WIRES POURED INTO the Red Cross and the Public Health Service demanding, pleading, begging for help. From Portsmouth, Virginia: “Urgently need two colored physicians wire prospects obtaining same.” From Carey, Kentucky: “Federal coal mines request immediate aid influenza…. Immediately rush answer.” From Spokane, Washington; “urgent need of four nurses to take charge other nurses furnished by local Red Cross chapter.”
The demands could not be met. Replies went back: “No colored physicians available.” “It is almost impossible to send nurses all being needed locally.” “Call for local volunteers with intelligence and practical experience.”
The failure to meet demand was not from lack of trying. Red Cross workers went from house to house searching for anyone with nursing experience. And when they knew of a skilled nurse, the Red Cross tracked her down. Josey Brown was a nurse watching a movie in a St. Louis theater when the lights went on, the screen went blank, and a man appeared onstage announcing that anyone named Josey Brown should go to the ticket booth. There she found a telegram ordering her to the Great Lakes Naval Training Station.
The Journal of the American Medical Association repeatedly—sometimes twice in the same issue—published an “urgent call on physicians for help in localities where the epidemic is unusually severe…. This service is just as definite a patriotic privilege as is that of serving in the Medical Corps of the Army or Navy…. As the call is immediate and urgent it is suggested that any physician who feels that he can do some of this work telegraph to the Surgeon General, USPHS, Washington, D.C.”
There were never enough.
Meanwhile, physicians attempted everything—everything—to save lives. They could relieve some symptoms. Doctors could address pain with everything from aspirin to morphine. They could control coughing at least somewhat with codeine and, said some, heroin. They gave atropine, digitalis, strychnine, and epinephrine as stimulants. They gave oxygen.
Some treatment attempts that went beyond symptomatic relief had solid science behind them, even if no one had ever applied that science to influenza. There was Redden’s approach in Boston based on Lewis’s experiments with polio. That approach, with variations, was tried over and over again around the world.
And there were treatments less grounded in science. They sounded logical. They were logical. But the reasoning was also desperate, the reasoning of a doctor ready to try anything, the reasoning that mixed wild ideas or thousands of years of practice and a few decades of scientific method. First-rate medical journals rejected articles about the most outlandish and ridiculous so-called therapies, but they published anything that at least seemed to make sense. There was no time for peer review, no time for careful analysis.
JAMA published the work of a physician who claimed, “Infection was prevented in practically 100% of cases when [my] treatment was properly used.” His approach had logic to it. By stimulating the flow of mucus, he hoped to help one of the first lines of defense of the body, to prevent any pathogen from attaching itself to any mucosal membrane. So he mixed irritating chemicals in powder form and blew them into the upper respiratory tract to generate large flows of mucus. The theory was sound; perhaps while mucus was actually flowing, it did some good.
One Philadelphia doctor had another idea, logical but more reaching, and wrote in JAMA that “when the system is saturated with alkalis, there is poor soil for bacterial growth.” Therefore he tried to turn the entire body alkaline. “I have uniformly employed, and always with good results, potassium citrate and sodium bicarbonate saturation by mouth, bowel and skin…. Patients must be willing to forego [sic] the seductive relief by acetylsalicylic acid [aspirin]…. My very successful experience in this epidemic cannot be dismissed as accidental or unique…. I urge its immediate trial empirically. Further investigation in laboratory or clinic may follow later.”
Physicians injected people with typhoid vaccine, thinking—or simply hoping—it might somehow boost the immune system in general even though the specificity of the immune response was well understood. Some claimed the treatment worked. Others poured every known vaccine into patients on the same theory. Quinine worked on one disease: malaria. Many physicians gave it for influenza with no better reasoning than desperation.
Others convinced themselves a treatment cured regardless of results. A Montana physician reported to the New York Medical Journal of his experimental treatment; “The results have been favorable.” He tried the treatment on six people; two died. Still he insisted, “In the four cases that recovered the results were immediate and certain.”
Two University of Pittsburgh researchers reasoned no better. They believed they had improved on the technique Redden had adopted from Flexner and Lewis. They treated forty-seven patients; twenty died. They subtracted seven deaths, arguing that the victims received the therapy too late. That still left thirteen dead out of forty-seven. Yet they claimed success.
One physician gave hydrogen peroxide intravenously to twenty-five patients in severe pulmonary distress, believing that it would get oxygen into the blood. Thirteen recovered; twelve died. This physician, too, claimed success: “The anoxemia was often markedly benefited, and the toxemia appeared to be overcome in many cases.”
Many of his colleagues tried similarly outlandish treatments and likewise claimed success. Many of them believed it.
Homeopaths believed that the epidemic proved their superiority to “allopathic” physicians. The Journal of the American Institute for Homeopathy claimed that influenza victims treated by regular physicians had a mortality rate of 28.2 percent—an absurdity: if that were so, the United States alone would have had several million deaths—while also claiming that twenty-six thousand patients treated by homeopaths, chiefly with the herbal drug gelsemium, had a mortality rate of 1.05 percent, with many homeopaths claiming no deaths whatsoever among thousands of patients. But the results were self-reported, making it far too easy to rationalize away those under their care who did die—to remove, for instance, from their sample any patient who, against their advice, took aspirin, which homeopaths considered a poison.
It was no different elsewhere in the world. In Greece one physician used mustard plasters to create blisters on the skin of influenza victims, then drained them, mixed the fluid with morphine, strychnine, and caffeine and reinjected it. “The effect was apparent at once, and in 36 to 48 or even 12 hours the temperature declined and improvement progressed.” But the mortality rate of his 234 patients was 6 percent.
It Italy one doctor gave intravenous injections of mercuric chloride. Another rubbed creosote, a disinfectant, into the axilla, where lymph nodes, outposts of white blood cells scattered through the body, lie beneath the skin. A third insisted that enemas of warm milk and one drop of creosote every twelve hours for every year of age prevented pneumonia.
In Britain the War Office published recommendations for therapy in The Lancet. They were far more specific than any guidance in the United States, and likely did relieve some symptoms. For sleep, twenty grains of bromide, opiates to relax cough, and oxygen for cyanosis. The recommendations warned that venesection was seldom beneficial, that alcohol was invaluable, but that little could be gained by giving food. For headache: antipyrin and salicylic acid—aspirin. To stimulate the heart: strychnine and digitalis.
In France, not until mid-October did the Ministry of War approach the Académie des Sciences for help. To prevent disease, some physicians and scientists advised masks. Others insisted arsenic prevented it. For treatment, the Pasteur Institute developed an antipneumococcus serum drawn as usual from horses, as well as a serum derived from the blood of patients who had recovered. (Comparisons proved the Cole and Avery serum far superior.) Anything that might lower fever was urged. Stimulants were recommended for the heart. So were “revulsions” that purged the body. Methylene blue, a dye used to stain bacteria to make them more visible under the microscope, was tried despite its known toxicity in the hopes of killing bacteria. Other doctors injected metallic solutions into muscle, so the body absorbed them gradually, or intravenously. (One doctor who injected it intravenously conceded that the treatment was “a little brutal.”) Cupping was recommended—using a flame to absorb oxygen and thus create a vacuum in a glass container, then placing it on the body, in theory to draw out poisons. One prominent physician called for “prompt bleeding” of more than pint of blood at the first signs of pulmonary edema and cyanosis, along with acetylsalicylic acid. He was hardly alone in prescribing bleeding. One physician who recommended a return to “heroic medicine” explained that the more the doctor did, the more the body was stimulated to respond. In disease as in war, he said, the fighter must seize initiative.
Across the world hundreds of millions—very likely tens of millions in the United States alone—saw no doctor, saw no nurse, but tried every kind of folk medicine or fraudulent remedy available or imaginable. Camphor balls and garlic hung around people’s necks. Others gargled with disinfectants, let frigid air sweep through their homes, or sealed windows shut and overheated rooms.
Advertisements filled the newspapers, sometimes set in the same small type as—and difficult to distinguish from—news articles, and sometimes set in large fonts blaring across a page. The one thing they shared: they all declared with confidence there was a way to stop influenza, there was a way to survive. Some claims were as simple as a shoe store’s advertising, “One way to keep the flu away is to keep your feet dry.” Some were as complex as “Making a Kolynos Gas Mask To Fight Spanish Influenza When Exposed to Infection.”
They also all played to fear. “How To Prevent Infection From Spanish Influenza…. The Surgeon General of the U.S. Army urges you to keep your mouth clean…. [use] a few drops of liquid SOZODONT.”“Help your Health Board Conquer Spanish influenza By Disinfecting your Home…Lysol Disinfectant.” “For GRIP…You are Safe When You Take Father John’s Medicine.” “Influ-BALM Prevents Spanish Flu.” “Special Notice to the Public. Telephone inquiries from Minneapolis physicians and the laity and letters from many parts of America are coming into our office regarding the use of Benetol,…a powerful bulwark for the prevention and treatment of Spanish influenza….” “Spanish influenza—what it is and how it should be treated:…Always Call a Doctor/ No Occasion For Panic…. There is no occasion for panic—influenza itself has a very low percentage of fatalities…. Use Vicks VapoRub.”
By the middle of October, vaccines prepared by the best scientists were appearing everywhere. On October 17 New York City Health Commissioner Royal Copeland announced that “the influenza vaccine discovered by Dr. William H. Park, director of the City Laboratories, had been tested sufficiently to warrant its recommendation as a preventive agency.” Copeland assured the public that “virtually all persons vaccinated with it [were] immune to the disease.”
In Philadelphia on October 19, Dr. C. Y. White, a bacteriologist with the municipal laboratory, delivered ten thousand dosages of a vaccine based on Paul Lewis’s work, with tens of thousands of dosages more soon to come. It was “multivalent,” made up of dead strains of several kinds of bacteria, including the influenza bacillus, two types of pneumococci, and several strains of other streptococci.
That same day a new issue of JAMA appeared. It was thick with information on influenza, including a preliminary evaluation of the experience with vaccines in Boston. George Whipple, another Welch product and later a Nobel laureate, concluded, “The weight of such statistical evidence as we have been able to accumulate indicates that the use of the influenza vaccine which we have investigated is without therapeutic benefit.” By “therapeutic” Whipple meant that the tested vaccines could not cure. But he continued, “The statistical evidence, so far as it goes, indicates a probability that the use of this vaccine has some prophylactic value.”
He was hardly endorsing Copeland’s statement, but at least he provided some hope.
The Public Health Service made no effort to produce or distribute any vaccine or treatment for civilians. It received requests enough. It had nothing to offer.
The Army Medical School (now the Armed Forces Institute of Pathology) in Washington did mount a massive effort to make a vaccine. They needed one. At the army’s own Walter Reed Hospital in Washington, the death rate for those with complicating pneumonia had reached 52 percent. On October 25 the vaccine was ready. The surgeon general’s office informed all camp physicians, “The value of vaccination against certain of the more important organisms giving rise to pneumonia may be considered to be established…. The Army now has available for all officers, enlisted men, and civilian employees of the Army, a lipo vaccine containing pneumococcus Types I, II, and III.”
The army distributed two million doses of this vaccine in the next weeks. This marked an enormous production triumph. Earlier a prominent British scientist had pronounced it impossible for the British government to produce even forty thousand doses on short notice. But the vaccine still protected only against pneumonias caused by Types I and II pneumococci, and it came too late; by then the disease had already passed through nearly all cantonments. When civilian physicians from New York to California begged for the vaccine from the army, the reply came back that the army had in fact produced “a vaccine for the prevention of pneumonia, but none is available for distribution.” The army feared a recrudescence among troops; it had good reason to fear one.
The Army Medical School had also produced a vaccine against B. influenzae, but of this Gorgas’s office spoke more cautiously: “In view of the possible etiologic importance of the bacillus influenzae in the present epidemic, a saline vaccine has been prepared by the Army and is available to all officers, enlisted men, and civilian employees of the Army. The effectiveness of bacillus influenzae vaccine…is still in the experimental stage.”
That army statement was not a public one. Nor really was a cautionary JAMA editorial: “Unfortunately we as yet have no specific serum or other specific means for the cure of influenza, and no specific vaccine for its prevention. Such is the fact, all claims and propagandists in the newspapers and elsewhere to the contrary not with standing…. Consequently the physician must keep his head and not allow himself to make more promises than the facts warrant. This warning applies especially to health officers in their public relations.” Nearly every issue contained a similar warning: “Nothing should be done by the medical profession that may arouse unwarranted hope among the public and be followed by disappointment and distrust of medical science and the medical profession.”
JAMA represented the American Medical Association. AMA leaders had worked for decades to bring scientific standards and professionalism to medicine. They had only recently succeeded. They did not want to destroy the trust only recently established. They did not want medicine to become the mockery it had been not so long before.
In the meantime physicians continued to try the most desperate measures. Vaccines continued to be produced in great numbers—eighteen different kinds in Illinois alone. No one had any real idea whether any would work. They had only hope.
But the reality of the disease was expressed in a recitation of events during the epidemic at Camp Sherman, Ohio, the single camp with the highest death rate. Its doctors precisely followed the standard treatment for influenza Osler had recommended in the most recent edition of his textbook—aspirin, rest in bed, gargles, and “Dover’s powders,” which were a combination of ipecac to induce vomiting and opium to relieve pain and cough. For complicating but standard pneumonias they followed “the usual recommendations for diet, fresh air, rest, mild purgation and elimination…. All cases were digitalized”—digitalis given in maximum possible dosages to stimulate the heart—“and reliance placed on soluble caffeine salt for quick stimulation. Strychnin in large doses hypodermically had a distinct value in the existing asthenia.”
Then, however, they reported their helplessness in the far too common “acute inflammatory pulmonary edema,” what today would be called ARDS. “This presented a new problem in therapy. The principles of treatment employed in pulmonary edema incident to dilation of the heart, though seemingly not indicated by the condition in question, were employed. Digitalis, a double caffeine salt, morphin [sic], and venesection”—bleeding again—“were without significant value…. Oxygen was of temporary value. Posture accomplished drainage but did not influence the end result. Pituitary solution, hypodermically, was suggested by the similarity of this condition to the results of gassing. No benefits were gained by its use.”
They tried everything, everything they could think of, until they finally took pity and stopped, abandoning some of the more brutal—and useless—treatments they had tried “on account of [their] heroic character.” By then they had seen enough of heroism from dying soldiers. They were finally willing to let them go in peace. Against this condition they could only conclude, “No especial measure was of avail.”
No medicine and none of the vaccines developed then could prevent influenza. The masks worn by millions were useless as designed and could not prevent influenza. Only preventing exposure to the virus could. Nothing today can cure influenza, although vaccines can provide significant—but nowhere near complete—protection, and several antiviral drugs can mitigate its severity.
Places that isolated themselves—such as Gunnison, Colorado, and a few military installations on islands—escaped. But the closing orders that most cities issued could not prevent exposure; they were not extreme enough. Closing saloons and theaters and churches meant nothing if significant numbers of people continued to climb onto streetcars, continued to go to work, continued to go to the grocer. Even where fear closed down businesses, where both store owners and customers refused to stand face-to-face and left orders on sidewalks, there was still too much interaction to break the chain of infection. The virus was too efficient, too explosive, too good at what it did. In the end the virus did its will around the world.
It was as if the virus were a hunter. It was hunting mankind. It found man in the cities easily, but it was not satisfied. It followed him into towns, then villages, then individual homes. It searched for him in the most distant corners of the earth. It hunted him in the forests, tracked him into jungles, pursued him onto the ice. And in those most distant corners of the earth, in those places so inhospitable that they barely allowed man to live, in those places where man was almost wholly innocent of civilization, man was not safer from the virus. He was more vulnerable.
In Alaska, whites in Fairbanks protected themselves. Sentries guarded all trails, and every person entering the city was quarantined for five days. Eskimos had no such luck. A senior Red Cross official warned that without “immediate medical assistance the race” could become “extinct.”
Neither Red Cross nor territorial government funds were available. The governor of Alaska came to Washington to beg Congress for $200,000—compared to the $1 million given to the Public Health Service for the entire country. A senator asked why the territory couldn’t spend any of the $600,000 in its treasury. The governor replied, “The people of Alaska consider that the money raised by taxes from the white people of Alaska should be spent for the improvements of the Territory. They need the money in roads a great deal…. They want to have the Indians in Alaska placed more on a parity with the Indians of other parts of the United States, where they are taken care of by the United States government.”
He got $100,000. The navy provided the collier USS Brutus to carry a relief expedition. At Juneau the party divided and went in smaller boats to visit villages.
They found terrible things. Terrible things. In Nome, 176 of 300 Eskimos had died. But it would get worse. One doctor visited ten tiny villages and found “three wiped out entirely; others average 85% deaths…. Survivors generally children…probably 25% this number frozen to death before help arrived.”
A later relief expedition followed, funded by the Red Cross, dividing itself in the Aleutian Islands into six groups of two doctors and two nurses each, then boarding other ships and dispersing.
The first group disembarked at a fishing village called Micknick. They arrived too late. Only half a dozen adults survived. Thirty-eight adults and twelve children had died. A small house had been turned into an orphanage for fifteen children. The group crossed the Naknek River to a village with a seafood cannery. Twenty-four adult Eskimos had lived there before the epidemic. Twenty-two had died; a twenty-third death occurred the day after the relief expedition arrived. Sixteen children, now orphans, survived. On Nushagak Bay the Peterson Packing Company had established a headquarters and warehouse. Nurses went hut to hut. “The epidemic of influenza had been most severe at this place, few adults living. On making a search Drs. Healy and Reiley found a few natives bedfast…. The doctors worked most faithfully but help arrived too late and five of the patients died.”
There was worse. Another rescue team reported, “Numerous villages were found but no sign of life about except for packs of half-starved, semi-wild dogs.” The Eskimos there lived in what was called a “barabara.” Barabaras were circular structures two-thirds underground; they were built like that to withstand the shrieking winds that routinely blew at hurricane force, winds that ripped conventional structures apart. One rescuer described a barabara as “roughed over with slabs of peat sod,…entrance to which is gained through a tunnel of from four to five feet in height, this tunnel being its only means of light and ventilation, in most cases; about the sides of these rooms are dug shelves and in these shelves, on mattresses of dried grasses and furs, the people sleep.”
Entire family groups, a dozen people or more, lived in this one room. “On entering these barabaras, Dr. McGillicuddy’s party found heaps of dead bodies on the shelves and floors, men, women, and children and the majority of the cases too far decomposed to be handled.”
The virus probably did not kill all of them directly. But it struck so suddenly, with such simultaneity, it left no one well enough to care for any others, no one to get food, no one to get water. And those who could have survived, surrounded by bodies, bodies of people they loved, might well have preferred to go where their family had gone, might well have wanted to no longer be alone.
And then the dogs would have come.
“It was quite impossible to estimate the number of dead as the starving dogs had dug their way into many huts and devoured the dead, a few bones and clothing left to tell the story.”
All the relief party could do was tie ropes around remains, drag them outside, and bury them.
On the opposite edge of the continent the story was the same. In Labrador man clung to existence with tenacity but not much more permanency than seaweed drying on a rock, vulnerable to the crash of surf at high tide. The Reverend Henry Gordon left the village of Cartwright in late October and returned a few days later, on October 30. He found “not a soul to be seen anywhere, and a strange, unusual silence.” Heading home, he met a Hudson’s Bay Company man who told him “sickness…has struck the place like a cyclone, two days after the Mail boat had left.” Gordon went from house to house. “Whole households lay inanimate on their kitchen floors, unable even to feed themselves or look after the fire.”
Twenty-six of one hundred souls had died. Farther up the coast, it was worse.
Of 220 people at Hebron, 150 died. The weather was already bitter cold. The dead lay in their beds, sweat having frozen their bedclothes to them. Gordon and some others from Cartwright made no effort to dig graves, consigning the bodies to the sea. He wrote, “A feeling of intense resentment at the callousness of the authorities, who sent us the disease by mail-boat, and then left us to sink or swim, filled one’s heart almost to the exclusion of all else….”
Then there was Okak. Two hundred sixty-six people had lived in Okak, and many dogs, dogs nearly wild. When the virus came it struck so hard so fast people could not care for themselves or feed the dogs. The dogs grew hungry, crazed with hunger, devoured each other, and then wildly smashed through windows and doors, and fed. The Reverend Andrew Asboe survived with his rifle beside him; he personally killed over one hundred dogs.
When the Reverend Walter Perret arrived, only fifty-nine people out of 266 still lived. He and the survivors did the only work there was. “The ground was frozen hard as iron, and the work of digging was as hard as ever work was. It took about two weeks to do it, and when it was finished it was 32 feet long, 10 feet wide, and eight feet deep.” Now began the task of dragging the corpses to the pit. They laid 114 bodies in the pit, each wrapped in calico, sprinkled disinfectants over them, and covered the trench, placing rocks on top to prevent the dogs from tearing it up.
In all of Labrador, at least one-third the total population died.
The virus pierced the ice of the Arctic and climbed the roadless mountains of Kentucky. It also penetrated the jungle.
Among Westerners the heaviest blows fell upon young adults densely packed together, civilian or military. Metropolitan Life Insurance found that 6.21 percent of all coal miners—not just those with influenza—whom it insured between the ages of twenty-five and forty-five died; in that same age group, 3.26 percent of all industrial workers it insured died—comparable to the worst rates in the army camps.
In Frankfurt the mortality rate of all those hospitalized with influenza—not all those with pneumonia—was 27.3 percent. In Cologne the mayor, Konrad Adenauer, who would become one of Europe’s great statesmen, said the disease left thousands “too exhausted to hate.”
In Paris the government closed only schools, fearing that anything else would hurt morale. The death rate there was 10 percent of influenza victims and 50 percent of those who developed any complications. “These cases,” noted one French physician, “were remarkable for the severity of the symptoms and the rapidity with which certain forms progressed to death.” Although the symptoms in France were typical of the disease elsewhere, deep into the epidemic physicians seemed to purposely misdiagnose it as cholera or dysentery and rarely reported it.
And populations whose immune systems were naive, whose immune systems had seen few if any influenza viruses of any kind, were not just decimated but sometimes annihilated. This was true not only of Eskimos but of all Native Americans, of Pacific Islanders, of Africans.
In Gambia, 8 percent of the Europeans would die, but from the interior one British visitor reported, “I found whole villages of 300 to 400 families completely wiped out, the houses having fallen in on the unburied dead, and the jungle having crept in within two months, obliterating whole settlements.”
Even when the virus mutated toward mildness, it still killed efficiently in those whose immune systems had rarely or never been exposed to influenza. The USS Logan reached Guam on October 26. Nearly 95 percent of American sailors ashore caught the disease, but only a single sailor died. The same virus killed almost 5 percent of the entire native population in a few weeks.
In Cape Town and several other cities in South Africa, influenza would kill 4 percent of the entire population within four weeks of the first reported cases. Thirty-two percent of white South Africans and 46 percent of the blacks would be attacked; 0.82 percent of white Europeans would die, along with at least 2.72 percent—likely a far, far higher percentage—of black Africans.
In Mexico the virus swarmed through the dense population centers and through the jungles, overwhelming occupants of mining camps, slum dwellers and slum landlords, and rural peasants alike. In the state of Chiapas, 10 percent of the entire population—not 10 percent of those with influenza—would die.
The virus ripped through Senegal, Sierra Leone, Spain, and Switzerland, leaving each devastated and keening with a death toll that in some areas exceeded 10 percent of the overall population.
In Brazil—where the virus was relatively mild, at least compared with Mexico or for that matter Chile—Rio de Janeiro suffered an attack rate of 33 percent.
In Buenos Aires, Argentina, the virus attacked nearly 55 percent of the population.
In Japan it attacked more than one-third of the population.
The virus would kill 7 percent of the entire population in much of Russia and Iran.
In Guam, 10 percent of the population would die.
Elsewhere the mortality exceeded even that. In the Fiji Islands, 14 percent of the population would die in the sixteen days between November 25 and December 10. It was impossible to bury the dead. Wrote one observer, “day and night trucks rumbled through the streets, filled with bodies for the constantly burning pyres.”
A very few—very few—isolated locations around the world, where it was possible to impose a rigid quarantine and where authorities did so ruthlessly, escaped the disease entirely. American Samoa was one such place. There not a single person died of influenza.
Across a few miles of ocean lay Western Samoa, seized from Germany by New Zealand at the start of war. On September 30, 1918, its population was 38,302, before the steamer Talune brought the disease to the island. A few months later, the population was 29,802. Twenty-two percent of the population died.
Huge but unknown numbers died in China. In Chungking one-half the population of the city was ill.
And yet the most terrifying numbers would come from India. As elsewhere, India had suffered a spring wave. As elsewhere, this spring wave was relatively benign. In September influenza returned to Bombay. As elsewhere, it was no longer benign.
Yet India was not like elsewhere. There influenza would take on truly killing dimensions. A serious epidemic of bubonic plague had struck there in 1900, and it had struck Bombay especially hard. In 1918 the peak daily influenza mortality in Bombay almost doubled that of the 1900 bubonic plague, and the case mortality rate for influenza reached 10.3 percent.
Throughout the Indian subcontinent, there was only death. Trains left one station with the living. They arrived with the dead and dying, the corpses removed as the trains pulled into station. British troops, Caucasians, in India suffered a case mortality rate of 9.61 percent. For Indian troops, 21.69 percent of those who caught influenza died. One hospital in Delhi treated 13,190 influenza patients; 7,044 of those patients died.
The most devastated region was the Punjab. One physician reported that hospitals were so “choked that it was impossible to remove the dead quickly enough to make room for the dying. The streets and lanes of the city were littered with dead and dying people…. Nearly every household was lamenting a death and everywhere terror reigned.”
Normally corpses there were cremated in burning ghats, level spaces at the top of the stepped riverbank, and the ashes given to the river. The supply of firewood was quickly exhausted, making cremation impossible, and the rivers became clogged with corpses.
In the Indian subcontinent alone, it is likely that close to twenty million died, and quite possibly the death toll exceeded that number.
Victor Vaughan, Welch’s old ally, sitting in the office of the surgeon general of the army and head of the army’s Division of Communicable Diseases, watched the virus move across the earth. “If the epidemic continues its mathematical rate of acceleration, civilization could easily,” he wrote in hand, “disappear…from the face of the earth within a matter of a few more weeks.”