Flu

1
THE PLAGUE YEAR
This is a detective story. Here was a mass murderer that was
around 80 years ago and who's never been brought to justice.
And what we're trying to do is find the murderer.
—Jeffery Taubenberger, molecular pathologist




When the plague came, on those chilly days of autumn, some said it was a terrible new weapon of war. The plague germs were inserted into aspirin made by the German drug company Bayer. Take an aspirin for a headache and the germs will creep through your body. Then your fate is sealed.
No, the plague came in on a camouflaged German ship that had crept into Boston Harbor under cover of darkness and released the germs that seeded the city. Boston, after all, was where the plague started. There was an eyewitness, an old woman who said she saw a greasy-looking cloud that floated over the harbor and wafted over the docks.
No, it was started by Germans who slipped into Boston Harbor on U-boats and then sneaked ashore, carrying vials of the plague germs with them. They let the germs loose in theaters and among crowds gathered for those interminable Liberty Bond rallies. Lieutenant Colonel Philip S. Doane, head of the Health Sanitation Section of the Emergency Fleet Corporation, said so, and he certainly was in a position to know. It was on page one of the Philadelphia Inquirer.
Soon the plague was everywhere. And no one was safe.
The sickness preyed on the young and healthy. One day you are fine, strong, and invulnerable. You might be busy at work in your office. Or maybe you are knitting a scarf for the brave troops fighting the war to end all wars. Or maybe you are a soldier reporting for basic training, your first time away from home and family.
You might notice a dull headache. Your eyes might start to burn. You start to shiver and you will take to your bed, curling up in a ball. But no amount of blankets can keep you warm. You fall into a restless sleep, dreaming the distorted nightmares of delirium as your fever climbs. And when you drift out of sleep, into a sort of semi-consciousness, your muscles will ache and your head will throb and you will somehow know that, step by step, as your body feebly cries out "no," you are moving steadily toward death.
It may take a few days, it may take a few hours, but there is nothing that can stop the disease's progress. Doctors and nurses have learned to spot the signs. Your face turns a dark brownish purple. You start to cough up blood. Your feet turn black. Finally, as the end nears, you frantically gasp for breath. A blood-tinged saliva bubbles out of your mouth. You die—by drowning, actually—as your lungs fill with a reddish fluid.
And when a doctor does an autopsy, he will observe your lungs lying heavy and sodden in your chest, engorged with a thin bloody liquid, useless, like slabs of liver.




They called the plague of 1918 influenza, but it was like no influenza ever seen before. It was more like a biblical prophecy come true, something from Revelations that predicted that first the world was to be struck by war, then famine, and then, with the breaking of the fourth seal of the scroll foretelling the future, the appearance of a horse, "deathly pale, and its rider was called Plague, and Hades followed at its heels."
The plague took off in September of that year, and when it was over, half a million Americans would lie dead. The illness spread to the most remote parts of the globe. Some Eskimo villages were decimated, nearly eliminated from the face of the earth. Twenty percent of Western Samoans perished. And no matter where it struck, the virus went after an unusual group—young adults who generally are spared the ravages of infectious diseases. The death curves were W-shaped, with peaks for the babies and toddlers under age 5, the elderly who were aged 70 to 74, and people aged 20 to 40.
Children were orphaned, families destroyed. Some who lived through it said it was so horrible that they would not even talk about it. Others tried to put it behind them as another wartime nightmare, somehow conflating it with the horrors of trench warfare and mustard gas. It came when the world was weary of war. It swept the globe in months, ending when the war did. It went away as mysteriously as it appeared. And when it was over, humanity had been struck by a disease that killed more people in a few months' time than any other illness in the history of the world.
When we think of plagues we think of strange and terrible illnesses. AIDS. Ebola. Anthrax spores. And, of course, the Black Death. We worry about horrifying symptoms—pustules, or fountains of blood gushing from every orifice. Or young men, who had had the bodies of gods, reduced to skeletal figures, hobbling down the street on withered limbs, leaning on canes, shivering with cold. Today we worry about germ warfare—a new virus made of a combination of smallpox and anthrax or smallpox and Ebola. Or we worry that a terrifying new disease is brewing somewhere, in a hot zone, and that it is poised, prepared, with the disruption of ancient forests, to break out and kill us all.
But influenza never makes the list of deadly plagues. It seems so innocuous. It comes around every winter and everyone gets it sooner or later. There is no good treatment once a person becomes ill, but no matter. Nearly everyone gets over it, few are the worse for the experience. It is just an inconvenient illness that inflicts, at most, a week or so of misery. Influenza is not supposed to be deadly, at least for young adults, who have little reason to fear death or disease.
Even its name, "influenza," hints at its usual pattern of coming around each winter. "Influenza" is an Italian word that, one hypothesis has it, was coined by the disease's Italian victims in the middle of the eighteenth century. Influenza di freddo means "influence of the cold."
Flu also, however, seems unavoidable. It is spread through the air and there is little that can be done to prevent being infected. "I know how not to get AIDS," says Alfred W. Crosby, a historian of the 1918 flu. "I don't know how not to get the flu."
And yet perhaps because the flu is so familiar, its terrors in 1918 were all the more dreadful. It is like a macabre science fiction tale in which the mundane becomes the monstrous.
When the illness was first observed, doctors were reluctant even to call it the flu. It seemed to be a new disease, they said. Some called it bronchopneumonia, others called it epidemic respiratory infection. Doctors suggested it might be cholera or typhus, or perhaps it was dengue fever or botulism. Still others said it was simply an unidentified pandemic disease. Those who used the term "influenza" insisted on enclosing it in quotation marks.
One way to tell the story of the 1918 flu is through facts and figures, a collection of data whose impact is numbing and whose magnitude is almost inconceivable.
How many became ill? More than 25 percent of the U.S. population.
What about servicemen, the very young and healthy who were the virus's favorite targets? The Navy said that 40 percent of its members got the flu in 1918. The Army estimated that about 36 percent of its members were stricken.
How many died worldwide? Estimates range from 20 million to more than 100 million, but the true number can never be known. Many places that were bludgeoned by the flu did not keep mortality statistics, and even in countries such as the United States, efforts at tabulating flu deaths were complicated by the fact that there was no definitive test in those days to show that a person actually had the flu. But still, the low end of the mortality estimates is stunning. In comparison, AIDS had killed 11.7 million people through 1997. World War I was responsible for 9.2 million combat deaths and around 15 million total deaths. World War II for 15.9 combat deaths. Historian Crosby remarks that whatever the exact number felled by the 1918 flu, one thing is indisputable: the virus "killed more humans than any other disease in a period of similar duration in the history of the world."
How lethal was it? It was twenty-five times more deadly than ordinary influenzas. This flu killed 2.5 percent of its victims. Normally, just one-tenth of 1 percent of people who get the flu die. And since a fifth of the world's population got the flu that year, including 28 percent of Americans, the number of deaths was stunning. So many died, in fact, that the average life span in the United States fell by twelve years in 1918. If such a plague came today, killing a similar fraction of the U.S. population, 1.5 million Americans would die, which is more than the number felled in a single year by heart disease, cancers, strokes, chronic pulmonary disease, AIDS, and Alzheimer's disease combined.
But the raw numbers cannot convey the scenes of horror and misery that swept the world in 1918, which became part of everyday life in every nation, in the largest cities and remotest hamlets.
Some tell of their personal epiphanies. Historian Crosby, a friendly bear of a man with snow-white hair and a short bushy beard, was at Washington State University one day, gazing at a wall of world almanacs. On a whim, he picked up an almanac from 1917 and looked up the U.S. life expectancy. It was, he recalls, about fifty-one years. He then turned to the almanac from 1919. The life expectancy was about the same. Then he looked at the 1918 almanac. The life expectancy was thirty-nine years, he says. "What the hell happened? The life expectancy had dropped to what it had been fifty years before." Then he realized what the explanation must be. It was the influenza epidemic, the flu his own father had lived through but had not spoken about to Crosby. "When you talk to people who lived through it, they think it was just their block or just their neighborhood," Crosby noted. The flu's enormous, almost unthinkable impact somehow had escaped attention. Crosby applied for a grant from the National Institutes of Health to study the 1918 flu and soon became the world's expert on that almost forgotten period of history.
No one knows for sure where the 1918 flu came from or how it turned into such a killer strain. All that is known is that it began as an ordinary flu but then it changed. It infected people in the spring of 1918, sickening its victims for about three days with chills and fever, but rarely killing them. Then it disappeared, returning in the fall with the power of a juggernaut.
In retrospect, medical experts talk of the two waves of the 1918 flu. The first was banal, and easily forgotten. No one mentioned plagues or germ warfare when the influenza epidemic first arrived. But when it came back, in the second wave, it had become something monstrous, bearing little resemblance to what is ordinarily thought of as the flu.
The earliest traces of the first wave of the 1918 flu are lost in the sands of time, a warning that only afterward seemed dire. The disease seemed trivial at the time, coming as it did in the midst of the disruptions and terrors of war. But for one of the first towns to be hit by the flu, the disease was not easily dismissed—not because it was so deadly but because it was so infectious.
It was February and the tourist season was in full swing in San Sebastián. The sunny town on the northern coast of Spain seemed a world apart from the dismal, dreary fighting just over the border in France. San Sebastián in the winter of 1918 was a place where you might forget the trenches and the wet, cold, muddy battles. You could escape the talk of mustard gas, that deadly green haze, that horrible new German weapon of war. You could find respite in a country that was still unaligned, where the days were warm and the nights soft and fragrant. You might forget that the rest of Europe was bogged down in an exhausting war to end all wars.
Then the flu came to town. It was nothing alarming—just three days or so of fever, aches, and pains. But it certainly was contagious. It seemed that nearly everyone who was exposed to the disease became ill about two days later. And the disease seemed to strike young, healthy adults, often sparing the old people and the children, who usually are the first to be felled by influenza.
What to do? If the world knew about the flu in San Sebastián, the tourist season would be finished. Who would want to go on vacation only to be laid up with the flu? Maybe the illness could be hushed up, the town's officials reasoned. Yet the word spread—San Sebastián was a place to be avoided.
At nearly the same time, some soldiers were becoming ill, although there was as yet no clear pattern of the disease's spread. Influenza arrived in March in the 15th U.S. Cavalry traveling to Europe.
Two months later, it seemed that everyone was getting sick. In Spain, eight million people were ill, including King Alfonso XIII. One-third of Madrid was sick with the flu, forcing some government offices to close. Even the trams stopped running. And this time, Spain was not alone—the first wave of the flu had spread widely.
The troops called it "three-day fever," according to some who suffered from it. One, Sergeant John C. Acker of the 107th Ammunition Train, 32nd Division, American Expeditionary Force, writing from France that April, said: "They started calling it the ‘three-day fever' here, but couldn't camouflage it with a name when it runs its course in a week or more. It hits suddenly and one's temperature nearly chases the mercury thru the top of the M.D.'s thermometer, face gets red, every bone in the body aches and the head splits wide open. This continues for three or four days and then disappears after considerable perspiration, but the ‘hangover' clings for a week or two."
But in the rest of the world, the illness came to be called the Spanish flu, to Spain's consternation. After all, the other countries of Europe, as well as the United States and countries in Asia, were hit too in that spring of 1918. Maybe the name stuck because Spain, still unaligned, did not censor its news reports, unlike other European countries. And so Spain's flu was no secret, unlike the flu elsewhere.
Nonetheless, the scope of the epidemic remains unclear. There were no requirements in those days to report cases of influenza—that became a practice in the United States only after, and as a consequence of, the second wave of the 1918 flu. And there was no reason in those days of war to keep track of what seemed like a minor illness. Reports on the flu's reaches were sporadic, reflecting mostly the practices of organizations such as prisons, the military, and some industries, which simply recorded absentees. There was no systematic attempt to track an epidemic.
There are records noting that at the Ford Motor Company more than 1,000 workers called in sick with the flu in March. In San Quentin prison, 500 of 1,900 prisoners became ill in April and May. On March 4, the flu came to Camp Funston (now Fort Riley) in Kansas, a training camp for 20,000 recruits. That month and the next, it also arrived at more than a dozen other Army camps, but no eyebrows were raised. After all, colds and flu were to be expected in training camps where thousands of men were brought together, mingling and passing viruses among themselves.
In April 1918, the epidemic appeared in France, laying waste to British, American, and French troops stationed there, as well as the civilian population. The next month, it was in England, where King George V got the flu. The epidemic crested in England in June; at the same time, it cropped up in China and Japan. In Asia, it also was called the "three-day fever" or, sometimes, "wrestler's fever."
Not surprisingly, the epidemic affected the war effort. Soldiers trying to fight in World War I were laid up by the flu in such numbers that some commanders complained that the disease was hindering their ability to fight.
King George's Grand Fleet could not even put to sea for three weeks in May, with 10,313 men sick. The British Army's 29th Division had planned to attack La Becque on June 30, but had to put off the operation because so many of its men were sick with the flu.
German General Erich von Ludendorff, the leader of the country's acclaimed offense, complained that the flu, or the Flanders fever, as the Germans called it, was thwarting his battle plans. It was not enough that the fighting men were hungry and cold and wet, trying to slog their way through fields of mud that could swallow a tank. Now there was this flu which, Ludendorff said, was weakening his men and lowering their morale. The flu, he added, contributed to the failure of his July offensive, a battle plan that nearly won the war for Germany.
He also groused about his staff's complaints about the flu. "It was a grievous business having to listen every morning to the Chiefs of Staff's recital of the number of influenza cases, and their complaints about the weakness of their troops."
Yet although much of the world fell ill that spring, there remained large areas that were untouched. Most of Africa and almost all of South America and Canada had no flu epidemic. And as summer arrived, even the countries that were hardest hit had a reprieve. The flu seemed to vanish without a trace.




But a few months later the flu was back with a vengeance.
It roared into the world, beginning in places where its impact was, at first, not widely known. The second wave of the 1918 pandemic still was highly contagious. But this time it was a killer. Its path was evident in retrospect, when demographers traced patterns of unusually high death rates among young adults. By August, notes Gerald Pyle, a medical geographer at the University of North Carolina, the disease "had grimly cut its swath among populations of the Indian subcontinent, Southeast Asia, Japan, China, a large part of the Caribbean, and parts of Central and South America."
Although about 20 percent of its victims had a mild disease and recovered without incident, the rest had one of two terrifying illnesses. Some almost immediately became deathly ill, unable to get enough oxygen because their lungs had filled with fluid. They died in days, or even hours, delirious with a high fever, gasping for breath, lapsing at last into unconsciousness. In others, the illness began as an ordinary flu, with chills, fever, and muscle aches, but no untoward symptoms. By the fourth or fifth day of the illness, however, bacteria would swarm into their injured lungs and they would develop pneumonia that would either kill them or lead to a long period of convalescence.
The second wave of the flu arrived in the United States in Boston, appearing among a group of sailors who docked at the Commonwealth Pier in August. The sailors were simply in transit, part of the vast movement of troops in a war that transformed daily life.
By then, the war effort had taken over the country. No man wanted to be left behind—the worst thing you could call a man was a slacker. And so a quarter of Americans had signed up to fight, with those men who remained behind embarrassed, apologizing for medical conditions that kept them from the front. The women spent their days visiting hospitals, bringing bright baskets of flowers and sweets, and wrapping bandages for the men abroad.
And then some of those sailors in Boston got sick.
On August 28, eight men got the flu. The next day, 58 were sick. By day four, the sick toll reached 81. A week later, it was 119, and that same day the first civilian was admitted to Boston City Hospital sick with the flu.
Deaths soon followed. On September 8, three people died from the flu in Boston: a Navy man, a merchant marine, and a civilian.
That same day, the flu appeared in Fort Devens, Massachusetts, thirty miles west of Boston.
Overnight, Fort Devens became a scene out of hell. One doctor, assigned to work in the camp that September, wrote despairingly to a friend about an epidemic that was out of control. The doctor's letter is dated September 29, 1918, signed with his first name, "Roy." Nothing more is known about who he was or what became of him. His letter was discovered more than sixty years later, in a trunk in Detroit, and was published in the British Medical Journal in December 1979, having been sent in by a Scottish doctor, N. R. Grist of the University of Glasgow, who saw it as a cautionary tale.
Roy wrote: "Camp Devens is near Boston, and has about 50,000 men, or did before this epidemic broke loose." The flu epidemic hit the camp four weeks earlier, he added, "and has developed so rapidly that the camp is demoralized and all ordinary work is held up till it has passed. All assemblages of soldiers are taboo."
The disease starts out looking like an ordinary sort of influenza, Roy explained. But when the soldiers are brought to the hospital at the Army base, they "rapidly develop the most viscous type of Pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones and a few hours later you can begin to see the Cyanosis extending from the ears and spreading all over the face, until it is hard to distinguish the colored man from the white. It is only a matter of a few hours then until death comes and it is simply a struggle for air until they suffocate. It is horrible. One can stand to see one, two, or twenty men die, but to see these poor devils dropping like flies gets on your nerves. We have been averaging about 100 deaths a day, and still keeping it up."
It became a problem just to dispose of the dead. "It takes Special trains to carry away the dead," Roy remarked. "For several days there were not coffins and the bodies piled up something fierce and we used to go down to the morgue (which is just back of my ward) and look at the boys laid out in long rows. It beats any sight they ever had in France after a battle. An extra long barracks has been vacated for the use of the Morgue, and it would make any man sit up and take notice to walk down the long lines of soldiers all dressed and laid out in double rows. We have no relief here, you get up in the morning at 5:30 and work steady until about 9:30 P.M., sleep, then go at it again."
Even medical experts were shocked by what they saw at Camp Devens. Just six days before Roy wrote his letter, on September 23, the U.S. Surgeon General had sent one of the nation's leading doctors to the camp to figure out what was going on. The doctor, William Henry Welch, was a pathologist, a scientist, and a physician whose honors were almost unprecedented. He had been president of the most prestigious science and medical societies, including the American Medical Association, the National Academy of Science, and the American Association for the Advancement of Science. Some said that he was as highly regarded in his time as Benjamin Franklin had been earlier.
But Welch was as unprepared as Roy for the 1918 flu. He had, in fact, thought that American troops were astonishingly healthy. In September 1918, Welch, along with Colonel Victor C. Vaughan, who also had been president of the American Medical Association, Dr. Rufus Cole, president of the Rockefeller Institute, and Simeon Walbach of Harvard Medical School, had just completed a tour of inspections of Army camps in the South. They were flush with the success of the public health effort that seemed to have made disease in the military almost a thing of the past. Welch, in fact, had concluded that the camps were in such good condition, the troops in such good health, that he could retire. He was seventy-one years old, a portly, genial bachelor, and felt he had completed his service to his country. Then he was called upon to investigate the carnage that was occurring at Fort Devens.
The four doctors were summoned to Washington to speak to the U.S. Surgeon General, Dr. William C. Gorgas, the man who had eliminated yellow fever from Cuba. Gorgas called the men into his office, barely glancing up from the papers on his desk when the distinguished team came in. Then he said, "You will proceed immediately to Devens. The Spanish influenza has struck that camp."
The doctors obeyed, of course, traveling to Union Station near the Capitol building in Washington and boarding the next train to Fort Devens. They arrived the following morning on a dreary day, when a frigid rain was falling and dying soldiers, sodden and chilled, were filing into the hospital, carrying their blankets, burning with fever, shivering with cold, and coughing up bloody mucus.
What the doctors saw horrified them. The camp, built for 35,000 men, was overcrowded with 45,000. And the influenza epidemic was running rampant. In just twenty-four hours preceding Welch's visit, 66 men had died. The day that Welch and his retinue came, 63 died. The hospital, built to hold 2,000, was overflowing with 8,000 men.
Vaughan wrote about the experience. He was a man who had seen epidemics before. He had seen typhoid fever and seen firsthand how that illness felled men in the Spanish-American War. But never had he seen anything like the influenza epidemic in Fort Devens, Massachusetts.
Vaughan said there was no point in discussing the history of the influenza epidemic, which "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." But the scene at Devens was one he could never forget.
When the group of medical officials arrived, they saw what Vaughan said was inscribed in his brain. These memories are "ghastly ones which I would tear down and destroy were I able to do so, but this is beyond my power," Vaughan wrote. "They are part of my being and will perish only when I die or lose my memory."
When he remembered Fort Devens, this is what he saw: " … hundreds of stalwart young men in the uniform of their country coming into the wards of the hospital in groups of ten or more. They are placed on the cots until every bed is full yet others crowd in. Their faces soon wear a bluish cast; a distressing cough brings up the blood stained sputum. In the morning the dead bodies are stacked about the morgue like cord wood. This picture was painted on my memory cells at the division hospital, Camp Devens, in the fall of 1918, when the deadly influenza virus demonstrated the inferiority of human inventions in the destruction of human life."
It was shocking. Here was Vaughan, in the midst of the first war to use modern weapons, a war that was felling young men with machine guns and gas warfare, and yet it was all nothing compared to this illness.
The others, too, were traumatized. Cole was stunned by the hospital scene. As the men stumbled into the sick ward, "there were not enough nurses and the poor boys were putting themselves to bed on cots, which overflowed out of the wards on the porches," Cole said.
And then there was the autopsy room. It was hard to even get in, with stiff bodies piling up, blocking the doctors' way. "Owing to the rush and the great number of bodies coming into the morgue, they were placed on the floor without any order or system, and we had to step amongst them to get into the room where an autopsy was going on," Cole said.
But once they got there, even Welch, the imperturbable, the one the others looked to for courage and strength, was shaken. Somehow that was the worst of all.
Standing over the autopsy table, Welch opened the chest of the corpse of a young man, exposing his lungs. It was a terrible sight. "When the chest was opened and the blue swollen lungs were removed and opened, and Dr. Welch saw the wet, foamy surfaces with little real consolidation, he turned," Cole said. "This must be some new kind of infection," Welch said. "Or plague."
Welch "was quite excited and obviously very nervous," Cole said. "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."
Cole, too, was shaken. It was, he said, "the only time I ever saw Dr. Welch really worried and disturbed."
By that time, the flu had spread beyond Fort Devens, beyond Boston, beyond the military. The entire state of Massachusetts was staggering from the virus.
Three days after Welch and his retinue visited Camp Devens, the state's health officials frantically wired for help, asking the U.S. Public Health Service to send doctors and nurses. The state's acting governor, Calvin Coolidge, sent a telegram to President Woodrow Wilson, the mayor of Toronto, and the governors of Vermont, Maine, and Rhode Island, saying "our doctors and nurses are being thoroughly mobilized and worked to the limit." Many sick people, he added, "receive no attention whatsoever." As many as 50,000 in Massachusetts had the flu. That day, September 26, 1918, 123 Bostonians died of the flu and 33 succumbed to pneumonia.
But it was impossible to divert doctors and nurses to Massachusetts since, by then, the flu was everywhere and everyone needed help. The disease was moving quickly throughout military bases and towns and cities across the nation. Hundreds of towns, cities, and military installations were hit.
The result was devastation on a scale that is hard to imagine. Each incident, each military installation that was struck, each town or city, each remote village, had its own monstrous tale of death, helplessness, and social collapse.
The situation was so dire that the same day that Massachusetts pleaded for help, the Provost Marshal General of the U.S. Army made a shocking announcement. A draft call of 142,000 men was canceled. This despite the fact that soldiers were desperately needed in Europe. But he had little choice. The flu had spread far and wide. Twelve thousand Americans had died of the flu in September, and virtually every Army camp to which the recruits would report was under quarantine.
While Roy was administering to the dying in Fort Devens, while Welch was visiting the camp, looking on almost in disbelief at what the flu had wrought, the disease crept into Philadelphia.
Perhaps Philadelphia was ravaged early in the epidemic's course because the flu spread so easily from the city's Naval Yard. The flu first struck those Navy seamen on September 11, 1918, not long after it had arrived in Fort Devens. Or perhaps it was because the city was near two large Army camps, Fort Dix in New Jersey and Fort Meade in Maryland, and both of them were hit by the flu a few days later. Or perhaps the flu got its start in Philadelphia because the city had a huge Liberty Loan Drive parade, which drew a crowd of 200,000 on September 20. Or maybe it was all of these combined that gave the virus its foothold. But whatever the reason, Philadelphia was among the hardest hit of all American cities. And it was almost completely unprepared.
Few public officials anticipated the disaster and almost no members of the public did. The outbreak, in fact, was preceded by soothing words from medical authorities with a sort of band-played-on bravado. The Journal of the American Medical Association opined that medical authorities should not be alarmed by the flu's nickname, "the Spanish flu." That name, the journal wrote, "should not cause any greater importance to be attached to it, nor arouse any greater fear than would influenza without the new name." Moreover, the journal said, the flu "has already practically disappeared from the Allied troops."
Yet as the flu spread, the city did take a few precautions. On September 18, its health officials began a public campaign against coughing, spitting, and sneezing. Three days later, the city made influenza a reportable disease, which meant that records had to be kept of numbers of cases. On that same day, September 21, however, scientists reported good news—it seemed that the battle against influenza was won. The Philadelphia Inquirer wrote that researchers had found the cause of the flu—a bacterium called Pfeiffer's bacillus. As a consequence, the paper wrote, the finding has "armed the medical profession with absolute knowledge on which to base its campaign against this disease."
But by October 1, the city was under siege. In one day, 635 cases of the flu were reported to public health officials. That, however, was an underestimate. Doctors had become so overwhelmed caring for the sick that most cases went unreported and the true numbers will never be known. On October 3, the city closed all schools, churches, theaters, pool halls, and other places of amusement in a frantic attempt to slow the spread of the disease.
In the week that ended on October 5, as many as 2,600 were reported to have died in Philadelphia of the flu or its complications. The next week, the flu death reports reached more than 4,500. Hundreds of thousands were ill. Sick people arrived at teeming hospitals in limousines, horse carts, and pushcarts.
Within a month after the flu arrived in Philadelphia, nearly 11,000 people died from the disease. On one fateful day, October 10, 1918, 759 Philadelphia flu victims died.
"Visiting nurses often walked into scenes resembling those of the plague years of the fourteenth century," wrote historian Alfred W. Crosby. "They drew crowds of supplicants—or people shunned them for fear of the white gauze masks that they often wore. They could go out in the morning with a list of fifteen patients to see and end up seeing fifty. One nurse found a husband dead in the same room where his wife lay with newly born twins. It had been twenty-four hours since the death and the birth and the wife had had no food but an apple which happened to be within reach."
Undertakers were overwhelmed, observed Crosby. "On one occasion, the Society for Organizing Charity called 25 undertakers before finding one able and willing to bury a member of a poor family. In some cases, the dead were left in their homes for days. Private undertaking houses were overwhelmed and some were taking advantage of the situation by hiking prices as much as 600 percent. Complaints were made that cemetery officials were charging fifteen dollar burial fees and then making the bereaved dig graves for the dead themselves."
At the city morgue, bodies were piled three and four deep "in the corridors and in almost every room," Crosby said. They were "covered only with dirty and often bloodstained sheets. Most were unembalmed and without ice. Some were mortifying and emitting a nauseating stench. The doors of the building were left open, probably for circulation of air, and the Grand Guignol chaos was on view to anyone who cared to look in, including young children."




Philadelphia's nightmare was a prelude to an epidemic that roared throughout the world, bringing with it accumulating tales of horror. No place was safe, few families were spared. By the first week of October, the flu had spread to every part of the globe except for a few remote islands and Australia.
In Ottawa, Canada, the local newspaper reported that "street cars rattled down Bank Street with windows open and plenty of room inside. Schools, vaudeville theaters, movie palaces are dark; pool halls and bowling alleys, deserted."
In Cape Town, South Africa, there was such a shortage of coffins that bodies were buried in mass graves, wrapped in blankets.
Katherine Anne Porter, who had been a newspaper reporter in Denver, nearly died of the flu herself. Her fiance was killed by the illness. She wrote a novella about her experience, Pale Horse, Pale Rider, a story told in almost dreamlike language and describing a nightmare: "All the theaters and nearly all of the shops and restaurants are closed, and the streets have been full of funerals all day and ambulances all night."
In Reading, England, a nurse wrote: "It happened so suddenly. In the morning we received an order to open up a new unit of flu and by night we'd moved into a converted convent. Almost before the desks were out the stretchers were in—60–80 to a classroom. We could hardly squeeze between the cots and oh, they were so sick! They came from a nearby airforce base … some had been lying unattended for days. They all had pneumonia. We knew those whose feet were black wouldn't live."
Buffalo Bill Cody lost his daughter-in-law and grandson. Writer Mary McCarthy was orphaned and sent to live with her uncle.
In France, John McCrae, a Canadian doctor assigned to the Medical Corps, had written the most famous poem about World War I, "In Flanders Fields." It is a paean to soldiers who died in battle: "In Flanders fields the poppies blow, between the crosses, row on row." McCrae himself died in the war, but not in battle. He was felled by pneumonia in 1918—which leading virologists say almost certainly was caused by influenza.
A doctor at the University of Missouri, D. G. Stine, wrote that from September 26 until December 6, 1918, 1,020 students got the flu. "I saw one patient die within 18 hours of this disease and 12 hours after being put to bed. I have seen a number of others menaced with death during the first 48 hours of the disease. The statement that influenza is uncomplicated is, I believe, erroneous," he wrote.
At Camp Sherman in Ohio, 13,161 men—about 40 percent of those at the camp—got the flu between September 27 and October 13, 1918. Of them, 1,101 died.
Army doctors tried every measure to stem the epidemic. They inoculated troops with vaccines made from body secretions taken from flu patients or from bacteria that they thought caused the disease. They made the men spray their throats each day and gargle with antiseptics or alcohol. They hung sheets between beds, and at one camp they even hung sheets in the centers of tables at mess halls. At Walter Reed Hospital, soldiers chewed tobacco each day, believing that it would ward off the flu.
Public health departments gave out gauze masks for people to wear in public. A New York doctor and collector of historical photographs, Dr. Stanley B. Burns, has a photograph in his archive of a minor league baseball game being played during the epidemic. It is a surreal image: The pitcher, the batter, every player, and every member of the crowd are wearing gauze masks.
In Tucson, Arizona, the board of health issued a ruling that "no person shall appear in any street, park, or place where any business is transacted, or in any other public place within the city of Tucson, without wearing a mask consisting of at least four thicknesses of butter cloth or at least seven thicknesses of ordinary gauze, covering both the nose and the mouth."
In Albuquerque, New Mexico, where schools were closed and movie theaters darkened, the local newspaper noted: "the ghost of fear walked everywhere, causing many a family circle to reunite because of the different members having nothing else to do but stay home."
Doctors gave out elixirs and vaccinated people against the flu, but to no avail. Crosby wondered about those flu vaccines. What was in them when no one knew what was causing the flu? He interviewed a doctor who had helped produce flu vaccines in 1918. The doctor, Crosby said, told him that the vaccines were just a soup made of blood and mucus of flu patients that had been filtered to get rid of large cells and debris. When they injected it into people's arms their arms became horribly sore. "So they thought it really worked."
Anecdotes spread. There was the story of four women who played bridge together one night. The next day, three were dead from the flu. There were tales of people who set off for work and died of influenza hours later.
Throughout the nation, families were ravaged. James D. H. Reefer of Kansas City wrote that when he was four and his brother was six, his thirty-year-old father and his twenty-seven-year-old mother got the flu and died within a few days of each other, unable to breathe as the flu destroyed the air sacs of their lungs. "Older members of the family later told me they ‘simply drowned,"' Mr. Reefer said.
Minnie Lee Tratham McMullan was just two years old in 1918, living in Streator, Illinois. Her mother, her eleven-year-old brother, and her newborn baby sister died of the flu in that summer. An older brother got the flu and recovered, and so did Minnie, although at one time she was so ill that her family thought she was dead. "They rolled me out on the patio and put a sheet over me," she says. "Then they said they found out I was alive."
With his wife dead, Minnie's father was at a loss to care for Minnie, her older sister, and her two older brothers. The four children, aged two, four, seven, and ten, moved to the home of one relative and then the next.
Years later, Minnie McMullan went to the cemetery in Streator and spoke to the caretaker, who told her that the dead were lined up along the road during that terrible time. "There were so many dying that they didn't have people to dig graves to put them in," she says.
But McMullan, the last member of her family who was alive in 1918, has no memory of the epidemic. All she knows is what her relatives told her, and they did not like to speak of the deaths and dying. "I'm glad I don't remember," she says.
At the same time, volunteers, largely women, bravely stepped forward to minister to the sick. In El Paso, Texas, where poor Mexicans were dying at alarming rates, a twenty-eight-room school, the Aoy School, was converted into a hospital for influenza patients, mostly Mexicans. The local newspaper described the scene on October 19: "Fifty-one Mexican men, women, and babies lay gasping in the improvised wards of Aoy School last night." They were "brought from the squalor of homes in the Mexican quarter of town, many of them in the last stages of pneumonia, all of them suffering from the lack of proper medical attention and comforts, the patients were transferred from the depths of poverty to the comparative comfort and care of a hospital equal in almost any respect to any in the city."
People from all over the city volunteered at the Aoy School, providing food and clothing, driving the sick to the hospital in their own cars. Women helped out as cooks, clerks, drivers, and nurse's aides. One wrote: "I am so glad I can help. I have not had a nurse's aide course, nor, in fact, any training. I probably have no qualifications for nursing except for my desire to relieve some of the suffering."
Perhaps none but a gifted novelist can tell what death from the 1918 flu looked like, how the stricken person appeared in those last hours of life when the horrors of the illness are fully unfurled. One of the few who attempted this was Thomas Wolfe. He was a student at the University of North Carolina in 1918 when he got a telegram from home, summoning him to return immediately. His brother, Benjamin Harrison Wolfe, was ill with the flu. He tells the thinly fictionalized story in Chapter 35 of his novel, Look Homeward, Angel.
Wolfe came home to a deathwatch. His brother was lying in a sickroom upstairs while his family waited for what they feared was inevitable. Wolfe went upstairs to the "gray, shaded light" of the room where Ben lay. And he saw, "in that moment of searing recognition," that his beloved twenty-six-year-old brother was dying.
"Ben's long thin body lay three-quarters covered by the bedding; its gaunt outline was bitterly twisted below the covers, in an attitude of struggle and torture. It seemed not to belong to him, it was somehow distorted and detached as if it belonged to a beheaded criminal. And the sallow yellow of his face had turned gray; out of this granite tint of death, lit by two red flags of fever, the stiff black furze of a three-day beard was growing. The beard was somehow horrible; it recalled the corrupt vitality of hair, which can grow from a rotting corpse. And Ben's thin lips were lifted, in a constant grimace of torture and strangulation, above his white somehow dead-looking teeth, as inch by inch he gasped, a thread of air into his lungs.
"And the sound of this gasping—loud, hoarse, rapid, unbelievable, filling the room, and orchestrating every moment in it—gave to the scene its final note of horror."
The next day, Ben grew delirious. "By four o‘clock it was apparent that death was near," Wolfe wrote. "Ben had brief periods of consciousness, unconsciousness, and delirium—but most of the time he was delirious. His breathing was easier, he hummed snatches of popular songs, some old and forgotten, called up now from the lost and secret adyts of his childhood; but always he returned, in his quiet humming, to a popular song of war-time—cheap, sentimental, but now tragically moving: ‘Just a Baby's Prayer at Twilight.'"
And then Ben sank into unconsciousness. "His eyes were almost closed; their gray flicker was dulled, coated with the sheen of insensibility and death. He lay quietly upon his back, very straight, without sign of pain, and with a curious upturned thrust of his sharp thin face. His mouth was firmly shut."
Wolfe stayed with Ben that night, fervently praying even though he had thought he did not believe in God or prayer. "‘Whoever You Are, be good to Ben to-night. Show him the way … Whoever You Are, be good to Ben to-night. Show him the way …' He lost count of the minutes, the hours: he heard only the feeble rattle of dying breath, and his wild synchronic prayer."
Wolfe fell asleep, then woke suddenly, calling his family in with a certain knowledge that the end was nigh. Ben quieted, lay still. "The body appeared to grow rigid before them." Then, in a last gasp, "Ben drew upon the air in a long and powerful respiration; his gray eyes opened. Filled with a terrible vision of all life in the one moment, he seemed to rise forward bodily from his pillows without support—a flame, a light, a glory." And so, Wolfe wrote, Ben "passed instantly, scornful and unafraid, as he had lived, into the shades of death."
Nothing could be done for Thomas Wolfe's brother, Ben. No one knew how to treat the flu. There was no medicine to quell the raging fevers, no way to get oxygen into sodden lungs. There was no way to prolong life and no way to soothe the dying. Treatment was what doctors called palliative—give the patient food, fresh air, if possible, and TLC. Those optimistic tales, told when the flu struck Philadelphia, that a bacterium that caused the flu had been isolated, turned out to be untrue. Yes, the bacterium was found. But no, it did not seem to lead to a treatment or a vaccine. The cause of the disease remained a mystery. In 1918, the widely proclaimed discovery of Pfeiffer's bacillus turned out to be a false trail. The influenza virus was beyond anyone's grasp.
It was not just that the epidemic struck during wartime, when the nation was distracted by the horrors of battle. It was also that the epidemic came before scientists had any idea of how to isolate an influenza virus and discern its secrets. It was a time when the germ theory of disease was known, and when scientists had discovered that there was such a thing as a virus. But no one had ever seen a virus—electron microscopes had not been invented and viruses are far too small to be seen with ordinary microscopes. And no one understood what viruses were, since DNA and RNA, the genetic material of viruses and the clues to their destructiveness, had not yet been discovered.
Even today, with the exquisite advances of molecular biology and the pharmaceutical industry, viral diseases—and influenza in particular—are largely untreatable. It's not that molecular biologists are ignorant about the inner workings of influenza viruses. They have known for decades that the simple influenza virus has only eight genes, each made of the material RNA, and that the viruses die in hours if left alone with no cells to infect. They know what the flu viruses look like—under an electron microscope, they are little balls or egg-shaped particles, although sometimes they form long filaments. They know how they are put together—flu virus particles are wrapped in a slippery fatty membrane, held in place by a protein scaffolding underneath. They know how the viruses burrow into a cell and burst out again by using hundreds of sharp protein shards that poke out of the virus's membrane. They even know why human influenza viruses infect only cells of the lungs—those are the only human cells with an enzyme that the virus needs to split one of its proteins during the manufacturing of new virus particles.
But what they do not know is how to make a medicine that is the equivalent of a penicillin for the flu. The best way to combat an influenza pandemic is with vaccines—if manufacturers have enough advance notice of a new flu strain to make enough vaccine to go around. Manufacturers could, if they understood what made the 1918 flu so deadly, stockpile vaccines sufficient to protect the population if that flu or one like it ever came again. That, however, would require knowing what the 1918 flu looked like. Yet the last victims of the flu died in 1918, taking the virus with them.
Under ordinary circumstances, that would be the end of the story. The flu lived in the soft tissues of the lungs, and the lungs decay almost immediately after death. The virus, in fact, should be gone long before a corpse's lungs decay.
But nothing about the 1918 flu was ordinary. And perhaps the most extraordinary story yet comes nearly a century later, when three people among the millions who died of the flu are turning out to contain, within their miraculously preserved lung tissue, a sort of Rosetta stone for the killer flu virus. Unknown to anyone when these three people suddenly died, they alone would hold the clues to protect the world in the twenty-first century.
The first of the three to become ill with influenza was an Army private, Roscoe Vaughan, just twenty-one years old in September 1918. Like every soldier, he must have been frightened and full of bravado. He must have expected to be in battles and have hoped he could be strong and true. As he arrived at Camp Jackson, seven miles east of Columbia, South Carolina, he joined a contingent of more than 43,000 young men being trained in artillery before they went overseas. They practiced maneuvers on the dunes, struggling over the loose, drifting sand, squinting in the bright glare of the South Carolina sun. Roscoe Vaughan was among them, fit and healthy. He surely thought that the adventure of his life was about to begin. In a way, it was.
Private Vaughan was unlucky enough to have come to a camp staggering under a sudden onslaught of influenza. The soldiers were easy prey for the flu, and the hospital, built high on a sandy hill, was flooded with sick young men. In August, 4,807 men were admitted as patients. In September, 9,598. One young doctor there, James Howard Park, Jr., said he literally watched men drop dead as they walked across the paths at the camp. One day he himself tagged thirty corpses.
Private Vaughan's medical records show that he became ill during the third week of September, feeling achy and feverish. It did not take long for the virus to do its work. On September 19, he reported to sick call, stricken with the flu. At 6:30 in the morning of September 26, he died, gasping for breath.
At 2 p.m., an Army doctor, Captain K. P. Hegeforth, arrived to do an autopsy. Private Vaughan, he wrote, was a "fairly well developed, well nourished man measuring five feet ten inches." He was chubby, with a "moderately thick layer of subcutaneous fat." But he was fit, with "muscles in good condition."
Private Vaughan had about 300 cc, or 1¼ cups, of clear fluid in his chest cavity. Over the entire surface of his left lung were small seepages of blood, ranging in size from a pinhead to a dime or larger. The air sacs were clogged with fluid.
Captain Hegeforth cut off a slice of one of Private Vaughan's sodden lungs for examination, impregnating the slice of lung with formaldehyde to preserve it, embedding it in a chunk of candle wax about the size of a thumbnail. Then he sent it to Washington, where it was stored in a small brown box on a shelf of a vast government warehouse.
While Private Vaughan was dying in South Carolina, Private James Downs, a thirty-year-old soldier at Camp Upton in New York, was also feeling ill. He had arrived at the camp, about sixty-five miles east of New York City, to prepare to go overseas to fight. It was a setting not very different from the one Private Vaughan found himself in—an embarkation camp on a flat, sandy stretch of land, this time between Long Island Sound and the Atlantic Ocean, dotted with pine trees and low sandy bushes. But the camp, built a year earlier, was jammed with 33,000 soldiers who struggled to drive over the nearly impassable roads.
In September 1918, the hospital was suddenly flooded with sick men—one out of every ten men in the camp was admitted to the hospital. Private Downs was among them. His records show he entered the base hospital on September 23. His face was flushed, he was delirious, and his temperature was 104 degrees.
The next day, he remained delirious, with the same high temperature, but his skin was turning dark from lack of oxygen. At 4:30 a.m. on September 26, three days after he was admitted to the hospital, Private Downs died of influenza, just two hours before Private Vaughan succumbed.
That same day, a Captain McBurney did an autopsy on Private Downs. He wrote that Downs was six feet tall, weighing 140 pounds. He had "no external signs of disease or injury."
The injury, of course, was internal—in Private Downs's lungs. They were filled with fluid, and a "bloody froth" exuded from them, Captain McBurney wrote. The doctor cut a small slice of James Downs's lung, soaked it in formaldehyde, encased it in wax, and sent it to the same Washington warehouse that stored the scrap of Private Vaughan's lung.
And there the lung specimens from Private Vaughan and Private Downs remained, for nearly eighty years, secreted among pathology tissue from millions of people who died of diseases both common and rare, in the Armed Forces Institute of Pathology's archives. The archives had begun in the Civil War, created by an executive order by President Abraham Lincoln. Since then, military doctors had been sending in thousands of pathology specimens a year, with as many as 50,000 a year sent in more recently. The number of tissue samples stored in the warehouse had swelled to about 3 to 4 million.
Several times in the past century, the warehouse specimens were moved as the ever-growing collection required more and more storage space. But the tiny paraffin cubes encasing lung cells from the autopsies of Roscoe Vaughan and James Downs remained in their boxes, of no interest to anyone until, at the end of the twentieth century, they were rediscovered by molecular biologists who thought it just might be possible to resurrect the flu virus from those ancient slices of lung.
Two months after Private Vaughan's death, influenza came to Teller Lutheran mission (now called Brevig), on the flat frozen tundra of the Seward Peninsula of Alaska. It was an isolated village of eighty people, ninety miles by dog sled from Nome, the nearest town, perched on the edge of a gray and chilly sea. Among the residents was an obese woman who, like the rest, lived in a soot-filled igloo with a window made of seal gut.
On the last Saturday in November, two visitors from Nome attended a crowded, standing-room-only service in the tiny chapel run by the missionaries. The visitors reported that there was much sickness in the city, but no one was unduly alarmed. The Eskimos treated the visitors to their traditional hospitality—a feast for the entire village of reindeer meat, hotcakes, blueberries in seal oil, and tea.
Two days later, on Monday, the first villagers fell ill with the flu. On Tuesday, the first person died, a woman named Mrs. Neelak. The minister set off for Teller, a village fourteen miles from the mission, seeking help. He returned, only to report that people in Teller were being decimated by the same illness.
One after another, the Eskimos died—seventy-two in all. One igloo had twenty-five dead bodies, frozen in the Arctic cold. Starving dogs had broken into another igloo and ripped apart a collection of corpses, leaving a gory mess of bones. Another igloo looked at first like the site of utter devastation. The seal-gut window had broken and snow had drifted in. The fire was out, the bone-chilling cold had penetrated the small space. And as rescuers peeked inside, they saw only a pile of corpses. Then, suddenly, three terrified children appeared from under deerskins and started shrieking. They had survived somehow on oatmeal, surrounded by the bodies of their family.
In the end, a three-week flu epidemic had left only five adults in the village; forty-six children were orphaned. Clara Fosso, the missionary's wife and one of the few adults who did not get the flu, wrote a letter to the Eskimos years later, still mourning the tragedy: "There was a spiritual revival among the Eskimos at the Mission on the last Sunday in November 1918, before the influenza disaster fell upon us. The whole settlement of Eskimos had crowded into the new school room for worship. We felt the spirit of the Lord among us, as the communicants stood at the altar and later met in prayer; many confessed to their faith. We were deeply moved. This was the last time we were gathered together. By the following Sunday most members had gone to a more beautiful service with their Savior. You, who are the sons and daughters of these children of God, may remember that many of them died testifying to their Lord and singing the hymn that we had shared on that last Sunday, ‘I Can Hear My Savior Calling.'"
Still in shock from the tragedy, the few able-bodied men that could be found in the nearby villages were left to bury the dead, an ordeal in the harsh Alaskan winter. The villages were so far north that the ground was permanently frozen. In order to dig into the rock-hard ground at Teller mission, miners pumped hot steam into the frozen earth, thawing it enough to dig a trench. They buried the flu victims in a common grave, marking the site with two large crosses, one at each end of the trench.
Among the dead was the obese woman, whose frozen body lay six feet underground in the mass grave. And there it remained for seventy years.
Copyright © 1999 by Gina Kolata All rights reserved