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“Humanity has but three great enemies: fever, famine and war; of these
by far the greatest, by far the most terrible, is fever.”
—Sir William Osler3
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Emergency hospital during 1918 pandemic, Kansas
It started, harmlessly enough, with a cough drowned out by the raging
world war. It was known as Spanish influenza only because censorship
by the warring governments wouldn’t allow reports of the spreading
illness for fear it would damage morale.4 However, Spain, being
neutral, allowed its press to publicize what was happening. The first
cable read, “A STRANGE FORM OF DISEASE OF EPIDEMIC CHARACTER HAS
APPEARED IN MADRID.” Because of the censors, even as millions were
dying around the globe, the world press was apt to report little about
the pandemic beyond what the Spanish King Alfonzo’s temperature was
that morning.5 In Spain they called it the French flu.6
“The year 1918 has gone,” the editors of the Journal of the American
Medical Association wrote in the Christmas issue, “a year momentous as
the termination of the most cruel war in the annals of the human race;
a year which marked the end, at least for a time, of man’s destruction
of man; unfortunately a year in which developed a most fatal
infectious disease….”7 That most fatal disease killed about 10 times
more Americans than did the war.8 In fact, according to the World
Health Organization (WHO), “The 1918 influenza pandemic killed more
people in less time than any other disease before or since,”9 the
“most deadly disease event in the history of humanity….”10
The word “epidemic” comes from the Greek epi, meaning “upon,” and
demos, meaning “people.” The word “pandemic” comes from the Greek word
pandemos, meaning “upon all the people.”11 Most outbreaks of disease
are geographically confined, just like most disasters in general.
Wars, famines, earthquakes, and acts of terror, for example, tend to
be localized both in time and space. We look on in horror, but may not
be affected ourselves. Pandemics are different. Pandemics are
worldwide epidemics. They happen everywhere at once, coast to coast,
and can drag on for more than a year.12 “With Hurricane Katrina,
people opened their homes, sent checks and people found safe havens,”
writes a global economic strategist at a leading investment firm, but
with a pandemic, “there is nowhere to turn, no safe place to
evacuate.”13
The word “influenza” derives from the Italian influentia, meaning
“influence,” reflecting a medieval belief that astrological forces
were behind the annual flu season.14 In 1918, though, the Germans
called it Blitzkatarrh.15 To the Siamese, it was Kai Wat Yai, The
Great Cold Fever.16 In Hungary, it was The Black Whip. In Cuba and the
Philippines, it was Trancazo, meaning “a blow from a heavy stick.” In
the United States, it was the Spanish Lady, or, because of the way
many died, the Purple Death.
Purple Death
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Influenza ward in army general hospital, Fort Porter, New York
(National Archives, 165-WW-269-B-4)
What started for millions around the globe as muscle aches and a fever
ended days later with many victims bleeding from their nostrils, ears,
and eye sockets.17 Some bled inside their eyes;18 some bled around
them.19 They vomited blood and coughed it up.20 Purple blood blisters
appeared on their skin.21
The Chief of the Medical Services, Major Walter V. Brem, described the
horror at the time in the Journal of the American Medical Association.
He wrote that “often blood was seen to gush from a patient’s nose and
mouth.”22 In some cases, blood reportedly spurted with such force as
to squirt several feet.23 “When pneumonia appeared,” Major Brem
recounted, “the patients often spat quantities of almost pure
blood.”24 They were bleeding into their lungs.
As victims struggled to clear their airways of the bloody froth that
poured from their lungs, their bodies started to turn blue from the
lack of oxygen, a condition known as violaceous heliotrope cyanosis.25
“They’re as blue as huckleberries and spitting blood,” one New York
City physician told a colleague.26 U.S. Army medics noted that this
was “not the dusky pallid blueness that one is accustomed to in
failing pneumonia, but rather [a] deep blueness…an indigo blue
color.”27 The hue was so dark that one physician confessed that “it is
hard to distinguish the colored men from the white.”28 “It is only a
matter of a few hours then until death comes,” recalled another
physician, “and it is simply a struggle for air until they
suffocate.”29 They drowned in their own bloody secretions.30
“It wasn’t always that quick, either,” one historian adds. “And along
the way, you had symptoms like fingers and genitals turning black, and
people reporting being able to literally smell the body decaying
before the patient died.”31 “When you’re ill like that you don’t
care,” recalls one flu survivor, now 100 years old. “You don’t care if
you live or die.”32
Major Brem described an autopsy: “Frothy, bloody serum poured from the
nose and mouth when the body was moved, or the head lowered…. Pus
streamed from the trachea when the lungs were removed.”33 Fellow
autopsy surgeons discussed what they called a “pathological
nightmare,” with lungs up to six times their normal weight, looking
“like melted red currant jelly.”34 An account published by the
National Academies of Science describes the lungs taken from victims
as “hideously transformed” from light, buoyant, air-filled structures
to dense sacks of bloody fluid.35
There was one autopsy finding physicians reported having never seen
before. As people choked to death, violently coughing up as much as
two pints of yellow-green pus per day,36 their lungs would sometimes
burst internally, forcing air under pressure up underneath their skin.
In the Proceedings of the Royal Society of Medicine, a British
physician noted “one thing that 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.”37 These pockets of air leaking from ruptured lungs
made patients crackle when they rolled onto their sides. In an unaired
interview filmed for a PBS American Experience documentary on the 1918
pandemic, one Navy nurse compared the sound to a bowl of Rice
Krispies. The memory of that sound—the sound of air bubbles moving
under people’s skin—remained so vivid that for the rest of her life,
she couldn’t be in a room with anyone eating that popping cereal.38
“[A] dead man has no substance unless one has actually seen him dead;
a hundred million corpses broadcast through history are no more than a
puff of smoke in the imagination.”
—Albert Camus, The Plague39
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Percent of population dying in U.S. cities
In 1918, half the world became infected and 25% of all Americans fell
ill.40 Unlike the regular seasonal flu, which tends to kill only the
elderly and infirm, the flu virus of 1918 killed those in the prime of
life Public health specialists at the time noted that most influenza
victims were those who “had been in the best of physical condition and
freest from previous disease.”41 Ninety-nine percent of excess deaths
were among people under 65 years old.42 Mortality peaked in the 20- to
34-year-old age group.43 Women under 35 accounted for 70% of all
female influenza deaths. In 1918, the average life expectancy in the
United States dropped precipitously to only 37 years.44
Calculations made in the 1920s estimated the global death toll in the
vicinity of 20 million, a figure medical historians now consider
“almost ludicrously low.”45 The number has been revised upwards ever
since, as more and more records are unearthed. The best estimate
currently stands at 50 to 100 million people dead.46 In some
communities, like in Alaska, 50% of the population perished.47
The 1918 influenza pandemic killed more people in a single year than
the bubonic plague (“black death”) in the Middle Ages killed in a
century.48 The 1918 virus killed more people in 25 weeks than AIDS has
killed in 25 years.49 According to one academic reviewer, this
“single, brief epidemic generated more fatalities, more suffering, and
more demographic change in the United States than all the wars of the
Twentieth Century.”50
In September 1918, according to the official published American
Medican Association (AMA) account, the deadliest wave of the pandemic
spread over the world “like a tidal wave.”51 On the 11th, Washington
officials disclosed that it had reached U.S. shores.52 September 11,
1918—the day Babe Ruth led the Boston Red Sox to victory in the World
Series—three civilians dropped dead on the sidewalks of neighboring
Quincy, Massachusetts.53 It had begun.
When a “typical outbreak” struck Camp Funston in Kansas, the
commander, a physician and former Army Chief of Staff, wrote the
governor, “There are 1440 minutes in a day. When I tell you there were
1440 admissions in a day, you realize the strain put on our Nursing
and Medical forces….”54 “Stated briefly,” summarized an Army report,
“the influenza…occurred as an explosion.”55
October 1918 became the deadliest month in U.S. history56 and the last
week of October was the deadliest week from any cause, at any time.
More than 20,000 Americans died in that week alone.57 Numbers, though,
cannot reflect the true horror of the time.
“They died in heaps and were buried in heaps.”
—Daniel Defoe, 1665
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Mass graves being dug in 1918
One survivor remembers the children. “We had little caskets for the
little babies that stretched for four and five blocks, eight high, ten
high.”58 Soon, though, city after city ran out of caskets.59 People
were dying faster than carpenters could make them.60 The dead lay in
gutters.61 One agonized official in the stricken East sent an urgent
warning West: “Hunt up your wood-workers and set them to making
coffins. Then take your street laborers and set them to digging
graves.”62 When New York City ran out of gravediggers, they had to
follow Philadelphia’s example and use steam shovels to dig trenches
for mass graves.63 Even in timber-rich Sweden, the dead were interred
in cardboard boxes or piled in mass graves because they simply ran out
of nails.64
Another survivor recalls:
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 are screaming, “Let me get a macaroni
box”—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 a
macaroni box, don’t take him away like that….”65
One nurse describes bodies “stacked in the morgue from floor to
ceiling like cordwood.” At the peak of the epidemic, she remembers
toe-tagging and wrapping more than one still-living patient in winding
sheets. In her nightmares, she wondered “what it would feel like to be
that boy who was at the bottom of the cordwood in the morgue.”66
They brought out their dead. Corpses were carted away in anything,
wheelbarrows—even garbage trucks.67 Often, though, the bodies were
just pushed into corners and left to rot for days. People too sick to
move were discovered lying next to corpses.68
All over the country, farms and factories shut down and schools and
churches closed. Homeless children wandered the streets, their parents
vanished.69 The New York Health Commissioner estimated that in New
York City alone, 21,000 children lost both parents to the pandemic.70
Around the world, millions were left widowed and orphaned.71 The New
York Times described Christmas in Tahiti.72 “It was impossible to bury
the dead,” a Tahitian government official noted. “Day and night trucks
rumbled throughout the streets filled with bodies for the constantly
burning pyres.”73 When firewood to burn the bodies ran out in India,
the rivers became clogged with corpses.74 In the remote community of
Okak, in northern Labrador, an eight-year-old girl reportedly survived
for five weeks at 20 below zero—among the corpses of her family. She
kept herself alive by melting snow for water with the last of her
Christmas candles while she lay listening to the sound of dogs outside
feasting off the dead.75 Colonel Victor Vaughan, acting Surgeon
General of the Army and former head of the AMA, lived through the
pandemic. “If the epidemic continues its mathematical rate of
acceleration,” Vaughan wrote in 1918, “civilization could easily
disappear from the face of the earth.”76
But the virus did stop. It ran out of human fuel; it ran out of
accessible people to infect. Those who lived through it were immune to
reinfection, so many populations were, in many respects, either immune
or dead. “[I]t’s like a firestorm,” one expert explained. “[I]t sweeps
through and it has so many victims and the survivors developed
immunity.”77 Influenza is “transmitted so effectively,” reads one
virology textbook, “that it exhausts the supply of susceptible
hosts.”78
As soon as the dying stopped, the forgetting began. As Arno Karlen
wrote in Man and Microbes, “Many Americans know more about mediaeval
plague than about the greatest mass death in their grandparents’
lives.”79 Commentators view the pandemic as so traumatic that it had
to be forced out of our collective memory and history. “I think it’s
probably because it was so awful while it was happening, so
frightening,” one epidemiologist speculates, “that people just got rid
of the memory.”80
For many, however, the virus lived on. As if the pandemic weren’t
tragic enough, in the decade that followed, a million people came down
with a serious Parkinson’s-like disease termed “encephalitis
lethargica,” the subject of the book and movie Awakenings.81 Some
researchers now consider this epidemic of neurological disease to be
“almost certainly” a direct consequence of viral damage to the brains
of survivors.82 The latest research goes a step further to suggest the
pandemic had ripples throughout the century, showing that those in
utero at the height of the pandemic in the most affected areas seemed
to have stunted lifespans and lifelong physical disability.83
“This is a detective story. Here was a mass murderer that was around
80 years ago and who’s never been brought to justice. And what we’re
trying to do is find the murderer.”
—Jeffery Taubenberger, molecular pathologist and arche-virologist84
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Johan Hultin and Mary
Where did this disease come from? Popular explanations at the time
included a covert German biological weapon, the foul atmosphere
conjured by the war’s rotting corpses and mustard gas, or “spiritual
malaise due to the sins of war and materialism.”85 This was before the
influenza virus was discovered, we must remember, and is consistent
with other familiar etymological examples—malaria was contracted from
mal and aria (“bad air”) or such quaintly preserved terms as catching
“a cold” and being “under the weather.”86 The committee set up by the
American Public Health Association to investigate the 1918 outbreak
could only speak of a “disease of extreme communicability.”87 Though
the “prevailing disease is generally known as influenza,” they
couldn’t even be certain that this was the same disease that had been
previously thought of as such.88 As the Journal of the American
Medical Association observed in October 1918, “The ‘influence’ in
influenza is still veiled in mystery.”89
In the decade following 1918, thousands of books and papers were
written on influenza in a frenzied attempt to characterize the
pathogen. One of the most famous medical papers of all time, Alexander
Fleming’s “On the Antibacterial Actions of Cultures of Penicillium,”
reported an attempt to isolate the bug that caused influenza. The full
title was “On the Antibacterial Actions of Cultures of Penicillium,
with Special Reference to Their Use in the Isolation of B.
Influenzae.” Fleming was hoping he could use penicillin to kill off
all the contaminant bystander bacteria on the culture plate so he
could isolate the bug that caused influenza. The possibility of
treating humans with penicillin was mentioned only in passing at the
end of the paper.90
The cause of human influenza was not found until 1933, when a British
research team finally isolated and identified the viral culprit.91
What they discovered, though, was a virus that caused the typical
seasonal flu. Scientists still didn’t understand where the flu virus
of 1918 came from or why it was so deadly. It would be more than a
half-century before molecular biological techniques would be developed
and refined enough to begin to answer these questions; but by then
where would researchers find 1918 tissue samples to study the virus?
The U.S. Armed Forces Institute of Pathology originated almost 150
years ago. It came into being during the Civil War, created by an
executive order from Abraham Lincoln to the Army Surgeon General to
study diseases in the battlefield.92 It houses literally tens of
millions of pieces of preserved human tissue, the largest collection
of its kind in the world.93 This is where civilian pathologist Jeffery
Taubenberger first went to look for tissue samples in the mid ’90s. If
he could find enough fragments of the virus he felt he might be able
to decipher the genetic code and perhaps even resurrect the 1918 virus
for study, the viral equivalent of bringing dinosaurs back to life in
Jurassic Park.94
He found remnants of two soldiers who succumbed to the 1918 flu on the
same day in September—a 21-year-old private who died in South Carolina
and a 30-year-old private who died in upstate New York. Tiny cubes of
lung tissue preserved in wax were all that remained. Taubenberger’s
team shaved off microscopic sections and started hunting for the virus
using the latest advances in modern molecular biology that he himself
had helped devise. They found the virus, but only in tiny bits and
pieces.95
The influenza virus has eight gene segments, a genetic code less than
14,000 letters long (the human genome, in contrast, has several
billion). The longest stands of RNA (the virus’s genetic material)
that Taubenberger could find in the soldiers’ tissue were only about
130 letters long. He needed more tissue.96
The 1918 pandemic littered the Earth with millions of corpses. How
hard could it be to find more samples? Unfortunately, refrigeration
was essentially nonexistent in 1918, a
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