The Great Influenza: The Epic Story of the Deadliest Plague in History - John M. Barry (2004)
Part VI. THE PESTILENCE
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.
This was still influenza, only influenza. The most common symptoms then as now are well known. The mucosal membranes in the nose, pharynx, and throat become inflamed. The conjunctiva, the delicate membrane that lines the eyelids, becomes inflamed. Victims suffer headache, body aches, fever, often complete exhaustion, cough. As one leading clinician observed in 1918, the disease was “ushered in by two groups of symptoms: in the first place the constitutional reactions of an acute febrile disease—headache, general aching, chills, fever, malaise, prostration, anorexia, nausea or vomiting; and in the second place, symptoms referable to an intense congestion of the mucous membranes of the nose, pharynx, larynx, trachea, and upper respiratory tract in general, and of the conjunctivae.” Another noted, “The disease began with absolute exhaustion and chill, fever, headache, conjunctivitis, pain in back and limbs, flushing of face…. Cough was often constant. Upper air passages were clogged.” A third reported, “In nonfatal cases…the temperature ranged from 100 to 103F. Nonfatal cases usually recovered after an illness of about a week.”
Then there were the cases in which the virus struck with violence.
To those who suffered a violent attack, there was often pain, terrific pain, and the pain could come almost anywhere. The disease also separated them, pushed them into a solitary and concentrated place.
In Philadelphia, Clifford Adams said, “I didn’t think about anything…. I got to the point where I didn’t care if I died or not. I just felt like that all my life was nothing but when I breathe.”
Bill Sardo in Washington, D.C., recalled, “I wasn’t expected to live, just like everybody else that had gotten it…. You were sick as a dog and you weren’t in a coma but you were in a condition that at the height of the crisis you weren’t thinking normally and you weren’t reacting normally, you sort of had delusions.”
In Lincoln, Illinois, William Maxwell felt “time was a blur as I was lying in that little upstairs room and I…had no sense of day or night, I felt sick and hollow inside and I knew from telephone calls my aunt had, I knew enough to be alarmed about my mother…. I heard her say, ‘Will, oh no,’ and then, ‘if you want me to…’ The tears ran down her face so she didn’t need to tell me.”
Josey Brown fell ill working as a nurse at the Great Lakes Naval Training Station and her “heart was racing so hard and pounding that it was going to jump out” of her chest and with terrible fevers she was “shaking so badly that the ice would rattle and would shake the chart attached to the end of the bed.”
Harvey Cushing, Halsted’s protégé who had already attained prominence himself but had yet to make his full reputation, served in France. On October 8, 1918, he wrote in his journal, “Something has happened to my hind legs and I wobble like a tabetic”—someone suffering from a long and wasting illness, like a person with AIDS who needs a cane—“and can’t feel the floor when I unsteadily get up in the morning…. So this is the sequence of the grippe. We may perhaps thank it for helping us win the war if it really hit the German Army thus hard [during their offensive].” In his case what seemed to be the complications were largely neurological. On October 31, after spending three weeks in bed with headache, double vision, and numbness of both legs, he observed, “It’s a curious business, unquestionably still progressing…with considerable muscular wasting…. I have a vague sense of familiarity with the sensation—as if I had met [it] somewhere in a dream.” Four days later: “My hands now have caught up with my feet—so numb and clumsy that shaving’s a danger and buttoning laborious. When the periphery is thus affected the brain too is benumbed and awkward.”
Cushing would never fully recover.
And across the lines lay Rudolph Binding, a German officer, who described his illness as “something like typhoid, with ghastly symptoms of intestinal poisoning.” For weeks he was “in the grip of the fever. Some days I am quite free; then again a weakness overcomes me so that I can barely drag myself in a cold perspiration onto my bed and blankets. Then pain, so that I don’t care whether I am alive or dead.”
Katherine Anne Porter was a reporter then, on the Rocky Mountain News. Her fiancé, a young officer, died. He caught the disease nursing her, and she, too, was expected to die. Her colleagues set her obituary in type. She lived. In Pale Horse, Pale Rider she described her movement toward death: “She lay on a narrow ledge over a pit she knew to be bottomless…and soft carefully shaped words like oblivion and eternity are curtains hung before nothing at all…. Her mind tottered and slithered again, broke from its foundation and spun like a cast wheel in a ditch…. She sank easily through deeps and deeps of darkness until she lay like a stone at the farthest bottom of life, knowing herself to be blind, deaf, speechless, no longer aware of the members of her own body, entirely withdrawn from all human concerns, yet alive with a peculiar lucidity and coherence; all notions of the mind, all ties of blood and the desires of the heart, dissolved and fell away from her, and there remained of her only a minute fiercely burning particle of being that knew itself alone, that relied upon nothing beyond itself for its strength; not susceptible to any appeal or inducement, being itself composed entirely of one single motive, the stubborn will to live. This fiery motionless particle set itself unaided to resist destruction, to survive and to be in its own madness of being, motiveless and planless beyond that one essential end.”
Then, as she climbed back from that depth, “Pain returned, a terrible compelling pain running through her veins like heavy fire, the stench of corruption filled her nostrils, the sweetish sickening smell of rotting flesh and pus; she opened her eyes and saw pale light through a coarse white cloth over her face, knew that the smell of death was in her own body, and struggled to lift her hand.”
These victims came with an extraordinary array of symptoms, symptoms either previously unknown entirely in influenza or experienced with previously unknown intensity. Initially, physicians, good physicians, intelligent physicians searching for a disease that fitted the clues before them—and influenza did not fit the clues—routinely misdiagnosed the disease.
Patients would writhe from agonizing pain in their joints. Doctors would diagnose dengue, also called “breakbone fever.”
Patients would suffer extreme fever and chills, shuddering, shivering, then huddling under blankets. Doctors would diagnose malaria.
Dr. Henry Berg at New York City’s Willard Parker Hospital—across the street from William Park’s laboratory—worried that the patients’ complaints of “a burning pain above the diaphragm” meant cholera. Noted another doctor, “Many had vomiting; some became tender over the abdomen indicating an intra-abdominal condition.”
In Paris, while some physicians also diagnosed cholera or dysentery, others interpreted the intensity and location of headache pain as typhoid. Deep into the epidemic Parisian physicians still remained reluctant to diagnose influenza. In Spain public health officials also declared that the complications were due to “typhoid,” which was “general throughout Spain.”
But neither typhoid nor cholera, neither dengue nor yellow fever, neither plague nor tuberculosis, neither diphtheria nor dysentery, could account for other symptoms. No known disease could.
In Proceedings of the Royal Society of Medicine, a British physician noted “one thing I have never seen before—namely the occurrence of subcutaneous emphysema”—pockets of air accumulating just beneath the skin—“beginning in the neck and spreading sometimes over the whole body.”
Those pockets of air leaking through ruptured lungs made patients crackle when they were rolled onto their sides. One navy nurse later compared the sound to a bowl of rice crispies, and the memory of that sound was so vivid to her that for the rest of her life she could not tolerate being around anyone who was eating rice crispies.
Extreme earaches were common. One physician observed that otitis media—inflammation of the middle ear marked by pain, fever, and dizziness—“developed with surprising rapidity, and rupture of the drum membrane was observed at times in a few hours after the onset of pain.” Another wrote, “Otitis media reported in 41 cases. Otologists on duty day and night and did immediate paracentesis [insertion of a needle to remove fluid] on all bulging eardrums….” Another: “Discharge of pus from the external ear was noted. At autopsy practically every case showed otitis media with perforation…. This destructive action on the drum seems to me to be similar to the destructive action on the tissues of the lung.”
The headaches throbbed deep in the skull, victims feeling as if their heads would literally split open, as if a sledgehammer were driving a wedge not into the head but from inside the head out. The pain seemed to locate particularly behind the eye orbit and could be nearly unbearable when patients moved their eyes. There were areas of lost vision, areas where the normal frame of sight went black. Some paralysis of ocular muscles was frequently recorded, and German medical literature noted eye involvement with special frequency, sometimes in 25 percent of influenza cases.
The ability to smell was affected, sometimes for weeks. Rarer complications included acute—even fatal—renal failure. Reye’s syndrome attacked the liver. An army summary later stated simply, “The symptoms were of exceeding variety as to severity and kind.”
It was not only death but these symptoms that spread the terror.
This was influenza, only influenza. Yet to a layperson at home, to a wife caring for a husband, to a father caring for a child, to a brother caring for a sister, symptoms unlike anything they had seen terrified. And the symptoms terrified a Boy Scout delivering food to an incapacitated family; they terrified a policeman who entered an apartment to find a tenant dead or dying; they terrified a man who volunteered his car as an ambulance. The symptoms chilled laypeople, chilled them with winds of fear.
The world looked black. Cyanosis turned it black. Patients might have few other symptoms at first, but if nurses and doctors noted cyanosis they began to treat such patients as terminal, as the walking dead. If the cyanosis became extreme, death was certain. And cyanosis was common. One physician reported, “Intense cyanosis was a striking phenomenon. The lips, ears, nose, cheeks, tongue, conjunctivae, fingers, and sometimes the entire body partook of a dusky, leaden hue.” And another: “Many patients exhibited upon admission a strikingly intense cyanosis, especially noticeable in the lips. This was not the dusky pallid blueness that one is accustomed to in a failing pneumonia, but rather [a] deep blueness.” And a third: “In cases with bilateral lesions the cyanosis was marked, even to an indigo blue color…. The pallor was of particularly bad prognostic import.”
Then there was the blood, blood pouring from the body. To see blood trickle, and in some cases spurt, from someone’s nose, mouth, even from the ears or around the eyes, had to terrify. Terrifying as the bleeding was, it did not mean death, but even to physicians, even to those accustomed to thinking of the body as a machine and to trying to understand the disease process, symptoms like these previously unassociated with influenza had to be unsettling. For when the virus turned violent, blood was everywhere.*
In U.S. Army cantonments, from 5 percent to 15 percent of all men hospitalized suffered from epistaxis—bleeding from the nose—as with hemorrhagic viruses such as Ebola. There are many reports that blood sometimes spurted from the nose with enough power to travel several feet. Doctors had no explanation for these symptoms. They could only report them.
“15% suffered from epistaxis….” “In about one-half the cases a foamy, blood-stained liquid ran from the nose and mouth when the head was lowered….” “Epistaxis occurs in a considerable number of cases, in one person a pint of bright red blood gushing from the nostrils….” “A striking feature in the early stages of these cases was a bleeding from some portion of the body…. Six cases vomited blood; one died from loss of blood from this cause.”
What was this?
“One of the most striking of the complications was hemorrhage from mucous membranes, especially from the nose, stomach, and intestine. Bleeding from the ears and petechial hemorrhages in the skin also occurred.”
One German investigator recorded “hemorrhages occurring in different parts of the interior of the eye” with great frequency. An American pathologist noted: “Fifty cases of subconjunctival hemorrhage [bleeding from the lining of the eye] were counted. Twelve had a true hemoptysis, bright red blood with no admixture of mucus…. Three cases had intestinal hemorrhage….”
“Female patients had a hemorrhagic vaginal discharge which was at first considered to be coincident menstruation, but later was interpreted as hemorrhage form the uterine mucosa.”
What was this?
Never did the virus cause only a single symptom. The chief diagnostician in the New York City Health Department summarized, “Cases with intense pain look and act like cases of dengue…hemorrhage from nose or bronchi…. Expectoration is usually profuse and may be blood-stained…paresis or paralysis of either cerebral or spinal origin…impairment of motion may be severe or mild, permanent or temporary…physical and mental depression. Intense and protracted prostration led to hysteria, melancholia, and insanity with suicidal intent.”
The impact on the mental state of the victims would be one of the most widely noted sequelae.
During the course of the epidemic, 47 percent of all deaths in the United States, nearly half of all those who died from all causes combined—from cancer, from heart disease, from stroke, from tuberculosis, from accidents, from suicide, from murder, and from all other causes—resulted from influenza and its complications. And it killed enough to depress the average life expectancy in the United States by more than ten years.
Some of those who died from influenza and pneumonia would have died if no epidemic had occurred. Pneumonia was after all the leading cause of death. So the key figure is actually the “excess death” toll. Investigators today believe that in the United States the 1918–19 epidemic caused an excess death toll of about 675,000 people. The nation then had a population between 105 and 110 million, compared to 285 million in 2004. So a comparable figure today would be approximately 1,750,000 deaths.
And there was something even beyond the gross numbers that gave the 1918 influenza pandemic terrifying immediacy, brought it into every home, brought it into homes with the most life.
Influenza almost always selects the weakest in a society to kill, the very young and the very old. It kills opportunistically, like a bully. It almost always allows the most vigorous, the most healthy, to escape, including young adults as a group. Pneumonia was even known as “the old man’s friend” for killing particularly the elderly, and doing so in a relatively painless and peaceful fashion that even allowed time to say good-bye.
There was no such grace about influenza in 1918. It killed the young and strong. Studies worldwide all found the same thing. Young adults, the healthiest and strongest part of the population, were the most likely to die. Those with the most to live for—the robust, the fit, the hearty, the ones raising young sons and daughters—those were the ones who died.
In South African cities, those between the ages of twenty and forty accounted for 60 percent of the deaths. In Chicago the deaths among those aged twenty to forty almost quintupled deaths of those aged forty-one to sixty. A Swiss physician “saw no severe case in anyone over 50.” In the “registration area” of the United States—those states and cities that kept reliable statistics—breaking the population into five-year increments, the single greatest number of deaths occurred in men and women aged twenty-five to twenty-nine, the second-greatest number in those aged thirty to thirty-four, the third-greatest in those aged twenty to twenty-four. And more people died in each of those five-year groups than the total deaths among all those over age sixty.
Graphs that correlate mortality rates and age in influenza outbreaks always—always, that is, except for 1918–19—start out with a peak representing infant deaths, then fall into a valley, then rise again, with a second peak representing people somewhere past sixty-five or so. With mortality on the vertical and age on the horizontal, a graph of the dead would like like a U.
But 1918 was different. Infants did die then in large numbers, and so did the elderly. But in 1918 the great spike came in the middle. In 1918 an age graph of the dead would look like a W.
It is a graph that tells a story of utter tragedy. Even at the front in France, Harvey Cushing recognized this tragedy and called the victims “doubly dead in that they died so young.”
In the American military alone, influenza-related deaths totaled just over the number of Americans killed in combat in Vietnam. One in every sixty-seven soldiers in the army died of influenza and its complications, nearly all of them in a ten-week period beginning in mid-September.
But influenza of course did not kill only men in the military. In the United States it killed fifteen times as many civilians as military. And among young adults still another demographic stood out. Those most vulnerable of all to influenza, those most likely of the most likely to die, were pregnant women. As far back as the year 1557, observers connected influenza with miscarriage and the death of pregnant women. In thirteen studies of hospitalized pregnant women during the 1918 pandemic, the death rate ranged from 23 percent to 71 percent. Of the pregnant women who survived, 26 percent lost the child. And these women were the most likely group to already have other children, so an unknown but enormous number of children lost their mothers.
The most pregnant word in science is “interesting.” It suggests something new, puzzling, and potentially significant. Welch had asked Burt Wolbach, the brilliant chief pathologist at the great Boston hospital known as “the Brigham,” to investigate the Devens cases. Wolbach called it “the most interesting pathological experience I have ever had.”
The epidemiology of this pandemic was interesting. The unusual symptoms were interesting. And the autopsies—and some symptoms revealed themselves only in autopsy—were interesting. The damage this virus caused and its epidemiology presented a deep mystery. An explanation would come—but not for decades.
In the meantime this influenza, for it was after all only influenza, left almost no internal organ untouched. Another distinguished pathologist noted that the brain showed “marked hyperemia”—blood flooding the brain, probably because of an out-of-control inflammatory response—adding, “the convolutions of the brain were flattened and the brain tissues were noticeably dry.”
The virus inflamed or affected the pericardium—the sac of tissue and fluid that protects the heart—and the heart muscle itself, noted others. The heart was also often “relaxed and flabby, offering strong contrast to the firm, contracted left ventricle nearly always present in post-mortem in patients dying from lobar pneumonia.”
The amount of damage to the kidneys varied but at least some damage “occurred in nearly every case.” The liver was sometimes damaged. The adrenal glands suffered “necrotic areas, frank hemorrhage, and occasionally abscesses…. When not involved in the hemorrhagic process they usually showed considerable congestion.”
Muscles along the rib cage were torn apart both by internal toxic processes and by the external stress of coughing, and in many other muscles pathologists noted “necrosis,” or “waxy degeneration.”
Even the testes showed “very striking changes…encountered in nearly every case…. It was difficult to understand why such severe toxic lesions of the muscle and the testis should occur….”
And, finally, came the lungs.
Physicians had seen lungs in such condition. But those lungs had not come from pneumonia patients. Only one known disease—a particularly virulent form of bubonic plague called pneumonic plague, which kills approximately 90 percent of its victims—ripped the lungs apart in the way this disease did. So did weapons in war.
An army physician concluded, “The only comparable findings are those of pneumonic plague and those seen in acute death from toxic gas.”
Seventy years after the pandemic, Edwin Kilbourne, a highly respected scientist who has spent much of his life studying influenza, confirmed this observation, stating that the condition of the lungs was “unusual in other viral respiratory infections and is reminiscent of lesions seen following inhalation of poison gas.”
But the cause was not poison gas, and it was not pneumonic plague. It was only influenza.