The Great Influenza

by John M. Barry

  By then the strain had lost much of its lethality. In Australia the death rates from influenza were far less than in any other Westernized nation on earth, barely one-third that of the United States, not even one-quarter that of Italy. But it was lethal enough.

  When it struck in January and February, the war had been over for more than two months. Censorship had ended with it. And so in Australia the newspapers were free to write what they wanted. And, more than in any other English-language newspaper, what they wrote of was terror.

  'We are told by some that the influenza is a return of the old 'Black death,'' reported one Sydney newspaper. Another quoted the classic, Daniel Defoe's Journal of the Plague Year (a work of fiction) for advice on precautions to take to prevent 'the influenza plague.' And headlines of terror ran day after day after day after day: 'How They Fought Plagues in the Old Days,' 'The Pneumonic Plague,' 'Fighting the Plague,' 'Plagues in the Past,''The Pagans and the Plague,''Did the Plague Start in NSW?' 'Catholic Chaplains in Plague Stricken Camps,' 'Catholics as Plague Fighters.'

  The pandemic itself (even in this its most mild incarnation in the developed world) was terrifying enough that those who lived through it as children remembered it not as influenza at all, but as plague. One Australian historian in the 1990s was recording oral histories. She was struck when people she interviewed mentioned 'Bubonic Plague,' and she explored the issue further.

  One subject told her, 'I can recall the Bubonic Plague, people dying by the hundreds around us that was come back from the First World War.'

  Another: 'We had to get vaccinated' . And I bear the scar today where I was inoculated against the Bubonic Plague.'

  Another: 'I can remember the Plague. There were doctors going around in cabs with gowns and masks over their faces.'

  Another: 'They all wore masks' after the war and how they used to be worried here in Sydney' about the Plague.'

  Another: 'We were quarantined, our food was delivered to the front door' . We didn't read about the Bubonic Plague. We lived it.'

  Another: '[T]hey called it the Bubonic Plague. But in France they called it bronchial pneumonia. See that's what they said my brother died from' .'

  Another: 'The Plague. The Bubonic Plague. Yes, I can remember that' . I always understood it was the same kind of flu that swept Europe, the Black Death in the Middle Ages. I think it was the same kind of thing, it was carried by fleas on rats.'

  Another: 'Bubonic Plague' I think it might have been called a form of influenza towards the finish' . The Bubonic Plague was a thing that stuck in my mind' '

  Yet this was after all only influenza, and the influenza that struck Australia in 1919 was weaker than it was anywhere else in the world. Perhaps the measure of the extraordinary power of the 1918 virus was this: in Australia, without a censored press, the memory that stuck in the mind was not of influenza at all. It was of the Black Death.

  *

  The virus was still not finished. All through the spring of 1919 a kind of rolling thunder moved above the earth, intermittent, unleashing sometimes a sudden localized storm, sometimes even a lightning bolt, and sometimes passing over with only a rumble of threatened violence in the distant and dark sky.

  It remained violent enough to do one more thing.

  CHAPTER THIRTY-TWO

  THE OVERWHELMING MAJORITY of victims, especially in the Western world, recovered quickly and fully. This was after all only influenza.

  But the virus sometimes caused one final complication, one final sequela. The influenza virus affected the brain and nervous system. All high fevers cause delirium, but this was something else. An army physician at Walter Reed Hospital investigating serious mental disturbances and even psychoses that seemed to follow an attack of influenza specifically noted, 'Delirium occurring at the height of the disease and clearing with the cessation of fever is not considered in this report.'

  The connection between influenza and various mental instabilities seemed clear. The evidence was almost entirely anecdotal, the worst and weakest kind of evidence, but it convinced the vast majority of contemporary observers that influenza could alter mental processes. What convinced them were observations such as these:

  From Britain: '' profound mental inertia with intense physical prostration. Delirium has been very common' . It has varied from mere confusion of ideas through all grades of intensity up to maniacal excitement.'

  From Italy: '' influenzal psychoses of the acute period' as a rule subside in two or three weeks. The psychosis, however, may pass into a state of mental collapse, with stupor which may persist and become actual dementia. In other cases' depression and restlessness' to [which] can be attributed the large number of suicides during the pandemic of influenza.'

  From France: '' frequent and serious mental disturbances during convalescence from and as a result of influenza' . The mental disturbances sometimes took on the form of acute delirium with agitation, violence, fear and erotic excitation and at other times was of a depressive nature' fear of persecution.'

  From different U.S. Army cantonments:

  '' The mental condition was either apathetic or there was an active delirium. Cerebration was slow' . The patient's statements and assurances were unreliable, a moribund person stating he felt very well' . In other cases, apprehensiveness was most striking.'

  '' The mental depression of the patient is often out of all proportion to the other symptoms.'

  '' Nervous symptoms appeared early, restlessness and delirium being marked.'

  '' melancholia, hysteria, and insanity with suicidal intent.'

  '' Toxic involvement of the nervous system was evident in all the more severe cases.'

  '' Many patients lay in muttering delirium which persisted after the temperature was normal.'

  '' Symptoms referable to the central nervous system were seen at times, as twitching of the muscles of the fingers, forearms, and face,' an active, even maniacal occasional delirium, or more usually the low mumbling type.'

  '' Infectious psychosis was seen in 18 cases, from simple transient hallucinations to maniacal frenzy with needed mechanical restraint.'

  Contemporary observers also linked influenza to an increase in Parkinson's disease a decade later. (Some have theorized that the patients in Oliver Sacks's The Awakening were victims of the 1918 influenza pandemic.) Many believed that the virus could cause schizophrenia, and in 1926, Karl Menninger studied links between influenza and schizophrenia. His study was considered significant enough that the American Journal of Psychiatry identified it as a 'classic' article and reprinted it in 1994. Menninger spoke of the 'almost unequalled neurotoxicity of influenza' and noted that two-thirds of those diagnosed with schizophrenia after an attack of influenza had completely recovered five years later. Recovery from schizophrenia is extremely rare, suggesting that some reparable process had caused the initial symptoms.

  In 1927 the American Medical Association's review of hundreds of medical journal articles from around the world concluded, 'There seems to be general agreement that influenza may act on the brain' . From the delirium accompanying many acute attacks to the psychoses that develop as 'post-influenzal' manifestations, there is no doubt that the neuropsychiatric effects of influenza are profound and varied' . The effect of the influenza virus on the nervous system is hardly second to its effect on the respiratory tract.'

  In 1934 a similar comprehensive review by British scientists agreed: 'There would appear to be no doubt that influenza exerts a profound influence on the nervous system.'

  In 1992 an investigator studying the connection between suicide and the war instead concluded, 'World War I did not influence suicide; the Great Influenza Epidemic caused it to increase.'

  A 1996 virology textbook said, 'A wide spectrum of central nervous system involvement has been observed during influenza A virus infections in humans, ranging from irritability, drowsiness, boisterousness, and confusion to the more serious manifestations of psychosis, delirium, and coma.'

  Th
e 1997 Hong Kong virus that killed six of the eighteen people infected provided some physical evidence. Autopsies of two victims showed 'edematous brains.' 'Edema' means 'swelling.' 'Most remarkably, bone marrow, lymphoid tissue, liver, and spleen of both patients were heavily infiltrated with [macrophages]' . One patient even had such cells on the meninges' (the membranes surrounding the brain and spinal cord) 'and in the white matter of the cerebrum.' The most likely reason for these macrophages to have infiltrated the brain was to follow the virus there, and kill it. And that 1997 pathology report echoes some from 1918: 'In cases accompanied by delirium, the meninges of the brain are richly infiltrated by serous fluid and the capillaries are injected.' Necropsy in the fatal cases demonstrated congestive lesions with small meningeal hemorrhages and especially in islands of edema in the cortical substance surrounding greatly dilated small vessels' hemorrhages into gray matter of the cord' [brain] tissue cells were altered in these zones of' edema.'

  In 2002 Robert Webster, one of the world's leading experts on the virus at St. Jude Children's Hospital in Memphis, observed, 'These viruses do from time to time get across to central nervous systems and play hell.' He recalled a child in Memphis who was an excellent student, got influenza, and became 'a vegetable. I've seen enough examples in my lifetime to believe' influenza can get into the brain. It's tenuous but real. Put the virus into chickens, it can go up the olfactory nerve and the chicken's dead.'

  The 1918 virus did seem to reach the brain. The war fought on that battlefield could destroy brain cells and make it difficult to concentrate, or alter behavior, or interfere with thinking, or even cause temporary psychosis. If this occurred in only a minority of cases, the virus's impact on the mind was nonetheless real.

  But that impact would, by terrible coincidence, have a profound effect indeed.

  *

  In January 1919 in France, Congressman William Borland of Kansas died, the third congressmen to be killed by the virus. That same month also in Paris, 'Colonel' Edward House, Wilson's closest confidant, collapsed with influenza - again.

  House had first gotten influenza during the first wave in March 1918, was confined to his home for two weeks, went to Washington and relapsed, and then spent three weeks in bed at the White House. Although a spring attack often conferred immunity to the virus, after the Armistice he was struck down a second time. He was in Europe then, and on November 30 he got up for the first time in ten days and met with French premier Georges Clemenceau for fifteen minutes. Afterward he noted, 'Today is the first day I have taken up my official work in person for over a week. I have had influenza 10 days and have been exceeding miserable' . So many have died since this epidemic has scourged the world. Many of my staff have died and poor Willard Straight among them.'

  Now, in January 1919, he was attacked still a third time. He was sick enough that some papers reported him dead. House wryly called the obituaries 'all too generous.' But the blow was heavy: more than a month after his supposed recovery he wrote in his diary, 'When I fell sick in January I lost the thread of affairs and I am not sure that I have ever gotten fully back.'

  There were affairs of some magnitude to attend to in Paris in early 1919.

  Representatives of victorious nations, of weak nations, of nations hoping to be born from the splinters of defeated nations, had all come there to set the terms of peace. Several thousand men from dozens of countries circled around the edges of decision making. Germany would play no role in these decisions; Germany would simply be dictated to. And among this host of nations, this virtual Tower of Babel, a Council of Ten of the most powerful nations supposedly determined the agenda. Even within this tight circle was a tighter one, the 'Big Four' - the United States, France, Britain, and Italy. And in reality only three of those four nations mattered. Indeed, only three men mattered.

  French premier Georges Clemenceau, known as 'the Tiger,' negotiated with a bullet in his shoulder, put there by an assassination attempt during the peace conference on February 19. Prime Minister Lloyd George of Great Britain faced such political problems at home he was described as 'a greased marble spinning on a glass table top.' And there was Wilson, who arrived in Europe the most popular political figure in the world.

  For weeks and then months the meetings dragged on, and tens of thousands of pages of drafts and memos and understandings went back and forth between ministers and staff. But Wilson, Clemenceau, and George did not much need these thousands of pages. They were not simply ratifying what foreign ministers and staffs had worked out, nor were they simply making decisions on options presented to them. They were themselves doing much of the actual negotiating. They were bargaining and wheedling, they were demanding and insisting, and they were rejecting.

  Often only five or six men would be in a room, including translators. Often, even when Clemenceau and George had others present, Wilson represented the United States alone, with no staff, no secretary of state, no Colonel House, who by now had been all but discarded as untrustworthy by Wilson. Interrupted only by Wilson's relatively brief return to the United States, discussions were interminable. But they were deciding the future of the world.

  *

  In October, at the peak of the epidemic in Paris, 4,574 people had died there of influenza or pneumonia. The disease had never entirely left that city. In February 1919, deaths in Paris from influenza and pneumonia climbed back up to 2,676, more than half the peak death toll. Wilson's daughter Margaret had influenza in February; she was kept in bed in Brussels at the American legation. In March another 1,517 Parisians died, and the Journal of the American Medical Association reported that in Paris 'the epidemic of influenza which had declined has broken out anew in a most disquieting manner' . The epidemic has assumed grave proportions, not only in Paris but in several of the departments.'

  That month Wilson's wife, his wife's secretary, Chief White House Usher Irwin Hoover, and Cary Grayson, Wilson's personal White House physician and perhaps the single man Wilson trusted the most, were all ill. Clemenceau and Lloyd George both seemed to have mild cases of influenza.

  Meanwhile the sessions with George and Clemenceau were often brutal. In late March Wilson told his wife, 'Well, thank God I can still fight, and I'll win.'

  On March 29, Wilson said, 'M. Clemenceau called me pro-German and left the room.'

  Wilson continued to fight, insisting, 'The only principle I recognize is that of the consent of the governed.' On April 2, after the negotiations for the day finished, he called the French 'damnable' - for him, a deeply religious man, an extreme epithet. He told his press spokesman Ray Stannard Baker, '[W]e've got to make peace on the principles laid down and accepted, or not make it at all.'

  The next day, April 3, a Thursday, at three P.M., Wilson seemed in fine health, according to Cary Grayson. Then, very suddenly at six o'clock, Grayson saw Wilson 'seized with violent paroxysms of coughing, which were so severe and frequent that it interfered with his breathing.'

  The attack came so suddenly that Grayson suspected that Wilson had been poisoned, that an assassination attempt had been made. But it soon became obvious the diagnosis was simpler, if only marginally more reassuring.

  Joseph Tumulty, Wilson's chief of staff, had stayed in Washington to monitor political developments at home. Grayson and he exchanged telegrams daily, sometimes several times a day. But the information of the president's illness was too sensitive for a telegram. Grayson did wire him, 'The President took very severe cold last night; confined to bed.' Simultaneously he also wrote a confidential letter to be hand-delivered: 'The President was taken violently sick last Thursday. He had a fever of over 103 and profuse diarrhoea' .[It was] the beginning of an attack of influenza. That night was one of the worst through which I have ever passed. I was able to control the spasms of coughing but his condition looked very serious.'

  Donald Frary, a young aide on the American peace delegation, came down with influenza the same day Wilson did. Four days later he died at age twenty-five.

  For sever
al days Wilson lay in bed, unable to move. On the fourth day, he sat up. Grayson wired Tumulty, 'Am taking every precaution with him' . Your aid and presence were never needed more.'

  Wilson for the first time was well enough to have visitors. He received American commissioners in his bedroom and said, 'Gentlemen, this is not a meeting of the Peace Commission. It is more a Council of War.'

  Just before getting sick Wilson had threatened to leave the conference, to return to the United States without a treaty rather than yield on his principles. He repeated that threat again, telling Grayson to order the George Washington to be ready to sail as soon as he was well enough to travel. The next day Gilbert Close, his secretary, wrote his wife, 'I never knew the president to be in such a difficult frame of mind as now. Even while lying in bed he manifested peculiarities.'

  Meanwhile the negotiations continued; Wilson, unable to participate, was forced to rely on House as his stand-in. (Wilson had even less trust in Secretary of State Robert Lansing, whom he largely ignored, than in House.) For several days Wilson continued to talk about leaving France, telling his wife, 'If I have lost the fight, which I would not have done had I been on my feet, I will retire in good order, so we will go home.'

  Then, on April 8, Wilson insisted upon personally rejoining the negotiations. He could not go out. Clemenceau and George came to his bedroom, but the conversations did not go well. His public threat to leave had infuriated Clemenceau, who privately called him 'a cook who keeps her trunk ready in the hallway.'

  Grayson wrote that despite 'that ill-omened attack of influenza, the insidious effects of which he was not in good condition to resist,' [the president] insisted upon holding conferences while he was still confined to his sickbed. When he was able to get up he began to drive himself as hard as before - morning, afternoon, and frequently evening conferences.'