and a ‘Sarge’ of Base Hospital No. 85,” WWI Questionnaire Collection: Medical Corps, MHI. 44. Channing Frothingham, “Function of a Base Hospital in a National Army Cantonment,” MCNA 2 (September 1918): 397. 45. Grace Crile, ed., George Crile: An Autobiography (Philadelphia: J. B. Lippincott, 1947), 315. 46. In War Department Special Regulation No. 28, “Sanitary Regulations and Control of Communicable Diseases” (Washington, D.C.: Government Printing Office, 1917), 7, empha-

sis added. These regulations were in effect during the entire war period, MDWW, vol. 1, 247. 47. Editorial, “On Loyalty,” MS 41 (October 1917): 475. 48. Fielding H. Garrison, “The Military Code,” MS 41 (December 1917): 726. 49. H. C. Coe, “Obedience to Orders,” MS 42 (May 1918): 564. See also Editorial, “Customs of the Service,” MS 41 (July 1918): 119– 22, on the importance of the salute to army order and discipline. 50. Edward F. Allen, Keeping Our Fighters Fit for War and After (New York: Century, 1918), 7. 51. MDWW, vol. 6, 123. 52. Frank R. Keefer, “The Sanitary Problems of Trench Warfare,” MS 38 (June 1916): 617. 53. MDWW, vol. 6; Medical Manual; and War Department, Special Regulations No. 28, “Sanitary Regulations and Control of Communicable Diseases” (Washington, D.C.: Government Printing Office, 1917). 54. Frederick Pottle, Stretchers: The Story of a Hospital Unit on the Western Front (New Haven: Yale University Press, 1929). 55. Pottle, Stretchers, 3. 56. Pottle, Stretchers, 11–12. 57. Pottle, Stretchers, 60. 58. Henry J. Nichols, “The Lobar Pneumonia Problem in the Army from the Viewpoint of the Recent Differentiation of Types of Pneumococci,” MS 41 (August 1917): 160. 59. WDAR, 1917, 346. 60. Percy M. Ashburn, A History of the Medical Department of the U.S. Army (Boston and New York: Houghton Mifflin, 1929), 317. 61. MDWW, vol. 1, 265. 62. WDAR, 1918, 486. On measles in individual camps, see Louis C. Duncan, “An Epidemic of Measles and Pneumonia in the 31st Division, Camp Wheeler, Georgia,” MS 41 (February 1918): 123 – 38; Wallace A. Pratt, “A Consideration of the Causes and Prevention of Primary Pneumonias and Pneumonias complicating Measles in the Unites States Army,” MS 42 (June 1918): 653 – 58; Walter W. Hamburger and Herbert Fox, “A Study of the Epidemics of Pneumococcus Infections, and Streptococcus Infections, and Measles at Camp Zachary Taylor, Kentucky, Autumn, 1917 to Summer, 1918,” MCNA 2 (September 1918): 321–78; and Herbert Fox, “History of Measles at Camp Zachary Taylor, Kentucky, Summer of 1917 to Winter of 1919,” MS 45 (August 1919): 185–99. 63. Duncan, “An Epidemic of Measles and Pneumonia,” 123–25. 64. WDAR, 1918, 480 – 88; MDWW, vol.

Notes to Chapter 2 | 201 9, 409–50; Edward B. Vedder, “The Epidemiology of the Sputum-Borne Diseases and Its Relation to the Health of the National Forces,” MS 44 (February 1919): 123–53; and Medical Department of the United States Army, Office of the Surgeon General, Preventive Medicine in World War II: Volume IV. Communicable Diseases Transmitted Chiefly through Respiratory and Alimentary Tracts (Washington, D.C.: Office of the Surgeon General, Department of the Army, 1958), 129–30. 65. Andrew Cliff, Peter Haggett, and Matthew Smallman-Raynor, Measles: An Historical Geography of Major Human Viral Diseases, from Global Expansion to Local Retreat, 1840 – 1990 (Oxford: Blackwell, 1993); and Anne Hardy, The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856 – 1900 (Oxford: Clarendon Press, 1993), chapter 2. 66. Vaughan, “Measles and Pneumonia in Our Camps,” 248 – 52; and WDAR, 1918, 480, 67. Vaughan, “Measles and Pneumonia in Our Camps,” 248. 68. MDWW, vol. 1, 987–89; and regarding “standard of care,” MDWW, vol. 6, 70. 69. Medical Manual, 76. 70. Douglas Valentine Johnson makes this argument in “‘A Few Squads Left’ and Off to France: Training the American Army in the United States for World War I,” Ph.D. diss., Temple University, 1992. 71. George G. Nasmith, “How the Health of the British Army Is Maintained,” AJPH 8 (April 1918): 259. 72. Woods Hutchinson, The Doctor in War (Boston: Houghton, Mifflin, 1918), 3. 73. MDWW, vol. 9, 414. 74. Vaughan, “Measles and Pneumonia in Our Camps,” 257. For the Medical Department’s rehearsal of their efforts to implement these policies, see MDWW, vol. 1, 991 – 92; MDWW, vol. 6, 68–69, and 173–85; and War Department, Special Regulations No. 28, “Sanitary Regulations and Control of Communicable Diseases,” 28. 75. On inspections, see MDWW, vol. 1, 249 – 56; and RG 112, Office of the Surgeon General, Entry 29, Box 417, NARA. 76. War Department, William Crawford Gorgas, “Sanitary Conditions at Army Camps: Communications from the Surgeon General of the Army to the Chief of Staff upon the Sanitary Conditions of the Army Camps and Cantonments” (Washington, D.C.: Government Printing Office, 1918); House Document No. 806, 65th Cong., 2nd sess. 77. Gorgas, “Sanitary Conditions in Army

Camps,” 7. The original report can be found in RG 112, Entry 31, Box 75, Camp Funston. By the end of the year, Camp Funston was one of the few camps where the army had constructed detention camps for men who had come in contact with infectious diseases—one for white, one for black soldiers. 78. MDWW, vol. 6, 68. 79. Committee on Public Information, The Official Bulletin (7 November 1917): 5. 80. The records of the Office of the Surgeon General include several boxes of these inquiries. See RG 112, Entry 29, Boxes 391, 393, and 394, NARA. 81. Senator Charles Townsend of Michigan speaking on information from sick soldiers, 65th Cong., 2nd sess., CR (7 February 1918): 1810. 82. Senator Charles Townsend of Michigan, CR, 7 February 1918, 1810. 83. Goldwater correspondence, January 1918, RG 112, Entry 29, Box 160, NARA. 84. Marion Huffman to Newton Baker, correspondence, 14 January 1918, RG 112, Entry 29, Box 160, NARA. 85. Grissinger, Medical Field Service in France, 3. 86. U.S. Congress, House, 65th Cong., 2nd sess., H. Res. 205, Resolution Proposing That an Inquiry be Made into the Hospital and Health Records of Camp Mills, Hempstead, Long Island (18 December 1917): 543. 87. Representative Frank Reavis of Nebraska on the surgeon general’s inspection of the training camps, 65th Cong., 2nd sess., CR, 18 January 1918, 1019. See also Representative Francis of New York, CR, 24 January 1918, 1242 – 44; and CR, 22 February 1918, 2546–50. 88. Representative Edwin Webb of North Carolina, 65th Cong., 2nd sess., CR, 22 February 1918, 2550. 89. U.S. Congress, House, Committee on Military Affairs, Army Appropriation Bill, 1919, 65th Cong., 2nd sess., December 1917, January and February 1918 (CIS Microfiche H208-1); and U.S. Congress, Senate, Committee on Military Affairs, Investigation of the War Department, vols. 1–8, 65th Cong., 2nd sess., December 1917, January, February, and March 1918 (CIS Microfiche S-127 A–B, and S-128 A–F). 90. NYT, 19 December 1917. 91. NYT, 20 and 21 January 1918; and Daniel R. Beaver, Newton D. Baker and The American War Effort, 1917 – 1919 (Lincoln: University of Nebraska Press, 1966), 87–93. 92. NYT, 20 January 1918; and Senator Chamberlain, speaking on a point of personal

202 | Notes to Chapter 2 privilege concerning a war cabinet, 65th Cong., 2nd sess., CR, 24 January 1918, 1199. 93. Chamberlain, CR, 24 January 1918, 1205. 94. NYT, 23 January 1918. See also the NYT editorial, 20 January 1918. 95. Representative Reavis on health conditions in the army training camps, CR, 18 January 1918, 1019. 96. Senate, Committee on Military Affairs, Investigation of the War Department, 2000. 97. Senate, Committee on Military Affairs, Investigation of the War Department, 1989 and 1994. 98. NYT, 26 January 1918. 99. Information on these trials by court martial is found in RG 153; for Charles W. Cole, see Box 5337, Case 107947, and for John Dwyer, see Box 5340, Case 108016, NARA. 100. Senate, Committee on Military Affairs, Investigation of the War Department, 1931. 101. Surgeon General to Adjutant General, 4 February 1918, RG 112, Entry 29, Box 130, NARA. 102. MDWW, vol. 1, 137–60, 791–93; and NYT, 22 December 1917. 103. Proceedings against officers, including medical officers, were rare. During the war period, the War Department tried fewer than 2,800 officers by general courts-martial, sentencing about one-third of them with dismissal from the army. WDAR, 1918, 236; and WDAR, 1919, vol. 1, 672. 104. U.S. Congress, House, Committee on Military Affairs, Army Appropriations Bill, 1919, letter from George W. Sparks (28 January 1918) 1233 (CIS Microfiche H208-1). 105. House, Committee on Military Affairs, Army Appropriations Bill, 1919, 1174. 106. House, Committee on Military Affairs, Army Appropriations Bill, 1919, 1163. 107. Quoted in John M Gibson, Physician to the World: The Life of General William C. Gorgas (Durham, N.C.: Duke University Press, 1950), 242. 108. Most historians believe that his January performances in Congress staunched the torrent of criticism. See Cramer, Newton D. Baker, 143; Beaver, Newton D. Baker, 103. Bakers’ papers include scores of congratulatory letters on his testimony. See Container 54, Newton D. Baker Papers, Library of Congress, Manuscript Collection, Washington, D.C. 109. Koistenen, Mobilizing for Modern War, chapter 9; Frederic L. Paxson, “The American War Government, 1917 – 1918,” AHR, October 1920, 54–76; John Dickinson,

The Building of an Army: A Detailed Account of Legislation, Administration, and Opinion in the United States, 1915 – 1920 (New York: Century, 1922); and Barry D. Karl, The Uneasy State, chapter 8. 110. Editorial, “Punishment of Army Medical Officers,” MS 42 (March 1918): 333. 111. Victor Vaughan, “The Rank and Authority of the Medical Officer,” JLCM 2 (May 1917): 595. 112. First lieutenants earned $2,000 per year ($166 per month, compared to the $30 for privates); majors, $3,000; colonels $4,000; and generals, such as Gorgas, earned $8,000 per year. U.S. Department of War, Register of the Army of the United States for 1918 (Washington, D.C.: Government Printing Office, 1918), 1156. 113. Franklin H. Martin, Fifty Years of Medicine and Surgery (Chicago: Surgical Publishing Company of Chicago, 1934), 380. Emphasis added. See also Martin’s letter to Marie Gorgas, 22 January 1923, in W. C. Gorgas Papers, Box 706, Hoole Collection. 114. Martin, Major General William Crawford Gorgas, 48. 115. Senator Robert Owen speaking on the grades of medical officers, 65th Cong., 1st sess., CR, 20 July 1917, 5330 – 34. Owen’s proposal allowed for just a few generals and increased the percentage of officers above the rank of major from 9 percent to 13 percent. Increased rank carried increased pay. 116. House, Committee on Military Affairs, Army Appropriations Bill, 1919, 1214. 117. Martin, Major General William Crawford Gorgas, 48. 118. “American Medical Association Special Bulletin,” 23 February 1918, RG 112, Entry 29, Box 19, NARA. 119. Louis Livingston Seaman, “The OwenDyer Bill for Increased Rank of Medical Officers,” JAMA 70 (27 April 1918): 1252 – 53. 120. Seaman, “The Owen-Dyer Bill,” 1254; and Senator Robert Owen on grades of medical officers in the army, 65th Cong., 2nd sess., CR, 31 May 1918, 7226–27. 121. Martin, Major General William Crawford Gorgas, 50. 122. Martin, Major General William Crawford Gorgas, 54. 123. Newton Baker to George Chamberlain, correspondence, 15 June 1918, RG 112, Entry 29, Box 20, NARA. The letter did not state the precise subject of the hearings. 124. Editorial, “The Passing of the General Staff,” MS 43 (July 1918): 74 – 76. Hoff did not name the medical reserve officers, but they

Notes to Chapter 3 | 203 may have been Victor Vaughan and William Welch. 125. Peyton C. March to Adjutant General, 27 July 1918, RG 112, Entry 29, Box 1, NARA. 126. Peyton C. March to William C. Gorgas, 27 July 1918, RG 112, Entry 29, Box 1, NARA; and “Retirement of Colonel John Van R. Hoff,” MS 43 (August 1918): 215. 127. Bailey Ashford, A Soldier in Science: The Autobiography of Bailey K. Ashford (New York: William Morrow, 1934), 29. 128. John Van R. Hoff to the Adjutant General, 30 July 1918, RG 112, Entry 29, Box 1, NARA. 129. “Restoration of the Record of Colonel John Van R. Hoff, Medical Corps, U.S. Army, Retired,” MS 46 (January 1920): 109. 130. There are two important sources on this matter. The first is a journal Gorgas kept on his trip to Europe in late 1918, “Notes on the Trip to France with Secretary Baker, September to October 1918,” William C. Gorgas Papers, Box 685, Hoole Collection, hereafter referred to as Gorgas Journal. The second source is a typescript of the journal which Marie Gorgas used for her biography of her husband, “Journal from Trip to France with Secretary Baker — 1918,” William C. Gorgas Papers, Box 686, Folder 1, hereafter referred to as Typescript of Gorgas Journal. Marie included in the typescript text from what were apparently Gorgas’s letters to her but did not distinguish between the two sources. Few of the original letters remain in the William C. Gorgas Papers and the Gorgas Family Papers. 131. Jefferson Kean, unpublished autobiography, 188, Ms. C14, Jefferson R. Kean Papers, NLM; and Gibson, Physician to the World, 215–18. 132. Gorgas Journal, 29 August 1918. 133. Gorgas Journal, 3 September 1918. 134. Gorgas Journal, 6 September 1918. 135. Typescript of Gorgas Journal, 23 September 1918. 136. Kean autobiography, 226–27. 137. Typescript of Gorgas Journal, 2 October 1918. 138. Gorgas Journal, 3 October 1918. 139. Gorgas Journal, 6 October 1918. Secretary Baker’s appointment of Merritte Ireland was not in itself controversial. One medical journal, for example, editorialized that “perhaps no army appointment in recent years has met with such universal approval in the regular service as that of Major General Merritte W. Ireland to be Surgeon General of the Army.” See New York Medical Journal 108 (12 October 1918): 643.

140. Typescript of Gorgas Journal, 10 October 1918; and William C. Gorgas to Marie Gorgas, 10 October 1918, William C. Gorgas Papers, Box 686, Hoole Collection. 141. Stanhope Bayne-Jones to George Denegre, 15 October 1918, Ms. C 371, Stanhope Bayne-Jone Papers, William C. Gorgas Papers, Hans Zinsser Papers, 1870 – 1969, NLM; and Gorgas Journal, 6 October 1918.

notes to chapter 3 Epigraph is from Victor C. Vaughan assisted by Henry F. Vaughan and George T. Palmer, Epidemiology and Public Health (St. Louis: C. V. Mosby, 1922), vol. 1, 8. 1. Order of Battle, vol. 3, pt. l, 504 – 9. In June 1918, the AEF held about 35 miles of the front. 2. On the German 1918 offensive see Martin Gilbert, The First World War: A Complete History (New York: Henry Holt, 1994), 393– 453; John Keegan, The First World War (New York: Alfred A. Knopf, 1999), 372 – 414; David Trask, The AEF and Coalition Warmaking, 1917 – 1918 (Lawrence: University of Kansas Press, 1993), 43 – 85; Rod Paschall, The Defeat of Imperial Germany, 1917–1918 (Chapel Hill, N.C.: Algonquin Books, 1989); and John J. Pershing, My Experiences in the World War (New York: Frederick A. Stokes, 1931), vol. 1, 352–400. 3. John L. Shephard to F. F. Russell, 30 March 1918, RG 112, Entry 31, Box 74, NARA. 4. “Influenza, Haskell, Kansas,” PHR 33 (5 April 1918): 502. John Barry tracks the origin of the epidemic in Haskell through the experiences of Loring Miner, a doctor in the town, in The Great Influenza: The Epic Story of the Deadliest Plague in History (New York: Viking, 2004), 91–98, and 453–56. 5. Victor C. Vaughan, “An Explosive Epidemic of Influenzal Disease at Fort Oglethorpe,” JCLM 3 (June 1918): 560 – 64 and 567–68; and George A. Soper, “History of Epidemiology and the Work of Epidemiologists in the Army Camps in America, 1917 – 1918,” unpublished report, RG 112, Entry 29, Box 429, NARA. 6. LaBruce Ward to Chief Surgeon, Base Section No. 2, 8 May 1918, RG 120, Entry 2109, Box 5493, NARA; and Ward MacNeal, “The Influenza Epidemic of 1918 in the American Expeditionary Forces in France and England,” AIM 23 (June 1919): 675–77. 7. Charles Foster to the Base Surgeon, memorandum, 22 May 1918, RG 120, Entry 2109, Box 5493, NARA.

204 | Notes to Chapter 3 8. Guy Emerson Bowerman, Jr., The Compensations of War: The Diary of an Ambulance Driver during the Great War, ed. Mark Carnes (Austin: University of Texas Press, 1983), 87. 9. Brigadier General R. Brown to Commanding General, 42nd Division, 1 June 1918, RG 120, Entry 1241, Box 122, NARA. 10. The most important works include MacFarlane Burnet and David O. White, Natural History of Infectious Disease, 4th ed. (Cambridge: Cambridge University Press, 1972); Paul W. Ewald, Evolution of Infectious Disease (Oxford: Oxford University Press, 1994); William H. McNeill, Plagues and Peoples (Garden City, N.Y.: Anchor Press, 1976); and Alfred W. Crosby, Ecological Imperialism: The Biological Expansion of Europe, 900 – 1900 (Cambridge: University of Cambridge Press, 1986). Ken De Bevoise, Agents of Apocalypse (Princeton, N.J.: Princeton University Press, 1995), provides an excellent case study of these processes in the colonial Philippines. 11. Vaughan, assisted by Vaughan and Palmer, Epidemiology and Public Health, vol. 1, 8. 12. David John Davis, “Bacteriology and the War,” Scientific Monthly 5 (November 1917): 398. 13. NYT, 28 June 1918. 14. Louis S. Duncan, “The Second Division at Chateau Thierry, June, 1918,” MS 48 (March 1921): 255. 15. Samuel Bradbury, “An Influenza Epidemic in Soldiers,” AJMS 156 (1918): 737. 16. “Spain: Undetermined Disease — Valencia,” PHR 33 (28 June 1918): 1087. 17. “A Memorandum on Influenza from the Medical Research Committee,” Lancet 2 (23 November 1918): 717 – 18; and Paschall, The Defeat of Imperial Germany, 159. 18. C. Averill, G. Young, and J. Griffiths, “The Influenza Epidemic in a Camp,” BMJ, 3 August 1918, 111–12; and C. J. Martin, “An Epidemic of Fifty Cases of Influenza among the Personnel of a Base Hospital, B.E.F., France,” BMJ, 14 September 1918, 281–82. 19. Erich von Ludendorff, Ludendorff’s Own Story, August 1914 – November 1918 (New York: Harper and Brothers, 1919), vol. 2, 277. 20. WDAR, 1919, 2749–51. 21. Memorandum C-158, 6 September 1918, RG 112, Box 4612, NARA. 22. NYT, 14, 15, and 18 August 1918; and “Measures for the Prevention of the Introduction of Epidemic Influenza,” PHR 33 (13 September 1918): 1540–44. On reportability, see PHR 35 (22 October 1920): 2507

23. C. P. Baxter to Chief Surgeon, AEF, 8 August 1918, and R. F. Metcalfe to Chief Surgeon, AEF, 26 August 1918, RG 120, Entry 2109, Box 5493, NARA. 24. See PHR from September 1918 to April 1920. The PHR special supplement, no. 34 on influenza, was widely circulated in the country. 25. MDWW, vol. 4, 49. 26. Paul G. Wooley to Surgeon General, 16 September 1918, RG 112, Entry 31, Box 84, NARA; and MDWW, vol. 6, 349. 27. Paul G. Woolley, “The Epidemic of Influenza at Camp Devens, Mass.,” JLCM 4 (March 1919): 330 – 31. See also WDAR, 1919, vol. 1, pt. 2, 1576–89; MDWW, vol. 4, 47 – 52; MDWW, vol. 5, 642 – 46; and MDWW, vol. 6, 349–71. 28. Jane G. Malloy, “Personal Accounts of Conditions in Camps,” n.d., RG 112, NARA, cited in Mary T. Sarnecky, A History of the U.S. Army Nurse Corps (Philadelphia: University of Pennsylvania Press, 1999), 121. 29. Ralph Smith and Arthur F. Poole, WWI Questionnaire Collection: Camp Devens, MHI. 30. MDWW, vol. 6, 353; Crosby, America’s Forgotten Pandemic, chap. 1; and Barry, The Great Influenza, 186–92. 31. Vaughan, assisted by Vaughan and Palmer, Epidemiology and Public Health, vol. 1, 8. 32. MDWW, vol. 4, 49–50. 33. On dispersion of influenza, see Pyle, The Diffusion of Influenza; K. David Patterson and Gerald F. Pyle, “The Geography and Mortality of the 1918 Influenza Pandemic,” BHM 65 (June 1991): 4 – 21; and Edgar Sydenstricker, “Preliminary Statistics of the Influenza Epidemic,” PHR 33 (27 December 1918): 2305–21. 34. MDWW, vol. 9, 139. 35. WDAR, 1919, vol. 1, pt. 2, 2749 – 51; and MDWW, vol. 9, 63–86. 36. Ernest E. Irons, “Pneumonia Following Influenza in the Camps in the United States,” MS 48 (March 1921): 276; and Camp Meade, WWI Miscellaneous Collection, MHI. 37. WDAR, 1919, vol. 1, pt. 2, 2158. The total camp population at this time is unclear. One report states that the camp had an average strength of 20,000, but that after the Thirty-ninth Division left for France in August, the strength was 10,000 or less. This would mean an influenza rate of as much as 70 percent. See WDAR, 1919, vol. 1, pt. 2, 1519 – 21. 38. WDAR, 1919, vol. 1, pt. 2, 2017. 39. WDAR, 1919, vol. 1, pt. 2, 2015; Alfred Friedlander et al., “The Epidemic of

Notes to Chapter 3 | 205 Influenza at Camp Sherman, Ohio,” JAMA 71 (16 November 1918): 1656; Irons, “Pneumonia Following Influenza in the Camps in the U.S.,” 276; and Frederick H. Lamb and Edward B. Brannin, “The Epidemic Respiratory Infection at Camp Cody,” JAMA 72 (12 April 1919): 1056. 40. Robert G. Torrey and Lawrence C. Grosh, “Acute Pulmonary Emphysema Observed during the Epidemic of Influenza Pneumonia at Camp Hancock, Georgia,” AJMS 157 (1919): 172. 41. Charles L. Mix, “Spanish Influenza in the Army,” NYMJ 108 (26 October 1918), 712. 42. Excerpts in this paragraph are from a letter, dated 29 September 1918, from one Scottish physician, Roy, to another, Burt, with no surnames provided, in N. R. Grist, “Pandemic Influenza 1918,” BMJ, 22 December 1979, 1632–33. 43. Lamb and Brannin, “The Epidemic Respiratory Infection at Camp Cody,” 1059. 44. Burt Wolbach and Channing Frothingham, “A Study of Pathology of Cases Dying at Camp Devens during the Influenza Epidemic in 1918,” Transactions of the American Academy of Physicians 38 (1923): 177. 45. Simon Flexner and James T. Flexner, William Welch and the Heroic Age of American Medicine (New York: Viking Press, 1941), 377. 46. Royal Reynolds Papers, Folder, “Memoir, 1881 – 1964: Reminiscences of Brig. Gen. Royal Reynolds, U.S. Army,” MHI. 47. Arthur S. Warner, WWI Questionnaire Collection: Camp Devens, MHI. 48. For more on the influenza epidemic in civilian communities, see Crosby, America’s Forgotten Pandemic; Gina Kolata, Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It (New York: Farrar, Straus, and Giroux, 1999); Lynette Iezzoni, Influenza 1918: The Worst Epidemic in American History (New York: TV Books, 1999); and Barry, The Great Influenza. 49. NYT, 16 October 1918; and Edgar Sydenstricker, “Preliminary Statistics of the Influenza Epidemic,” PHR 33 (27 December 1918): 2305–21. 50. W. H. Frost, “Statistics of Influenza Morbidity,” PHR 35 (12 March 1920), 584–97. 51. Andrew Noymer and Michel Garenne, “Long-term Effects of the 1918 ‘Spanish’ Influenza Epidemic on Sex Differentials of Mortality in the USA,” in Howard Phillips and David Killingray, eds., The Spanish Influenza Pandemic of 1918 – 1919: New Perspectives (New York: Routledge, 2003), 202.

52. Sydenstricker, “Preliminary Statistics of the Influenza Epidemic,” 2313. 53. Senator Henry Cabot Lodge speaking on H. J. Res. 333, a resolution to aid in combating the disease known as influenza, 65th Cong., 2nd sess., CR, 28 September 1918, 10896. 54. H. J. Res. 333, a resolution to aid in combating the disease known as influenza, 65th Cong., 2nd sess., CR, 28 September 1918, 10895–97, 10900–17; and Senate Committee on Appropriations, Suppression of Spanish Influenza, 65th Cong., 2nd sess. 55. S. J. Res. 63, a resolution to establish a reserve for the Public Health Service, 65th Cong., 2nd sess., CR, 15 October 1918, 11267 – 88; Senate Committee on Appropriations, Influenza in Alaska, 65th Cong., 3rd sess., 6 January 1919; and House Committee on Appropriations, Influenza in Alaska and Porto Rico, 65th Cong., 3rd sess., 13 January 1919. 56. MDWW, vol. 9, 66–67. 57. WDAR, 1919, vol. 1, pt. 2, 2755. 58. WDAR, 1919, vol. 1, pt. 2, 1469. 59. MDWW, vol. 9, 68. 60. MDWW, vol. 9, 68–86. These rates varied significantly from unit to unit. Ward MacNeal in fact wrote that pneumonia mortality ranged from 5 to 100 percent in AEF hospitals, in “The Influenza Epidemic of 1918 in the American Expeditionary Forces,” 660. In the 1990s, untreated pneumonia still had a mortality rate of 30 percent, and pneumonia mortality combined with influenza was the sixth most common cause of death in the United States. See Jacalyn Duffin, “Pneumonia,” in Kenneth Kiple, ed., The Cambridge World History of Human Disease (New York: Cambridge University Press, 1993), 939. 61. Joseph L. Miller and Frank B. Lusk, “Empyema at Camp Dodge,” MCNA 2 (September 1918): 537–42; and M. C. Winternitz, Isabel M. Wason, and Frank McNamara, The Pathology of Influenza (New Haven: Yale University Press, 1920); MDWW, vol. 11, section on empyema; and Peter D. Olch, “Evarts A. Graham in World War I: The Empyema Commission and Service in the American Expeditionary Force,” JHMAS 44 (October 1989): 430–46. 62. MDWW, vol. 9, 160–63. 63. MDWW, vol. 5, 486–90, 514–17, and 539–41; and James Albert Honeji, History and Roster of the United States Army General Hospital No. 16 (New Haven: Yale University Press, 1919), 17. 64. MDWW, vol. 9, 162 – 63. Some physicians also believed that the influenza of 1918

206 | Notes to Chapter 3 led to an outbreak of encephalitis lethargica (Parkinson’s disease) in the 1920s, but the causation has not been proved. See R. T. Ravenholt, “Encephalitis Lethargica,” in Kenneth Kiple, ed., The Cambridge World History of Human Disease (New York: Cambridge University Press, 1993), 708–13. Similarly, a study conducted decades after the war also found that influenzal pneumonia did not increase the risk of lung cancer in World War I veterans. See Gilbert W. Beebe, “Lung Cancer in World War I Veterans: Possible Relation to MustardGas Injury and 1918 Influenza Epidemic,” Journal of the National Cancer Institute 25 (1960): 1231–52. 65. Mix, “Spanish Influenza in the Army,” 714. 66. Grist, “Pandemic Influenza 1918,” 1633. 67. WDAR, 1919, vol. 1, 1605. 68. Mary E. Hallock, Oral History Interview, 1 September 1983, East Texas Research Center, Ralph W. Steen Library, Stephen F. Austin State University, Nacogdoches, Texas. 69. MDWW, vol. 1, 999; and “Memorandum from the Secretary of War,” 5 October 1918, RG 112, Entry 29, Box 393, NARA. 70. A. E. Truby, “Report of Inspection in Relation to the Epidemic of Influenza and Pneumonia at Camp Jackson, S.C., made 16 October 1918,” inspection report, 23 October 1918, RG 112, Entry 31, Box 125, NARA; and NYT, 2 October 1918. 71. “Method of Handling Influenza Epidemic at a Camp,” 30 September 1918, MDWW, vol. 1, 1000–1003. 72. MDWW, vol. 9, 163–65. 73. Theda E. Schulte, “History of the Base Hospital ‘Camp Mills,’ Mineola, Long Island, New York” (1919), OHA 308, Smith Scrapbook, Otis Historical Archives, National Museum of Health and Medicine, Armed Forces Institute of Pathology, Washington, D.C. 74. John A. McQueen, WWI Questionnaire Collection: Medical Corps, MHI. 75. J. R. Steward, “Field Director’s Report, Camp Dodge, Iowa, Period Covering Influenza Epidemic,” 17 October 1918, RG 200, Box 689, NARA. 76. Gregory K. Culver, “Disease, Medicine, and Public Policy in the Jackson Purchase Region of Kentucky, 1870 – 1920,” Ph.D. diss., Southern Illinois University, 2000, 215. 77. Culver, “Disease, Medicine, and Public Policy,” 216–17. 78. NYT, 27 September 1918; and Barry, The Great Influenza, 212–19. 79. NYT, 9 October 1918; WDAR, 1919,

vol. 1, pt. 2, 1684 – 85; and Pettit, “A Cruel Wind,” 105. 80. WDAR, 1919, vol. 1, pt. 3, 3794. 81. Charles L. Johnston, 6 October 1918, and undated, “Life at Camp Funston: Reflections of Army Sergeant Charles L. Johnston,” www2.okastate.edu/ww1hist. On underreporting, also see Sydenstricker, “Preliminary Statistics of the Influenza Epidemic,” 2305 – 21. 82. Marybelle Burch, “I Don’t Know Only What We Hear: The Soldiers’ View of the 1918 Influenza Epidemic,” Indiana Medical History Quarterly 9 (1983): 25. 83. Investigation of absentees in government service,” 14 October 1918, index of correspondence, September to November 1918, RG 163, Entry 9, Box 5, NARA. 84. Wright Stevens, WWI Questionnaire Collection: Camp Devens, MHI. 85. John A. McQueen, WWI Questionnaire Collection: Medical Corps, MHI. 86. Aaron Glicksman, WWI Questionnaire Collection: Camp Jackson, MHI. 87. Carl Dragstedt, WWI Questionnaire Collection: Medical Corps, Base Hospitals, MHI. 88. W. H. Frost, “Epidemic Influenza in Foreign Countries,” PHR 34 (20 June 1919): 1361–76. 89. Richard Collier, The Plague of the Spanish Lady: The Influenza Pandemic of 1918 – 1919 (New York: Atheneum, 1974). 90. For example, see WDAR, 1919, vol. 1, pt. 2, 2148. 91. Victor C. Vaughan, “The Bacteriology of Influenza,” JLCM 4 (November 1918), 85. 92. Howard Phillips and David Killingray, eds., The Spanish Influenza Pandemic of 1918 – 1919: New Perspectives (New York: Routledge, 2003); Ann H. Reid, Thomas G. Fanning, Thomas A. Janczewski, and Jeffrey K. Taubenberger. “Characterization of the 1918 “Spanish” Influenza Virus Neuraminidase Gene,” Proceedings of the National Academy of Sciences 97 (2000): 6785– 90; and Kolata, Flu. On virology, see Edwin D. Kilbourne, “Pandora’s Box and the History of Respiratory Viruses,” History and Philosophy of Life Sciences 14 (1992): 299–308. 93. War Department, Surgeon General’s Office, Index—Catalogue of the Library of the Surgeon-General’s Office (Washington, D.C.: Government Printing Office, 1919). 94. Scholars continue to debate the geographic origin of the flu today. Alfred Crosby and John Barry argue that the epidemic emerged in Kansas in March 1918, while Gina Kolata speculates that the flu began in Asia in

Notes to Chapter 3 | 207 Flu. See also Gerald F. Pyle, The Diffusion of Influenza: Patterns and Paradigms (Totowa, N.J.: Rowman and Littlefield, 1986), 40. Those arguing for an origin in Kansas often cite dust storms that swept the state in March and the smoke from the burning of manure in training camps as being associated with an increase in respiratory disease that month. See MDWW, vol. 4, 68; George Draper, “Some Observation on the Susceptibilities of the Recruits to Disease,” MS 45 (July 1919): 99; and John L. Shephard to F. F. Russell, 30 March 1918, RG 112, Entry 31, Box 74, NARA. On transmission by Germans, see, for example, “Think Influenza Came in U-Boat,” NYT, 19 September 1918. 95. For example, Eugene L. Opie et al., Epidemic Respiratory Disease: Pneumonias and Other Infections of the Respiratory Tract Accompanying Influenza and Measles (St. Louis: C. V. Mosby, 1921), 14; and “Date of the Origin of the Influenza Epidemic,” Medical Record 97 (10 January 1920): 71. 96. MacNeal, “The Influenza Epidemic of 1918 in the American Expeditionary Forces,” 657; and Edwin O. Jordan, Epidemic Influenza: A Survey (Chicago: American Medical Association, 1927). 97. Opie et al., Epidemic Respiratory Disease, 15; Vaughan assisted by Vaughan and Palmer, Epidemiology and Public Health, 312–18; and Hans Zinsser, “The Etiology and Epidemiology of Influenza,” Medicine 1 (1922): 213–309. 98. Vaughan assisted by Vaughan and Palmer, Epidemiology and Public Health, 314. 99. Warren T. Vaughan, Influenza: An Epidemiologic Study, American Journal of Hygiene Monograph Series, no. 1 (July 1921): 65. 100. MDWW, vol. 9, 133. 101. Martin J. Synnott and Elbert Clark, “The Influenza Epidemic at Camp Dix, N.J.,” JAMA 71 (30 November 1918): 1817. 102. George A. Soper, “The Influenza-Pneumonia Pandemic in the American Army Camps during September and October, 1918,” Science, 8 November 1918, 451. 103. Irving P. Lyon, Charles F. Tenney, and Leopold Szerlip, “Some Clinical Observations on the Influenza Epidemic at Camp Upton,” JAMA 72 (14 June 1919): 1726. 104. For example, Winternitz et al., The Pathology of Influenza, introduction. 105. MDWW, vol. 9, 65–86. 106. Zinsser, Rats, Lice, and History, 43. 107. Alan M. Chesney and Frank W. Snow, “A Report of an Epidemic in an Army Post of the American Expeditionary Forces in France,” JLCM 6 (November 1920): 95.

108. S. L. Walker, J. E. Van Valzah, and C. P. Eck, “Observations upon the Influenza Epidemic of 1918 in the American Army in France,” December 1918, unpublished report, RG 120, Entry 2119, Box 5560A, NARA. 109. William G. MacCallum, “Pathology of Epidemic Pneumonia in Camps and Cantonments in 1918,” Medical Record, 10 May 1919, 778. 110. J. F. Siler to commanding officers, 19 October 1918, memorandum, RG 120, Entry 2119, Box 5540, NARA. 111. Warfield Longcope to Chief Surgeon, AEF, 9 October 1918, RG 120, Entry 2109, Box 5493, NARA; and Deane C. Howard and Albert G. Love, “Influenza — U.S. Army, MS 46 (May 1920): 530. 112. MDWW, vol. 9, 126. 113. George Soper, “The Pandemic in the Army Camps,” JAMA 71 (7 December 1918): 1901. 114. Vaughan, “An Explosive Epidemic of Influenzal Disease at Fort Oglethorpe,” 563. 115. William L. Moss, “Epidemiological Activities at Base Section No. 2,” in G. Clymer, History of the U.S. Army Base Hospital No. 6, and Its Part in the American Expeditionary Force, 1917 – 1918 (Boston: Clymer, 1924), 108. 116. Soper, “The Influenza Pneumonia Pandemic in the American Army Camps,” 453. 117. John Garret Nelson, “The Work We Did,” in J. F. Geisinger, ed., History of the U.S. Army Base Hospital No. 45 in the Great War (Richmond, Va.: William Byrd Press, 1924), 252. 118. W. H. Frost, “The Epidemiology of Influenza,” PHR 34 (15 August 1919): 1834– 35; Vaughan assisted by Vaughan and Palmer, Epidemiology and Public Health, 343–49; and Pyle, The Diffusion of Influenza, 40. For more recent studies of the age factor, see Christopher Langford, “The Age Pattern of Mortality in the 1918 – 19 Influenza Pandemic: An Attempted Explanation Based on Data for England and Wales,” Medical History 46 (2002): 1 – 20; and Andrew Noymer, and Michel Garenne, “The 1918 Influenza Epidemic’s Effects on Sex Differentials in Mortality in the United States,” Population and Development Review 26 (2000): 565–81. 119. Victor C. Vaughan, “The Influenza in Germany,” JLCM 4 (December 1918): 145. 120. Frost, “The Epidemiology of Influenza,” 1833; and Jordan, Epidemic Influenza. 121. Ward J. MacNeal, “Report on Influenza Epidemic,” 27 December 1918, RG 120, Entry 2119, Box 5560A, NARA.

208 | Notes to Chapter 3 122. “Epidemic Influenza among American Soldiers Abroad,” Boston Medical and Surgical Journal, 26 December 1918, 802. 123. On the animal reservoir theory, see Robert G. Webster, “Influenza,” in Stephen S. Morse, ed., Emerging Viruses (New York: Oxford University Press, 1993); Martin M. Kaplan and Robert G. Webster, “The Epidemiology of Influenza,” Scientific American 237 (1977): 88 – 106; Arthur M. Silverstein, Pure Politics and Impure Science: The Swine Flu Affair (Baltimore: Johns Hopkins University Press, 1981); Kolata, Flu, chapters 3, 5, 8, and 10; Barry, The Great Influenza, 101 – 2, 111 – 14; and Joel Williams et al., “Meeting the Challenge of Emerging Pathogens: The Role of the United States Air Force in Global Influenza Surveillance,” Military Medicine 162 (1997): 82–86. 124. Jeffrey K. Taubenberger et al., “Initial Genetic Characterization of the 1918 ‘Spanish’ Influenza Virus,” Science 275 (21 March 1997): 1793–96; and Elizabeth Pennisi, “First Genes Isolated from the Deadly 1918 Flu Virus,” Science 275 (21 March 1997): 1739. 125. Ewald, Evolution of Infectious Disease; Burnet and White, Natural History of Infectious Disease; Judith Hooper, “A New Germ Theory,” Atlantic Monthly, February 1999, 41 – 53; and Randolph M. Nesse and George C. Williams, “Evolution and the Origins of Disease,” Scientific American, November 1998, 86–93. 126. Ewald, Evolution of Infectious Disease, 112. 127. Ewald, Evolution of Infectious Disease, 110–11. 128. “If physiology and tissue characteristics differ with age in ways relevant to pathogen reproduction, one would expect the strains evolving within a given age group to be of relatively high virulence in that age group.” Ewald, Evolution of Infectious Disease, 113. Scientists do not yet fully understand this mechanism. From his review of the literature, Crosby, for example, suggests that young, healthy adults used their strength to respond so vigorously to the virus that they flooded their lungs with immune fluids and induced the lethal pneumonia. See Forgotten Pandemic, 222; Burnet, Natural History of Infectious Disease, 202 – 12; and Mills, “1918 – 1919 Influenza Pandemic—The Indian Experience,” 22–23. 129. Diary of William A. Livergood, The Doughboy Center, Diaries, Letters, and Biographies, http://www.worldwar1.com/dbc/biograph.htm. 130. Bradbury, “An Influenza Epidemic in Soldiers,” 737.

131. Arthur A. Hoehn, WWI Questionnaire Collection, MHI. 132. Albert M. Ettinger and A. Churchill Ettinger, A Doughboy with the Fighting 69th (New York: Pocket Books, 1992), 73–74. 133. Francis Patrick Duffy, Father Duffy’s Story (New York: George H. Doran Company, 1919), 253.

notes to chapter 4 Epigraph comes from Hans Zinsser, Rats, Lice, and History (New York: Little, Brown, 1935, New York: Bantam, 1971), 112. 1. Biographical information from Edgar Erskine Hume, The Golden Jubilee of the Association of Military Surgeons of the United States (Washington, D.C.: Association of Military Surgeons, 1941), 237–38. 2. The following narrative is taken from Jefferson R. Kean’s war diary, Ms. C14, Jefferson R. Kean Papers, NLM. 3. Alfred Crosby makes this point in America’s Forgotten Pandemic (Cambridge: Cambridge University Press, 1989), 322–23. 4. Sandra M. Tomkins, “The Failure of Expertise: Public Health Policy in Britain during the 1918 – 19 Influenza Epidemic,” SHM 5 (December 1992): 441; and T. J. Mitchell and G. M. Smith, Medical Services: Casualties and Medical Statistics of the Great War, in W. G. MacPherson, ed., History of the Great War Based on Official Documents (1931; reprint, London: Imperial War Museum, 1997), 86. 5. Martha L. Hildreth, “The Influenza Epidemic of 1918–1919 in France: Contemporary Concepts of Aetiology, Therapy, and Prevention,” SHM 4 (August 1991): 278. 6. F. H. Garrison, “The German Medical History of the War,” MS 46 (April 1920): 437; and Jürgen Müller, “Die spanische Influenza 1918/19. Der Einfluss des Ersten Weltkrieges auf Ausbreitung, Krankheitsverlauf und Perzeption einer Pandemie” [Spanish Influenza, 1918 – 1919: The Influence of the First World War on the Spread, Course and Perception of an Epidemic], in Wolfgang U. Eckart and Christoph Gradmann, eds., Die Medezin und der Erste Weltkrieg [Medicine and the First World War] (Pfaffenweiler, Germany: Centaurus-Verlagsgesellschaft, 1996). 7. Leonard P. Ayres, The War with Germany: A Statistical Summary (Washington, D.C.: Government Printing Office, 1919), 109–13. 8. Walter D. McCaw to James Harbord, “Influenza and Pneumonia Situation,” 18 October 1918, RG 120, Entry 2109, Box 5493, NARA.

Notes to Chapter 4 | 209 9. MDWW, vol. 6, 1103. 10. WDAR, 1919, vol. 1, pt. 2, 1429–41. 11. Bess Furman, A Profile of the United States Public Health Service, 1799 – 1948 (Washington, D.C.: U.S. Government Printing Office, 1973), 10 – 11; Alan M. Kraut, Silent Travelers: Germs, Genes, and the “Immigrant Menace” (Baltimore: Johns Hopkins University Press, 1994); and Howard Markel, Quarantine! East European Jewish Immigrants and the New York City Epidemics of 1892 (Baltimore: Johns Hopkins University Press, 1997). 12. MDWW, vol. 6, 359. On the transport of soldiers, see MDWW, vol. 6, 414–30; War Department and U.S. Navy, Annual Reports, 1919; Order of Battle of the United States Land Forces in the World War, facsimile reprint (Washington, D.C.: Center of Military History, United States Army, 1988), 3:1, 498– 525; War Department Bulletin 44 (26 July 1918); Albert Gleaves, A History of the Transport Service: Adventures and Experiences of U.S. Transports and Cruisers in the World War (New York: George H. Doran, 1921); and William J. Wilgus, Transporting the AEF in Western Europe, 1917–1919 (New York: Columbia University Press, 1931). 13. Gleaves, History of the Transport Service, 189. 14. MDWW, vol. 6, 417. 15. Charles W. Berry, “Transport Sanitation,” AJPH 8 (September 1918): 690. 16. Ivan Farnworth, Oral History, Mss. Sc 3191, L. Tom Perry Special Collections Library, Harold B. Lee Library, Brigham Young University, Provo, Utah. 17. On sanitary precautions on troop transports, see MDWW, vol. 6, 414–30. 18. Mary Dobson, U.S. Army Nurse, quoted in Lyn Macdonald, The Roses of No Man’s Land (London: Joseph, 1980), 289. 19. Gleaves, History of the Transport Service, 190–91. 20. Robert H. Ivy, “The Influenza Epidemic of 1918: Personal Experience of a Medical Officer in World War I,” Military Medicine 125 (1960): 620. 21. E. W. Gibson, 57th Infantry, in James H. Hallas, Doughboy War: The American Expeditionary Force in World War I (Boulder, Colo.: Lynne Rienner, 2000), 294–95. 22. Fred D. Baldwin, “The American Enlisted Man in World War One,” Ph.D. diss., Princeton University, 1964, 162. 23. Crosby, Forgotten Pandemic, 125 – 36; and MDWW, vol. 6, 425–26. 24. Crosby says there were two thousand men with influenza aboard the ship, which comports to the common 25 percent morbidity

rate. Harbord remembers four thousand rather than two thousand men, but I have stayed with the more conservative number of two thousand. James G. Harbord, The American Army in France, 1917–1919 (Boston: Little, Brown, 1936), 552–53. 25. Memorandum, C-362, 24 September 1918, RG 120, Entry 2109, Box 5493, NARA; and MDWW, vol. 1, 998. 26. MDWW, vol. 1, 1000 – 1003; and MDWW, vol. 6, 352–71. 27. MDWW, vol. 6, 352. 28. Charles Richard to Adjutant General, 25 September 1918, RG 112, Entry 29, Box 394, NARA; and MDWW, vol. 6, 353–54. 29. MDWW, vol. 6, 357. 30. War Department, Second Report of the Provost Marshall General to the Secretary of War on the Operations of the Selective Service System to December 20, 1918 (Washington, D.C.: Government Printing Office, 1919), 237. 31. Frederick Palmer, Newton D. Baker: America at War (New York: Dodd, Mead, 1931), 410 – 11. War Department officials debated the number of divisions throughout the war, the final controversy being whether or not Pershing’s plan for eighty divisions included training and replacement divisions. The armistice mooted the argument. 32. Paul F. Braim, The Test of Battle: The American Expeditionary Forces in the MeuseArgonne Campaign (Newark: University of Delaware Press, 1987), 71–72. 33. MDWW, vol. 6, 362. 34. MDWW, vol. 6, 363. 35. MDWW, vol. 6, 359. 36. MDWW, vol. 6, 359. 37. MDWW, vol. 6, 360. 38. Peyton C. March, The Nation at War (Garden City, N.Y.: Doubleday, Doran, 1932), 359–60. This was probably William Welch of Johns Hopkins. 39. March, The Nation at War, 360. 40. March, The Nation at War, 92 – 93. March noted different figures in his annual report for 1919, stating that “some of the best medical advice at the disposal of the department,” recommended a 40 percent reduction, and that he approved a 15 percent decrease “believing that this was sufficient reduction to afford every safeguard that was warranted by the urgency of the military situation and that it would afford, in effect, every advantage that was practicable”; WDAR, 1919, vol. 1, pt. 1, 243. 41. Gleaves, History of the Transport Service, 190. 42. Gleaves, History of the Transport Service, 191.

210 | Notes to Chapter 4 43. Crosby, Forgotten Pandemic, 140. 44. MDWW, vol. 6, 362, and Harbord to Pershing, cable, 8 October 1918, RG 120, Entry 29, Box 3785, NARA. 45. MDWW, vol. 6, 363–64. 46. WDAR, 1919, 2755. 47. Palmer, Newton D. Baker, 365–66. 48. Palmer, Newton D. Baker, 364. 49. Arthur N. Chamberlain, “The Influenza Epidemic in the American E.F.,” unpublished report, December 1918, RG 120, Entry 1682, Box 82, NARA. 50. Merritte Ireland speech, “Experiences of Major General Ireland in the World War,” 27 May 1925, in MS C 117, Merritte Ireland Papers, NLM. 51. Pershing, My Experiences in the World War, vol. 2, 327. 52. Pershing, My Experiences in the World War, vol. 2, 320. 53. A. N. Stark to Office of Chief Surgeon, AEF, memorandum, 18 November 1918, RG 120, Entry 24, Box 3391, NARA. 54. William Holmes Dyer, “War Time Diary of Dr. William Holmes Dyer,” unpublished manuscript, Lincoln Public Library, Lincoln, Illinois. 55. Donald Smythe, Pershing: General of the Armies (Bloomington: University of Indiana Press, 1986), 206 – 7; Rod Paschall, The Defeat of Imperial Germany, 1917 – 1918 (Chapel Hill, N.C.: Algonquin, 1989), 181 – 92; and Braim, The Test of Battle, 135. 56. Smythe, Pershing, 200 – 207; and John S. D. Eisenhower, Yanks: The Epic Story of the American Army in World War I (New York: Touchstone, 2001), 246–49. On paralysis, also see Braim, The Test of Battle, and Cooke, Pershing and His Generals, 131. 57. Smythe, Pershing, 200. 58. Smythe, Pershing, 208. 59. James Seidule compares monthly casualty rates for American armies during military operations in the Civil War (13,000 per month); World War I (43,000 per month); and World War II (24,000 per month) in “Morale in the American Expeditionary Forces during World War I,” Ph.D. diss., Ohio State University, 1997, 131. 60. A. W. Brewster to Chief of Staff, 21 October 1918, RG 120, Entry 6, Box 378, NARA; Trask, The AEF and Coalition Warmaking, 146; and Joseph W. A. Whitehorne, The Inspectors General of the United States Army, 1903 – 1939 (Washington, D.C.: Office of the Inspector General and the Center of Military History, 1998), 222–23. 61. WDAR, 1919, vol. 1, pt. 3, 3237; and A. N. Stark, “Medical Activities of the Ameri-

can Expeditionary Forces in the Zone of the Armies,” MS 47 (August 1920): 172. 62. John Keegan, The First World War (New York: Alfred A. Knopf, 1999), passim; and Lyn MacDonald, To the Last Man: Spring 1918 (New York: Carroll and Graf, 1999). 63. Pershing, My Experiences in the World War. For a discussion of the historiography of AEF competence, see Braim, The Test of Battle, 144–70. 64. Smythe, Pershing; Braim, The Test of Battle; and Seidule, “Morale in the American Expeditionary Forces during World War I.” 65. Trask, The AEF and Coalition Warmaking, 128–30, 175. 66. Braim, The Test of Battle, 168. 67. George Van Horn Moseley to Chief of Staff, “Epidemic Disease and Its Effect on Effectives,” 22 October 1918, RG 120, Entry 2109, Box 5493, NARA. 68. Few historians have weighed the role of the influenza epidemic in American military performance. Paschall, Defeat of Imperial Germany; Jennifer D. Keene, Doughboys, the Great War, and the Remaking of America (Baltimore: Johns Hopkins University Press, 2001); and Meirion and Susie Harries, The Last Days of Innocence: America at War, 1917 – 1918 (New York: Random House, 1997), acknowledge the influenza epidemic as a serious problem during the war, but I have found that only Alfred Crosby, America’s Forgotten Pandemic, and James Seidule “Morale in the American Expeditionary Forces during World War I,” explore the consequences of the epidemic. 69. Morris Robert Werner, “Orderly!” (New York: Cape and H. Smith, 1930), 200. 70. WDAR, 1919, vol. 1, pt. 3, 3269. 71. MDWW, vol. 9, 5. Also on medical record-keeping problems in France, see a series of memos by Albert Love and Charles Lynch concerning the statistical section of the official history of the Medical Department in the war, such as Albert Love to Charles Lynch, memorandum, 27 June 1922, and Charles Lynch to General McCaw, memorandum, 6 October 1922, RG 112, Entry 29, Box 146, NARA. 72. C. A. L. Binger, “Report on Epidemic of ‘Spanish Flu’ in 84th Division,” unpublished report, RG 120, Entry 2109, Box 5493, NARA. 73. John Pershing to James Harbord, memorandum, 19 December 1918, RG 120, Entry 16, Box 101, NARA. 74. “First Aid on Four Fronts in World War I,” Letters written by William D. Conklin; http://www.longwood.k12.ny.us/history/upton /conk.htm. 75. Robert Graves, Good-bye to All That,

Notes to Chapter 4 | 211 rev. ed. (New York: Anchor Books, 1985), 282–86. 76. Haven Emerson, “General Survey of Communicable Diseases in the A.E.F.,” MS 49 (October 1921): 414–20. 77. Charles Lynch, “Authoritative Data of the Medical Department,” RG 112, Entry 29, Box 159, NARA. 78. Crosby, America’s Forgotten Pandemic, 205–6. 79. MDWW, vol. 9, 66 – 67; and Secretary of War to H. P. Burton, 14 August 1919, RG 112, Entry 29, Box 20, NARA. 80. WDAR, 1919, vol. 1, pt. 3, 3378–79. 81. Moseley to Chief of Staff, “Epidemic Disease and Its Effect on Effectives”; and Crosby, America’s Forgotten Pandemic, 154 – 55. 82. WDAR, 1919, vol. 1, pt. 3, 3379. 83. J. R. Shook to Chief Surgeon, VII Army Corps, “Report on Pneumonia,” 17 October 1918, RG 120, Entry 2109, Box 5494, NARA. 84. Ayres, The War with Germany, 113–18; and Paschall, Defeat of Imperial Germany, 191. 85. William L. Moss to commanding general, 86th Division, 6 October 1918, RG 120, Entry 2109, Box 5493, NARA; and William L. Moss, “Epidemiological Activities in Base Section No. 2,” in G. Clymer, History of the U.S. Army Base Hospital No. 6, and Its Part in the American Expeditionary Force, 1917 – 1918 (Boston: Clymer, 1924), 108–9. 86. WDAR, 1917, 339; and MDWW, vol. 2, 310–14. The figures are inexact because the number of troops in France and the number of hospital beds available changed weekly. 87. No one description captures the AEF medical service because the organization varied from division to division and hospital to hospital. See MDWW, vol. 8, 105–222; Medical Manual, 1916; J. R. Darnall, “War Service with an Evacuation Hospital,” MS, April 1937, 261–76; Richard V. N. Ginn, The History of the U.S. Army Medical Service Corps (Washington, D.C.: Office of the Surgeon General and Center of Military History, United States Army, 1997), 37 – 90; Jay W. Grissinger, Medical Field Service in France (Washington, D.C.: Association of Military Surgeons, 1928); and War Department, William Crawford Gorgas, “Inspection of Medical Services with the American Expeditionary Forces: Confidential Report to the Secretary of War” (Washington, D.C.: Government Printing Office, 1919). 88. WDAR, 1919, vol. 1, pt. 3, 3235. For Stark’s report, see WDAR, 1919, vol. 1, pt. 3, 3224–41, and A. N. Stark, “Medical Activities

of the American Expeditionary Forces in the Zone of the Armies,” MS 47 (August 1920): 154–76. 89. WDAR, 1919, vol. 1, pt. 3, 3235. 90. MDWW, vol. 8, 147. 91. Warfield T. Longcope to William McCaw, “Influenza Epidemic,” 9 October 1918, RG 120, Entry 2109, Box 5493, NARA. 92. John Garret Nelson, “The Work We Did,” in J. F. Geisinger, ed., History of the U.S. Army Base Hospital No. 45 in the Great War (Richmond, Va.: William Byrd Press, 1924), 252. 93. Moss, “Epidemiological Activities in Base Section No. 2,” in Clymer, History of the U.S. Army Base Hospital No. 6, 109. 94. Hugh Young, A Surgeon’s Autobiography (New York: Harcourt and Brace, 1940), 379. 95. MDWW, vol. 2, 983. 96. Grace Crile, ed., George Crile: An Autobiography (Philadelphia: J. B. Lippincott, 1947), 350–51. 97. Crile, George Crile: An Autobiography, 351. 98. Richard Derby, “Wade in, Sanitary!” The Story of a Division Surgeon in France (New York: G. P. Putnam’s Sons, 1919), 172. 99. Diary of William Estes, William L. Estes Papers, Lehigh University Libraries, Special Collections. I am grateful to Barbara Traister for providing me with a transcript of the relevant portions of the Estes diary. 100. Arthur N. Chamberlain, “The Influenza Epidemic in the American E.F.,” unpublished report, December 1918, RG 120, Entry 1682, Box 82, NARA. 101. Clymer, History of the U.S. Army Base Hospital No. 6, 16. 102. Louis B. Wilson, “The Pathologic Service of the American Expeditionary Force,” MS 45 (December 1919): 702. 103. MDWW, vol. 8, 695. 104. A.S.R., “Letters to the Editor,” AJN 19 (March 1919): 469–70. 105. Brewster to Chief of Staff, 21 October 1918, RG 120, Entry 6, Box 378, NARA. 106. Charles Richard, “Memorandum,” 24 September 1918, RG 112, Box 4613, NARA. 107. George A. Soper, “The Influenza Pneumonia Pandemic in the American Army Camps,” Science, 8 November 1918, 453. 108. Elton E. Mackin, Suddenly We Didn’t Want to Die: Memoirs of a World War I Marine (Novato, Calif.: Presidio Press, 1993), 247. 109. Albert M. Ettinger and A. Churchill Ettinger, A Doughboy with the Fighting 69th (New York: Pocket Books, 1992), 187.

212 | Notes to Chapter 4 110. The Lost Battalion Archives Page, 29 September 1957, http://www.longwood.k12 .ny.us/history/upton/lb3.htm. 111. Seidule, “Morale in the American Expeditionary Forces,” 259. 112. Seidule, “Morale in the American Expeditionary Forces,” 55. 113. Quoted in David G. McCullough, Truman (New York: Simon and Schuster, 1992), 136. 114. Harry T. Pressly, Saving the World for Democracy (Clarinda, Iowa: Artcraft, 1933), 113. 115. Edward S. Hodgson, Jr., “Letters from the Front: Edward and Mary Hodgson in World War I — and Postwar Transformations at Home in Delaware,” Delaware History 27 (Spring–Summer 1997): 181. 116. Hodgson, “Letters from the Front,” 165. 117. Hodgson, “Letters from the Front,” 182. 118. Pressly, Saving the World for Democracy, 117. 119. Pressly, Saving the World for Democracy, 115. 120. Pressly, Saving the World for Democracy, 125. 121. Pressly, Saving the World for Democracy, 157. 122. Pressly, Saving the World for Democracy, 243. 123. Russell Dale to Parents, 10 October 1918, Russell Dale Papers, Box 2, WWI Questionnaire Collection: Medical Corps, MHI. 124. “The Personal Diary of William J. ‘Bill’ Schira, March 4, 1918 to July 6, 1919,” http://www.hcu.ox.ac.uk/mirrors/raven.cc.uka ns.edu:80/~kansite/ww_one/memoir/Schira/Sc hira.htm. 125. This recommendation may have been first made by a medical officer at the embarkation camp at Newport News, Virginia. See memo from Surgeon, Port of Embarkation, Newport News, to Commanding General, 7 October 1918, RG 112, Entry 29, Box 393, NARA. 126. MDWW, vol. 6, 364. 127. NYT, 3 November 1918. 128. “Finding Uncle Henry and Nurse Josephine Finch, Too,” The Doughboy Center, Diaries, Letters, and Biographies, http://www .worldwar1.com/dbc/muenzel.htm. 129. Jefferson R. Kean, unpublished autobiography, 229, Ms. C14, Jefferson R. Kean Papers, NLM. 130. NYT, 29 October 1918. 131. MDWW, vol. 1, 1004.

notes to chapter 5 Epigraph is from Ward J. MacNeal, “The Influenza Epidemic of 1918 in the American Expeditionary Force in France and England,” AIM 23 (June 1919): 665. 1. Ward J. MacNeal, “The Influenza Epidemic of 1918 in the American Expeditionary Force in France and England,” AIM 23 (June 1919): 657 – 88. The original manuscript can be found in RG 120, Entry 2119, Box 5560A, and RG 120, Entry 2109, Box 5473, NARA. 2. These percentages are for autopsies in AEF hospitals with laboratories. See Robert S. Henry, The Armed Forces Institute of Pathology: Its First Century, 1862 – 1962 (Washington, D.C.: Office of the Surgeon General, Department of the Army, 1964), 180; and Louis B. Wilson, “The Autopsy Service of the American Expeditionary Forces,” Transactions of the Association of American Physicians 34 (1919): 294. 3. MDWW, vol. 1, 918–19. 4. MacNeal, “The Influenza Epidemic of 1918 in the AEF,” 663; and M. W. Lyon, “Gross Pathology of Epidemic Influenza at Walter Reed General Hospital,” JAMA 72 (29 March 1919): 924–29. 5. MacNeal, “The Influenza Epidemic of 1918 in the AEF,” 664. 6. MacNeal, “The Influenza Epidemic of 1918 in the AEF,” 664–65. 7. MacNeal, “The Influenza Epidemic of 1918 in the AEF,” 662. 8. M. C. Winternitz, Isabel M. Wason, and Frank McNamara, The Pathology of Influenza (New Haven: Yale University Press, 1920). On pathology during the war, see Cay-Rüdiger Prüll, “Pathology at War 1914 – 1918: Germany and Britain in Comparison,” in Roger Cooter, Mark Harrison, and Steve Sturdy, eds., Medicine and Modern Warfare, The Wellcome Institute Series in the History of Medicine (Amsterdam: Rodopi B. V., 1999). 9. Eugenia Tognotti makes a similar argument about bacteriologists in “Scientific Triumphalism and Learning from Facts: Bacteriology and the ‘Spanish Flu’ Challenge of 1918,” SHM 16 (2003): 97–110. See also Sandra M. Tomkins, “The Failure of Expertise: Public Health Policy in Britain during the 1918 – 19 Influenza Epidemic,” SHM 5 (December 1992): 441; and Sandra M. Tomkins, “Colonial Administration in British Africa during the Influenza Epidemic of 1918–1919,” Canadian Journal of African Studies 28 (1994): 60–83. 10. Kate Hathaway to Secretary of War

Notes to Chapter 5 | 213 Newton Baker, letter, 5 October 1918, RG 112, Entry 29, Box 393, NARA. 11. Fred S. Crum and Merritte Ireland correspondence, October 1918, RG 112, Entry 29, Box 391, NARA. 12. See correspondence in RG 112, Entry 29, Boxes 393, 394, and 395, NARA; and RG 90, Central File, 1897 – 1923, Boxes 144 – 46, NARA, Denver. 13. Katerina Poskocil to Newton Baker, letter, 27 October 1918, RG 112, Entry 29, Box 393, NARA. 14. The Sherwood and Frelinghuysen correspondence is in RG 112, Entry 29, Box 393, NARA. 15. Charles Curtis and Office of the Surgeon General, correspondence, October and November 1918, RG 112, Entry 31, Box 71, NARA. 16. Jouette Shouse to Robert Noble, correspondence, October 1918, RG 112, Entry 31, Box 74, NARA. 17. Senate Committee on Military Affairs, Delay in Casualty Lists, 65th Cong., 3rd sess., 3, 5, 9 December 1918; House Committee on Military Affairs, Notification of Illness of Soldiers, 65th Cong., 2nd sess., 11 February 1918, H. Report 300; and War Department Bulletin No. 44, 26 July 1918, 2–3. 18. House Committee on Military Affairs, Hearings on American Purple Cross Association, 65th Cong., 1st sess, 5 September 1917. 19. On repatriation, see G. Kurt Piehler, “The War Dead and the Gold Star: American Commemoration of the First World War,” in John R. Gillis, ed., Commemorations: The Politics of National Identity (Princeton, N.J.: Princeton University Press, 1994); G. Kurt Piehler, Remembering War the American Way (Washington, D.C.: Smithsonian Institution Press, 1995), 95–107; and Mark Meigs, Optimism from Armageddon: Voices of American Participants in World War I (New York: New York University Press, 1997), 175–87. 20. Editorial, “The Doughnut or the Hole,” MS 44 (April 1919): 393. 21. E. Alexander Powell, The Army behind the Army (New York: Charles Scribner’s Sons, 1919), 458–59. 22. Cecilia Elizabeth O’Leary, To Die For: The Paradox of American Patriotism (Princeton, N.J.: Princeton University Press, 1999). 23. See, for example, Vera Brittain, Testament of Youth (1933; reprint with a preface by Shirley Williams, New York: Penguin Books, 1978); Siegfried Sassoon, Memoirs of an Infantry Officer (1930; reprint, London: Faber and Faber, 1966 and 1969); and John Dos Pas-

sos, Three Soldiers (1921; reprint with introduction by Townsend Ludington, New York: Penguin Books, 1997). 24. George L. Mosse, Fallen Soldiers: Reshaping the Memory of the World Wars (New York: Oxford University Press, 1990), 7. See also Paul Fussell, The Great War and Modern Memory (New York: Oxford University Press, 1975). 25. Piehler, Remembering War, chapter 3; Meigs, Optimism from Armageddon, 162–69; and Thomas W. Lacqueur, “Memory and Naming in the Great War,” in John R. Gillis, ed., Commemorations: The Politics of National Identity (Princeton, N.J.: Princeton University Press, 1994). 26. Meigs, Optimism from Armageddon, 149–55. 27. Leonard P. Ayres, The War with Germany: A Statistical Summary (Washington, D.C.: Government Printing Office, 1919), 123. 28. James R. Church, “French Casualty Statistics,” MS 48 (February 1921): 239; and Fielding H. Garrison, “Notes on the History of Military Medicine,” MS 51 (August 1922): 212 – 13. See also Wm. Seaman Bainbridge, “Some Lessons of the World War in Medicine and Surgery from the German Viewpoint,” MS 49 (October 1921): 384. Nick Bosanquet estimates that the British army saw one death from disease for every fifteen in battle in “Health Systems in Khaki: The British and American Medical Experience,” in Hugh Cecil and Peter Liddle, eds., Facing Armageddon: The First World War Experienced (London: Pen and Sword, 1996), 459. 29. Victor C. Vaughan, “Report of the Proceedings of the Medical Veterans of the World’s War at the First Meeting in Atlantic City, N.J., June 11 and 12, 1919,” MS 45 (October 1919): 455. 30. McAndrew manuscript, “The Military Lessons of the World War,” RG 120, Entry 15, Box 100, NARA. 31. U.S. Army Quartermaster Corps American Graves Registration Service, History of the American Graves Registration Service (Washington, D.C.: Government Printing Office, n.d.). 32. War Department, Quartermaster Corps, Graves Registration Service, “Technical Instructions,” Bulletin No. 9a, November 1918, 13. I am grateful to Luther Hanson, Curator of Collections, U.S. Quartermaster Museum, Fort Lee, Virginia, for providing me with this pamphlet. 33. Garry Wills, Lincoln at Gettysburg: Words that Remade America (New York: Simon and Schuster, 1992).

214 | Notes to Chapter 5 34. This section is now called “Section 18.” There is apparently little documentation on federal policy regarding segregation in national cemeteries. According to Tom Sherlock, historian at Arlington National Cemetery, such segregation was not officially abolished until 1948 when President Harry Truman desegregated the armed forces. 35. Piehler, Remembering War, 4, 94 – 117; and Meigs, Optimism at Armageddon, 225 – 26. The U.S. government did distinguish some graves by religion, marking those of Jewish soldiers with the Star of David instead of a cross. 36. K. Walter Hickel, “War, Region, and Social Welfare: Federal Aid to Servicemen’s Dependents in the South, 1917 – 1921,” JAH 87 (March 2001): 1362–91. 37. Treasury Department, Bureau of War Risk Insurance, Military and Naval Insurance and Military and Naval Compensation Claims as a Result of the World War (Washington, D.C.: Government Printing Office, 1920), 63. 38. On concepts of manliness in World War I, see George L. Mosse, The Image of Man: The Creation of Modern Masculinity (New York: Oxford University Press, 1996); and Graham Dawson, “The Blond Bedouin: Lawrence of Arabia, Imperial Adventure and the Imagining of English-British Masculinity,” in Michael Roper and John Tosh, eds., Manful Assertions: Masculinities in Britain Since 1800 (London: Routledge, 1991). On the role of manliness in both civilian and military affairs in late nineteenth and early twentieth century American society, see Kristin L. Hoganson, Fighting for American Manhood: How Gender Politics Provoked the Spanish-American and the Philippine-American Wars (New Haven: Yale University Press, 1998); Emily Rosenberg, “Revisiting Dollar Diplomacy: Narratives of Money and Manliness,” Diplomatic History 22 (Spring 1998): 155 – 70; and Gail Bederman, Manliness and Civilization: A Cultural History of Gender and Race in the United States, 1880 – 1917 (Chicago: University of Chicago Press, 1995). 39. The Purple Heart was created during the Revolutionary War but fell into disuse in the nineteenth century. It was revived in 1932 and awarded to several thousand World War I veterans retroactively. See Order of Battle, vol. 3, pt. 1, 76. 40. Frank A. Holden, War Memories (Athens, Ga.: Athens Book Co., 1922). 41. Evelyn Raymond Schneider, WWI Questionnaire Collection, Army Nurse Corps, MHI.

42. Meigs, citing The Martian (Hospital Newspaper of Mars, Savoie), 27 April 1919, in Optimism at Armageddon, 175. 43. Army Regulations, article 22, paragraph 162-1/2; and Medical Manual, 80, 96. See also Joseph H. Ford, Details of Military Medical Administration (Philadelphia: P. Blakiston’s Son, 1918), 27. 44. Medical Manual, 141. 45. Jay Turnbull, Evacuation Hospital No. 9, to Commanding Officer, 805th Pioneer Infantry, 18 October 1918, RG 120, 805th Pioneers, Box 345, NARA. 46. War Department, Army Regulations, 1913, corrected to April 15, 1917 (Washington, D.C.: Government Printing Office, 1917), article 22. I am grateful to Darcie Foust, Curator, the Adjutant General Corps Museum, Fort Jackson, South Carolina, for providing me with this information. 47. L. G. Tighe to Lucy J. Hill, letter, 17 October 1918, RG 391, files of Battery A, 339th Field Artillery Regiment, 88th Division, NARA. I am grateful to Mitchell Yockelson, archivist at the National Archives, for bringing this letter to my attention. 48. Correspondence between commanding officer and J. J. Working, March 1918, RG 391, files of Battery A, 339th Field Artillery Regiment, 88th Division, Box 1769, NARA. 49. Francis Patrick Duffy, Father Duffy’s Story (New York: George H. Doran, 1919); and Gustav Stearns, From Army Camps and Battlefields (Minneapolis: Augsburg Publishing House, 1919). 50. For example, William C. Hickey to Mr. and Mrs. A. J. Hewlett, 16 October 1918, and William C. Hickey to Lucy J. Hill, 22 October 1918, RG 391, files of Battery A, 339th Field Artillery Regiment, 88th Division, NARA. 51. Elton E. Mackin, Suddenly We Didn’t Want to Die: Memoirs of a World War I Marine (Novato, Calif.: Presidio Press, 1993), 58– 63, 98–100; and James H. Hallas, Doughboy War: The American Expeditionary Force in World War I (Boulder, Colo.: Lynne Rienner Publications, 2000). 52. J. R. Steward, “Field Director’s Report, Camp Dodge, Iowa; Period Covering Influenza Epidemic,” RG 200, Box 689, NARA. 53. Correspondence regarding investigation of First Lieutenant Louis W. Schreiber, October and November 1918, RG 112, Entry 31, Box 71, NARA. 54. Correspondence between Merritte Ireland and George Simmons regarding D. E. Compere, February and March 1920, RG 112, Entry 29, Box 160, NARA. 55. Representative Fess speaking on health

Notes to Chapter 5 | 215 conditions in the army training camps, 65th Cong., 2nd sess., CR, 7 February 1918, 1832. 56. Quoted in Piehler, Remembering War, 88. 57. WDAR, 1919, vol. 1, pt. 2, 1433, 1435. 58. Lawrence Stallings, The Doughboys, AEF: 1917 – 1918 (New York: Harper and Row, 1963), 163, 323, 369. 59. Ettinger and Ettinger, A Doughboy with the Fighting 69th; and Duffy, Father Duffy’s Story. 60. Louis L. Collins, History of the 151st Field Artillery, Rainbow Division (Saint Paul: Minnesota War Records Commission, 1924). 61. Regimental History, Three Hundred and Forty-first Field Artillery, 89th Division (Kansas City, Mo.: Union Bank Note Company, n.a., n.d.) 62. Joint War History Commissions of Michigan and Wisconsin, The 32nd Division in the World War, 1917–1919 (Madison: Wisconsin History Commission, 1920). 63. MDWW, vol. 1, 587–604. 64. Quoted in John F. Fulton, Harvey Cushing: A Biography (Springfield, Ill.: Charles C. Thomas, 1946), 434. 65. Roy C. Fravel, “The Patient,” in J. F. Geisinger, ed., History of the U.S. Army Base Hospital No. 45 in the Great War (Richmond, Va.: William Byrd Press, 1924), 170. 66. Alfred E. Cornbeise, ed., War Diary of a Combat Artist: Harry Everett Townsend (Niwot: University Press of Colorado, 1991), 122. 67. “In Memoriam,” The Dooins’ 3 (7 December 1918): 1, in WWI Questionnaire Collection, Medical Corps, MHI. Roger Cooter comments on the phenomenon of “effeminizing the military victims of disease,” in “Of War and Epidemics: Unnatural Couplings, Problematic Conceptions,” SHM 16 (2003): 293. 68. Harold Barclay, A Doctor in France, 1917 – 1919 (New York, private printing, 1923), 60, 73. 69. Harvey Cushing, From a Surgeon’s Journal, 1915 – 1918 (Boston: Little, Brown, 1936), 490. 70. Philip A. Kalisch and Margaret Scobey, “Female Nurses in American Wars: Helplessness Suspended for the Duration,” Armed Forces and Society 9 (Winter 1983): 215–44. 71. NYT, 2 January 1919. 72. Dora E. Thompson, “How the Army Nursing Service Met the Demands of War,” in National League of Nursing Associations Twenty-fifth Annual Report (Baltimore: Williams and Wilkins, 1919), 134. 73. W. M. Haulsee, F. G. Howe, and A. C. Doyle, Soldiers of the Great War (Washington,

D.C.: Soldiers Record Publishing Association, 1920). 74. Mazyck P. Ravenel, “Preventive Medicine and War,” AJPH 10 (January 1920): 28. 75. Frederick H. Lamb and Edward Brannin, “The Epidemic Respiratory Infection at Camp Cody,” JAMA 72 (12 April 1919): 1062. 76. On gender distinctions during war, see Margaret Higonnet, ed., Behind the Lines: Gender and the Two World Wars (New Haven: Yale University Press, 1987); Miriam Cooke and Angela Woollacott, eds., Gendering War Talk (Princeton, N.J.: Princeton University Press, 1993); Michael Adams, The Great Adventure: Male Desire and the Coming of World War I (Bloomington: Indiana University Press, 1990); and Dawson, “The Blond Bedouin,” in Roper and Tosh, eds., Manful Assertions. 77. Editorial, “Physicians and Patriotism,” MS 41 (November 1917): 611. Aesculapius refers to the Greek God of medicine who became so skilled that Zeus feared him and had him killed. 78. “Personal Recollections of General Gorgas by Victor Vaughan,” William C. Gorgas Papers, Box 706, Folder 4, Hoole Collection. 79. On soldiers’ contempt for the homefront, see Fussell, The Great War and Modern Memory, 82 – 90; and Stéphane AudoinRouzeau, Men at War, 1914 – 1918: National Sentiment and Trench Journalism in France during the First World War, trans. Helen McPhail (Providence: Berg, 1992). 80. Mackin, Suddenly We Didn’t Want to Die, 136. 81. Senate Committee on Military Affairs, Housing for Sick Soldiers, 65th Cong., 2nd sess., 13 December 1918. 82. Ms. C 155, Stanhope Bayne-Jones Papers, 1870–1969, Box 10, Folder B-36, NLM; and Ms. C 149, Eclat Club Minutes, Box 1, NLM. 83. “Our London Letter,” Medical Record, 10 August 1918, 252. 84. Percy M. Ashburn, A History of the Medical Department of the U.S. Army (Boston and New York: Houghton Mifflin, 1929), 333. 85. E. L. Munson, Editorial, MS 41 (June 1917): 720. For another example, see H. C. Coe, “Bravery — Physical and Moral,” MS 42 (May 1918): 563. 86. Champe McCulloch, “The Scientific and Administrative Achievement of the Medical Corps of the United States Army,” Scientific Monthly 4 (May 1917): 410. 87. Editorial, “Is All Well with the Sanitary Services?” MS 41 (July 1917): 129. See also

216 | Notes to Chapter 5 Victor Vaughan, “The Rank and Authority of the Medical Officer,” JLCM 2 (May 1917): 595. 88. Albert E. Cowdrey, War and Healing: Stanhope Bayne-Jones and the Maturing of American Medicine (Baton Rouge: Louisiana State University Press, 1992), 52–72. 89. Richard Derby, “Wade in, Sanitary!” The Story of a Division Surgeon in France (New York: G. P. Putnam’s Sons, 1919), 122. 90. Chester C. Nash, Jr., WWI Questionnaire Collection, Medical Corps, MHI. 91. Edward Erskine Hume, “The Medical Book of Merit: United States Army and Navy Decorations Awarded to Medical Officers for Distinguished Service in the World War,” MS 56 (March 1925): 241–92; and American Battle Monuments Commission, American Armies and Battlefields in Europe (1938; republished by Center for Military History, Washington, D.C.: Government Printing Office, 1995). 92. George A. Soper, “The Efficacy of Existing Measures for the Prevention of Disease,” JAMA 73 (8 November 1919): 1409. See also Frederick Gay, “The Present Status of our Knowledge Concerning the Etiology of Influenza,” JLCM 5 (May 1920): 543. 93. J. T. Borden and R. S. Leopold, “Influenza,” U.S. Naval Medical Bulletin 13 (October 1919): 681. 94. House Committee on Military Affairs, Proposed Legislation Affecting the Medical Corps of the U.S. Army, 16 April 1918 and 7 June 1918, 65th Cong., 2nd sess., 29. 95. Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850 – 1945 (Cambridge: Cambridge University Press, 1987), 39 – 51; and Florence Nightingale, Notes on Nursing: What It Is, and What It Is Not (1860; reprint, Philadelphia: J. P. Lippincott, 1946). 96. Sarah E. Dock, “The Relation of the Nurse to the Doctor and the Doctor to the Nurse,” AJN 17 (February 1917): 394. Emphasis added. 97. MDWW, vol. 9, 163–64. 98. Pershing telegram, 3 October 1918, MDWW, vol. 6, 362. 99. Nancy Bristow, “‘You Can’t Do Anything for Influenza’: Doctors, Nurses and the Power of Gender during the Influenza Epidemic in the United States,” in Howard Phillips and David Killingray, eds., The Spanish Influenza Pandemic of 1918 – 1919: New Perspectives (New York: Routledge, 2003). 100. Thompson, “How the Army Nursing Service Met the Demands of War,” 125. 101. Mary Beard, “The Significance of the

War,” Public Health Nurse 9 (October 1917): 324. 102. Aileen Cole Stewart, WWI Questionnaire Collection, Army Nurse Corps, MHI. See also Darlene Clark Hine, “The Call That Never Came: Black Women Nurses and World War I, an Historical Note,” Indiana Military History Journal 8 (January 1983): 23–27. 103. House Committee on Military Affairs, Proposed Legislation Affecting the Medical Corps of the U.S. Army, 16 April 1918 and 7 June 1918, 65th Cong., 2nd sess. 104. On rank for army nurses, see Philip A. Kalisch, “How Army Nurses Became Officers,” Nursing Research 25 (May – June 1976): 164–77; and Mary T. Sarnecky, A History of the U.S. Army Nurse Corps (Philadelphia: University of Pennsylvania Press, 1999), 146 – 48. Army nurses did not receive actual commissioned status until 1947. 105. Quoted in Kalisch, “How Army Nurses Became Officers,” 175. 106. Conference report on the Army Reorganization Act of 1920, section 10, Medical Department, 66th Cong., 2nd sess., CR, 28 May 1920, 7816; emphasis added. 107. Sarnecky, A History of the U.S. Army Nurse Corps, 146–48. 108. Jay W. Grissinger, Medical Field Service in France (Washington, D.C.: Association of Military Surgeons, 1928), 130. 109. Collins, History of the 151st Field Artillery, 176. On third wave of influenza, see “Epidemic Influenza: A Recrudescence of the Disease,” PHR 33 (6 December 1918): 2153– 54; MDWW, vol. 9, 84; Grissinger, Medical Field Service in France. 110. “War Time Diary of Dr. William Holmes Dyer,” unpublished manuscript, Lincoln Public Library, Lincoln, Illinois. 111. Collins, History of the 151st Field Artillery; and Frederick Pottle, Stretchers: The Story of a Hospital Unit on the Western Front (New Haven: Yale University Press, 1929), 315. 112. For example, see M. A. W. Shockley to Adjutant General, AEF, “Summary of Investigation of Respiratory Diseases, 42nd Division, Third Army,” 1 April 1919, RG 407, Entry 2054, NARA. 113. Headquarters, Third Army Corps, Bulletin No. 39, 27 October 1918, RG 120, Entry 1241, Box 122, NARA. 114. Anthony G. Finan, ed., All for Heaven, Hell, or Hoboken: The World War I Diary Letters of Clair M. Pfennig, Flash Ranger, Company D, 29th Engineers, AEF (St. Louis: Crimson Shamrock Press, 1998), 195.

Notes to Chapter 6 | 217 115. Finan, ed., All for Heaven, Hell, or Hoboken, 201. 116. Senator John Bankhead presenting a resolution from the legislature of the state of Alabama regarding the influenza, 65th Cong., 3rd sess., CR, February 1919, 4107; and Representative Simeon Fess speaking on PHS activities regarding influenza, 65th Cong., 3rd sess., CR, 26 February 1919, 4372. 117. Newton Baker to H. P. Burton, letter, 14 August 1919, RG 112, Entry 29, Box 20, NARA. 118. S. J. Res. 76, to enable the PHS to investigate influenza and allied diseases, 66th Cong., 1st sess.; and Senate Report 233, Investigation of Influenza, 1 October 1919, 66th Cong., 1st sess. 119. Representative Fiorello La Guardia speaking on conditions at Walter Reed Hospital, 65th Cong., 3rd sess., CR, 15 January 1919, 1473. 120. On Brest and Camp Pontanezen see Senate Committee on Military Affairs, Army Camp at Brest, France, 65th Cong., 3rd sess., 15 February 1919; Joseph W. A. Whitehorne, The Inspectors General of the United States Army, 1903 – 1939 (Washington, D.C.: Office of the Inspector General and the Center of Military History, 1998), 265 – 70; Editorial, “Camp Pontanezen, Brest, France,” MS, March 1920, 301 – 6; and MDWW, vol. 2, 465–72. 121. H. C. Fisher to William C. McCaw, 1 October 1918, RG 120, Entry 2622, Box 2911, NARA. 122. NYT, 21 and 22 February 1919, and 3 March 1919. 123. James G. Harbord, The American Army in France, 1917 – 1919 (Boston: Little, Brown, 1936), 554. 124. Frederick L. Paxson, Postwar Years: Normalcy, 1918–1923 (Berkeley: University of California Press, 1948). 125. House Committee on Military Affairs, Army Reorganization, 66th Cong., 1st sess., 3 October 1919, 463. See also Senate Committee on Military Affairs, Reorganization of the Army, 66th Cong., 1st sess., 4 September 1919, 598 – 613; and “General Ireland Discusses Army Reorganization,” JAMA 73 (18 October 1919): 1224–26. 126. House Committee on Military Affairs, Army Reorganization, 472. 127. See conference report on the Army Reorganization Act of 1920, section 10, Medical Department, 66th Cong., 2nd sess., CR, 28 May 1920, 7816; and Ginn, The History of the U.S. Army Medical Service Corps, 93–96.

128. House Select Committee on Expenditures in the War Department, hearings on War Expenditures, 66th Cong., 1st sess., July through October 1919. 129. War Department, William Crawford Gorgas, “Inspection of Medical Services with the American Expeditionary Forces: Confidential Report to the Secretary of War” (Washington, D.C.: Government Printing Office, 1919), 47. 130. “Report of Gen. Pershing,” 65th Cong., 3rd sess., CR, 30 December 1918, 914–17. 131. WDAR, 1919, vol. 1, pt. 1, 623. 132. “Surgeon General Gorgas and the Responsibility of the Medical Department of the Army,” JAMA 70 (18 May 1918): 1460. 133. Editorial, American Medicine, December 1918, 767–69. 134. Editorial, MS 46 (March 1920): 314.

notes to chapter 6 The epigraph comes from Mazyck Ravenel, “Preventive Medicine and War,” AJPH 10 (January 1920): 27. 1. Joan W. Scott, “The Evidence of Experience,” in J. Chandler, A. Davidson, and H. Harootunian, eds., Questions of Evidence (Chicago: University of Chicago Press, 1994). 2. Merritte W. Ireland, “Plans for Reorganizing the Medical Department of the Army,” American Medicine, July 1920, 361–68. 3. Charles Lynch, “Authoritative Data on the Medical Department,” manuscript, in RG 112, Entry 29, Box 159, NARA. 4. James M. Phalen, “Chiefs of the Medical Department, U.S. Army, 1775 – 1940,” Army Medical Bulletin, no. 52 (April 1940): 94–100; and John J. Pershing, “Surgeon General Merritte W. Ireland,” in Percy M. Ashburn, A History of the Medical Department of the U.S. Army (Boston and New York: Houghton Mifflin, 1929), 394–96. 5. Pershing, “Surgeon General Merritte W. Ireland,” 395–96. 6. Bailey Ashford, A Soldier in Science: The Autobiography of Bailey K. Ashford (New York: William Morrow, 1934), 314–15. 7. See, for example, Desmond Manderson, “‘Disease, Defilement, Depravity’: Towards an Aesthetic Analysis of Health,” in Lara Marks and Michael Worboys, eds., Migrants, Minorities, and Health (London: Routledge, 1997); Rajnarayan Chandavarkar, “Plague Panic and Epidemic Politics in India, 1896 – 1914,” in Terence Ranger and Paul Slack, eds., Epidemics and Ideas: Essays on the Historical

218 | Notes to Chapter 6 Perception of Pestilence (Cambridge: Cambridge University Press, 1994); Paul Weindling, “A Virulent Strain: German Bacteriology as Scientific Racism, 1890 – 1920,” in Waltraud Ernst and B. Harris, eds., Race, Science and Medicine, 1700 – 1960 (London and New York, 1999); and Tera Hunter, To ’Joy My Freedom (Boston: Harvard University Press, 1997), chapter 9. See also Charles E. Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge: Cambridge University Press, 1992); and Charles E. Rosenberg and Janet Golden, eds., Framing Disease: Studies in Cultural History (New Brunswick: Rutgers University Press, 1992). 8. Merritte Ireland, “Progress in Disease Prevention and Health Conservation in the Army,” speech, 1922, Ms. C 117, Merritte Weber Ireland Papers, 1911–1931, NLM. 9. On legislation to reorganize the army after the war, see John Dickinson, The Building of an Army: A Detailed Account of Legislation, Administration, and Opinion in the United States, 1915 – 1920 (New York: Century, 1922), chapter 9; and Stephen Skowronek, Building a New American State: The Expansion of National Administrative Capacities, 1877 – 1920 (New York: Cambridge University Press, 1982), 242–47. 10. Joseph W. A. Whitehorne, The Inspectors General of the United States Army, 1903– 1939 (Washington, D.C.: Office of the Inspector General and the Center of Military History, 1998), 325; and Marvin A. Kreidberg and Merton G. Henry, History of Military Mobilization in the United States Army, 1775 – 1945, Department of the Army, Pamphlet No. 20-212 (Washington, D.C.: Department of the Army, 1955), 379. 11. MDWW, vol. 1, 6–7. 12. MDWW, vol. 1, 3. 13. Fielding H. Garrison, “Medical and Surgical History of the War,” MS 43 (September 1918): 347 – 50; MDWW, vol. 1, 13 – 18; and Champe C. McCulloch, report, 1 February 1919, RG 112, Entry 29, Box 148, NARA. 14. A Medical and Surgical History of the British Army Which Served in Turkey and the Crimea during the War against Russia in the Years 1854–55–56, 2 vols., presented to both houses of Parliament, London, 1858; and United States Army, Medical and Surgical History of the War of the Rebellion, 6 vols. (Washington, D.C.: Government Printing Office, 1870–88). On other countries’ medical histories, see Fielding H. Garrison, “The German Medical History of the War,” MS 46 (April 1920): 427 – 30; Otto von Schjerning, Handbuch der

ärtzlichen Erfahrungen im Weltkriege 1914/18 [Handbook of Medical Experiences in the World War, 1914–1918] (Leipzig: J. A. Barth, 1921 – 22); Sir W. G. MacPherson et al., History of the Great War Based on Official Documents. Medical Services, 12 vols. (London: His Majesty’s Stationary Office, 1923–31); and A. Macphail, The Medical Services: Official History of the Canadian Forces in the Great War, 1914–1919 (Ottawa: Department of National Defence, 1925). 15. War Department, Office of the Surgeon General, Index-Catalogue of the Library of the Surgeon-General’s Office, 3rd series, 10 vols. (Washington, D.C.: Government Printing Office, 1918–1932). 16. M. C. Winternitz, Isabel M. Wason, and Frank McNamara, The Pathology of Influenza (New Haven: Yale University Press, 1920), 9. 17. War Department, Office of the Surgeon General, MDWW (Washington, D.C.: Government Printing Office, 1921–29), vols. 1–15. 18. Proceedings — 71st Annual Session, American Medical Association, New Orleans, 26 April to 30 April 1919, JAMA 74 (1919): 1319. The War Department never completed an official history of the war. Chief of Staff Charles P. Summerall rejected a monograph, “Major Operations, U.S. Army in the World War,” in 1929. See memo to Summerall, 9 July 1929, RG 407, NARA. 19. “Army Medical History,” MS 64 (February 1929): 281; and William G. Morgan, “Contributions of the Medical Department of the United States Army to the Advancement of Knowledge,” MS 66 (1930): 788. 20. William H. Cruikshank to Merritte Ireland, 10 December 1920, correspondence, RG 112, Entry 29, Box 146, NARA. 21. “Method of Procedure in Handling Manuscripts by the Board of Publications,” in MDWW, vol. 1, 1303 – 4. See also “Board of Publications,” in MDWW, vol. 1, 520–24; and “Manuscripts from Medical Officers in the Army,” CSJM 16 (May 1918): 231. 22. See George Draper, “Some Observations on the Susceptibilities of the Recruits to Disease,” MS 45 (July 1919): 99 – 106; Edgar Sydenstricker, Health and the Environment (New York: McGraw-Hill, 1933, and New York: Arno Press and the New York Times, 1972); Editorial, “Heredity,” American Medicine, February 1920, 72–73; and Thomas Andrew Dodds, “Richard Cabot: Medical Reformer during the Progressive Era, 1890 – 1920,” Annals of Internal Medicine 119 (1993): 417–22. 23. Wyndham B. Blanton and Ernest E. Irons, “A Recent Epidemic of Acute Respira-

Notes to Chapter 6 | 219 tory Infection at Camp Custer, Michigan: Preliminary Laboratory Report,” JAMA 71 (14 December 1918): 1990. 24. Much of this discussion is based on Jacalyn Duffin, “Pneumonia,” in Kiple, ed., The Cambridge World History of Human Disease, 938–42. 25. MDWW, vol. 9, 163. 26. MDWW, vol. 6, 891. 27. J. N. Hall, Murray C. Stone, and John C. Simpson, “The Epidemic of Pneumonia Following Influenza at Camp Logan, Texas,” JAMA 71 (14 December 1918): 1987. 28. MDWW, vol. 9, 5. 29. Women included Loy McAfee, M.D., army contract surgeon, who served as assistant editor in chief, and Julia C. Stimson and Dora E. Thompson, of the Army Nurse Corps., who wrote several sections of the history. 30. WDAR, 1918, 334. 31. William Crawford Gorgas, “Sanitary Conditions at Army Camps,” House Document No. 806, 65th Cong., 2nd sess., 1. 32. William L. Moss, “Epidemiological Activities in Base Section No. 2,” in G. Clymer, History of the U.S. Army Base Hospital No. 6, and Its Part in the American Expeditionary Force, 1917 – 1918 (Boston: Clymer, 1924), 102. 33. I. W. Brewer, “Report of Epidemic of ‘Spanish Influenza,’ Which Occurred at Camp A. A. Humphreys, VA., during September and October, 1918,” JLCM 4 (December 1918): 103. 34. MDWW, vol. 9, 110–11. 35. MDWW, vol. 9, 111. 36. Brewer, “Report of Epidemic of ‘Spanish Influenza,’” 93–94. 37. J. E. Walker, S. L. Van Valzah, and C. P. Eck, “Observations upon the Influenza Epidemic of 1918 in the American Army in France,” unpublished manuscript, December 1918, RG 120, Entry 2119, Box 5560A, NARA. 38. Zinsser to Chief Surgeon, First Army Corps, AEF, 13 October 1918, RG 120, Entry 2109, Box 5494, File 710, NARA. 39. J. R. Shook to Chief Surgeon, Seventh Army Corps, 17 October 1918, memorandum, RG 120, Entry 2109, Box 5494, NARA. 40. William C. Gorgas, “Thrift in Health— Applications of the Lesson of Military Sanitation to Peace Times,” 6 December 1918, William C. Gorgas Papers, Hoole Collection. 41. WDAR, 1919, vol. 1, pt. 3, 3029. 42. On the state of bacteriology during the war period, see Stanley Joel Reiser, Medicine and the Reign of Technology (Cambridge: Cambridge University Press, 1978); Ton Van

Helvoort, “History of Virus Research in the 20th Century: The Problem of Conceptual Continuity,” History of Science 32 (1994): 185–235; and William D. Foster, A History of Medical Bacteriology and Immunology (London: William Neinemann, 1970). 43. George B. Foster, “The Etiology of Common Colds: The Probable Role of a Filterable Virus as the Causative Factor,” JAMA 66 (15 April 1916): 1180–83. Thanks to Dale C. Smith for explaining this topic to me. 44. MDWW, vol. 12, 399. 45. Victor C. Vaughan, “Notes on Influenza,” JLCM 4 (December 1918): 146. 46. See Charles Lynch and James G. Cumming, “The Role of the Hand in the Distribution of Influenza Virus and the Secondary Invaders,” MS 43 (December 1918): 597 – 630; Charles Lynch and James Cumming, “The Epidemiology of Influenza-Pneumonia,” JLCM 5 (March 1920): 364–73; and Thomas W. Jackson, “The Other Side of the Question of Indirect Contact Infection in Acute Respiratory Diseases,” MS 46 (May 1920): 570–73. 47. MDWW, vol. 9, 111. 48. Edwin Henry Schorer et al., “Pneumonia and Empyema in the Late Winter of 1917– 1918,” Medical Record 95 (26 April 1919): 673 – 80; and H. R. Wahl, George B. White, and H. W. Lyall, “Some Experiments on the Transmission of Influenza,” JID 25 (1919): 419–26. 49. Timothy Leary, “The Use of Influenza Vaccine in the Present Epidemic,” AJPH, October 1918, 754; Russell L. Cecil and J. Harold Austin, “Results of Prophylactic Inoculation against Pneumococcus in 12,519 Men,” JEM 28 (July 1918): 19 – 41; and P. F. McGuire, Wesley C. Cox, and John D. Nourse, “Protection Afforded by Anti-Pneumococcus Vaccination against Respiratory Infections,” MS 49 (November 1921): 559 – 65. Medical scientists were able to develop vaccines for influenza during World War II. 50. Editorial, “Value of Vaccination against Influenza,” JAMA 71 (9 November 1918): 1583; and “Vaccines against Influenza,” PHR 33 (1 November 1918): 1866. 51. E. O. Jordan quoted in “Society Proceedings,” JAMA 71 (21 December 1918): 2097. 52. MDWW, vol. 9, 90. Emphasis added. 53. MDWW, vol. 9, 90; Edgar Sydenstricker, “Preliminary Statistics of the Influenza Epidemic,” PHR 33 (27 December 1918): 2318; and W. H. Frost, “The Epidemiology of Influenza,” PHR 34 (15 August 1919): 1834. 54. Gorgas, “Thrift in Health,” 4; and Hermann M. Biggs, “The Recent Epidemic of

220 | Notes to Chapter 6 Influenza,” American Review of Reviews (1919): 71. 55. William C. Gorgas, “Health Problems of the Army,” AJPH 7 (November 1917): 937–39; Haven Emerson et al., “The Control of Communicable Diseases,” PHR 32 (12 October 1917): 1706–27; and Allan Brandt, No Magic Bullet: A Social History of Venereal Disease in the United States since 1880 (New York: Oxford University Press, 1987). 56. Ernest E. Irons, “Pneumonia Following Influenza in the Camps in the United States,” MS 48 (March 1921): 278. 57. Victor C. Vaughan, Henry F. Vaughan, and George T. Palmer, Epidemiology and Public Health (St. Louis: C. V. Mosby, 1922), vol. 1, 356. 58. Edgar S. Linthicum, “Special Report on Influenza,” 26 November 1918, RG 120, Entry 2109, Box 5493, NARA. See also Draper, “Some Observations on the Susceptibilities of the Recruits to Disease,” 99–106. 59. MDWW, vol. 9, 93. 60. MDWW, vol. 6, 173–85. 61. Victor C. Vaughan and George T. Palmer, “Communicable Diseases in the National Guard and National Army of the United States during the Six Months from September 29, 1917, to March 29, 1918,” JLCM 3 (August 1918): 699. 62. George A. Soper, “The Efficacy of Existing Measures for the Prevention of Disease,” JAMA 73 (8 November 1919): 1408. 63. On ethnicity and disease, see Howard Markel, Quarantine! East European Jewish Immigrants and the New York City Epidemics of 1892 (Baltimore: Johns Hopkins University Press, 1997); Naomi Rogers, Dirt and Disease: Polio before FDR (New Brunswick, N.J.: Rutgers University Press, 1992); Alan M. Kraut, Silent Travelers: Germs, Genes, and the “Immigrant Menace” (Baltimore: Johns Hopkins University Press, 1994); and Lara Marks and Michael Worboys, eds., Migrants, Minorities, and Health (London and New York: Routledge, 1997). 64. Walter H. Brown, “Health Problems of the Foreign Born,” AJPH 9 (January 1919): 104; and Dean Brundage, “Sickness and Absenteeism during 1919 in a Large Industrial Establishment,” PHR 35 (10 September 1920): 2143–54. 65. Albert G. Love and Charles B. Davenport, Defects Found in Drafted Men (Washington, D.C.: Government Printing Office, 1920). 66. Office of the Surgeon General, “Malingering in U.S. Troops, Home Forces, 1917,” MS 42 (March 1918): 263; and for example of ethnicity in morale inspections, see memoran-

dum to Charles Dentsch, 12 September 1918, RG 120, Entry 195, Box 1, NARA. 67. In MDWW, vol. 9, see, for example, “Inflammatory Diseases of the Respiratory Tract,” 73; “Measles,” 420; and “Mumps,” 452–53. 68. WDAR, 1918, 338. 69. WDAR, 1918, 358. 70. WDAR, 1918, 491–93. 71. WDAR, 1919, vol. 1, pt. 2, 1580. 72. Many scholars have only recently accepted the social basis of racial categories and the theory that race alone does not increase or decrease a person’s susceptibility to disease. On race and disease, see Sandra Harding, ed., The “Racial” Economy of Science: Toward a Democratic Future (Bloomington: Indiana University Press, 1993); and Waltraud Ernst and B. Harris, eds., Race, Science and Medicine, 1700 – 1960 (London and New York: Routledge, 1999); Richard S. Cooper, Charles N. Rotimi, and Ryk Ward, “The Puzzle of Hypertension in African-Americans,” Scientific American, February 1999, 56 – 63; and Richard Cooper, “A Case Study in the Use of Race and Ethnicity in Public Health Surveillance,” PHR 109 (January – February 1994): 46–52. 73. Carol L. Barsh, “Sickle Cell Trait, Policy and Research Paradigms,” Science as Culture 7 (September 1998): 379–92; Melbourne Tapper, In the Blood: Sickle Cell Anemia and the Politics of Race (Philadelphia: University of Pennsylvania Press, 1998); and Keith Wailoo, Drawing Blood: Technology and Disease Identity in Twentieth-Century America (Baltimore: Johns Hopkins University Press, 1997), 135–61. 74. Edward H. Beardsley, A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth-Century South (Knoxville: University of Tennessee Press, 1987), chapter l; and Vanessa Northington Gamble, “Under the Shadow of Tuskegee: African Americans and Health Care,” AJPH 87 (November 1997): 1773–78. 75. Albert B. Kellogg, “Port Labor, WWI,” in U.S. Army War College File 127 – 23, “Replies to Army War College Questionnaires of 7 May 1924 Concerning the Use of Negro Manpower in Time of War,” MHI. 76. U.S. Army War College, report, “Use to be Made of Negroes in the U.S. Military Service,” WWI Questionnaire Collection, MHI. 77. Beardsley, A History of Neglect, 16–31; Vanessa N. Gamble, Germs Have No Color Line: Blacks and American Medicine, 1900 – 1940 (New York: Garland, 1989), 129 – 30; David McBride, From TB to AIDS: Epidemics

Notes to Chapter 6 | 221 among Urban Blacks since 1900 (Albany: State University of New York Press, 1991); Susan L. Smith, Sick and Tired of Being Sick and Tired: Black Women’s Health Activism in America, 1890–1950 (Philadelphia: University of Pennsylvania Press, 1995); John S. Haller, Jr., “The Physician versus the Negro: Medical and Anthropological Concepts of Race in the Late Nineteenth Century,” BHM 44 (1970): 154 – 67; and Todd L. Savitt, “Entering a White Profession: Black Physicians in the New South, 1880 – 1920,” BHM 61 (1987): 507 – 40. 78. Frederick L. Hoffman, Race Traits and Tendencies of the American Negro (New York: American Economic Association, 1896), 329. 79. Carol Taylor, “W. E. B. Du Bois’s Challenge to Scientific Racism,” Journal of Black Studies 11 (June 1981): 449–60. See also C. V. Roman, American Civilization and the Negro —The Afro-American in Relation to National Progress (Philadelphia: F. A. Davis, 1916); and John A. Kenney, “Health Problems of the Negroes,” Annals of the American Academy of Political and Social Science (March 1911): 354–64. 80. Charles V. Roman, “Fifty Years’ Progress of the American Negro in Health and Sanitation,” JNMA 9 (April–June, 1917): 62. 81. Editorial, “Our Preventable Death Rate,” JNMA 9 (January–March 1917): 28. 82. Weston P. Chamberlain, “Demography in so far as It Relates to the Vital Statistics of Armies,” MS 39 (December 1916): 587. 83. “The Incidence of Disease Contrasted for White and Colored Troops,” JAMA 72 (17 May 1919): 1468; and Albert G. Love and Charles B. Davenport, “A Comparison of White and Colored Troops in Respect to Incidence of Disease,” Proceedings of the National Academy of Sciences 5 (15 March 1919): 58– 67. 84. Paul G. Wooley to Victor Vaughan, memorandum, 17 June 1918, RG 112, Entry 31, Box 84, NARA. 85. MDWW, vol. 1, 1041–42. 86. MDWW, vol. 4, passim. 87. Charles H. Williams, Negro Soldiers in World War I: The Human Side (1923; New York: AMS Press, 1970), 26. 88. Leon A. Congdon, “A Study of the Army Ration and Its Relation to the Height and Weight of Soldiers in Army Cantonments,” MS 48 (May 1921): 569–80. 89. J. S. White to Charles C. Ballou, 24 August 1918, and J. S. White to Commanding General of 92nd Division, 21 November 1918, RG 120, Entry 1241, Box 63, NARA. Many

but not all of the Ninety-Second’s officers, including the commander, Charles Ballou, were white. 90. Thomas Scanlan to Commanding General of 92nd Division, no date, RG 120, Entry 1241, Box 63, NARA. 91. Robert Stevens, WWI Questionnaire Collection: Pioneer Infantry, MHI. 92. WDAR, 1919, vol. 1, pt. 2, 3762. 93. Wilbur Turner to Base Surgeon, Base Section 3, 13 September 1918, RG 120, Entry 2109, Box 5493, NARA. 94. WDAR, 1919, vol. 1, pt. 2, 3763–64. 95. Merritte Ireland, “Introduction,” Merritte Ireland Papers, Ms. C 117, Box 2, Folder 29, NLM. This appears to be a draft of the introduction to the MDWW. 96. See W. Allison Sweeney, History of the American Negro in the Great World War (Chicago: Cuneo-Henneberry, 1919); Mark Ellis, Race, War, and Surveillance: African Americans and the United States Government during World War I (Bloomington: Indiana University Press, 2001), 74 – 101; and Arthur E. Barbeau and Lorette Henri, The Unknown Soldiers: Black American Troops in World War I (Philadelphia: Temple University Press, 1974). For more examples of racism in the army during the war, see a special edition of the Journal of Negro Education 12 (Summer 1943); and Addie W. Hunton and Katherine M. Johnson, Two Colored Women with the American Expeditionary Force (New York: Brooklyn Eagle, 1920). 97. John Richards, “Some Experiences with Colored Soldiers,” Atlantic Monthly 124 (1919): 184. 98. Richards, “Some Experiences with Colored Soldiers,” 190. 99. Chester Heywood, Negro Combat Troops in the World War (Worcester, Mass.: Commonwealth, 1928; reprint edition, New York: AMS Press, 1969), 2. 100. Hugh Young, A Surgeon’s Autobiography (New York: Harcourt, Brace, 1940), 361– 62. 101. Albert M. Ettinger and A. Churchill Ettinger, A Doughboy with the Fighting 69th (New York: Pocket Books, 1992), 199. 102. “War Time Diary of Dr. William Holmes Dyer,” unpublished manuscript, Lincoln Public Library, Lincoln, Illinois. Emphasis in the original. 103. L. L. Smith to Chief of Staff, 14 March 1919, RG 120, Entry 2622, Box 2913, NARA. 104. James S. Allen to Haven Emerson, 2 October 1918, RG 120, Entry 2109, Box 5493, NARA. 105. Russell L. Cecil, “Pneumonia and

222 | Notes to Chapter 6 Empyema at Camp Upton, N.Y.,” MCNA 2 (September 1918): 568. 106. Paul G. Woolley, “The Epidemic of Influenza at Camp Devens, Mass.,” JLCM 4 (March 1919): 337. 107. Baldwin Lucke, Toynbee Wright, and Edwin Kime, “Pathologic Anatomy and Bacteriology of Influenza,” AIM 24 (August 1919): 157. 108. Joseph L. Miller and Frank B. Lusk, “Epidemic of Streptococcus Pneumonia and Empyema at Camp Dodge, Iowa,” JAMA 71 (31 August 1918): 703; and W. H. Frost, “Statistics of Influenza Morbidity,” PHR 35 (12 March 1920): 592. 109. MDWW, vol. 9, 106. 110. MDWW, vol. 9, 95. 111. Some obviously did not discuss race because their study group was all white. For example, Harry D. Orr, “Examination of Recruits for the Army and Militia,” AJPH 7 (May 1917): 485–88. 112. C. N. B. Camac, “Serum Treatment of Lobar Pneumonia,” Transactions of the Association of American Physicians 33 (1918): 394. 113. Warren T. Vaughan, Influenza: An Epidemiologic Study, (Baltimore: American Journal of Hygiene Monograph Series, No. 1, July 1921), 175. 114. MacNeal, “The Influenza Epidemic of 1918 in the American Expeditionary Forces,” 675; and unpublished report, author and date unknown, RG 112, Entry 31, Box 57, NARA. 115. Alfred Friedlander et al., “The Epidemic of Influenza at Camp Sherman, Ohio,” JAMA 71 (16 November 1918): 1652 – 56; Charles L. Mix, “Spanish Influenza in the Army,” New York Medical Journal 108 (26 October 1918): 709 – 18; and Jack Gittings, “Observations on the Military Value of the Immunity Conferred by Previous Attacks of Measles, Scarlet Fever, and Mumps,” MS 44 (June 1919): 642. 116. W. G. MacCallum, “Pathology of the Pneumonia Following Influenza,” JAMA 72 (8 March 1918): 720–23; and W. G. MacCallum, “Pathology of Epidemic Pneumonia in Camps and Cantonments in 1918,” Medical Record (10 May 1919): 776–84. 117. Merritte Ireland, address on occasion of dinner given by Drs. Martin and McLean, 4 October 1919, Ms. C 117, Merritte Ireland Papers, NLM. 118. “Report of the Proceedings of the Medical Veterans of the World’s War at the First Meeting at Atlantic City, N.J., 11 and 12 June 1919,” MS 45 (October 1919): 453. 119. CSJM 17 (March 1919): 88.

120. Edgar Erskine Hume, The Golden Jubilee of the Association of Military Surgeons of the United States (Washington, D.C.: Association of Military Surgeons, 1941). 121. Steve Sturdy, “War as Experiment: Physiology, Innovation and Administration in Britain, 1914 – 1918,” in Roger Cooter, Mark Harrison, and Steve Sturdy, War, Medicine and Modernity (Stroud, England: Sutton Publishing, 1998); and Nick Bosanquet, “Health Systems in Khaki: The British and American Medical Experience,” in Hugh Cecil and Peter Liddle, eds., Facing Armageddon: The First World War Experienced (London: Pen and Sword, 1996). 122. Stanley Joel Reiser, Medicine and the Reign of Technology (Cambridge: Cambridge University Press, 1978), chapter 4; and William G. Rothstein, “Pathology: The Evolution of a Specialty in American Medicine,” in William G. Rothstein, ed., Readings in American Health Care: Current Issues in Socio-Historical Perspective (Madison: University of Wisconsin Press, 1995). 123. Ira M. Rutkow, American Surgery: An Illustrated History (Philadelphia: LippincottRaven, 1998), 29–300. 124. Lewis Pilcher quoted in Rutkow, American Surgery, 300. 125. MDWW, vol. 11; Grace Crile, ed., George Crile: An Autobiography (Philadelphia: J. B. Lippincott, 1947); and Rutkow, American Surgery. 126. Young, A Surgeon’s Autobiography, 532. 127. Helen Dore Boylston, Sister: The War Diary of a Nurse (New York: Ives Washburn, 1927), 81. 128. Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989), 95– 98; and Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850 – 1945 (Cambridge: Cambridge University Press, 1987), 180–98. 129. K. Walter Hickel, “Medicine, Bureaucracy, and Social Welfare: The Politics of Disability Compensation for American Veterans for World War I,” in Paul K. Longmore and Lauri Umansky, The New Disability History: American Perspectives (New York: New York University Press, 2001); Treasury Department, Bureau of War Risk Insurance, Military and Naval Insurance and Military and Naval Compensation Claims as a Result of the World War (Washington, D.C.: Government Printing Office, 1920); John Duffy, “The American Medical Profession and Public Health: From Support to Ambivalence,” BHM 53 (Spring

Notes to the Conclusion | 223 1979): 1–22; and Ronald L. Numbers, Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912–1920 (Baltimore: Johns Hopkins University Press, 1978). 130. Nancy Tomes, The Gospel of Germs: Men, Women, and the Microbe in American Life (Boston: Harvard University Press, 1998), 241 – 42; and Kerr L. White, Healing the Schism: Epidemiology, Medicine, and the Public’s Health (New York: Springer-Verlag, 1991), 76. 131. Memorandum from the Secretary of War, “How to Strengthen Our Personal Defense against Spanish Influenza,” 5 October 1918, RG 112, Entry 29, Box 393, NARA; and NYT, 2 October 1918. 132. Joshua B. Lee, “Home then What? Second Prize,” in James Louis Small, ed., Home then What? The Mind of the Doughboy (New York: George H. Doran, 1920). 133. Michel Foucault has explained the dynamics and power of this process in The History of Sexuality: An Introduction, vol. 1, trans. Robert Hurley (New York: Vintage Books, 1990). 134. Francis A. Winter, “The Medical Department in the Lines of Communication, A.E.F.,” MS 44 (June 1919): 591. 135. John M. Gibson, Physician to the World: The Life of General William C. Gorgas (Durham, N.C.: Duke University Press, 1950), 270–80. 136. Mary Dobson, U.S. Army Nurse, Base Hospital No. 63, Savenay, quoted in Lyn MacDonald, The Roses of No Man’s Land (New York: Simon and Schuster, 1989), 292. 137. Dobson, quoted in MacDonald, The Roses of No Man’s Land, 292.

notes to the conclusion The epigraph comes from Elton E. Mackin, Suddenly We Didn’t Want to Die: Memoirs of a World War I Marine (Novato, Calif.: Presidio Press, 1993), 183. 1. Information on Private Vaughan (no relation to Victor Vaughan) comes from Gina Kolata, Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It (New York: Farrar, Straus, and Giroux, 1999), 28–30, and 212–14. 2. WDAR, 1919, 1742 – 45; and MDWW, vol. 5, 687–92. 3. W. W. Herrick to Commanding Officer, base hospital, 12 September 1918, memorandum, RG 112, Entry 31, Box 125, NARA. 4. A. E. Truby, “Report of Inspection in Relation to the Epidemic,” 23 October 1918, unpublishedreport,RG112,Entry31,Box125,NARA.

5. Jeffrey K. Taubenberger et al., “Initial Genetic Characterization of the 1918 ‘Spanish’ Influenza Virus,” Science 275 (21 March 1997): 1793 – 96; Malcolm Gladwell, “The Dead Zone,” New Yorker, 29 September 1997, 52 – 65; and Gina Kolata, “Scientists Uncover Clues to Flu Epidemic of 1918,” NYT, 16 February 1999. For a more detailed story on the discovery of the virus, see Kolata, Flu. 6. John R. Gillis, “Memory and Identity: The History of a Relationship,” in John R. Gillis, ed., Commemorations: The Politics of National Identity (Princeton, N.J.: Princeton University Press, 1994); and Cecilia Elizabeth O’Leary, To Die For: The Paradox of American Patriotism (Princeton, N.J.: Princeton University Press, 1999). 7. Elaine Scarry, The Body in Pain: The Making and Unmaking of the World (New York: Oxford University Press, 1985); and Mark Meigs, Optimism from Armageddon: Voices of American Participants in World War I (New York: New York University Press, 1997), 161–62. 8. See, for example, Eric Hobsbawm, The Age of Extremes: A History of the World, 1914 – 1991 (New York: Vintage Books, 1994); and Modris Ekstein, Rites of Spring: The Great War and the Birth of the Modern Age (Boston: Houghton Mifflin, 1989). 9. Terra Ziporyn, Disease in the Popular American Press: The Case of Diphtheria, Typhoid Fever, and Syphilis, 1870 – 1920 (New York: Greenwood Press, 1988), 153. 10. Heywood Broun, Our Army at the Front (New York: C. Scribner’s Sons, 1919). 11. Myron Echenberg observes a similar silence in Senegal, in “The Dog That Didn’t Bark: Memory and the 1918 Influenza Epidemic in Senegal,” in Howard Phillips and David Killingray, eds., The Spanish Influenza Pandemic of 1918 – 1919: New Perspectives (New York: Routledge, 2003). 12. Regarding the concept of “ownership” of a memory, see Nicoletta F. Gullace, “White Feathers and Wounded Men: Female Patriotism and the Memory of the Great War,” Journal of British Studies 36 (April 1997): 178 – 206. 13. George A. Soper, “The Pandemic in the Army Camps,” JAMA 71 (7 December 1918): 1899. 14. WDAR, 1919, vol. 1, pt. 1, 80. 15. Alexander Lambert, “Medicine as a Determining Factor in War,” Scientific Monthly 9 (July 1919): 93. 16. Victor Vaughan, A Doctor’s Memories (Indianapolis: Bobbs Merrill, 1926), 432. 17. Elton E. Mackin, Suddenly We Didn’t

224 | Notes to the Conclusion Want to Die: Memoirs of a World War I Marine (Novato, Calif.: Presidio Press, 1993), 183. 18. H. Res. 505, a bill to authorize a congressional investigation of the losses of the Thirty-fifth Division during the Argonne Battle, 65th Cong., 3rd sess.; House Committee on Rules, Losses of Thirty-fifth Division during the Argonne Battle, pts. 1 and 2, 24 January 1919, and 17 and 20 February 1919, 65th Congress, 3rd sess., CIS microfiche H 215-7 and H 215-8; and Senate Committee on Military Affairs, American Troops in the Argonne, pts. 1 and 2, 18 and 22 February 1919, 65th Cong., 3rd sess., CIS microfiche S 129-20-A and B. A recent book by Robert H. Ferrell, Collapse at Meuse-Argonne: The Failure of the Missouri-Kansas Division (Columbia: University of Missouri Press, 2004), does not consider the influenza epidemic as a factor in the division’s collapse. 19. Senate Committee on Military Affairs, American Troops in the Argonne, pt. 1, 5. 20. House Committee on Rules, Losses of Thirty-fifth Division, pt. 1, 70. Emphasis added. 21. House Committee on Rules, Losses of Thirty-fifth Division, pt. 2, 6. 22. The Thirty-fifth Division also did not suffer the highest casualty rate of the AEF divisions. Paul Braim ranked it only eighteen among the twenty-nine combat divisions with 8,025 casualties, citing “Final Report of Assistant Chief of Staff, G-3 to Commander-inChief, American Expeditionary Forces (2 July 1919).” See Braim, The Test of Battle: The American Expeditionary Forces in the MeuseArgonne Campaign (Newark: University of Delaware Press, 1987), 181. 23. Leonard P. Ayres, The War with Germany: A Statistical Summary (Washington, D.C.: Government Printing Office, 1919), 122–23. 24. Albert G. Love, “War Casualties,” Army Medical Bulletin No. 24 (Carlisle, Pa.: Army Medical Field Service School, 1931), 12. 25. Frederick L. Hoffman, “American Mortality Progress during the Last Half Century,” in Mazyck P. Ravenel, ed., A Half Century of Public Health (New York: American Public Health Association, 1921), 115. Parentheses in original. 26. Order of Battle, vol. 3, pt. 1, 73–74. 27. U.S. Congress, Senate, Senate Doc. 40, Battle Deaths in the Great War: Estimate of the Number of Men of the Principle Nations Engaged in the Great War Who Were Killed in Battle or Died of Wounds, 23 June 1919, 66th Cong., 1st sess.

28. Martin Gilbert, The First World War: A Complete History (New York: Henry Holt, 1994), 541. 29. See, for example, C. St. Clair Drake, “The Influence of the War on Preventive Medicine and Public Health,” JAMA 73 (13 September 1919): 803 – 5; Ethan Flagg Butler, “Influences of the World War on the Development of Civil Practice,” MS, November 1922, 494 – 507; and R. F. Jones, “Preventive Medicine and Its Relation to Military Medicine,” MS, December 1922, 663–68. 30. “Transactions of the 17th Annual Conference of State and Territorial Health Officers of the United States Public Health Service,” Public Health Bulletin 105 (January 1920). 31. Hans Zinsser, Rats, Lice, and History (New York: Little, Brown, 1935; New York: Bantam, 1971), 58, 113. 32. A. Hunter Dupree, Science in the Federal Government: A History of Policies and Activities to 1940 (Cambridge, Mass.: Harvard University Press, 1957), 316. 33. Richard A. Gabriel and Karen S. Metz, A History of Military Medicine, vol. 11 (New York: Greenwood Press, 1992), 243. 34. Among the most scholarly works are Alfred Crosby, America’s Forgotten Pandemic (1976; Cambridge: Cambridge University Press, 1989); Phillips and Killingray, eds., The Spanish Influenza Pandemic of 1918 – 1919; and John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History (New York: Viking, 2004). More popular works include Kolata, Flu; Robin Marant Henig, “Flu Pandemic,” New York Times Magazine, 29 November 1992, 28; Pete Davies, The Devil’s Flu: The World’s Deadliest Influenza Epidemic and the Scientific Hunt for the Virus That Caused It (New York: Henry Holt, 2000); and a PBS documentary, Influenza, 1918 (1999), and its companion book: Lynette Iezzoni, Influenza 1918: The Worst Epidemic in American History (New York: TV Books, 1999). 35. Gilbert, The First World War, 477; A. J. P. Taylor, The First World War: An Illustrated History (Middlesex, England: Penguin Books, 1966), 229; John Keegan, The First World War (New York: Alfred A. Knopf, 1999); and Hew Strachan, The First World War (New York: Viking, 2003). 36. Paul Fussell, The Great War and Modern Memory (London: Oxford University Press, 1975); David Kennedy, Over Here: The First World War and American Society (Oxford: Oxford University Press, 1980), 189, 198; and Harvey A. DeWeerd, President Wilson Fights His War: World War I and the

Notes to the Conclusion | 225 American Intervention (New York: Macmillan, 1968). 37. Rod Paschall, The Defeat of Imperial Germany, 1917–1918 (Chapel Hill, N.C.: Algonquin, 1989); Meirion and Susie Harries, The Last Days of Innocence: America at War, 1917 – 1918 (New York: Random House, 1997); Byron Farwell, Over There: The United States in the Great War, 1917 – 1918 (New York: W. W. Norton, 1999); Robert H. Zieger, America’s Great War: World War I and the American Experience (Lanham, Md.: Rowman and Littlefield, 2000); Gary Mead, The Doughboys: America and the First World War (Woodstock, N.Y.: Overlook Press, 2000); and Jennifer D. Keene, Doughboys, the Great War, and the Remaking of America (Baltimore: Johns Hopkins University Press, 2001). 38. Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982); and James H. Cassedy, Medicine in America: A Short History (Baltimore: Johns Hopkins University Press, 1991), 121. 39. John S. Haller, Farmcarts to Fords: A History of the Military Ambulance, 1790 – 1925 (Carbondale: Southern Illinois University Press, 1992), 185; and Robert H. Moser, “Of Plagues and Pennants,” Military Review, May 1965, 71–84. 40. Richard V. N. Ginn, The History of the U.S. Army Medical Service Corps (Washington, D.C.: Office of the Surgeon General and Center of Military History, United States Army, 1997), 85, n. 58. 41. Fussell, The Great War and Modern Memory; and Ilana R. Bet-El, Conscripts: Lost Legion of the Great War (Stroud, England: Sutton Publishing, 1999).

42. Thomas W. Laqueur, “Memory and Naming in the Great War,” and G. Kurt Piehler, “The War Dead and the Gold Star: American Commemoration of the First World War,” both in John R. Gillis, ed., Commemorations: The Politics of National Identity (Princeton, N.J.: Princeton University Press, 1994); and Jay Winter, Sites of Memory, Sites of Mourning: The Great War in European Cultural History (Cambridge: Cambridge University Press, 1995). 43. Adrian Gregory, The Silence of Memory: Armistice Day, 1919–1946 (Oxford: Berg Publishers, 1994). 44. Arthur F. Hurst, Medical Diseases of War, 3rd ed. (Baltimore: Williams and Wilhelm, 1943); and Winfield Scott Pugh, ed., War Medicine: A Symposium (New York: Philosophical Library, 1942). 45. Ebbe Curtis Hoff and Phoebe Hoff, eds., Preventive Medicine in World War II, vol. 4 (Washington, D.C.: Office of the Surgeon General, 1958), 8. 46. John T. Greenwood, “‘Disease Was an Unrelenting Foe’: The U.S. Army Medical Department in the Papua and New Guinea Campaigns, March 1942–May 1944,” unpublished paper delivered February 2001 at the U.S. Army – Japanese Ground Self-Defense Force Military History Exchange, Tokyo, Japan. 47. Personal communication with Professor Paul Ewald, Amherst College, fall 2000. 48. Kolata, Flu, 305–6; Arno Karlen, Man and Microbes (New York: Touchstone, 1996), 226; and Henig, “Flu Pandemic,” 28–31. 49. Fielding H. Garrison, “Notes on the History of Military Medicine,” MS 49 (November 1921): 481–82. 50. Garrison, “Notes on the History of Military Medicine,” 484.

Select Bibliography

a rc h i va l r e c o r d s National Archives and Records Administration (NARA), Washington, D.C., and College Park, Maryland Record Group 90, Records of the Public Health Service Record Group 107, Records of the Secretary of War Record Group 112, Records of the Surgeon General of the Army Record Group 120, Records of the American Expeditionary Force Record Group 159, Records of the Army Advocate General Record Group 163, Records of the Selective Service Record Group 200, Records of the American Red Cross Record Group 391, Records of U.S. Regular Army Mobile Units Record Group 407, Records of the Office of Adjutant General National Library of Medicine (NLM), Bethesda, Maryland Ms C14, Jefferson R. Kean Papers Ms C92, William Otway Owen Papers Ms C117, Merritte Weber Ireland Papers Ms C137, Champe Carter McCulloch Papers Ms C155, Stanhope Bayne-Jones, Papers, 1870–1969 Ms C183, Harvey Williams Cushing Papers Library of Congress, Manuscript Division, Washington, D.C. Newton Baker Papers William C. Gorgas Papers William Gibbs McAdoo Papers Military History Institute (MHI), Military History Research Collection, Carlisle Barracks, Pennsylvania Army Nurse Corps Collection Perry Boyer Papers Russell Dale Papers

Forty-second Division Collection Military Medical Periodical Collection Raymond Oliver Papers Royal Reynolds Papers Fredric Washburn Papers World War I Questionnaire Collection W. S. Hoole Special Collections, University of Alabama, Tuscaloosa, Alabama Gorgas Family Papers W. C. Gorgas Papers

periodicals reviewed, 1917 – 1920 American Journal of Hygiene American Journal of Nursing American Journal of Public Health American Journal of the Medical Science American Medicine Archives of Internal Medicine Boston Journal of Medicine and Surgery British Medical Journal Bulletin of Johns Hopkins Hospital California State Journal of Medicine Journal of the American Medical Association Journal of Experimental Medicine Journal of Infectious Diseases Journal of Laboratory and Clinical Medicine Journal of the Military Service Institution of the United States Journal of the National Medical Association Lancet Medical Clinics of North America Medical Record Military Surgeon Monographs of the Rockefeller Institute for Medical Research Proceedings of the National Academy of Sciences Public Health Nurse Red Cross Bulletin Review of War Surgery and Medicine Science

227

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g ov e r n m e n t p u b l i c at i o n s American Battle Monuments Commission. American Armies and Battlefields in Europe: A History, Guide, and Reference Book. Washington, D.C.: Government Printing Office, 1938; Center for Military History, 1995. Public Health Service. Annual Reports, Supplemental Reports, Weekly Reports, and Bulletins United States Congress. Congressional Record, Hearings, and, Documents, 1917 – 1920. Washington, D.C. War Department. Annual Reports. Washington, D.C.: Government Printing Office, 1916–1920. War Department. General Orders and Bulletins, 1918. Washington, D.C.: Government Printing Office, 1919. War Department. Manual for the Medical Department, United States Army. Washington, D.C.: Government Printing Office, 1916. War Department. Final Report of the Provost Marshal General to the Secretary of War on the Operations of the Selective Service System to July 15, 1919. Washington, D.C., 1919. War Department. Order of Battle of the United States Land Forces in the World War, 3 vols. Washington, D.C.: Government Printing Office, 1931–1949. War Department. Office of the Surgeon General. Medical Department of the United States Army in the World War, Washington, D.C.: Government Printing Office, 1921 – 1929, vols. 1–15: 1. Surgeon General’s Office (1923), by Charles Lynch, F. W. Weed and Loy McAfee. 2. Administration: AEF (1927), by J. H. Ford. 3. Finance and Supply (1928), by E. P. Wolfe. 4. Mobilization Camps and Ports of Embarkation (1928), by A. S. Bowen. 5. Military Hospitals in the U.S. (1923), by F. W. Weed. 6. Sanitation in the U.S. (1926), by W. P. Chamberlain; and Sanitation in the AEF, by various authors. 7. Training (1927), by W. N. Bispham. 8. Field Operations (1925), by Charles Lynch, Joseph H. Ford, and Frank W. Weed. 9. Communicable and Other Diseases (1928), by Joseph F. Siler.

10. Neuropsychiatry in the U.S. (1929), by Pearce Bailey, Frankwood E. Williams, and Paul O. Komora; and Neuropsychiatry in the AEF (1929), by Thomas W. Salmon and Norman Fenton. 11. Surgery (1924 – 1927), by various authors. 12. Pathology of Acute Respiratory Disease and of Gas Gangrene Following War Wounds (1929), by George R. Callender and James F. Coupal. 13. Physical Reconstruction and Vocational Education (1927), by A. G. Crane; and The Army Nurse Corps, by Julia C. Stimson. 14. Medical Aspects of Gas Warfare (1926), by W. D. Bancroft et al. 15. Statistics (1919, 1925), by C. B. Davenport and A. G. Love.

p u b l i s h e d p r i m a ry s o u rc e s Ashburn, Percy M. A History of the Medical Department of the U.S. Army. Boston and New York: Houghton Mifflin, 1929. Ashford, Bailey. A Soldier in Science: The Autobiography of Bailey K. Ashford. New York: William Morrow, 1934. Ayres, Leonard P. The War with Germany: A Statistical Summary. Washington, D.C.: Government Printing Office, 1919. Barclay, Harold. A Doctor in France, 1917 – 1919. New York: Private printing, 1923. Bayne-Jones, Stanhope. The Evolution of Preventive Medicine in the U.S. Army, 1607 – 1939. Washington, D.C.: Office of the Surgeon General of the Army, 1968. Borden, Mary. The Forbidden Zone. London: Heinemann, 1929. Bowerman, Guy Emerson, Jr. The Compensations of War: The Diary of an Ambulance Driver during the Great War. Edited by Mark Carnes. Austin: University of Texas, 1983. Boylston, Helen Dore. Sister: The War Diary of a Nurse. New York: Ives Washburn, 1927. Brown, Raymond Shiland. Base Hospital No. 9, A.E.F.: A History of the Work of the New York Hospital Unit. New York: N.p., 1920. Clymer, G. History of the U.S. Army Base Hospital No. 6, and Its Part in the American Expeditionary Force, 1917 – 1918. Boston: Clymer, 1924. Coplin, William Michael Late. American Red Cross Base Hospital No. 38. Philadelphia: N.p., 1923. Crile, Grace, ed. George Crile: An Autobiography. Philadelphia: J. B. Lippincott, 1947. Cushing, Harvey. From a Surgeon’s Journal, 1915–1918. Boston: Little, Brown, 1936.

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Index

Acquitania, 147 African Americans: as army officers, 30, 34, 109; combat divisions, 34, 171; disease rates in army, 167– 68; exclusion from the Medical Corps, 15, 29–31; in labor battalions, 142, 170, 172; living conditions in army, 169–73; physicians, 30–31, 34, 109, 145, 160, 169– 72; racial stereotypes in army, 29–30, 156, 168, 169, 172–74; segregation of, in army, 29–31, 33, 36, 133, 161, 173, 214n34; and Selective Service, 34; war service of 33, 172; women during war, 145 Allen, Gov. Henry J., 185 American College of Surgeons, 26, 154 American Expeditionary Forces (AEF): influenza in, 1–2, 6–10, 70–72, 74, 80–81, 89–90, 122– 23, 137, 146–47, 175, 185; medical services, 43, 47, 114–17; at Meuse-Argonne, 6, 108–110; military performance of, 110–11, 117–18; morale, 118–119; Parching leadership of, 25, 107, 122; sanitary conditions of, 1, 160–62; at St. Mihiel, 6; sick rates, 111–

13, 186–87; stragglers, 110, 111, 117–18. See also Army, U.S.; War Department, U.S.; Parching, John J. American Hospital Association, 57 American Medical Association (AMA), 16, 63, 157, 163; war activities, 25–26; women members, 28–29; William C. Gorgas, president of, 119. See also Journal of the American Medical Association (JAMA) American Red Cross, 23, 29; hospitals in U.S. army, 43, 84–85, 126; and influenza epidemic, 84–85, 136, 145; nurses, 43, 145 Armed Forces Institute of Pathology, 182 Army, British, 31, 69, 188; combat deaths to disease deaths ratio, 132; influenza in, 73, 87, 99; medical service, 25, 50, 142, 157 Army, French, influenza in, 99 Army, German, 10, 25, 69, 70, 88, 98, 123; disease rates in, 132; influenza in, 6, 72, 73, 99, 137; 1918 offensive, 70, 99, 109–10. See also Meuse-Argonne campaign Army, Japanese, 51 Army Medical School, 19

237

238 | Index Army Nurse Corps, 43, 45, 144; military rank, 28, 145–46; uniforms, 34, 35–36. See also Nurses, in U.S. army Army, U.S.: casualty rates, 71, 210n59; courts martial, 48, 59, 60–61, 117, 162; uniforms, 35– 37; See also American Expeditionary Forces (AEF); Army, U.S., camps; Army, U.S., divisions; Army, U.S., forts Army, U.S., Army of Occupation, 130, 146, 147 Army, U.S., camps: Camp Beauregard, 56, 59, 76; Camp Bowie, 56; Camp Custer, 159; Camp Devens, 6, 11, 74–76, 78–79, 82, 84, 86, 104, 174; Camp Dix, 14, 75, 85, 88; Camp Dodge, 6, 75, 76, 82, 84, 89, 135, 136, 171, 175; Camp Doniphan, 56; Camp Funston, 6, 56, 59, 70, 75, 76, 79, 83, 86, 127, 129, 136; Camp Gordon, 33; Camp Grant, 85, 171; Camp Greenleaf, 52, 75; Camp Jackson, 35–37, 83, 86, 181; Camp Kearney, 75; Camp Lee, 165; Camp Logan, 159; Camp MacArthur, 56, 134; Camp Meade, 76; Camp Mills, 57, 84, 86, 101; Camp Morrison, 136; Camp Oglethorpe, 6, 59, 70, 94; Camp Pike, 56; Camp Sherman, 76, 145; Camp Sevier, 56; Camp Taylor, 76, 85, 174; Camp Upton, 6, 49, 76, 89, 163, 174; detention and observation, to control disease transmission, 53– 54, 56, 164 Army, U.S., divisions: First Division, 118; Second Division, 46, 72, 116, 143; Twenty-sixth Division, 67, 113, 143; Thirty-second Division,

135, 138, 190; Thirty-fifth Division, 119, 185–86; Thirty-sixth Division, 74; Forty-second Division, 47, 71, 118, 135, 137–38, 147; Seventy-seventh Division, 118, 166; Seventy-eighth Division, 14; Eightieth Division, 94; Eightyfourth Division, 112; Eighty-sixth Division, 113; Eighty-eighth Division, 113, 135, 161; Eighty-ninth Division, 23, 70; Ninety-second Division, 30, 31, 34, 109, 171, 173; Ninety-third Division, 31, 34, 172–73 Army, U.S., Eleventh Engineers, 72, 94 Army, U.S., First Army, 108, 109, 114 Army, U.S., forts: Fort Benjamin Harrison, 45; Fort Brown, 18; Fort Des Moines, 31; Fort Oglethorpe, 59, 70, 94; Fort Riley, 6, 59, 126; Fort Sam Houston, 154, 175 Army, U.S., General Staff, 53, 59, 106, 173; congressional reform of, 150; review of MDWW, 158; tension with Medical Department, 9, 41–42, 53, 55, 59, 61–62, 73, 107. See also March, Peyton Army, U.S., Medical Department, 25, 28; accountability of, 37, 42, 44, 46, 50, 57, 130, 148, 151, 184; and measles in camps, 58–61; medical accomplishments, 21–22, 176–77; and the MDWW, 124, 156–66, 167; prestige of, 18, 20, 21–22; and rank for medical officers, 63–64; reform after SpanishAmerican War, 23, 25; reorganization after war, 149–50, 153–55, 156; tensions with War Department, 9, 41–42, 48, 50, 51, 53–54; during World War II, 189–90. See

Index | 239 also Gorgas, William C.; Ireland, MerritteW.; Military medicine Army, U.S., Provost Marshall, 105 Army, U.S., Third Army, 146–47 Army War College, 62, 64, 168 Autopsies, 1, 3, 10, 49–50; of influenza victims, 78–79, 86, 116, 125–26, 157, 174–75, 181–82 Ayres, Leonard P., 185, 186, 192n17 Baker, Newton E., 56, 105; on African Americans in the army, 30–31, 34; burial of soldiers, 130; before Congress, 59–61, 64, 65; and influenza, 113, 128, 148, 184, 185– 86; William C. Gorgas, 58, 66–67, 104; and women in the Medical Corps, 29 Banks, Morley, 134 Barclay, Harold, 139 Bayne-Jones, Stanhope, 1, 173; and William C. Gorgas, 26, 67, 143 Beard, Mary, 145 Bible, 11, 135 Billings, John Shaw, 22 Black Death, 4. See also Plague Blacks. See African Americans Blech, Gustavus, 48 Blue, Rupert, 25, 26, 187 Borland, Rep. William, (Mo.), 5 Boston, Mass., 142; second wave of influenza in, 6, 74, 79 Bowerman, Guy Emerson, 71 Boylston, Helen Dore, 177 Bradbury, Samuel, 72, 73, 94 Braisted, W. C., 26 Brest, France: influenza in, 6, 98, 102, 103, 120; conditions in Camp Pontanezen, 148–49, 172–73 Brewer, Isaac, 159–60 Bring Home the Soldier Dead League, 130

Brittain, Vera, 31, 131 Broun, Heywood, 184 Campbell, Rep. Philip P., (Kans.), 184 Camp Pontanezen. See Brest, France Camps. See Army, U.S., camps Cannon, George E., 30 Carrel-Dakin treatment, 177 Cemeteries, 5, 117, 130, 132; American cemeteries in France, 134, 135; Arlington National Cemetery, 133, 179; influenza victims buried in, 117, 179, 180; segregation in American national, 133 Censorship, 88, 99 Chamberlain, Sen. George C., (N.Y.), 58 Chamberlain, Weston, 170 Chaplains, army, 96, 134, 135 China, 88 Cholera, 74, 165; and armies, 4, 10, 20, 49, 74, 176; mitigation measures against, 20, 51 Citizenship, 34, 42, 43; and military service, 10, 34, 128, 130–31, 135; required for medical officers, 28, 29; the “social contract” and citizen soldiers, 43, 198n14 Civil War, 17, 108, 110; casualty rate, 210n59; cemeteries, 133; medical history of, 156 Clemenceau, Georges, 109 Clothing, in U.S. Army, 34, 36, 42, 44, 60, 130, 178; for black and white soldiers, 170, 171–72; for the dead, 133; medical officer recommendations and complaints concerning, 39, 55, 56, 59, 119, 159, 160–62; in the MDWW, 161, 165; for nurses, 36 Coe, H. C., 27 Cole, Rufus, 75, 79, 104

240 | Index Cole, Charles, 59–61 Colgate Company, 83 Collier, Richard, 87 Committee on Public Information (CPI), 56 Congress, U.S., 10, 19, 40, 50, 129; and William C. Gorgas, 16, 57–60; and influenza, 5, 80, 128, 151, 184, 185; investigation of army camp conditions, 1917–1918, 56– 61, 63, 70, 129, 160; and postwar health conditions in army, 148–49; postwar reorganization of army, 150, 153, 156; and rank for medical officers, 62–64, 67; and rank for nurses, 145–46; War Department reforms after Spanish-American War, 23; and war mobilization, 42, 44, 45, 128–29, 133 Conklin, William, 112 Cooper, Gary, 134 Council on National Defense, 26, 57 Crile, George, 26, 50, 115, 175 Crimean War, 157, 177 Crookshank, F. G., 190 Crosby, Alfred, 107, 187 Crowder, Enoch, 85 Cuba, 153; William C. Gorgas in, 15– 16, 18, 22 Curtis, Sen. Charles, (Kan.), 129 Cushing, Harvey, 26, 62, 138, 139 Cyanosis, 78, 88 Dale, Russell, 120–21 Darnall, Carl, 22 Davenport, Charles B., 24, 166, 170 Death rates. See Morbidity and mortality rates Defects Found in Drafted Men, 166 Dental Corps, 45 Derby, Richard, 116, 143

DesJardins, Arthur U., 126 Detention camps, 46, 53–54 Diarrhea, 99, 150 Diphtheria, 37, 134, 183 Disease: death by, versus death in combat, 128, 133, 137–39, 180; dental, 51, 83; diet and, 51; racialist theories of, 167–75; war and, 8, 11–13, 55, 72, 123, 184, 186. See also individual disease names; Disease transmission; Morbidity and mortality rates Disease transmission, 15, 92, 161; airborne, 163; cultural vectors theory, 93–94; insect vectors, 16, 18, 21 Dobson, Mary, 102, 179 Doctors. See Physicians Dos Passos, John, 131 Draft. See Selective Service Drew, Charles, 6 Duffy, Francis Patrick, 96, 135, 138 Duncan, Louis, 54, 72 Dwyer, John, 59–60, 61 Dyer, William Holmes, 36, 109, 147, 173 Dysentery, 51, 95, 99, 118; and armies, 4, 16, 20, 55 Effective and non-effective troop rates, 46; influenza and, 9, 72, 74, 82, 98, 106, 108, 111–13, 119, 160; measles and, 54, 55; in World War II, 190 Eggleston, Ben, 147 Emerson, Haven, 9 Empyema, 81, 163 England, influenza in, 73, 87, 99 Epidemics, 4, 9, 15, 37, 49, 54, 189; measles and pneumonia, 54–56, 129; prevention of, 49, 59,73, 147; in training camps, 42, 54, 57; in-

Index | 241 terpretation of, 156; typhoid, 22– 23, 51, 130, 177; yellow fever, 18. See also Disease; Influenza Epidemiologists, 72, 157; in AEF, 70, 89, 115, 125; in U.S. army, 5, 9, 74, 88–89, 139, 157, 176, 189; PHS, 79, 92 Estes, William, 116 Ethnicity, 131; in the army, 28, 33, 34, 165–66, 175 Ettinger, Al, 95–96, 118, 138, 173 Eugenics, 24, 40, 166, 169 Evolutionary biology, 92–93 Ewald, Paul C., 93–94, 190 Fall, Sen. Albert, (N.M.), 5 Farnworth, Ivan, 100–101, 103 Fess, Rep. S. D., (Ohio), 136 Field of Honor Association, 130 Flexner, Simon, 26 Flu. See Influenza France, influenza in, 6, 70, 71, 73–74, 80–81, 97–98, 99. See also American Expeditionary Forces (AEF); Army, French; Brest, France Frost, Wade Hampton, 79, 92, 164 Furbush, Charles L., 66–67 Gangrene, 81, 126, 131, 177 Gardner, Rep. Augustus, (Mass.), 58 Garrison, Fielding H., 22, 26, 50, 190 Gender roles; 182; medical officers and 15, 28, 31, 35, 144; nurses and, 35, 139, 144 George Washington, 102 General Staff. See Army, U.S., General Staff Germ theory of disease, 20–21, 36, 87, 158, 163 Germany, 28, 39, 69, 99, 183; influenza in, 6, 72, 73, 87, 99, 148;

influenza victims buried in 130. See also Army, German Gibson, E. W., 103 Gleaves, Albert, 106 Goldwater, S. S., 57 Gompers, Samuel, 5 Gorgas, Marie, 18, 65–67, 179 Gorgas, William C.: biographical information, 14–20, 53; comparison with Merritte Ireland, 154–55; and health of the army, 21, 53, 150; and increased rank for medical officers, 62–64; and influenza epidemic, 70, 75, 151, 164; and Panama, 15, 18–20; recruiting of Medical Corps, 25–28, 40; retirement from army, 65–67, 104; on the role of Medical Department, 37, 50, 142, 151, 157, 161; and sanitation in army camps, 14–15, 56–59, 160; and Spanish-American War, 15, 18; testimony to Congress, 58–61; and yellow fever, 14– 15, 16, 18–19, 22, 66, 175, 179 Graves Registration Service, 133 Graves, Robert, 112, 133 Grayson, Cary T., 64 Grissinger, Jay W., 47, 57, 146 Hagadorn, Charles, 85–86 Hallock, Mary E., 82, 84 Harbord, James, 112, 149; and influenza, 103, 105, 111, 122 Haskell Institute, 6, 70 Hill, Charles, 135 Hill, Lucy, 135 Hodgson, Edward, 119 Hoehn, Arthur, 94 Hoff, John Van R., 64–65 Hoffman, Frederick, 169 Holden, Frank A., 134

242 | Index Hookworm, 22 Hospital Corps, 36, 45; orderlies in, 120, 121–22; orderlies’ experience with influenza, 84, 112, 121, 144 Hospitals, U.S. army, 45, 49–50, 81; admissions, 74, 76, 80, 93, 99, 112, 159, 160, 167, 181, 186, 189; in AEF, 45, 49, 80, 89, 93, 103, 107, 111, 114–16, 146, 147, 150; AEF evacuation, 109, 115, 121, 126; American Red Cross, 43, 84– 85, 126; influenza epidemic impact on, 5, 6, 9, 12, 70–71, 73, 74–76, 79, 82, 85, 87, 123, 138; male orderlies’ experiences in, 84, 112, 121, 144; postwar conditions in, 148, 150; sanitation, 84; segregation in, 145, 171; soldiers’ experiences in, 120–22, 123, 126, 137, 139, 143, 147, 179, 181; teaching, 21; at training camps, 35–37, 39, 54, 55, 56, 57, 59, 60, 76, 129– 30; World War II, 189 Housing, U.S. army, 41, 60, 104, 158, 165; crowded conditions in, 39, 73, 83, 100; density of, 59, 104, 160–61; racial segregation in, 145, 161, 170–71, 174; sanitary conditions in, 51, 83, 160–61 Huffman, Marion, 57 Hutchinson, Woods, 25 Immunity to disease, 165–66, 170; acquired for measles, 54–55; acquired for yellow fever, 18, 54; among recruits in training camps, 54–55, 56, 165–66; individual responses to influenza, 81, 94, 122, 159, 179 Immunization, 15, 129, 158; antitetanus, 21, 177; in army training

camps, 41, 43, 48, 52; experimental, 49, 84, 162; smallpox, 22, 51, 177; typhoid, 22, 23, 51, 52, 163 Immunology, 19 Imperialism, 19 Index Catalogue, 88, 157 Influenza: animal reservoirs, 92; complications of, 1, 4, 71, 72, 76, 81, 90, 92, 135, 150, 159, 174, 205n64; epidemic as “exceptional event,” 11, 150–51, 187–88; explosive nature of, 72, 88, 90; face masks as prophylactic, 55, 83, 114, 163; geographical dispersion of, 2, 8, 72–73, 75–76, 79–80, 90, 93, 98; historiography of, 11, 12– 13, 98, 110, 111, 118, 145; historical memory of, 8, 10, 157–58, 179, 187–90; medical treatment, 70–71, 84, 115, 139, 144, 159; names for, 74, 87, 191n5; origin of, 6, 79, 84, 87–88, 125, 178, 206n94, 208n123; quarantine effort, 56, 74, 83, 86, 100, 105–6, 107, 158; statistics, 192n17; susceptibility of young adults, 208n128; symptoms, 70–71, 76, 78, 87, 106, 159. See also Influenza, morbidity and mortality rates; Pneumonia; Virus, influenza Influenza, morbidity and mortality rates, 2, 129; and age differentials, 5, 12, 90–92, 94, 159, 164–174; in the AEF, 99, 110, 112, 150, 163; civilian, 79, 92, 164, 184; and ethnicity, 164–66; and length of service, 165; and non- effective rates, 46, 98, 190; in U.S. training camps, 73, 75, 76, 80, 85, 86, 89, 90, 98, 106, 132, 154, 159, 160; in other armies, 99; and race, 161,

Index | 243 167–69, 173–74; worldwide, 80. See also Influenza; Pneumonia Insects, as disease vectors, 53; lice, 21, 95, 131, 137, 187; mosquitos, 14, 16, 18–19, 51 Ireland, Merritte W., 23, 172, 175; appointed army surgeon general, 66–67, 104, 142; biographical information, 154–55; and influenza, 123–24, 156; and MDWW, 157– 58, 179; and reorganization of the Medical Department, 149, 153; on John Parching, 106–7; rank for nurses, 146 Italy, 1, 69, 73, 157 Ivy, Robert, 102 Janifer, Clarence S. 31 Jordan, Edwin O., 5, 88, 92 Journal of the American Medical Association (JAMA), 28, 163, 170 Kean, Jefferson R., 23, 66, 123, 176; diary tracking influenza in the AEF, 97–98 Koch, Robert, 20 La Guardia, Rep. Fiorella, (N.Y.), 148 Laboratories, in U.S. army, 45, 49, 162, 182; AEF at Dijon, 1, 2, 70, 89, 116, 125, 143; new technologies, 15, 21, 176; women working in, 29 Lee, Josuha, 178 Leviathan, USS, 100, 102–3, 172 Lice, 95, 131, 137 Lincoln, Abraham, 133 Livergood, William, 94 Living conditions. See Housing, U.S. army

Lodge, Henry Cabot, 80 Love, Albert G., 166, 170, 176, 186 Ludendorff, Erich von, 73 Lynch, Charles, 158 MacArthur, Douglas, 190 MacCallum, William, 175 Mackin, Elton, 118, 142, 181, 185 MacNeal, Edward, 2–3, 7, 81 MacNeal, Ward J., 4, 11; and autopsy reports, 3, 125–26; death of son, 2–3, 7, 81; on origin and cause of influenza epidemic, 88, 92; and influenza epidemic, 1–3, 10, 70–71, 175, 187 Malaria, 15, 16; African Americans and, 168, 169; mitigation measures, 19, 51, 187; and World War II, 190 Malloy, Jane, 75 March, Peyton C., 67; and John Parching, 105–7; and influenza epidemic, 100, 104–7, 122; on rank for military officers, 62–64; reprimand of John Van R. Hoff, 64–65 Marines, U.S., 43, 118, 142, 173 Martin, Franklin, 26; on rank for medical officers, 62–64 Mayo, Charles H., 26, 53, 62 Mayo, William, 26 McAdoo, William, 44 McCarthy, Mary, 5 McCrae, Thomas, 138 Measles, 16, 51, 53, 63, 134, 159, 168; epidemics in army camps, 54– 57, 59, 85, 129, 136, 148; and pneumonia, 54, 63, 129, 148 Medal of Honor. See Military awards and medals Medical Corps, 18, 19, 55, 65, 145; exclusion of women and blacks from,

244 | Index Medical Corps (Continued) 28–33, 36, 44; expansion during war, 25–28; increased rank for members, 62–64; mortality rate in war, 145; postwar organization, 153, 176; professionalization of, 23, 40; successes of, 25, 40 Medical Department. See Army, U.S., Medical Department Medical Department in the World War, The, 157–58; on age and influenza, 164; on clothing and pneumonia, 161; on housing and pneumonia, 161; influenza epidemic, 159–65, 178–79; on length of service and influenza, 165; on pneumonia, 159, 161; on race and disease, 160, 167, 174; summary of, 159–64 Medical education, 12, 20 Medical evacuation. See Medical transport Medical Manual, The, 46, 132 Medical officers: and African Americans, 30–31, 34, 168–75; as agents of the government, 32, 45– 46, 127, 156; and army chain of command, 9, 10, 40, 50, 53, 62, 67; and army nurses, 144–45; courts martial of, 59–61; experience with influenza in training camps, 74–75, 78–79, 82, 84, 88, 101–2, 136, 156; experience with influenza in the AEF, 1–2, 70–71, 72, 73, 90, 109, 112–13, 115–16, 120, 126, 138, 146; helplessness in influenza epidemic, 7, 10–11, 84, 87, 128, 142, 143– 45, 150–51, 158, 181; manliness, 11, 27, 133, 143; and military rank, 29, 34, 39, 40, 62–63, 67,

104, 133, 145–46; naval, 142, 176; as non-combatants, 127, 137, 139, 140, 142–43, 144, 152; numeric strength in army, 25, 26, 28, 45; and private practice, 26–27, 44, 48; public opinion, 57, 59–61; requirements for, 28; status of, 15, 24, 26, 35, 50, 53, 143, 149, 155; and scientific medicine, 15, 19–22, 24, 36, 51, 182; tension with War Department, 10, 41–42, 61–67, 107; unique position of, 7, 9–10, 12, 40, 126. See also Influenza; Medical Corps; Military medicine; Military Surgeon Medical research, 21; and genetics, 168; and human experimentation, 49, 200n42; and influenza, 3, 11, 89–90, 162–63, 182; military as opportunity for, 27, 49, 176–77. See also Scientific medicine Medical Reserve Corps, 153, 185; congressional action regarding, 40, 45; and women physicians, 28–29. See also Medical Corps Medical and Surgical History of the War of the Rebellion, 157 Medical technology. See Medical research Medical transport, 47, 93, 150, 199n28; on battlefield, 46–47; during influenza epidemic, 103, 108, 114–17, 121; improvements in, 23; and Meuse-Argonne campaign, 116, 186. See also Troop transport Medical Women’s National Association (MWNA), 28–29 Melton, Robert, 136 Meningitis, 51, 53, 54, 74, 81

Index | 245 Meuse-Argonne campaign, 134, 172, 181, 190; American Cemetery, 179; historians on, 110–11; impact of influenza on, 6, 9, 80, 99, 105, 107, 108–10, 114–20, 123, 138; need for replacements, 107; Thirtyfifth Division experience, 185–86 Mexico, U.S. Punitive Expedition, 21, 154 Military awards and medals, 34, 40, 131, 132, 134; Croix de Guerre, 31; Distinguished Service Cross, 143; Distinguished Service Medal, 40, 143, 154; Medal of Honor, 134, 143; Purple Heart, 134, 214n39; wound stripe, 134 Military Surgeons, Association of, 26, 65, 127, 154 Military Surgeon, 37, 50, 130, 140, 142, 151, 158, 170, 176; on courts martial of medical officers, 61; March reprimand of van R. Hoff, 64–65 Military medicine, 7; advances in, 20–22; conflicting missions of, 41, 46–48, 99–100, 107; history of, 12, 24, 153; and malingering, 48– 49, 61, 101, 114, 166; nature of, 44–50; similar to public health, 48; and surgery, 26, 42, 114, 176– 77 Military and Naval Insurance Act, 44 Montague, Henry E., 138 Morbidity and mortality rates: infant, 20, 24; measles, 57; postwar calculation of, 186–87; in training camps, 39, 59, 73; typhoid fever, 22; World War II, 189–90. See also, Influenza, morbidity and mortality rates Moseley, George Van Horn, 111

Moss, William L., 113 Muenzel, Henry, 123 Mumps, 51, 54, 168 Munson, Edward L., 142 National Library of Medicine, 22 Navy, U.S., 43, 176; Surgeon General W. C. Braisted, 26; and influenza, 100, 102, 103, 112; and troop transport, 143 New York City, 176; influenza in, 73; public health, 20, 73, 128, 164 New York Times, 124, 178; and influenza, 72, 73, 76, 79, 83, 139; on training camp sanitation controversy, 57–59 Nichols, Henry, 53 Nightingale, Florence, 144 Non-combatants, 139, 140, 142; medical officers as, 127, 137, 140, 142, 144, 152 Nurses, in U.S. army, 43, 129, 176, 177, 189; African American, 145, 171; and army decorations, 134; deaths from influenza, 76, 78, 133, 138, 139, 179, 181; military funerals for, 139; effectiveness of nursing care, 144–45; experiences with influenza in army training camps, 75, 82, 84, 134, 135, 145; experiences with influenza in the AEF, 102, 116–17, 121–22, 123, 124, 134, 147, 179; gender roles and 35, 139, 144; as non-combatants, 140, 144; status in the army, 28, 34, 35–36, 144–45; See also Army Nurse Corps Orderlies. See Hospital Corps Owen, William O., 62 Owen, Sen. Robert L., (Okla.), 62–64

246 | Index Owen-Dyer bill on rank for medical officers, 63–64 Panama Canal Zone, 14–15, 16, 18– 19, 85 Paratyphoid, 189 Parching, John J., 21, 23, 25, 31, 69– 70, 99, 149, 150; and influenza epidemic, 105, 107–8, 112–13, 122, 144–45; and Merritte Ireland, 154; at Meuse Argonne, 108–111, 181; and Peyton March, 105–7; on rank for nurses, 146 Pathologists, 75, 175; and influenza, 78–79, 126, 174; women pathologists working as contract surgeons, 29. See also Autopsies; Pathology Pathology, 50, 176; and influenza, 78–79, 86, 90, 157–58, 164, 182. See also Autopsies; Pathologists Pfeiffer’s bacillus, 87, 97, 162 Pfennig, Clair F., 147–48 Phillips, Duncan, 6 Physicians, 4, 19, 23, 65, 73, 139, 151, 156; African American, 6, 29–31, 34, 104, 170; after World War I, 176, 178, 182, 187, 190; draft considered for, 25; history of medicine, 12; PHS Reserve, 80; recruited to Medical Corps, 25–28, 62, 141, 152; scientific medicine, 19, 20–21, 24; screening recruits, 32; White House physician, 64; women, 28–29, 31, 196n61. See also American Medical Association (AMA); Medical officers Plague, 4, 13, 74 Pneumonia, 14–15, 58; in AEF, 98, 99; complication of influenza, 2, 9, 10, 70, 76–78, 81–82, 87, 90, 105, 120, 135, 144, 150, 159–60, 181; complication of measles, 54–

55, 64; danger of evacuating victims from field of battle, 114–15; mortality of, 90, 98, 113, 147, 165, 184, 190, 205n60; courts martial regarding, 59–60; differential rates for black and white soldiers, 161, 167–74; experimental vaccines, 163; treatment for, 53, 82, 84, 104. See also Influenza Porter, Katherine Anne, 5, 13 Pottle, Frederick, 51–53, 147 Powell, Alexander, 130 President Grant, 102 President Lincoln, USS, 100 Pressley, Harry T., 120 Progressive Era, 41–42, 158, 166, 178, 184; and Progressivism, 51, 124, 160 Provost Marshall. See Army, U.S., Provost Marshall Prudential Insurance Company, 129, 169, 186 Public Health Service (PHS), 176; and influenza epidemic, 23–24, 70, 72, 79–80, 148; PHS studies, 163–64, 187; Rupert Blue as surgeon general, 25, 26; war activities of, 42 Public health, 20, 74, 88, 158, 166, 177; army nationwide assessments of, 22, 32–33, 166; comparison with military medicine, 43, 48; ethnicity and, 166; influenza and, 80, 87, 148, 187, 189; postwar nature of, 177–78; race and, 170 Public health education, 33, 80, 177, 178, 189 Puerto Rico, 22, 80 Purple Heart. See Military awards and medals Quarantine 39, 43, 48, 51, 157, 161; as measure to control influenza epi-

Index | 247 demic, 56, 74, 83, 86, 100, 105–6, 107, 158; and detention and observation camps, 53–54, 56, 164 Rankin, Rep. Jeannette, (Mont.), 57 Rats, Lice, and History, 187 Ravenel, Mazck, 153 Red Cross. See American Red Cross Reed, Walter, 18, 23, 25, 175 Richard, Charles, 104–6, 118, 160 Richards, John, 172–73 Rinehart, Mary Roberts, 149 Robertson, H. E., 126 Rockefeller Institute, 26 Rockefeller Foundation, 16, 66, 179 Roman, Charles V., 170 Roosevelt, Theodore, 16, 19, 116, 137 Russell, Frederick, 22 Russia, 69, 88, 183 Salvation Army, 43 Sam Browne belt, 34, 105 Sanitary Corps, 45, 88 Sanitation, 20, 176–77; in the AEF, 23, 57, 150, 158–59; at army training camps, 14, 149, 158–59; Medical Department recommendations on, 51, 53, 63–64, 67, 150; in Panama, 19–20. See also Public health Sassoon, Sigfried, 131 Schira, William, 121–22 Schneider, Evelyn Raymond, 134 Schulte, Theda, 84 Scientific medicine, 15, 19, 20–22, 36, 187, 190; failure of in influenza epidemic, 75, 125–26, 151, 156, 182, 184; Medical Department achievements and, 21–22, 36, 158; racism and, 168, 170, 174 Scott, Emmett, 30, 171

Scott, Hugh, 14–15, 85 Seaman, Louise Livingston, 63 Selective Service, 32–33, 104–5, 107; and the draft, 32–33, 128; physicial condition of draftees, 54, 73, 165, 166 Shakespeare, Edwin O., 23 Shallenberger, Rep. Ashton, (Neb.), 60 Sherwood, Rep. Isaac, (Ohio), 129 Shouse, Rep. Jouette, (Kan.), 129 Shreiber, Louis W., 136 Sickness rates. See Morbidity and mortality rates Siler, Joseph, 1, 89, 176 Simpson, Frank, 26 Smallpox, 4, 22, 51, 74, 177 Somme, battle of, 69, 99 Soper, George A., 88, 90, 118, 166, 184 Spain, 1, 88; influenza in, 72, 74, 87 Spanish Influenza. See Influenza Spanish-American War, 4, 15, 18, 137; typhoid scandal during, 22– 23, 26, 40, 51, 130, 177 St. Mihiel, battle of, 6, 99, 109, 179 Stallings, Lawrence, 137–38 Stars and Stripes, 107 Sternberg, George, 22, 25 Stevens, Wright, 86 Stevens, Robert, 172 Steward, J. R., 85 Stretcher bearers. See Medical transport Strott, George, 46 Surgeon General: the office of, 82, 104, 129, 160, 161, 170, 177, 180; Navy, 26, 27; PHS, 25, 26, 27, 86. See also Gorgas, William C.; Ireland, Merritte; Richard, Charles Surgery, 26, 114, 176–77, 189; soldiers required to submit to, 48

248 | Index Sydenstricker, Edgar, 79, 164 Syphilis, 1, 169, 184 Taubenberger, Jeffrey, 182 Tetanus, 21, 177 Thompson, Dora, 139, 145 Tighe, L. G., 135, 187 Townsend, Sen. Charles, (Mich.), 56– 57 Townsend, Harry Everett, 138 Training, military, 43, 70, 147, 156; and Americanization, 33; influenza epidemic interference with, 8, 9, 80, 104, 113; measles epidemics interferrence with, 54–55; recommendations of medical officers regarding schedules, 41, 46, 53, 73, 104, 106, 160, 165 Training camps. See Army, U.S., camps Traub, Peter, 85, 86 Treasury Department, U.S., 44, 133 Trench fever, 95, 137, 189 Trench warfare: and the AEF, 110, 118, 132, 137; conditions of, 16, 69, 92–96, 131, 159; and evolution of influenza virus, 6, 8, 71– 72, 92–94, 96, 190 Troop transport, 47, 70, 161; burial at sea, 129; controversy during epidemic, 10, 41, 100–106; during influenza epidemic, 6, 9, 55, 75, 80, 111, 114–17, 121, 186; of immune troops, 122; as vector for influenza virus, 2, 75, 93–94, 96, 98. See also Medical transport Truman, Harry S., 119 Tuberculosis, 1, 20, 32; and influenza, 81 Trumbull, Jay, 134 Typhoid Commission, 23, 39

Typhoid fever, 16, 24, 37, 49, 74, 88, 159; and armies, 4, 10, 20, 55, 95, 177; scandal during Spanish-American War, 22–23, 40, 51, 130, 177; immunization, 22, 51–52, 163; journalist reporting on, 184; sanitation measures against, 1 20, 49, 51 Typhus, 166; and armies, 4, 20, 177; louse as vector for, 21, 95, 137. U.S. Congress. See Congress, U.S. U.S. Army. See Army, U.S. Uniforms: army, 34–35, 43, 133, 161; for army nurses, 34, 139 Van Loosen, Bertha, 28 Vaughan, Roscoe, 181–82 Vaughan, Victor C., 26, 45, 54, 142, 187; biographical information, 39– 41; at Camp Evens, 75, 104; eugenic views of, 24; on increased rank for medical officers, 62, 67; and influenza epidemic, 69, 70, 71–72, 75, 87, 88, 90, 132, 162, 165; member of Typhoid Commission, 23; memory of influenza epidemic, 132, 185; on sanitation in camps, 53, 55, 56, 67, 165; and Spanish-American War, 18, 23, 39–40 Vaughan, Warren T., 174 Venereal disease, 29, 32, 48, 51, 133– 34; War Department mitigation measures, 51, 164 Verdun, battle of, 69, 99, 121 Veterans, 65, 148, 177; medical veterans’ organizations, 40, 132; Spanish-American War, 39; World War I, 82, 118, 136, 176, 190 Veterinary Corps, 45

Index | 249 Virology, 7, 162 Virus, influenza: 1918 strain, 2, 5, 6, 182; destructiveness of, 126; evolution of, 8, 68, 70, 71, 72, 74, 81, 92–94, 100, 102, 125; origin of, 92–93 Voorheis, John, 118 Walter Reed Hospital, 126, 148, 154 War Department, U.S.: and African Americans, 28, 30–31, 33–34, 145; awards and decorations, 34, 134, 143; medical policies, 9, 10, 15, 45, 50, 53–56, 99, 105–8, 114, 148, 160–161; and mobilization, 70; Order of Battle, 186–87; and rank for medical officers, 39, 42–44, 62–64; recruiting medical officers, 25–26; recruiting soldiers, 32; support for soldiers, 40, 42–44; troop transport, 100–102, 105–8, 122; and voluntary associations, 42–43; and women, 28–29. See also Army, U.S.; Army, U.S., Medical Department; Baker, Newton E.; March, Peyton C.; Selective Service Warner, Arthur, 79 Washington, George, 21–22 Webb, Rep. Edwin, (N.C.), 57 Welch, William Henry, 26, 34–35, 62; at Camp Evens, 75, 79, 104; on Gorgas camp inspection tour, 56 Western Front, 4, 67, 69, 70, 142; conditions on, 16, 21, 93, 94–95; evolution of influenza virus on, 70–73, 93–96; influenza epidemic, 6, 96, 108, 110, 118. See also Meuse-Argonne campaign; Trench warfare

White, John B., 134 Wilcox, Reynold Webb, 19 Wilhelmina, USS, 102 Williams, Charles, 171 Wilson Administration: and demobilization, 149; and war mobilization, 28, 34 57, 128, 166. See also Wilson, Woodrow Wilson, Woodrow, 28, 120, 123, 149; congressional criticism of, 57, 58– 60, 61; and William C. Gorgas, 16; on health of soldiers, 33, 44, 56; and influenza, 5, 106; on rank for medical officers, 62, 80; and war aims, 9, 43, 107, 108–9, 120, 131, 133. See also Wilson Administration Women, 5, 92, 164; authors of MDWW, 160; exclusion from Medical Corps, 15, 28–30, 31, 35, 144; flu victims, burial of, 133, 139; as non-combatants, 142, 144; physicians, 28–29, 196n61; as Victorian housewives, 36. See also Army Nurse Corps; Nurses, in U.S. army Wood, Leonard, 23 Woolley, Paul G., 174 World War I, 69–70; Armistice, 110, 146, 184; and disease, 4, 15–16, 53; demobilization, 123, 149, 184; historiography of, 109, 110, 117, 187–89; memoirs, 11, 12, 23, 51, 73, 110, 112, 133, 137–38, 171, 179, 188; literature, 131; veterans 40, 82, 118, 132, 136, 148, 176, 177, 190. See also American Expeditionary Forces (AEF); War Department, U.S.; Meuse-Argonne campaign World War II, 6, 110, 176, 183, 189– 90

250 | Index X-rays, 176, 177, 188 Yellow fever, 22, 40, 51, 54, 34, 97, 167; and armies, 10, 16, 20, 23; William C. Gorgas and, 14–15, 16, 18–19, 22, 66, 175, 179; control of in Cuba and Panama, 14–15, 18–20, 175 YMCA, 42, 84, 161, 178 York, Alvin, 134

Young, Hugh, 26, 115, 177; on African Americans and venereal disease, 29–30, 173 Young Men’s Hebrew Association, 43 Zinsser, Hans, 1, 45, 176; on disease and war, 4, 89, 97; and influenza epidemic, 88, 159, 161; Rats, Lice, and History, 187 Ziporyn, Terra, 184

About the Author

Carol R. Byerly has worked for the United States Congress and the American Red Cross. She now teaches history at the University of Colorado and is a research scholar of military medical history for the Office of the Surgeon General of the United States Army.

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