THE PHILADELPHIA KILLER

Retired Air Force Captain Ray Brennan, 61, a tall, graying man who loved to collect seashells, had been having heart trouble for some years. But he was the bookkeeper of American Legion Post #42 in Towanda, Pa., and, as his sister Maize Travis said, "All he lived for was these conventions." So Brennan set off for Philadelphia last month to attend a state Legion convention--an affair traditionally devoted to parading and merrymaking. He came home "tired," his sister recalled, and three days later he had chest pains, a fever and difficulty in breathing. "He didn't want to go to the hospital," said Mrs. Travis. "We had to fight him all the way." That very night, with his lungs filling with a bloody froth, Brennan died of an apparent heart attack.

That was on July 27, and Brennan was the first. Three days later, in Clearfield, Pa., Legionnaire Frank Aveni, 60, died in much the same way. And so did three other Pennsylvania veterans. On Sunday, Aug. 1, there were six more, ranging in age from 39 to 82, scattered in towns all around the state. All of them had attended the Legion convention that was held in Philadelphia from July 21 to 24, and all had the same signs and symptoms--headaches, chest pains, high fevers and lung congestion.

The first person to see a pattern in the outbreak of illness seems to have been Dr. Ernest Campbell, a physician in Bloomsburg, Pa., who noticed that three patients with the same symptoms had been to a convention together. He called health authorities to arrange for tests but was told that the state laboratory was closed for the weekend.

On Saturday, July 31, the Legion's state adjutant, Edward Hoak, 52, learned that eight Legionnaires had developed chest pains and fevers in the week since the convention and that a ninth had died. The bad news soon grew from a trickle to a torrent. Next day a note from his secretary informed him that another Legionnaire had died; a colleague telephoned to report yet another death. Calls to other Legion officials turned up still more conventiongoers in hospitals.

Hoak went to bed that Sunday night without reaching state health authorities. On Monday morning, they called him. Having heard that several Legionnaires had entered a Williamsport hospital with symptoms of something that soon came to be known as "Legion Disease," an official in the state's division of communicable diseases asked Hoak if he was aware of an unusual number of illnesses among his colleagues. Hoak's reply confirmed the worst: there was an invisible, impersonal mass killer on the loose. The knowledge rekindled, despite all the advances of modern medicine, humanity's ancient memories of epidemics beyond understanding or control. Even as the first waves of shock and fear began to spread through Pennsylvania and beyond, the search for the killer began in one of the most intensive efforts at medical sleuthing ever undertaken in the U.S.

Now that the alert had been sounded, the case files quickly swelled. Within the week, more than 130 people, mostly men, had been stricken and hospitalized, and 25 had died. Each fresh report fueled the nation's anxiety, producing panicky calls to doctors and hospitals across the U.S. from people who developed any of the reported and not uncommon symptoms. For those relatively few who encountered the real thing, it was, as Richard Dolan of Williamsport, Pa., said, "unbelievable." His cousin, Jimmy Dolan, 39, became ill at the convention and died a week later. "It just has everybody stunned. Fellows your age, your friends, are dead. I never expected anything so sudden."

Nor did any of the 2,000 Pennsylvania Legionnaires who gathered in Philadelphia with friends and relatives for their convention. Staying in half a dozen different hotels, eating in various restaurants all over town, they listened to speeches, met old buddies and reminisced about their military experiences. "It was just like any other Legion convention," recalls Joe Chase of Philadelphia. "We were drinking, dancing, voting, having a good time. And now this horror."

The horror struck swiftly--and, it seemed, impartially. It claimed Charles Seidel, 82, a World War I veteran from Reading. People in Williamstown, an Appalachian town of clapboard houses, were stunned by the death of John Bryant Ralph, 41, a former newspaper publisher, horn player, baseball fan and one of the community's most popular citizens. Some avoided the funeral out of fear of contagion, but many others came to pay their last respects and watch sadly as Dolan, who had already attended his cousin's funeral the day before, presented the flag to Ralph's mother, Mildred Ralph. "It's terrible," said Betty Malick, 54, a friend, as she watched cemetery workers cover the grave. "The way they fought for their country and then had to lose their lives to something they didn't even know the cause of."

The fear was heightened with the report of the death of Andrew Hornack, 47, of Monessen, Pa. Hornack, a bus driver, did not attend the convention. All he did was drive the Keystone Cadet Junior Drum and Bugle Corps to Philadelphia for a parade the day before the convention closed. By the middle of the following week, he had come down with the disease. After a few days his condition worsened, and his mother insisted on taking him to the hospital, where he died. That event worried all the families of the children who had ridden Hornack's bus to Philadelphia. Said Mrs. Gertrude Tretter, a parent of one of the band members, who had acted as a chaperone on the trip: "It's really quite scary."

More reports, fresh frissons: a New Jersey truck driver, Richard Wells of Turnersville, was hospitalized with severe fever and other symptoms of the unknown illness; so was Aldo Provenzano, 46, of Cherry Hill, N.J. Wells had delivered food to one of the hotels where Legionnaires stayed during the convention; Provenzano works in Philadelphia and had lunch in at least one restaurant patronized by Legionnaires. A New York State couple who attended the convention had to be hospitalized. A hot line set up by Philadelphia city officials to handle requests for information logged up to 400 calls an hour. A few people canceled vacation plans and the Legion called off an excursion that was supposed to bring 600 boys and girls to the city.

Then, as mysteriously as it began, the outbreak seemed to level off. There were no instances of victims passing on the illness to their families and friends, and so the first terrible fears of a rampaging epidemic began to dissipate. The disease seemed to spare completely the large 41st International Eucharistic Congress of Catholics in Philadelphia last week (see RELIGION). But the mystery of what caused the Legion deaths remained to be solved, and until it was, no one could be sure the killer might not just as suddenly revive, reappear and strike in force again.

In an effort to track down the Philadelphia killer, some 150 federal and state disease detectives--physicians, biologists, chemists--set to work in Pennsylvania in a massive microbe hunt that resembled a police dragnet. Working round the clock, state officials turned an office in Harrisburg into a sort of "war room." One wall of the makeshift headquarters was covered with a map pierced with colored pins tracing the outbreak of Legionnaires' disease--red pins for deaths, yellow ones for reported illness. At several desks, shirtsleeved workers transferred information onto large sheets of graph paper. At others, workers telephoned the state's more than 300 hospitals, trying to determine the exact number of victims and the exact circumstances surrounding each case.

As in most disease detection, much of the work is being done in the laboratory. Samples of tissues, fluids and waste have been obtained from the bodies of those who have died from the disease as well as those who appear to be surviving it. Some are being analyzed at state laboratories in Philadelphia; others have been sent to the U.S. Public Health Service's Center for Disease Control in Atlanta, where researchers are performing a series of sophisticated tests to try to isolate and identify the disease agent (see box page 68).

Like police work, most medical sleuthing is done in the field by the "shoe leather" epidemiologists, some from the state's public health service, others from the CDC. They crisscrossed the state to interrogate every one of the stricken Legionnaires and the families and friends of the deceased. Their quest: a common denominator, a set of experiences that would link all the victims, such as meals taken together, rooms in the same hotel, exposure to similar contamination. Their method: careful questioning and cross-referencing.

"Hello, I'm part of the medical team investigating this weird disease," said Dr. Stephen Thacker, 28, as he sat down beside Thomas Payne's bed in Chambersburg Hospital. "How do you feel? When did you first feel sick? Where did you eat and stay in Philadelphia? When did you arrive there? When did you leave? Did you go to the testimonial dinner? Or the go-getter's breakfast? Did you go to the hospitality rooms for the state commander or other officials? Did you have any contact with pigs?"

In some ways the detectives' legwork raised more questions than it answered. A check of the hotels at which the conventiongoers had stayed revealed no outbreak of the mysterious illness among employees who had come in contact with the Legionnaires. The investigators could find no evidence that any of the victims had been exposed to pigs, which have been implicated as the animal reservoir for the swine-flu virus. Nor could the disease detectives explain another apparent contradiction: why some people developed the disease, while others, who ate the same meals, drank the same drinks or shared their rooms during the convention, did not. "This is an amazing disease," said Dr. Robert Gens, director of Pennsylvania's bureau for adult health services. "People dying quickly of interstitial pneumonia is really amazing."

The failure of the interviewers to find the answer put the main burden on the scientific sleuths working in state and federal laboratories. Their task involved a painstaking process of elimination, in which known disease agents were sought, and, if absent, exonerated.

One of the first suspects to be screened--because potentially most worrisome on a national scale--was swine flu, a seemingly virulent form of influenza that first surfaced last winter at Fort Dix, N.J., where it infected about a dozen soldiers and killed one. Swine flu may also be related to the flu that killed over half a million Americans in 1918-19 (see box). Some felt that the rapid onset of the Legionnaires' disease was typical of flu. Others thought that the appearance of a condition similar to viral pneumonia, which can also be a result of influenza, was a convincing clue.

To determine if influenza was the killer, the researchers took solutions made from tissues taken from disease victims and injected them into three kinds of cultures--chick embryos, human and monkey cells, and live mice. The viruses would indicate their presence by killing the living cells and by killing or infecting the mice. They would reveal their existence in the chicks indirectly. Fluid from the infected chick eggs was mixed with samples of normal animal blood to see if the embryonic cells would agglutinate, or "clump" together; if they did, it would mean that a virus was present.

Some doctors hoped, in a way, that the tests would show that the villain was indeed an influenza virus, since at least some vaccines against flu were already available for use. But it was not to be so simple a case. After reviewing the results of their first set of tests, scientists ruled out swine flu or any flu as a suspect.

Another early suspect was ornithosis, a disease transmitted through bird droppings and direct handling of infected birds. "The picture in Philadelphia fits ornithosis like a glove," said Dr. Pascal Imperato, chief epidemiologist of the New York City health department. "The symptoms, the fact that this is obviously a common-source outbreak, the fact that there has been no secondary spread of the disease. All these point to ornithosis above all else, and ornithosis is very hard to isolate." An Allentown, Pa., physician, Dr. Gary Lattimer, tended to agree. Assuming that the disease fitted this diagnosis, he treated three of his patients with the antibiotic tetracycline, which combats a number of illnesses, and reported that all were improving.

This hypothesis, however, also failed to test out. CDC researchers screened the tissues for evidence of antibodies to bird-carried viruses. The results were negative. CDC tests found no indication of either plague or typhoid fever. So the search went on into more exotic terrain. Tests also ruled out tularemia (rabbit fever), a deadly tropical disease known as Lassa fever, and Marburg disease, a viral disease from Africa. Further screening seemed to dismiss fungi as a suspect; no fungus is known to produce the fatally fulminating pneumonia typical of Legion disease.

Each possibility dismissed narrowed the track. By week's end Dr. Leonard Bachman, Pennsylvania's secretary of health, suspected that some unidentified natural toxin could have been responsible for the outbreak, and the CDC tended to agree. Using this suspicion as a hypothesis, epidemiologists are now taking another look at the restaurants in which the Legionnaires ate and the hotels in which they stayed, and are studying environmental conditions to determine if they might have played a role in the disease. They are investigating the possibility that the conventiongoers were exposed to some kind of poisonous substance during their stay.

Whatever killed the Legionnaires, the disease detectives concede, may, in the end, prove impossible to detect. "There's an outside chance we may never find out the cause," said CDC Director David Sencer. "I think we will. But there are times when disease baffles us all. It may be a sporadic, a onetime appearance."

Whatever the solution--or the lack of one--to the mystery of the Philadelphia killer, the outbreak served as a jarring reminder that all the marvels of modern technology have not yet made the U.S. immune to a sudden pestilence. Indeed many medical experts warn that the U.S. is still largely unprepared for an onslaught of swine flu, which some fear could hit the U.S. this winter. The new flu, although probably not as dangerous as the World War I variety, could be at least as virulent as the Asian strains that have swept the country in recent years.

President Ford has pushed for the inoculation of virtually all Americans against swine flu, a massive effort that would involve the manufacture and administration of more than 200 million shots of vaccine. Ford's program, however, has yet to get off the ground. Some doctors oppose wholesale immunization on the ground that the risks--fevers, headaches and other reactions in many of those inoculated--may not be justified in the light of the uncertainty about whether the epidemic will actually arrive. Drug manufacturers have questioned whether they can produce enough vaccine in time, while local officials have complained that the cost of the inoculations will greatly exceed the $135 million appropriated for the program by Congress.

But the biggest difficulty has been the refusal of insurance companies to cover the program. Fearful of being held liable for adverse reactions among those inoculated, one company after another refused to insure drug manufacturers, stalling the antiflu effort before it had a chance to get started.

For a while last week it seemed as if this obstacle might be overcome. Spurred by the initial fear that the Pennsylvania deaths might be due to swine flu, the House Health and Environment Subcommittee hastily approved a bill that would, in effect, make the Government liable for injury claims arising out of the immunization program. Many Congressmen were uncomfortable with the bill, which they thought might set an unwelcome precedent. Said Democratic Representative Henry Waxman of California: "I feel, as a representative of the U.S. Government, that we were blackjacked by the insurance industry." But despite their reservations, many felt sufficiently scared by the Pennsylvania tragedy to give the measure their approval.

By late last week their views had changed. Convinced by reports from both Harrisburg and Atlanta that the Legion disease was not swine flu, many Congressmen began to express second thoughts about the measure, which they felt could expose the Government to an enormous array of claims. By the end of the week the measure was languishing. Said one Senate staffer: "It is not clear now how critical it is to act precipitously on legislation whose full implication we don't understand."

His attitude is understandable. There is no need for Congress to rush pell-mell into passing legislation that could present the Government with unwanted and unnecessary obligations. But there is also a need for action to prepare for a possible swine-flu epidemic. Most Americans are probably safe from the disease that struck Pennsylvania's American Legionnaires. But few are likely to have any protection against the swine flu. Fewer still are likely to escape exposure to it if it comes. The last major flu virus caused or contributed to some 30,000 deaths when it swept the U.S. in the winter of 1968-69. Swine flu could be just as deadly.

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