The Great Influenza

The influenza pandemic of 1918 came in waves, as do many pandemics. While the spring wave was relatively tame, the second wave was virulent. There are three possible explanations as to why. One is that the two waves were caused by different viruses. This is unlikely. The second is that the mild virus in the United States encountered a second influenza virus in Europe and combined to create a new virus, but most influenza experts do not support this. The third, which is the most commonly accepted theory today, is that the virus adapted to man and, in doing so, became more deadly as it spread from person to person and became more comfortable living in a human host. This theory is supported in part by research into the “passage” phenomenon originally studied by French scientists in the 1870s. While a pathogen can weaken as it passes from person to person, most virologists agree with Nobel Prize-winning scientist Macfarlane Burnet who argued that the virus likely existed in its basic form by the time it arrived in France but continued to mutate there, becoming more deadly.

On June 30, 1918, a British ship called City of Exeter arrived in Philadelphia after a brief quarantine. Onboard were men who had died of pneumonia likely brought on by influenza. They seemed to have suffered greatly, with blood coming out of their noses among other unusual symptoms. As rumors swirled that the “Spanish Flu” had slowed the German offensive in Europe, Philadelphians became worried the ship itself had the virus. To quell rumors and preserve war morale, two physicians simply lied to the press that the ship did not contain influenza. By this time, the virus had already gone through several mutations, and doctors in England had begun to recognize that victims suffered extreme damage to the lungs. And though the cases from City of Exeter did not spread, US health officials took the virus seriously for the first time, as it had clearly become more deadly than it used to be.

The pandemic was spreading slowly, like when “water comes to a boil in a pot” and creates one bubble, then more bubbles, and then gradually “a roiling violent chaos” (180). The pandemic similarly spread all around the world with little flare-ups on several continents. Across the world, seemingly anywhere ships landed—Brest, France; Freetown, Sierra Leone; Boston, Massachusetts—saw outbreaks of the virus. Officials hoped the viruses were isolated, but they were not, as would be proven at Camp Devens.

Camp Devens was a large army camp 35 miles outside of Boston. It was a well-run camp with good onsite medical personnel and facilities, but it had been built to hold 36,000 men. In September 1918 it held 45,000, and it became the site of the first massive outbreak of influenza.

It is unknown exactly how Devens got the virus. It may have come from Boston Harbor, developed independently from elsewhere, or even have been the source of the minor outbreak in Boston that seemed to precede it. Regardless, when it hit Devens, it “exploded” (187). Over 1,500 men reported sick on one day, with nearly 20% of the camp on sick report. And pneumonia and deaths piled up too. Hospitalizations amassed to such an extent that doctors and nurses were overwhelmed and would no longer admit patients to the hospital, regardless of severity of illness. Doctors noted how rapidly the virus took hold and how quickly cyanosis developed. Cyanosis is when a patient starts turning blue due to the lungs’ inability to transfer oxygen into the blood. Death typically occurred shortly after cyanosis appeared.

Just as Devens was reporting its first outbreak, Welch, Cole, and Vaughan were finishing tours of southern army bases, tours they had started months earlier to inspect army medical facilities throughout the country. They stopped in Asheville, North Carolina, to relax when they got a report they needed to go to Devens right away. In Devens they saw the hospital crowded at more than twice capacity, piles of corpses littering the morgue, and incredibly young victims in the autopsy rooms. None of the men thought it could be simply influenza. Welch even said, “This must be some new kind of infection or plague” (190).

Welch made three calls that day. He called Burt Wolbach, a pathologist and Harvard professor in Boston, and asked him to perform autopsies to find out what the disease was. Then he called Oswald Avery at the Rockefeller Institute in New York to start work on treatment. And he called Charles Richard, the acting army surgeon general while Gorgas was at the front, and warned him that the disease, whatever it was, was going to spread.

But the spreading had already started. A ship that was known to be carrying infected passengers left Boston for New Orleans, where three crewmen got off the ship and died. Hundreds of sailors from Boston arrived in Philadelphia by train. Others went to Chicago. The disease was also spreading as far away as Bombay, India, where it killed at a rate double that of a bubonic plague outbreak in 1900. As the virus spread, “two parallel struggles emerged,” one involving all cities in the United States as they fought to contain the virus’s spread, and one that the “tight community of scientists” would need to fight in the little time they had (193).

On September 7, 1918, sailors from Boston arrived in Philadelphia, and what happened there “would prove—too often—to be a model for what would happen elsewhere” (198). Philadelphia was typical of other cities in the war in that it had seen an influx of new residents as wartime industries boomed. In Philadelphia the big industry was shipbuilding, but thousands of people were also working in steel, locomotive building, and munitions factories. The city was overcrowded, much like the army barracks at Camp Devens. Unlike the army barracks, though, Philadelphia was also mismanaged as one of the most poorly run and corrupt cities in America. Like many cities of the day, Philadelphia was run by a political machine. The boss, Republican State Senator Edwin Vare, controlled all political appointments and had appointed Dr. Wilmer Krusen as head of the health department. He actually was not a bad doctor, but he lacked a basic understanding of or commitment to public health issues. He was “by nature someone who thought most problems disappeared on their own” (200).

The commanding officer at the Philadelphia naval yard called in Paul Lewis of the University of Pennsylvania to help. Lewis had worked with Flexner on polio treatments years earlier and was trusted by Welch as well. He loved the lab and the rigors of the scientific method. But he recognized that the cases in Philadelphia—now known to definitely be influenza—were so severe that normal, slow scientific methods and procedures had to be thrown aside. A week after influenza arrived in Philadelphia, hundreds of people were sick, including five physicians and 14 nurses at a civilian hospital.

Meanwhile, influenza had already spread to the Great Lakes Naval Training Station near Chicago. Morgues contained bodies stacked on top of bodies. Yet despite the cases piling up in Boston, Philadelphia, and at the Great Lakes Training Station, there was no public announcement about influenza. Krusen did nothing and even denied that influenza posed any public threat. Lewis was not allowed to say anything publicly, and the newspapers assured readers that “influenza posed no danger, was as old as history, and was usually accompanied by a great miasma, foul air, and plagues of insects” (204). As the virus spread through Philadelphia, Krusen did not even cancel public events such as the Liberty Loan parade scheduled for September 28.

Adding to the problem was the total war being waged by the United States. Such war necessitated sacrifice from everyone, and sacrifice was only acceptable by the public if morale was good. Thus, there could be no news that would dispirit the populace. Free speech became stifled as well, as J. Edgar Hoover’s American Protective League arrested anyone who spoke out against the war or the nation. And bad news about influenza was considered speaking out against the war. Krusen continued to tell people they were fine and insisted on going forward with patriotic fundraisers such as the parade. Hundreds of thousands of people attended it, leading to increasing numbers of infections (since influenza spreads easily in crowds) and making Philadelphia resemble the naval stations and army camps.

While Devens had not been prepared for influenza, other army cantonments and navy bases were. Though Gorgas’s office warned the military about the influenza virus, few could contain it. The outbreak at Camp Grant, near Rockford, Illinois, was typical of that of other bases, except for one tragic incident.

Welch, Cole, and Russel visited Camp Grant in June 1918 and came away very impressed with the health protocols at the camp. Joe Capps, the chief of service at the camp hospital, had especially impressed the scientists with an innovation: Patients suffering from respiratory ailments wore gauze masks to cut down on their ability to spread the disease to other soldiers. Welch came away from the visit recommending two things be implemented in other camps: a mandatory quarantine period for all new arrivals and the use of masks for patients at all camps. Capps even wrote an article for the August 1918 issue of the Journal of the American Medical Association about the use of masks and the general point that “‘one of the most vital measures in checking contagion’ is eliminating crowding” (211). Sadly, Capp’s advice was ignored at his own camp by its new commander, Colonel Charles Hagadorn.

Given that the camp was already cold by mid-September, Hagadorn decided to crowd men into barracks instead of tents to keep them warm. He believed that “disease could be controlled” because of what he had seen Gorgas do in the Panama Canal Zone with malaria (213). And malaria was serious, unlike this virus, which “was only influenza” (213). Still, Hagadorn did order a quarantine that would keep most troops on base. When officers who had arrived from Devens reported ill, he immediately isolated them in the hospital. The problem was that they had already infected others by the time they showed symptoms. And before symptoms occurred in those they infected, those soldiers had similarly infected others, who infected still others. Thus, the quarantine did little good, as asymptomatic people still transmitted influenza. Additionally, there were too few beds, doctors, nurses, and ambulances for the sick, which numbered in the thousands.

All training at the camp ceased. Even the production of the gauze masks Capp had encouraged ceased. The only thing that went on was the disease, as “endless rows of men coughing, lying in bloodstained linen, surrounded by flies” became the norm (215). Worse, men from Camp Grant had already been transported to Camp Hancock in Georgia. As much as 10% of the train carrying those soldiers might have been infected. The situation at Hancock quickly looked like the situation at Grant. Other camps reported similar numbers. Meanwhile, at Grant, Hagadorn yielded all authority to the medical personnel. Capps tested a pneumonia serum and found that it worked fairly well, but there wasn’t anywhere near enough of it to go around. Deaths piled up, yet the Chicago Tribune reported the good news that the epidemic had been defeated at the camp. This was a lie. On October 8, 1918, Hagadorn himself died, but not of influenza. He shot himself, no doubt remembering his orders to overcrowd the barracks.

After the Liberty Loan parade in Philadelphia, Krusen finally admitted to the public that the “epidemic in the civilian population ‘was assuming the type found in naval stations and cantonments’” (220). The city had so many cases that a dozen emergency hospitals were built and that hundreds of deaths per day became normal. While Krusen did ban all public meetings in the city in early October, the press still downplayed the severity of the virus. As seemingly everyone in Philadelphia was sick or knew someone who was sick, trust in Krusen and the press disappeared.

Lewis continued trying to figure out how to fight influenza in his laboratory, but he was thrown off his usual game by an inability to use the scientific method. He had to guess at things and work in shorthand rather than probing problems deeply. And the youth of the victims horrified him, especially as his own lab assistants fell ill.

Bodies piled up throughout the city. The morgue was so full that bodies were often left in the homes where they had died, putrefying and leaking liquids. The symptoms of the virus were scary too: “Blood poured from noses, ears, eye sockets; some victims lay in agony; delirium took others away while living” (224). With distrust in official channels rising and the epidemic’s symptoms worsening, rumors circulated that this was not influenza but the plague. Nothing any doctor did seemed to work, and most nurses or doctors were unable to visit patients anyway (and when they did visit, they wore surgical masks that scared patients and their families). There simply weren’t enough healthcare workers. They tried every drug and treatment they had, including outdated ones like bleeding patients out. But nothing worked. The city became eerily still as streets became empty.

This “plague” had already spread on the Atlantic and Gulf Coasts of the United States, and it was making its way inward via rail. Soon it would be everywhere.