The Great Influenza

by John M. Barry

  When the laborers returned to their homes, they carried more than their wages. Soon influenza spread through the force of men who coaled the ships. And this influenza was not mild. On August 24, two natives died of pneumonia while many others were still sick.

  On August 27, the HMS Africa pulled into port. She too needed coal, but five hundred of the six hundred laborers of the Sierra Leone Coaling Company did not report to work that day. Her crew helped coal her, working side by side with African laborers. She carried a crew of 779. Within a few weeks, nearly six hundred were sick. And fifty-one were dead - 7 percent of the entire crew died.

  The transport HMS Chepstow Castle, carrying troops from New Zealand to the front, coaled at Freetown on August 26 and 27; within three weeks, out of her 1,150 men, influenza struck down nine hundred of them. The death toll on her was thirty-eight.

  The Tahiti coaled at the same time; sixty-eight men aboard her died before she reached England, the same day as the Chepstow Castle. After docking, crew of the two ships suffered eight hundred more cases and 115 more deaths.

  In Sierra Leone itself, officials soon after estimated that influenza killed 3 percent of the entire African population, nearly all of them dying within the next few weeks. More recent evidence suggests that the death toll was most likely considerably more than that, possibly double that figure - or higher.

  *

  Across the Atlantic, at Commonwealth Pier in Boston, the navy operated a 'receiving ship.' The name was a misnomer. It was actually a barracks where as many as seven thousand sailors in transit ate and slept in what the navy itself called 'grossly overcrowded' quarters.

  On August 27, two sailors reported to sick bay with influenza. On August 28, eight more sailors reported ill. On August 29, fifty-eight men were admitted.

  As in Brest and Freetown and aboard ship, men began to die. Fifty of the men were quickly transferred to the Chelsea Naval Hospital, where Lieutenant Commander Milton Rosenau and his young assistant Lieutenant John J. Keegan, worked.

  The sailors were in better than good hands. While Keegan would later become dean of the University of Nebraska Medical School, Rosenau was one of the giants of the day. Strong, solid, and thick-necked, he looked as intimidating and determined as a wrestler staring down an opponent. Yet he was uniformly polite and supportive, and people enjoyed working under him. A prime mover in creating the U.S. Public Health Service Hygienic Laboratory and later the president of the Society of American Bacteriologists, he was best known for his textbook, Preventive Medicine and Hygiene, which was referred to as 'The Bible' for both army and navy medical officers. Only a few weeks earlier, he had met with Welch, Gorgas, and Vaughan to discuss how to prevent or contain any new epidemic.*

  Rosenau and Keegan immediately isolated the men and did everything possible to contain the disease, working backward from each victim to trace and isolate people with whom the patients had had contact. But the disease was too explosive. They turned their attention to bacteriological analysis, seeking the pathogen so they could prepare a vaccine or serum. Their findings did not satisfy them, and within a few weeks they began using human volunteers from the navy brig in the first experiments in the world to determine if a virus caused the disease.

  Long before that any hopes of containing the disease had collapsed. On September 3 a civilian suffering from influenza was admitted to the Boston City Hospital. On September 4 students at the Navy Radio School at Harvard, in Cambridge across the Charles River from Boston proper, fell ill.

  And then came Devens.

  CHAPTER SIXTEEN

  CAMP DEVENS sat on five thousand acres in rolling hills thirty-five miles northwest of Boston. It included fine farmland along the Nashua River, as well as what had been until recently heavily forested land cut down now to tree stumps. Like the other cantonments in the country it was thrown together with amazing speed, at the rate of 10.4 buildings a day. In August 1917 it opened with fifteen thousand men although the camp was incomplete - its sewage was still being discharged directly into the Nashua River.

  Like most other camps, it had suffered from measles and pneumonia. The medical staff was first rate. An inspection of the Devens hospital had given it an excellent review down to its kitchen, noting, 'The mess officer is well informed and alert.'

  In fact the Devens medical staff was so good that Frederick Russell was preparing to rely on it to launch several major new scientific investigations. One involved correlating the existence of streptococci in the mouths of healthy soldiers with streptococcal infections of the throat. Another sought an explanation for the far higher morbidity rates of pneumonia among blacks over whites. Still another involved measles. Late in the summer at Devens, Major Andrew Sellards had passed infectious material from a recent measles case through a porcelain filter to isolate the virus, had inoculated four monkeys with it, and on August 29 began inoculating a series of human volunteers.

  The only problem at Devens was that it was built to hold a maximum of thirty-six thousand men. On September 6, Devens held just over forty-five thousand men. Still, the camp hospital could accommodate twelve hundred and it was caring for only eighty-four patients. With enough medical personnel to run several simultaneous research efforts, with a highly competent clinical staff, with a virtually empty hospital, Devens seemed ready for any emergency.

  It wasn't.

  *

  A week before any reported illness in the harbor, Boston public health authorities worried: 'A sudden and very significant increase reported the third week of August in the cases of pneumonia occurring in the army cantonment at Camp Devens in the district seems to justify a suspicion that an influenza epidemic may have started among the soldiers there.'

  While the eruption at Devens might still have come from the Navy Commonwealth Pier facility, it might also have developed independently. It might even have spread to Boston from Devens. At any rate, on September 1, four more soldiers at Devens were diagnosed with pneumonia and admitted to the hospital. In the next six days, twenty-two more new cases of pneumonia were diagnosed. None of these, however, were considered to be influenza.

  On September 7, a soldier from D Company, Forty-second Infantry, was sent to the hospital. He ached to the extent that he screamed when he was touched, and he was delirious. He was diagnosed as having meningitis.

  The next day a dozen more men from his company were hospitalized and suspected of having meningitis. It was a reasonable diagnosis. Symptoms did not resemble those of influenza, and a few months earlier the camp had suffered a minor epidemic of meningitis, and the doctors (lacking any false pride) had even called Rosenau for help. He had come himself, along with six bacteriologists; they had worked nearly around the clock for five days, identifying and quarantining 179 carriers of the disease. Rosenau had left the camp impressed with army medicine; even though he and his staff had done much of the work, he had advised navy superiors that the same effort would not have been possible in the navy.

  Now, over the next few days, other organizations began reporting cases of influenza-like disease. The medical staff, good as it was, did not at first connect these various cases to each other or to the outbreak on Commonwealth Pier. They made no attempt to quarantine cases. In the first few days no records of influenza cases were even kept because they 'were looked upon as being examples of the epidemic disease which attacked so many of the camps during the spring.' In the overcrowded barracks and mess halls, the men mixed. A day went by. Two days. Then, suddenly, noted an army report, 'Stated briefly, the influenza' occurred as an explosion.'

  It exploded indeed. In a single day, 1,543 Camp Devens soldiers reported ill with influenza. On September 22, 19.6 percent of the entire camp was on sick report, and almost 75 percent of those on sick report had been hospitalized. By then the pneumonias, and the deaths, had begun.

  On September 24 alone, 342 men were diagnosed with pneumonia. Devens normally had twenty-five physicians. Now, as army and civilian medical staff poured into the camp, more tha
n two hundred and fifty physicians were treating patients. The doctors, the nurses, the orderlies went to work at 5:30 A.M. and worked steadily until 9:30 P.M., slept, then went at it again. Yet on September 26 the medical staff was so overwhelmed, with doctors and nurses not only ill but dying, they decided to admit no more patients to the hospital, no matter how ill.

  The Red Cross, itself by then overwhelmed by the spread of the disease to the civilian population, managed to find twelve more nurses to help and sent them. They were of little help. Eight of the twelve collapsed with influenza; two died.

  For this was no ordinary pneumonia. Dr. Roy Grist, one of the army physicians at the hospital, wrote a colleague, 'These men start with what appears to be an ordinary attack of LaGrippe or Influenza, and when brought to the Hosp. they very rapidly develop the most vicious 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 their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white.'

  Blood carrying oxygen in arteries is bright red; without oxygen in veins it is blue. Cyanosis occurs when a victim turns blue because the lungs cannot transfer oxygen into the blood. In 1918 cyanosis was so extreme, turning some victims so dark (the entire body could take on color resembling that of the veins on one's wrists) it sparked rumors that the disease was not influenza at all, but the Black Death.

  Grist continued, 'It is only a matter of a few hours then until death comes' . It is horrible. One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies' We have been averaging about 100 deaths per day' . Pneumonia means in about all cases death' . We have lost an outrageous number of Nurses and Drs., and the little town of Ayer is a sight. It takes special trains to carry away the dead. For several days there were no coffins and the bodies piled up something fierce' . 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 dead soldiers all dressed and laid out in double rows' . Good By old Pal, God be with you till we meet again.'

  *

  Welch, Cole, Victor Vaughan, and Fredrick Russell, all of them colonels now, had just finished a tour of southern army bases. It was not their first such tour, and as before, knowing that an army barracks offered explosive tinder, they had been inspecting camps to find and correct any practice that might allow an epidemic to gain a foothold. They also spent much time discussing pneumonia. After leaving Camp Macon in Georgia, they had retired for a few days of relaxation to Asheville, North Carolina, the most fashionable summer retreat in the South. The Vanderbilts had built one of the most elaborate estates in the country there, and not many miles away Welch's old colleague William Halsted had built a virtual castle in the mountains (today Halsted's home is a resort called the High Hamptons).

  At the Grove Park Inn, one of the most elegant settings in the city, they listened to a concert. Welch lit a cigar. A bellboy promptly told him smoking was not allowed. He and Cole withdrew to the veranda and began talking. Another bellboy asked them to please be quiet during the concert. Welch left in disgust.

  Meanwhile Russell wrote Flexner, 'We are all well. Welch, Vaughan, and Cole, and I have had a very profitable trip and have begun to believe that immunity' (in this he was referring to efforts to manipulate the immune system) 'is the most important thing in pneumonia, as in other infectious diseases. It makes a good working hypothesis and one we will try to follow up by working in the lab, wards, and in the field this fall and winter. Bonne chance.'

  The group returned to Washington on a Sunday morning relaxed and in good spirits. But their mood changed abruptly as they stepped off the train. An escort had been waiting for them and his anxiety quickly communicated itself. He was taking them to the surgeon general's office - immediately. Gorgas himself was in Europe. His deputy barely looked up as they opened the door: 'You will proceed immediately to Devens. The Spanish influenza has struck that camp.'

  *

  They arrived at Devens eight hours later in a cold and drizzling rain. The entire camp was in chaos, the hospital itself a battlefield. The war had come home indeed. As they entered the hospital, they watched a continuous line of men filing in from the barracks carrying their blankets or being themselves carried.

  Vaughan recorded this sight: 'hundreds of young stalwart 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 and yet others crowd in. The faces wear a bluish cast; a distressing cough brings up the blood-stained sputum.'

  Care was almost nonexistent. The base hospital, designed for twelve hundred, could accommodate at most (even with crowding 'beyond what is deemed permissible,' according to Welch) twenty-five hundred. It now held in excess of six thousand. All beds had long since been filled. Every corridor, every spare room, every porch was filled, crammed with cots occupied by the sick and dying. There was nothing antiseptic about the sight. And there were no nurses. When Welch arrived seventy out of two hundred nurses were already sick in bed themselves, with more falling ill each hour. Many of them would not recover. A stench filled the hospital as well. Bed linen and clothing were rank with urine and feces from men incapable of rising or cleaning themselves.

  Blood was everywhere, on linens, clothes, pouring out of some men's nostrils and even ears while others coughed it up. Many of the soldiers, boys in their teens, men in their twenties (healthy, normally ruddy men) were turning blue. Their color would prove a deadly indicator.

  The sight chilled even Welch and his colleagues. It was more chilling still to see corpses littering the hallways surrounding the morgue. Vaughan reported, 'In the morning the dead bodies are stacked about the morgue like cord wood.' As Cole recalled, '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.'

  In the autopsy room they saw the most chilling sights yet. On the table lay the corpse of a young man, not much more than a boy. When he was moved in the slightest degree fluid poured out of his nostrils. His chest was opened, his lungs removed, other organs examined carefully. It was immediately apparent this was no ordinary pneumonia. Several other autopsies yielded similar abnormalities.

  Cole, Vaughan, Russell, the other members of this scientific team were puzzled, and felt an edge of fear. They turned to Welch.

  He had studied with the greatest investigators in the world as a young man. He had inspired a generation of brilliant scientists in America. He had visited and seen diseases in China, the Philippines, and Japan that were unknown in the United States. He had read scientific journals in many languages for years, heard back-channel gossip from all the leading laboratories in the world. Surely he would be able to tell them something, have some idea.

  He did not reassure. Cole stood beside him, thinking he had never seen Welch look nervous before, or excited in quite this way. In fact Cole was shaken: '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 for Dr. Welch.'

  Then Welch said, 'This must be some new kind of infection or plague.'

  *

  Welch walked out of the autopsy room and made three phone calls, to Boston, New York, and Washington. In Boston he spoke to Burt Wolbach, a Harvard professor and chief pathologist at the the great Boston hospital the Brigham, and asked him to perform autopsies. Perhaps there was a clue to this strange disease there.

  But Welch also knew that any treatment or prevention for this would have to come from the laboratory. From the Rockefeller Institute in New York he summoned Oswald Avery. Avery had been refused a commission in the Rockefeller army unit because he was Canadian, but on August 1 he had become an American citizen. By coincidence, the same day Welch called him, Ave
ry was promoted from private to captain. More importantly, he had already begun the investigations that would ultimately revolutionize the biological sciences; influenza would confirm him in this work.

  Later that day both Avery and Wolbach arrived and immediately began their respective tasks.

  The third call Welch made was to Washington, to Charles Richard, the acting army surgeon general while Gorgas was at the front. Welch gave a detailed description of the disease and his expectations of its course at Devens and elsewhere. For this was going to spread. He urged that 'immediate provision be made in every camp for the rapid expansion of hospital space.'

  *

  Richard responded instantly, sending orders to all medical personnel to isolate and quarantine all cases and segregate soldiers from civilians outside the camps: 'It is important that the influenza be kept out of the camps, as far as practicable' . Epidemics of the disease can often be prevented, but once established they cannot well be stopped.' But he also conceded the difficulty: 'There are few diseases as infectious as influenza' . It is probable that patients become foci of infection before the active symptoms' . No disease which the army surgeon is likely to see in this war will tax more severely his judgement and initiative.'

  He also warned both the army adjutant general and chief of staff, 'New men will almost surely contract the disease. In transferring men from Camp Devens a virulent form of the disease will almost surely be conveyed to other stations' . During the epidemic new men should not be sent to Camp Devens, nor should men be sent away from that camp.'

  The next day, with reports already of outbreaks in other camps, Richard tried to impress upon the chief of staff the lethality of the disease, relating what Welch had told him: 'The deaths at Camp Devens will probably exceed 500' . The experience at Camp Devens may be fairly expected to occur at other large cantonments' . With few exceptions they are densely populated, a condition which tends to increase the chance for 'contact' infection and the virulence and mortality of the disease' . It may be expected to travel westward and involve successively military stations in its course.' And he urged that the transfer of personnel from one camp to another be all but eliminated except for the most 'urgent military necessities.'