The Great Influenza

by John M. Barry

  Medical care was making little difference anyway. Mary Tullidge, daughter of Dr. George Tullidge, died twenty-four hours after her first symptoms. Alice Wolowitz, a student nurse at Mount Sinai Hospital, began her shift in the morning, felt sick, and was dead twelve hours later.

  On October 1, the third day after the parade, the epidemic killed more than one hundred people (117) in a single day. That number would double, triple, quadruple, quintuple, sextuple. Soon the daily death toll from influenza alone would exceed the city's average weekly death toll from all causes - all illnesses, all accidents, all criminal acts combined.

  On October 3, only five days after Krusen had let the parade proceed, he banned all public meetings in the city (including, finally, further Liberty Loan gatherings) and closed all churches, schools, theaters. Even public funerals were prohibited. Only one public gathering place was allowed to remain open: the saloon, the key constituency of the Vare machine. The next day the state health commissioner closed them.

  The first temporary facility to care for the sick was set up at Holmesburg, the city's poorhouse. It was called 'Emergency Hospital #1' the Board of Health knew more would follow. Its five hundred beds were filled in a day. Ultimately there would be twelve similar large hospitals run with city help, three of them located in converted Republican Clubs in South Philadelphia. It was where people had always gone for help.

  In ten days (ten days!) the epidemic had exploded from a few hundred civilian cases and one or two deaths a day to hundreds of thousands ill and hundreds of deaths each day.

  Federal, municipal, and state courts closed. Giant placards everywhere warned the public to avoid crowds and use handkerchiefs when sneezing or coughing. Other placards read 'Spitting equals death.' People who spat on the street were arrested - sixty in a single day. The newspapers reported the arrests even while continuing to minimize the epidemic. Physicians were themselves dying, three one day, two another, four the next. The newspapers reported those deaths (on inside pages with other obituaries) even while continuing to minimize the epidemic. Health and city workers wore masks constantly.

  What should I do? people wondered, with dread. How long will it go on? Each day people discovered that friends and neighbors who had been perfectly healthy a week (or a day) earlier were dead.

  And city authorities and newspapers continued to minimize the danger. The Public Ledger claimed nonsensically that Krusen's order banning all public gatherings was not 'a public health measure' and reiterated, 'There is no cause for panic or alarm.'

  On October 5, doctors reported that 254 people died that day from the epidemic, and the papers quoted public health authorities as saying, 'The peak of the influenza epidemic has been reached.' When 289 Philadelphians died the next day, the papers said, 'Believing that the peak of the epidemic has passed, health officials are confident.'

  In each of the next two days more than three hundred people died, and again Krusen announced, 'These deaths mark the high water mark in the fatalities, and it is fair to assume that from this time until the epidemic is crushed the death rate will constantly be lowered.'

  The next day 428 people died, and the daily death toll would keep climbing for many days yet - approaching double even that figure.

  Krusen said, 'Don't get frightened or panic stricken over exaggerated reports.'

  But Krusen's reassurances no longer reassured.

  *

  One could not listen to Paul Lewis speak on any subject and not sense the depth of his knowledge and his ability to see into a problem, envision possible solutions and understand their ramifications. Other scientists in the city did not defer to him, but they looked to him.

  He had been working on this problem for three weeks now. He hardly ever left his laboratory. Nor did his assistants, except for the ones who fell ill. Every scientist in Philadelphia was spending every waking minute in the laboratory as well.

  The laboratory was his favorite place anyway, more even than home. Normally, everything in his work gave him peace; the laboratory gave him peace, including the mysteries that he embraced. He settled into them like a man casting off into an impenetrable ocean fog, a fog that made one feel both alone in and part of the world.

  But this work did not give him peace. It wasn't the pressure exactly. It was that the pressure forced him off rhythm, forced him to abandon the scientific process. He developed a hypothesis and focused on it, but the shorthand process by which he arrived at it made him uncomfortable.

  So did hearing the news of the deaths. The youth and vitality and promise of the dead horrified. The waste of their promise horrified. He worked harder.

  *

  Arthur Eissinger, president and 'honor man' of Penn's class of 1918, died. Dudley Perkins, a Swarthmore football hero, died. Nearly two-thirds of the dead were under forty.

  It was a common practice in 1918 for people to hang a piece of crepe on the door to mark a death in the house. There was crepe everywhere. 'If it was a young person they'd put a white crepe at the door,' recalled Anna Milani. 'If it was a middle-aged person, they'd put a black crepe, and if it was an elderly one, they put a grey crepe at the door signifiying who died. We were children and we were excited to find out who died next and we were looking at the door, there was another crepe and another door.'

  There was always another door. 'People were dying like flies,' Clifford Adams said. 'On Spring Garden Street, looked like every other house had crepe over the door. People was dead there.'

  Anna Lavin was at Mount Sinai Hospital: 'My uncle died there' . My aunt died first. Their son was thirteen' . A lot of young people, just married, they were the first to die.'

  But the most terrifying aspect of the epidemic was the piling up of bodies. Undertakers, themselves sick, were overwhelmed. They had no place to put bodies. Gravediggers either were sick or refused to bury influenza victims. The director of the city jail offered to have prisoners dig graves, then rescinded the offer because he had no healthy guards to watch them. With no gravediggers bodies could not be buried. Undertakers' work areas were overflowing, they stacked caskets in halls, in their living quarters - many lived above their businesses.

  Then undertakers ran short of coffins. The few coffins available suddenly became priceless. Michael Donohue's family operated a funeral home: 'We had caskets stacked up outside the funeral home. We had to have guards kept on them because people were stealing the caskets' . You'd equate that to grave robbing.'

  There were soon no caskets left to steal. Louise Apuchase remembered most vividly the lack of coffins: 'A neighbor boy about seven or eight died and they used to just pick you up and wrap you up in a sheet and put you in a patrol wagon. So the mother and father screaming, 'Let me get a macaroni box' [for a coffin] (macaroni, any kind of pasta, used to come in this box, about 20 pounds of macaroni fit in it) please please let me put him in the macaroni box, don't take him away like that'.''

  Clifford Adams remembered 'bodies stacked up' stacked up out to be buried'. They couldn't bury them.' The bodies backed up more and more, backed up in the houses, were put outside on porches.

  The city morgue had room for thirty-six bodies. Two hundred were stacked there. The stench was terrible; doors and windows were thrown open. No more bodies could fit. Bodies lay in homes where they died, as they died, often with bloody liquid seeping from the nostrils or mouths. Families covered the bodies in ice; even so the bodies began to putrefy and stink. Tenements had no porches; few had fire escapes. Families closed off rooms where a body lay, but a closed door could not close out the knowledge and the horror of what lay behind the door. In much of the city, a city more short of housing than New York, people had no room that could be closed off. Corpses were wrapped in sheets, pushed into corners, left there sometimes for days, the horror of it sinking in deeper each hour, people too sick to cook for themselves, too sick to clean themselves, too sick to move the corpse off the bed, lying alive on the same bed with the corpse. The dead lay there for days, while the living lived w
ith them, were horrified by them, and, perhaps most horribly, became accustomed to them.

  Symptoms were terrifying. Blood poured from noses, ears, eye sockets; some victims lay in agony; delirium took others away while living.

  Routinely two people in a single family would die. Three deaths in a family were not uncommon. Sometimes a family suffered even more. David Sword lived at 2802 Jackson Street. On October 5 the sixth member of his family died of influenza, while the North American reported that three other family members in the hospital 'may also die of the plague.'

  The plague. In the streets people had been whispering the word. The word slipped, somehow, once, by accident, into that newspaper. The 'morale' issue, the self-censorship, the intent by editors to put every piece of news in the most positive possible context, all meant that no newspaper used that word again. Yet people did not need newspapers to speak of the Black Death. Some bodies were turning almost black. People had seen them, and they had lost faith in what they read anyway. One young medical student called in to treat hundreds of patients recalled, 'The cyanosis reached an intensity that I have never seen since. Indeed the rumor got about that the Black Death had returned.' The newspapers quoted Dr. Raymond Leopold, sounding reasonable: 'There is abundant reason for such a rumor' . It is true that many bodies have assumed a dark hue and have given off a pronounced odor after death.' But he gave his assurance, 'There is no truth in the black plague assertion.'

  He was of course correct. But how many trusted the newspapers anymore? And even if the Black Death had not come, a plague had and, with it, so had terror.

  The war had come home.

  *

  Long before Hagadorn's suicide, long before the marchers in Philadelphia began to parade down the city streets, influenza had seeded itself along the edges of the nation.

  On September 4 it had reached New Orleans, with the three seamen (who soon died) carried to the hospital off the Harold Walker from Boston. On September 7 it had reached the Great Lakes Naval Training Station, with sailors transferred from Boston. In the next few days ports and naval facilities on the Atlantic and Gulf Coasts (in Newport, New London, Norfolk, Mobile, and Biloxi) also reported this new influenza. On September 17, 1918, 'the extensive prevalence of an influenza-like disease' was reported in Petersburg, Virginia, outside Camp Lee. That same day, the several hundred sailors who had departed Philadelphia earlier for Puget Sound arrived; eleven men had to be carried from the ship on stretchers to a hospital, bringing the new virus to the Pacific.

  The virus had spanned the country, establishing itself on the Atlantic, in the Gulf, on the Pacific, on the Great Lakes. It had not immediately erupted in epidemic form, but it had seeded itself. Then the seeds began to sprout into flowers of flame.

  The virus followed rail and river into the interior of the continent, from New Orleans up the Mississippi River into the body of the nation, from Seattle to the East, from the Great Lakes training station to Chicago and from there along the railroad lines in many directions. From each original locus fingers reached out, unevenly, like sparks shooting out, often jumping over closer points to farther ones - from Boston to Newport, for example, and only then reaching backward to fill in Brockton and Providence and places in between.

  On September 28, when the Liberty Loan paraders marched through Philadelphia streets, there were as yet only seven cases reported in Los Angeles, two in San Francisco. But the virus would get there soon enough.

  *

  In Philadelphia meanwhile fear came and stayed. Death could come from anyone, anytime. People moved away from others on the sidewalk, avoided conversation; if they did speak, they turned their faces away to avoid the other person's breathing. People became isolated, increasing the fear.

  The impossibility of getting help compounded the isolation. Eight hundred fifty Philadelphia doctors and more nurses were away in the military. More than that number were sick. Philadelphia General Hospital had 126 nurses. Despite all precautions, despite wearing surgical masks and gowns, eight doctors and fifty-four nurses (43 percent of the staff) themselves required hospitalization. Ten nurses at this single hospital died. The Board of Health pleaded for help from retired nurses and doctors if they remembered 'even a little' of their profession.

  When a nurse or doctor or policeman did actually come, they wore their ghostly surgical masks, and people fled them. In every home where someone was ill, people wondered if the person would die. And someone was ill in every home.

  Philadelphia had five medical schools. Each one dismissed its classes, and third-and fourth-year students manned emergency hospitals being set up in schools and empty buildings all over the city. The Philadelphia College of Pharmacy closed as well, sending its students out to help druggists.

  Before University of Pennsylvania medical students went out to man the hospitals, they listened to a lecture from Alfred Stengel, the expert on infectious diseases who had treated the crew of the City of Exeter what seemed so long ago. Stengel reviewed dozens of ideas that had been advanced in medical journals. Gargles of various disinfectants. Drugs. Immune sera. Typhoid vaccine. Diphtheria antitoxin. But Stengel's message was simple: This doesn't work. That doesn't work. Nothing worked.

  'His suggestion for treatment was negative,' Isaac Starr, one of those Penn students, who became an internationally known cardiologist, recalled. 'He had no confidence in any of the remedies that had been proposed.'

  Stengel was correct. Nothing they were yet doing worked. Starr went to Emergency Hospital #2 at Eighteenth and Cherry Streets. He did have help, if it could be called that, from an elderly physician who had not practiced in years and who brought Starr into touch with the worst of heroic medicine. Starr wouldn't forget that, the ancient arts of purging, of venesection, the ancient art of opening a patient's vein. But for the most part he and the other students elsewhere were on their own, with little help even from nurses, who were so desperately needed that in each of ten emergency hospitals supplied by the Red Cross only a single qualified nurse was available to oversee whatever women came as volunteers. And often the volunteers reported for their duty once and, from either fear or exhaustion, did not come again.

  Starr had charge of an entire floor of an emergency hospital. He thought at first his patients had 'what appeared to be a minor illness' with fever but little else. Unhappily the clinical features of many soon changed.' Most striking again was the cyanosis, his patients sometimes turning almost black. 'After gasping for several hours they became delirious and incontinent, and many died struggling to clear their airways of a blood-tinged froth that sometimes gushed from their nose and mouth.'

  Nearly one-quarter of all the patients in his hospital died each day. Starr would go home, and when he returned the next day, he would find that between one-quarter and one-fifth of the patients in the hospital had died, replaced by new ones.

  Literally hundreds of thousands of people in Philadelphia were falling ill. Virtually all of them, along with their friends and relatives, were terrified that, no matter how mild the symptoms seemed at first, within them moved an alien force, a seething, spreading infection, a live thing with a will that was taking over their bodies - and could be killing them. And those who moved about them feared - feared both for the victims and for themselves.

  The city was frozen with fear, frozen quite literally into stillness. Starr lived twelve miles from the hospital, in Chestnut Hill. The streets were silent on his drive home, silent. They were so silent he took to counting the cars he saw. One night he saw no cars at all. He thought, 'The life of the city had almost stopped.'

  Part VI

  THE PESTILENCE

  CHAPTER TWENTY

  THIS WAS INFLUENZA, only influenza.

  This new influenza virus, like most new influenza viruses, spread rapidly and widely. As a modern epidemiologist already quoted has observed, Influenza is a special instance among infectious diseases. This virus is transmitted so effectively that it exhausts the supply of susceptible hosts. This
meant that the virus sickened tens of millions of people in the United States (in many cities more than half of all families had at least one victim ill with influenza; in San Antonio the virus made more than half the entire population ill) and hundreds of millions across the world.

  But this was influenza, only influenza. The overwhelming majority of victims got well. They endured, sometimes a mild attack and sometimes a severe one, and they recovered.

  The virus passed through this vast majority in the same way influenza viruses usually did. Victims had an extremely unpleasant several days (the unpleasantness multiplied by terror that they would develop serious complications) and then recovered within ten days. The course of the disease in these millions actually convinced the medical profession that this was indeed only influenza.

  But in a minority of cases, and not just in a tiny minority, the virus manifested itself in an influenza that did not follow normal patterns, that was unlike any influenza ever reported, that followed a course so different from the usual one for the disease that Welch himself had initially feared some new kind of infection or plague. If Welch feared it, those who suffered with the disease were terrified by it.

  Generally in the Western world, the virus demonstrated extreme virulence or led to pneumonia in from 10 to 20 percent of all cases. In the United States, this translated into two to three million cases. In other parts of the world, chiefly in isolated areas where people had rarely been exposed to influenza viruses - in Eskimo settlements of Alaska, in jungle villages of Africa, in islands of the Pacific - the virus demonstrated extreme virulence in far more than 20 percent of cases. These numbers most likely translate into several hundred million severe cases around the world in a world with a population less than one-third that of today.