Deaths of 6 to 14 Who Attended Convention Studied

Epidemiologists from the United States Public Health Service and the Pennsylvania State Health Department began an investigation yesterday of an apparent outbreak of a mysterious illness that might have caused from six to 14 deaths among 10,000 people who attended a state American Legion convention in Philadelphia July 21-24.  Estimates of the number of persons affected vary.

The Pennsylvania Health Secretary, Dr. Leonard Bachman, said at a news conference in Harrisburg that there had been 12 nonfatal cases of the illness and "at least" six deaths from an illness with similar symptoms among the legionnaires since July 25.  The ages of those who died ranged from 39 to 82 years.

After the conference, state legion officials said they knew of 14 persons who had died of similar symptoms resembling a bad cold and of another 35 people who had been hospitalized throughout the state.  Some victims were reported to have had chills, fevers to 107 degrees and chest pains.

"There's no cause for any panic," Dr. Bachman said.

In Philadelphia, where one million visitors have come for the Eucharistic Congress, the acting city health commissioner, Dr. Lewis Polk, told The Associated Press, "We are not involved in any kind of outbreak or epidemic."

A spokesman for the Center for Disease Control in Atlanta said that at Dr. Bachman's request the Public Health Service facility had sent a team of five epidemiologists to help Pennsylvania doctors determine whether the deaths were related and, if so, whether they were due to a common source outbreak of a viral, bacterial or other illness contracted at the convention.

The spokesman for the Atlanta center said that its epidemiologists did not know of a similar outbreak elsewhere at present.

When Dr. Bachman was asked whether six deaths among a group of 10,000 might not be unusual, he said:

"Certainly I considered very strongly the chance [of such a death rate].  But these men were in their forties and fifties and I find it very hard that this was coincidental.  We are not operating on the theory that this was just coincidence, but I suppose that's a possibility."

At Dr. Bachman's order, the epidemiologists are expected to visit every hospital in Pennsylvania "to locate additional cases."  Among other tasks, they will study the autopsy results, interview the patients' doctors, and collect specimens from the dead legionnaires in additional to those who are recuperating or are well, so that laboratory technicians can try to identify the cause of the apparent outbreak.

Dr. Bachman said:  "This is the kind of a detective investigation in which we are trying to get a handle on the problem.  Certainly these [deaths] resemble a virus [cause], but until we have full information we're not ruling out any cause."

Swine Flu Considered

Among the diagnostic considerations is swine flu, he said.

He added, "The investigation will get at whether any of these six [victims] were sick going to the convention.  We determined one individual was sick."

The situation apparently came to the attention of health officials through members of the Legion, Edward T. Hoak, an official of the Pennsylvania American Legion, told United Press International:

"I came in last night and found notices that three or four of the legionnaires had died.  Then we started putting it together.  They all had one thing in common.  They were all at the Philadelphia convention between July 21 and 24."

Initially, food poisoning was suspected but the pattern of illness and the types of symptoms made that a less likely diagnosis.

Bob Costello, a spokesman for Dr. Bachman, told The Associated Press:  "It doesn't seem to be related to food poisoning.  They have flu symptoms.  It looks like flu."

Dr. William Parkin, the state's chief epidemiologist, said:  "In the few households we have contacted, we have found no secondary spread to family members.  That may be the exception rather than the rule as we get more information."

However, to help prevent any possible secondary spread and to help diagnose the illness, Joseph Adams, commander of the Pennsylvania Legion, urged all legionnaires who attended the convention and their families to get in touch with a doctor immediately if they were experiencing any symptoms or discomfort.

20 FLU-LIKE DEATHS IN PENNSYLVANIA,
115 ILL, A MYSTERY

Health Officials Intensifying Search to Find Cause--Legionnaires Stricken

By LAWRENCE K. ALTMAN
Special to The New York Times

HARRISBURG, Pa., Aug. 3--The death toll from an explosive outbreak of a mysterious flu-like disease in Pennsylvania rose to 20 today as teams of Federal and state epidemiologists intensified their search to identify the cause of the illnesses.

An additional 115 people, some in serious condition, were hospitalized throughout the state with high fevers, generalized malaise, muscle aches, respiratory complaints and headaches--the symptoms most commonly associated with the disease.

Pennsylvania health officials said at a news conference here that autopsies of four persons in different hospitals indicated that they had died of a severe viral pneumonia.  The conclusion was based on findings that showed that the persons died of a type of pneumonia more generally associated with viruses than bacteria.

Attended Legion Convention

All the victims had attended a state American Legion convention in Philadelphia July 21-24.  There are no reports thus far of the disease's spreading to anyone who was not among the 10,000 people attending the convention.

Dr,. Leonard Bachman, the Pennsylvania Secretary of Health, said at the news conference that it would be at least two more days before laboratory tests by the State Health Department and the Center for Disease Control in Atlanta could determine what caused so many people to get sick and die in one of the most perplexing outbreaks of respiratory illness in recent years.

Swine influenza is among a long list of many possibilities according to Dr. Bachman, who said, "As long as we don't have the cause, no cause is ruled out.

Dr. Bachman said that if influenza virus was identified as the cause of the outbreak, then the medical teams that have been preparing for a previously planned mass swine flu immunization program would be called on to deliver vaccine against whatever type of influenza was involved.

"The biggest problem would be obtaining and distributing the vaccine," Dr. Bachman said.

He emphasized that the figures on the number of cases and deaths were not firm because "it became apparent from our reporting systems" that the number of newly reported cases had not yet leveled off.

"There is no evidence of secondary spread" of the infection from those who became ill after attending the convention to others who did not, Dr. Bachman said.  But he added that "it is too early to discount the possibility of the disease spreading to those who may have had contact with those in attendance."

"We're not certain [the outbreak] is confined to legionnaires," Dr. Bachman continued, but we have no other documented cases."

The lack of secondary spread does not necessarily preclude the possibility that the disease is infectious or contagious.

Dr. Jay Satz, who directs the State Health Department's division of virology and immunology, speculated that the virus might in some unknown way become less deadly as it passed from human to human.

Dr. Satz pointed out that in the outbreak of influenza at Fort Dix, N.J. last February, when swine influenza virus was discovered, other recruits who contracted the disease later showed evidence of a mild, symptomless infection.

Seek 'Common Denominator'

"We're trying to find the common denominator" in this outbreak, said Dr. William Parkin, the state's chief epidemiologist.  He added, "There is no common characteristic except that all the known victims were at the convention.  They stayed at a number of different hotels.  Some people were there for just one day, but not the same day."

As the epidemiologists began trying to determine what factors distinguished the group of people who became ill from those who did not, they were seeking answers to a number of other baffling questions such as the following:

Just how did the outbreak start among the legionnaires in Philadelphia?  Did one legionnaire bring the disease with him, and if so, where from?  Did the legionnaires pick up the infection from people in Philadelphia who though infected with the virus were not sick enough to experience symptoms?

Why when the disease appears to have a short incubation period, have doctors not yet detected secondary spread?

Why is there no evidence of cases among employees of the hotels where the legionnaires ate, slept and socialized.

Is the presumed causative virus a new one, a new variant of an older, well-established virus, or an unusually severe outbreak of a common respiratory virus?

If the causative virus belongs to the influenza group, why did the outbreak occur in the summer rather than later in the year, the usual influenza season.  If it is influenza, is it the Victoria strain that was prevalent last year in this country and that is causing outbreaks now in Australia, where it is winter?  Is it the swine strain?  If so, will this outbreak die out like the first one at Fort Dix?

Why have coughing and running noses not been among the reported symptoms of this respiratory disease?

To answer these and other questions, epidemiologists from the United States Public Health Service's Center for Disease Control in Atlanta and the State Health Department fanned out across Pennsylvania today to begin a series of interviews with members of the victims' households and the doctors of those affected.

The epidemiologists were trying to gather a wide variety of facts about each patient, such as age, sex, date of onset of illness, a list of symptoms and prescribed drugs, travel itinerary, and possible previous illness.  They were also seeking to learn which symptoms, if any, had developed among family members and close contacts.

Epidemiologists visited hospitals to which several patients had been admitted.  They also called officials at hospitals where just one patient was under treatment and did a telephone survey of other hospitals to find possible new cases.

They got in touch with health officials in New Jersey about two suspected cases in the southern part of that state.  And they chased as many false rumors as positive leads.

At the same time, the epidemiologists swabbed the throats of ill patients and some of their contacts.  They also collected fecal and blood samples from these individuals.  These specimens were sent to a state laboratory in Philadelphia and to the Center for Disease Control in Atlanta.

Laboratory Testing

Meanwhile, scientists and technicians in the laboratory began injecting these samples and those taken at autopsies into test tubes containing a variety of living cells and into chick embryos in the hope of identifying the positive virus.

Viruses, unlike bacteria, cannot be grown on artificial media in the laboratory.  Viruses must be grown in living cells and the process takes several days.  Bacteria can be identified in a day or two.  Further, bacteria can be identified directly by examination of their growth patterns, and under the microscope.  Viruses are identified by indirect means and can be seen only under an electron microscope.

Dr. Satz said that the specimens, which had been taken from 40 patients and packed in ice, had arrived in excellent condition.

"This means to me that if there is a virus present in these specimens, we should be able to detect it."  Dr. Satz said, adding "We have antisera [testing solutions] for all known viruses."  The scientists were concentrating on viruses known to cause respiratory infection because the autopsy findings from the first four cases uniformly showed a condition called interstitial pneumonia in both lungs.  This type of pneumonia involves inflammation of the microscopic lining between the air sacs and is typically associated with viral rather than bacterial pneumonias.

The epidemiologists and virologists work independently but in liaison.  As Dr. Parkin, the state epidemiologist, said in an interview:  "What if the laboratory results are negative and we do not find a virus?  We will need the best epidemiologic data we can get, because it may be all we get."

2 Hospitalized in Jersey

TURNERSVILLE, N.J., Aug. 3 (AP)--Two men have been admitted at hospitals in southern New Jersey with symptoms resembling the mysterious virus that has killed 20 persons who attended the American Legion convention in Philadelphia.

Officials of the State Department of Health have taken test specimens from Richard Wells, 37 years old, of Turnersville, who was admitted at Washington Memorial Hospital here last night, and Aldo Provenzano, 46, of Cherry Hill, who was admitted at West Jersey Hospital in Voorhees Township this afternoon.

Philadelphia Puzzle

Because American mortality statistics are normally low, it seems unlikely that chance alone can account for the tragic occurrence of 22 deaths and the hospitalization of at least 130 people among those associated with an American Legion convention in Philadelphia last month.  Attention to this phenomenon has been heightened by earlier warnings of the possibility of a swine flu epidemic.

In an atmosphere of understandable concern, two usually obscure medical specialties, that of the pathologist and the epidemiologist, now move to center stage.  The pathologists seek to find the cause of death and illness, analyzing tissues obtained at autopsy and also studying blood, urine, saliva and other fluids from those who are sick or who have recovered.  Every possibility is investigated, including chemical, bacterial, viral, fungal and other possible causes.  The epidemiologists are the detectives of modern medicine.  They search for some common factor linking the victims that might explain their illness.

The classic triumph for epidemiology came in 1849 when the English physician, John Snow, noticed amidst the confusion of a London cholera epidemic that the victims had all drunk from the same pump in Broad Street.  When he took the handle off the pump to prevent its use, the epidemic was virtually stopped in its tracks.

The solution to the Philadelphia mystery is not likely to be that simple.  Nevertheless, the concentration of cases so far encourages hope that a pin-pointed cause -- and not some very contagious disease -- is at the root of this illness.  Presumably, too, there is a good chance that the mystery will be unraveled as soon as pathologists' studies are completed.  Armed with the rich arsenal of scientific medicine, the investigators are fortunately well equipped to solve the alarming puzzle, to deal with the threat of infectious disease and to prevent panic.

Mystery Disease Search Is Pressed as 2 More Die

HARRISBURG, Pa., Aug. 4--Two more deaths were recorded here today as public health officials pressed their laboratory search for an unidentified organism they believe responsible for the deaths of 22 people so far who were associated with a convention in Philadelphia last month.

While researchers said today that they still had not determined the precise cause of the influenza-like infection that hospitalized at least 130 others, they ruled out most bacteria and food or water contaminants.  They suggested that the most likely source was a virus, a fungus or some toxic substance.

Moreover, they said that a continued absence of any evidence of "secondary transference" of the disease to members of the victims' families would indicate that, whatever its cause, it is less likely to be swine influenza.

Meanwhile, a physician in Allentown, Pa., disclosed today that three cases under his care there had been successfully treated with the antibiotic tetracycline.  This was done on the premise that the three had ornithosis, a viral disease transmitted through droppings and discarded feathers of birds.

Dr. Gary Lattimer said the men attended the American legion's state convention in July and returned home complaining of muscle pain, headaches, high fevers, chest pains, shortness of breath, sputum-producing coughs -- the symptoms regarded by epidemiologists as criteria for the mysterious infection....

"Not enough is known for us to rule out anything," Dr. Leonard C. Bachman, Pennsylvania's Secretary of Health, said in a briefing at which he announced the death of Mrs. Ida Disque, a 55-year-old Philadelphian who was the 22d victim....

In Philadelphia and here in the state capital, as scores of other communities across Pennsylvania, doctors' offices were flooded today with calls from anxious patients with real or imagined symptoms.

Although city officials and state authorities said there was no evidence of panic, several local medical associations said their physician-members were reporting a drastic increase in the number of calls from patients....

The first results of specimen tests are expected in Atlanta and in Philadelphia tomorrow....

Mystery Disease Called Not Contagious

WASHINGTON, Aug. 5--The Federal government's chief epidemiologist told a Senate hearing today that the number of new cases of the mysterious flu-like disease that has killed 23 persons in Pennsylvania was "diminishing rapidly" and that the ailment did not seem to be contagious.

Dr. David J. [S]encer, director of the National Center for Disease Control, told a hearing of the Senate Health subcommittee that since the ailment was not spreading it was almost certainly not swine influenza, as had first been feared.

He testified that his scientists had determined several diseases that the mystery disease was not--such as plague and several other exotic ailments -- but that they were still unsure of its identity and might never know its cause....

Doctors Doubt Flu Virus Caused Mystery Deaths
Illness Claims 23d Life, With 138 Still in Hospitals -- Gov. Shapp Calls It Too Early for Tests to Be Conclusive

By LAWRENCE K. ALTMAN
Special to The New York Times

HARRISBURG, Pa., Aug. 5--Influenza virus "is probably not" the cause of an outbreak of a mysterious flu-like illness that has now claimed its 23d victim among Pennsylvania American Legion conventioneers, Gov. Milton J. Shapp said here today.

The illness has also been linked to 138 other persons who are hospitalized throughout the state, some in critical condition, with high fevers, muscle aches and respiratory symptoms.

With the possibility of swine influenza as the cause lessened but not entirely ruled out, the Center for Disease Control in Atlanta, a unite of the United States Public Health Service, sent a team of environmental health experts to Philadelphia to investigate a possible chemical, poisonous or other toxicologic cause of the disease....

To seek clues as to what might have made the legionnaires sick after they met in Philadelphia July 21 to 25, the environmental health team will probably take samples from the air-conditioning system, carpeting, wallpaper, kitchens and other areas from the hotels where the legionnaires ate and slept, Dr. Leonard C. Bachman, the Pennsylvania Secretary of Health, said....

FLU IS RULED OUT IN MYSTERY CASES
Federal Center's Director Says Disease Does Not Pose a Major Threat

ATLANTA, Aug. 6--The director of the Federal Government's main center for public health investigations said today that the mysterious disease outbreak in Pennsylvania appeared to be subsiding and to pose no apparent threat to the health of the nation in general.

"I think all of us can breathe a sigh of relief that this is not flu," said Dr. David J. Sencer, director of the Federal Center for Disease Control, at a news conference here....

When the sudden outbreak of illness was first discovered early this week, flu was considered a possible cause.  Like flu, the outbreak seemed to have developed explosively and the deaths followed high fever and pneumonia.  Furthermore, American public health experts have been worried since February over evidence that a new flu variant against which most Americans had no immunity may be abroad in the population.  This variance of the flu virus, the so-called swine flu, is the target of the nationwide immunization program currently being organized.

Fears of Disaster Allayed

Had the outbreak in Pennsylvania been swine flu, it would have realized some of the worst fears of public health specialists that influenza might erupt throughout the nation before vaccine against it was available.  Many thousands of cases and thousands of deaths might have been expected.

Today, however, Dr. Sencer said the epidemic in Pennsylvania seemed to have peaked and to be now in the downswing.  There has been no firm evidence of its spread beyond those directly involved with the convention, he said, and none of the laboratory studies done here or elsewhere have revealed flu virus or any other viruses that could be linked to the mysterious disease.

The common bacterial diseases, including those spread through food and drink, were largely ruled out earlier in the week.  Despite laboratory search there has also been no evidence that any disease-causing fungi were involved.

Dr. Sencer said that all aspects of the laboratory work were still continuing and that infection of some kind cannot be ruled out completely.  He indicated, however, that the emphasis in the search had shifted toward toxic chemicals, either natural or man-made....

Legion Asks 10,000 for Disease Clues

By LAWRENCE K. ALTMAN
Special to The New York Times

HARRISBURG, Pa., Aug. 8-- A mysterious respiratory disease killed its 26th and 27th victims today as American Legion and state officials asked all persons who attended a convention at which the disease was apparently spread to meet at legion posts throughout Pennsylvania tomorrow night....

In the latest development in the week-long epidemiologic investigation, officials asked delegates, family members, auxiliary members and any other persons who were at the convention to go to the Legion posts to answer 23 detailed questions about activities at the convention.

The questionnaire covers all four days of the convention but some questions seem to focus on events of July 23.  Eleven victims of the disease have told investigators they spent only one day, July 23, at the convention.

Epidemiologists who designed the questionnaire hope the answers will provide clues to what caused the outbreak.  Officials have expressed bafflement about the cause and nature of the disease....

Legion Death Study Finds A Similar Outbreak in '74
3 Members of Odd Fellows Died After Pennsylvania Parley -- More Get Questionnaire in Current Case

HARRISBURG, Pa., Aug. 9--Federal and Pennsylvania health officials, already investigating an outbreak of illness that followed an American Legion convention in Philadelphia three weeks ago, have also begun looking into a just-discovered outbreak of respiratory ailments that followed another organization's convention in Philadelphia two years ago.

The American Legion outbreak has killed 27 persons and has made 128 persons sick.  Some patients remain in critical condition throughout the state....

In the other outbreak three members of the Independent Order of Odd Fellows died and 16 became ill with respiratory symptoms after 1,500 of them met in Philadelphia Sept. 14-20, 1974, according to Dr. David W. Fraser.  He heads the field investigation of the American Legion outbreak for the Federal Center of Disease Control in Atlanta.  The Odd Fellows stayed at the same hotels the Legionnaires did, from July 21-24.

At a news conference, Dr. Fraser said it was "hard to pin down" what illness the Odd Fellows had had because the symptoms were not specific.  Dr. Fraser said "we're not certain what it was, if it was a disease."

Dr. Denis Lucey 3d, a Pennsylvania health official, said that members of the Odd Fellows had just notified health officials about their experience after reading about the Legion outbreak.

Connection Unsure

The health officials, emphasized that it was not clear at present if, or how, the outbreak among the Odd Fellows and the legionnaires were linked.  However, this unusual retrospective investigation was among the scores of leads that epidemiologists were pursuing in their effort to solve the American Legion mystery....

On the basis of preliminary data, epidemiologists have calculated that the victims began to become ill about six days after exposure to whatever it was that caused the outbreak.  The incubation period ranged from two to 10 days.

What caused the outbreak?  What was the common source?  Why did 155, relatively few of the legionnaires, become sick?  Were there 10,000 people at the convention as Legion officials say?  Or 2,5000 as the hotel registration seemed to show?  How many came who did not stay at hotels?

Those questions are among hundreds that the investigating epidemiologists have asked themselves.

As Dr. Fraser said, "Lots of thoughts go through my head but I've got to generate a firm hypothesis and then test it."....

The situation closest resembling the present outbreak that Dr. Fraser could recall was a pneumonia outbreak that involved 94 people in July and August of 1965 at St. Elizabeths Hospital in Washington [D.C.].

The death rate in that outbreak was 17 percent, the same as in the American Legion case.

However, unlike the American Legion outbreak, patients at St. Elizabeth's developed a staggered gait in addition to their respiratory symptoms.  The neurological symptom has not appeared in the present outbreak.

The cause of the St. Elizabeths outbreak was never discovered....

"The pathology reports are inconclusive," Dr. Fraser said.  The reports show nonspecific changes such as protein rich material in the air sacks and swelling in the spaces between the air sacks.

The fat deposits seen in microscopic examination of the liver could have been due to the drinking of alcohol to excess at other times and places or due to an unknown chemical, [poison] or other toxin, Dr. Fraser said.

The medical detectors are now collecting material from all the autopsies so they can be reviewed by an expert in one center.

The science of pathology involves visual not written comparisons.  Accordingly, it is considered important that the expert review all the material for subtle similarities that could provide the clue to the cause of the Legion outbreak.  Presumably, a pathologist would review the material from the autopsies -- if they were done -- in the Odd Fellows outbreak.

Doctors Find Hint The Legion Illness May Have Spread

HARRISBURG, Pa., Aug. 13--Epidemiologists investigating the mysterious outbreak of the so-called legionnaire's disease, say they have found indications that two persons who attended the International Eucharistic Congress in Philadelphia last week may have contracted the respiratory illness.

The findings were presented today at an Atlanta meeting of Federal Epidemiologists, officials from the Pennsylvania and Philadelphia health departments and experts in toxicology, pharmacology and pathology.

The two cases, both involving men hospitalized Wednesday suffering from an illness with symptoms like those of the legionnaire's disease, are the first indication that the malady might have affected persons not directly connected with the legion meeting....

In addition to the two cases described by Dr. Polk, medical detectives are investigating the possibility that the disease struck some people who attended a candlemakers' convention in Philadelphia that ended July 21.

The end of that convention coincided with the beginning of the legion's convention, which was held July 21 to July 24.

The number of people associated with that convention who were affected by or died of the mysterious disease has fluctuated as medical investigation progress.

At the last news conference that was held by Pennsylvania health officials three days ago, the case total was 155, including 27 deaths.

However, at the meeting in Atlanta today, epidemiologists presented a revised case count of 145, including 24 deaths.  The new case count was based on investigations in Philadelphia yesterday by a team headed by Dr.. David Fraser....

Mystery Disease Takes 26th Life as New Tests Further Lessen Likelihood That a Virus Is Its Cause

HARRISBURG, Pa., Aug. 17--Scientists reported today new test results further reducing the likelihood that a virus caused the mysterious disease discovered among participants in the Pennsylvania American Legion convention.

At the same time, the disease claimed another life, raising the death toll to 26, and the case count rose to 173, including the 26 fatalities.  Among the additions to the list were two persons who had become ill after attending the International Eucharistic Congress in Philadelphia earlier this month.

They were the third and fourth cases involving participants in the congress.  The first two were placed on the list last week.

A state health official meanwhile issued orders banning the use of metal instruments in future autopsies on victims of the disease.  The order was issued because the possibility had been raised that metal instruments used in the last two autopsies might have contaminated tissue samples on which tests for nickel were to be conducted.

Health officials said one of the first patients who attended the eucharistic congress was hospitalized in Pennsylvania with fever and respiratory symptoms, but the declined to provide further details.

Morton D. Rosen, Pennsylvania's Deputy Secretary for Health, did say in an interview, however:  "This person went to the Bellevue Stratford Hotel after July 1."

That hotel is the focus of an attempt to trace the cause of the disease among legionnaires, many of whom stayed there during the state convention July 21-24....

Many knives contain nickel.  Dr. Sunderman said in an earlier interview that he suspected human tissues could become contaminated with nickel from nickel-bearing knives used in autopsies....

Meanwhile, Dr. Jay Satz, who is the Pennsylvania Health Department's chief virologist, said in a telephone interview from his laboratory in Philadelphia that he had not detected evidence of viral infection in blood samples taken from 14 survivors of the mysterious disease....

Dr. Satz said that the test results indicated that if a virus was involved in the outbreak, it was not of a variety usually seen in the community.

"I do not totally rule out a virus [as the cause] but if it is one, it's a new one that would show different growth characteristics and new immunological responses," he said....

Philadelphia Hotel Acts to Save Image In Mystery Disease

PHILADELPHIA, Aug. 19 (AP)--The Bellevue Stratford Hotel has asked its public relations agency, Spiro & Associates to conduct a campaign to restore its image, which had been damaged by the mystery of "legionnaires' disease."

The hotel, which is on Broad Street, has been the preferred lodging of most of the city's visiting dignitaries since it opened in 1904.  A state American Legion convention was held there last month.

Twenty-six people have died, and 146 others have been infected by the unidentified disease.

Several person who attended the International Eucharistic Congress and stayed at the Bellevue also became ill.

Yesterday, city health officials cited the hotel for 19 plumbing violations.

The lobby of the stately hotel is nearly empty.  The dining room, where reservations are usually a must, had only four occupied tables yesterday.  Usually, 200 people eat breakfast at the hotel's coffee shop each day.  Only a handful appeared yesterday....

Bartender's Autopsy Seeks Link to Mystery Disease

HARRISBURG, Pa., Aug. 31--Extraordinary precautions were taken at the autopsy today of a bartender at the Bellevue Stratford Hotel in Philadelphia to determine if he might have been the victim of a mysterious disease that has killed 28 people and sickened another 151 in Pennsylvania.

The bartender ... died at Burlington County Memorial Hospital in Mount Holly, N.J., last night after developing symptoms similar to those experienced by victims of the epidemic.  He was admitted on Aug. 23 with a high fever and evidence of pneumonia.

However [he] suffered from chronic lymphocytic leukemia, a form of blood cancer, and his death was tentatively attributed to pneumonia as a complication of the blood disorder....

Just one Bellevue Stratford Hotel employee is on the official case list, Dr. Lewis Polk, Philadelphia health commissioner, said in a telephone interview last week.  That employee was listed as [an] air conditioning maintenance worker....

In another matter, Dr. Leonard Bachman, the Pennsylvania Secretary for Health, strongly criticized the Center for Disease Control and other Federal health officials for their "inability to provide leadership to the nationwide swine flu campaign."

The Legion Disease:  So Little Still Is Known About the Body

Stumped.  Baffled.  Five weeks after a mysterious illness killed 26 persons associated with a Philadelphia American Legion convention, two more from a Roman Catholic meeting in the same city, and a 29th victim associated with neither event, the cause was no clearer than initially.  The hordes of eager young field investigators loosed on the Pennsylvania countryside, the troops of epidemiologists, the phalanxes of sober pathologists -- all have come to dead ends in their investigations of the epidemic which, itself, seems to have burned out spontaneously.

Nickel carbonyl, an industrial toxin few had ever heard of five weeks ago, has been prominently proposed as the cause of the disease, because nickel carbonyl produces  similar symptoms--damage to the lungs and other organs, fevers, an incubation period of a few days.  Tests by an expert on nickel poisoning at the University of Connecticut have shown high levels of nickel in tissue samples of disease victims.  But there is still not the slightest indication how, or if, nickel carbonyl was present in Philadelphia when the legionnaires got sick.  And many doctors continue to doubt that the nickel compound will ever be proven to have caused the epidemic.

Research on the illness continues.  Microscope slides of pathologic tissue are being exchanged among various experts throughout the country, and plasma specimens are being re-examined.  An answer may yet be found, but, in diseases of populations as in diseases of individuals, the longer after the initial "work-up" the cause remains unknown, the less likely it ever will be known.

The "Legion epidemic" epitomizes some of the frustrations of modern medicine.  With all that is apparently known of disease there is still not the slightest clue to its cause.  It is not even known if the epidemic was an infectious disease, much less whether it was an infective virus, much less which virus.  At this point the epidemiologists studying it can merely mutter, "Maybe something in the air, maybe something in the water, maybe something in the food," and go back to their slides and chromatographs.

Assuming that there really was an epidemic with a common cause, as opposed to a bizarre coincidental upswing in the number of deaths that might be expected among any large group of men primarily in late middle age, we should not be too surprised if the agent is never identified.  Disease detectives, like homicide detectives, have their share of unsolved cases.

The truth is that physicians and scientists know comparatively little about how the body functions, and not much more about how it malfunctions....

This is not to indicate despair at the state of modern medicine, only to recall how much mystery remains.  Because of this, physicians will continue -- must continue -- to apply partially understood therapies to barely-understood illness.  It is foolish for critics of medicine to puff up righteously about "unproven therapies."  Very little in medicine is proven.  Diagnosis and treatment move haltingly, ahead a few steps here, back a few there, into blind alleys often enough.  Breakthroughs are rare, increments common.  The practicing physician learns to live with this frustration, though not to enjoy it....

Tests Cast Doubts on Nickel Carbonyl as Cause of Legionnaires' Illness

Nickel carbonyl, one of several possible causes suggested for the Philadelphia mystery disease, has emerged as the subject of not only one of the most tantalizing hyp[ot]heses but also in some ways one of the most improbable.

There are ways in which nickel carbonyl poisoning closely resembles the symptoms of the so-called "legionnaires disease" in Philadelphia.  But there seems almost no way the Philadelphia victims could have come in contact with the toxic substance, especially in the quantities needed to fell 179 persons....

Dr. F. William Sunderman Sr., director of the Institute for Clinical Sciences in Philadelphia and, with his son, a recognized expert on nickel carbonyl poisoning, has said that the compound can form spontaneously under a variety of everyday conditions.

However, his son, Dr. F. William Sunderman Jr., of the University of Connecticut, disagrees.  "You might get very small amounts forming like that [accidentally] but not lethal amounts that would affect lots of people," he said....

"If it does turn out to be nickel," the younger Dr. Sunderman said, "I can't see any other way for them to get it expect that it was a willful act -- somebody bringing it in there deliberately."

The possibility of sabotage or murder as the cause of the Philadelphia disease has been quietly speculated upon by various investigators and officials but, pending a possible conclusive finding of nickel carbonyl in the victim's lungs, there is no reported evidence to support such a theory.

'Legionnaires' Disease'

The most disturbing aspect of the outbreak of so-called "legionnaires' disease" is that one of the most intensive and extensive epidemiological investigations in history has had no luck in ascertaining its cause.  A large number of possible factors have been eliminated, but the actual responsible cause is as unknown now as when the first American Legion member fell ill last July.

In this unsatisfactory situation a closer look is being taken now by epidemiologists at the course followed by the Pennsylvania State Department of Health and the  Federal Center for Disease control in Atlanta in their studies of the ailment's origins.  For months before the disease struck so unexpectedly, the C.D.C. in Atlanta had been warning the American people that an epidemic of swine flu might be on the way and that unprecedented measures were required to meet that menace.  The news of the first deaths of American Legion members fitted so well into the swine flu theory that apparently the epidemiological investigation began with the researchers under the impression that their predictions about a deadly influenza outbreak were being realized.

Now everyone concerned knows that legionnaires' disease is not swine flu; as a matter of fact no cases of swine flu have been observed anywhere in the world for many months.  Now, too, scientists' opinions about the possible cause of legionnaires' disease have turned toward the area of poisons, of toxic substances that number in the thousands.  Unfortunately, however, because of the assumptions on which the epidemiological study began early last August, samples of victims' tissues and body excreta which are needed to investigate different toxins are now exceedingly scarce.  This shortage could prove decisive in leaving the mystery unsolved.

Even laymen may wonder why toxicologists played so little role in the early state and Federal investigations, and may hope that the initial errors made in studying legionnaires' disease will not be repeated in future investigations of outbreaks of mysterious illnesses.  The Center for Disease Control has not added to the luster of its record by its performance here.

POSSIBLE NEW VIRUS FOUND IN OUTBREAK
But Doctor in Jersey Says Study Has Not Shown If It Is Cause of Legionnaire's Disease

Preliminary results of tests done in the New Jersey Department of Health on specimens from a man who died in the outbreak of Legionnaire's disease last summer showed evidence of what may be a new virus, according to an assistant New Jersey Health Commissioner.

But the assistant commissioner, Dr. Martin Goldfield, who did the viral studies, said in an interview that it was too early to know if the possible new virus was the cause of Legionnaire's disease.  The mysterious malady killed 29 people and made 151 others sick after a state American Legion convention in Philadelphia last August.

Dr. Goldfield said that his team of scientists in Trenton has isolated from fecal specimens from the victim of Legionnaire's Disease a spherical viral particle about 20 to 22 nanometers in size, that is, about one-millionth of an inch.

Dr. Goldfield said that after he collected samples from the man in a New Jersey hospital, his team found that the virus would grow in two independent testing systems in the laboratory.  The first is a collection of human cancer cells called rhabdomyosarcoma.  The second is green monkey cells.

"We have an interesting lead which may be important, or which may be nothing with respect to Legionnaire's disease," Dr. Goldfield said....

Dr. Goldfield said that he had no doubts that the virus isolated in the New Jersey laboratories had come from the victim of Legionnaire's disease.  But he emphasized that it was impossible to extrapolate the results of that single case to the entire outbreak.

Further, he said, the virus may have no relationship to the victim's disease, that is, it was just a harmless virus that was in the victim's stool, the virus could explain the victim's illness but have nothing to do with the 179 other cases on the official list.

What made the finding so interesting was the fact that all tests to date show it to be a previously unknown virus, or even a combination of two viruses.

"What we're dealing with appears to be something new," Dr. Goldfield said.  "But whether it is a new agent to which some humans have antibody (a protective blood substance) indicating that it's a previously undescribed human pa[t]hogen (disease producer), or whether it has significance to the basic issue, I don't know."....

In the early phase of the testing, Dr. Goldfield's team found that samples derived from the fecal specimens caused illness, in suckling mice but not in other conventional testing systems.  After the researchers succeeded in purifying the virus from mouse carcasses, they did a series of immunological tests that allowed them to identify the virus under the electron microscope.

It was only when they began to use green monkey cells and the human rhabdomyosarcoma cells -- uncommon testing systems -- that they succeeded in getting the virus to grow in independent systems.

In the monkey cells, Dr. Goldfield said, "to our great surprise we found the virus" quickly lost its ability to produce disease in the suckling mice.  However, the virus continued to produce damage in the green monkey cells.

Other tests have led Dr. Goldfield to suspect that his team is probably dealing with two viruses.

Philadelphia Hotel Closing, a Casualty Of 'Legion Disease'
Special to The New York Times

PHILADELPHIA, Nov. 10--The Bellevue Stratford, this city's principal convention hotel and a cultural landmark in whose ballroom thousands of Main Line debutantes waltzed into Philadelphia society, became today another casualty of last summer's unsolved mystery epidemic of "legionnaires' disease."

Officials of the company that owns the hotel announced this morning that the 72-year-old Bellevue Stratford will close next week.  The decision follows a three-month fiscal decline brought about by public reaction to the hotel's apparent role in the outbreak of the disease....

Pathologist Studying the 'Legion' Disease Caught a Like Illness

PHILADELPHIA, Nov. 14--More than three months after the mystifying outbreak of "legionnaires' disease" in Pennsylvania, scores of researchers around the country are still trying to find the cause, and in at least one instance one of them has fallen ill with a disease strikingly similar to the one she was investigating.

The researcher, Dr. Sheila Moriber Katz, a pathologist at Hahnemann Medical College and Hospital here, has recovered from what was diagnosed clinically as "viral pneumonia" shortly after she had tested samples from one of the patients in the epidemic.

Despite extensive tests, experts have been unable to determine which virus, if any, caused her pneumonia, whether her illness was a coincidence or whether she acquired legionnaires' disease as an occupational hazard in her laboratory.

Nevertheless, the case served to warn others about the dangers of research and to renew speculation that the disease, which killed 29 people and sickened 151, was caused by some as yet undetected virus....

Scientists Link the Legion Disease To a Hitherto Unknown Bacterium

WASHINGTON, Jan. 18--Federal scientists believe that they have discovered the cause of the mysterious legionnaires' disease that killed 29 persons who were in Philadelphia during an American Legion convention there last July.

The apparent cause was a hitherto unknown bacterium discovered by scientists at the Center for Disease Control in Atlanta.  The center is the Federal agency that has been searching for the cause of the mysterious deaths since midsummer.

Announcing the discovery today, Dr. David Sencer, director of the center, said that the bacteria have been "quite definitely associated with the disease."  The newly discovered type of bacterium also appears to have been the cause of an earlier outbreak of fatal pneumonia among patients at St. Elizabeths Hospital here in 1965.

"The present findings provide very strong evidence that the two epidemics were caused by the bacterium," said a report on the discovery released today by the center.

The report said that there had not been time to identify the organism, thus leaving open the question of whether it was something entirely new to medical science or some obscure germ that had previously been seen but not identified with pneumonia in humans.

The source of the bacteria and the manner in which they were transmitted to humans in Philadelphia and in the earlier outbreak at St. Elizabeths Hospital are unknown.  However, it is believed that the discovery announced today will aid greatly in the search for answers to the key questions of source and mode of transmission....

The bacteria described today are difficult to grow in the laboratory.  The feat of growing and discovering them was credited to Dr. Charles C. Shepard and Dr. Joseph E. McDade of the Atlanta center.  Dr. Shepard is chief of a research unit normally concerned with leprosy and rickettsial diseases.  Dr. McDade is a research microbiologist in the same unit....

Although unidentified, the organisms are being called bacteria because of their size and physical characteristics the report said.

Even after they grew the bacteria-like organisms, the scientists lacked an important link in the chain of evidence connecting the germs to the legionnaires' disease.  They had to prove that other persons who became ill in the mysterious outbreak had been infected with the same germs.

The customary way of doing this, short of finding the germ in each person, is to show that the patients developed protective antibodies against the microbe.  Testing 33 legionnaires who had the pneumonia but recovered from it, the scientists found evidence that 29 were infected.  Furthermore, in many of the patients, blood samples taken early and late in their illness showed a sharp rise in the level of antibodies.  This is considered strong evidence of infection.

The same bacteria-like organism was linked to the mysterious outbreak of pneumonia at St. Elizabeths Hospital more than 10 years ago.  The hospital is a mental institution operated by the Federal Government.   At a news conference in Atlanta today, Dr. Sencer said that tests had shown antibodies to the newly found bacteria in 13 of 14 blood samples from St. Elizabeths Hospital patients tested up to noon today.

The samples of blood had been preserved for more than a decade to permit further studies whenever a new clue to the mystery was discovered....

Whose Disease?

The commander of the Suffolk County American Legion has asked the American Medical Association to assign a medical name to the "legionnaires disease."  The present name, he feels, "attaches not only a stigma, but also tends to stereotype, label, and defame the American Legion."  One can almost hear the gasp of apprehension in Philadelphia, which still remembers that when the ailment was first discovered there last year, some called it the Philadelphia disease.  In time, no doubt, Latin will come to the rescue.  But now it is surely more important to worry about a cure....

Legionnaires' Disease Gets a Scientific Name

ATLANTA, Nov. 18 (AP)--The pneumonia-like illness that killed 29 persons after a 1976 American Legion Convention in Philadelphia has been give a scientific name.

Commonly known as legionnaires' disease, researchers now call it Legionella pneumophila.

The name was proposed at the International Symposium on Legionnaires Disease this week at the Center for Disease Control.

Dr. Don J. Brenner, chief of the Enteric Bact[er]ia Section of the center, said the name would probably be permanent unless a scientist challenged it.

Researchers at the conference said the organism appeared to be a new type of bacterium representing a new genus, Legionella.

To come up with the name, scientists used four prefixes and suffixes.  "Legio" means army, "ella" means small, "pneumo" means lung and "phila" means loving.

"I guess you could say the legionnaires' bacteria is a small army that loves lungs," Don Berreth, a spokesman for the disease center, said.

Philadelphia Hotel Is Back in Business

PHILADELPHIA, Sept. 26--When the Bellevue Stratford Hotel closed three years ago following an outbreak of legionnaires' disease, many wondered whether the hotel, long a cultural landmark, would ever open again.  The then-mysterious disease, which killed 29 persons and hospitalized more than 100 others associated with a state American Legion convention held at the Bellevue Stratford, crippled the hotel's already faltering business.

But a local real estate developer saw the possibilities for a revival of the once-premier hotel.  He bought it last year for $8.2 million, spent more than $25 million for restoration and brought in San Francisco's Fairmont Hotel Company to run it.  The hotel reopened today under a new name -- the Philadelphia Fairmont....

Germs of Legionnaire's Disease Found to Thwart Body Defenses

WASHINGTON, May 11 (UPI)--The bacteria that cause legionnaires disease, killer of 34 people in Philadelphia four years ago, are particularly dangerous because of their ability to evade some body defenses, a New York doctor reported today.

Dr. Marcus A. Horwitz of Rockefeller University said that he and Dr. Samuel C. Silverstein had found in laboratory tests that the microbes penetrate the white blood cells that should kill them.  The germs then use the defensive cells as a shelter and multiply rapidly inside them.

"It is now appreciated that legionnaires disease occurs worldwide and it appears to be a major form of pneumonia in the United States," Dr. Horwitz said at a briefing before reporting to the annual meeting of the American Society for Clinical Investigation.

Dr. Horwitz said that the new findings suggested that a vaccine producing only antibodies to fight off invading bacteria might not be effective.  He said that some antibiotics, particularly erythromycin, appear to be effective in treating Legionnaire's disease.

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