Table of Contents:

Foreword

Introduction

I. Storm Gathering

1. 1918

2. Master of Metamorphosis

3. H5N1

4. Playing Chicken

5. Worse Than 1918?

6. When, Not If

II. When Animal Viruses Attack

1. The Third Age

2. Man Made

3. Livestock Revolution

4. Tracing the Flight Path

5. One Flu Over the Chicken's Nest

6. Coming Home to Roost

7. Guarding the Henhouse

III. Pandemic Preparedness

1. Cooping Up Bird Flu

2. Race Against Time

3. Tamiflu

IV. Surviving the Pandemic

1. Don't Wing It

2. Our Health in Our Hands

3. Be Prepared

V. Preventing Future Pandemics

1. Tinderbox

2. Reining in the Pale Horse

Topics

References 1-3,199

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Influenza ward

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