The Great Influenza: The Epic Story of the Deadliest Plague in History - John M. Barry (2004)
Part IV. IT BEGINS
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.
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 than 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, Avery 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.”
Gorgas had fought his own war, to prevent epidemic disease from erupting in the camps. He had lost.
On August 27, the same day the first sailors at Commonwealth Pier fell ill, the steamer Harold Walker had departed Boston, bound for New Orleans. En route fifteen crew members had fallen ill; in New Orleans the ship unloaded its cargo and put three crewmen ashore. The three men died. By then the Harold Walker had proceeded to Mexico.
On September 4, physicians at the New Orleans naval hospital made the first diagnosis of influenza in any military personnel in the city; the sailor had arrived in New Orleans from the Northeast. That same date a second patient also reported ill with influenza; he was serving in New Orleans. Forty of the next forty-two patients who entered the hospital had influenza or pneumonia.
On September 7 three hundred sailors from Boston arrived at the Philadelphia Navy Yard. Many of them, mixing with hundreds of other sailors, were almost immediately transferred to the navy base in Puget Sound. Others had already gone from Boston to north of Chicago to the Great Lakes Naval Training Station, the largest facility of its kind in the world.
On September 8 at the Newport Naval Base in Rhode Island, more than one hundred sailors reported sick.
The virus was reaching south along the coast, jumping inland to the Midwest, spanning the nation to the Pacific.
Meanwhile, at the Chelsea Naval Hospital, Rosenau and his team of physicians were also overwhelmed—and well aware of the larger implications. Even before Avery arrived, he and Keegan had begun the first effort in the country, and possibly in the world, to create an immune serum that would work against this new mortal enemy. Simultaneously Keegan sent off a description of the disease to the Journal of the American Medical Association,warning that it “promises to spread rapidly across the entire country, attacking between 30 and 40 percent of the population, and running an acute course.”
Keegan was incorrect only in that he limited his estimate to “the entire country.” He should have said “the entire world.”
This influenza virus, this “mutant swarm,” this “quasi species,” had always held within itself the potential to kill, and it had killed. Now, all over the world, the virus had gone through roughly the same number of passages through humans. All over the world, the virus was adapting to humans, achieving maximum efficiency. And all over the world, the virus was turning lethal.
Around the world from Boston, in Bombay, which like so many other cities had endured a mild epidemic in June, the lethal virus exploded almost simultaneously. There it quickly began killing at a rate more than double that of a serious epidemic of bubonic plague in 1900.
As the virus moved, two parallel struggles emerged.
One encompassed all of the nation. Within each city, within each factory, within each family, into each store, onto each farm, along the length of the track of the railroads, along the rivers and roads, deep into the bowels of mines and high along the ridges of the mountains, the virus would find its way. In the next weeks, the virus would test society as a whole and each element within it. Society would have to gather itself to meet this test, or collapse.
The other struggle lay within one tight community of scientists. They, men like Welch, Flexner, Cole, Avery, Lewis, Rosenau, had been drafted against their will into a race. They knew what was required. They knew the puzzle they needed to solve. They were not helpless. They had some tools with which to work. They knew the cost if they failed.
But they had very little time indeed.