1918: A killer worse than a war

Figure 1 -- People infected with the Spanish Flu

In 1918 two wars were raging. One was was reported on daily in the newspapers, and most families new at least one person sent off to battle. The other was a surreptitious pest that didn't stop on the battlefield, traveling around the world, infesting anyone in the vicinity of its victim.

The surreptitious war was waged by a killer that was not seen by the naked eye. Scientists new about virus's, yet they had never seen one as the electron microscope hadn't been invented yet.  They had yet to learn about DNA and RNA, "the genetic material of viruses."  They didn't know the lungs were the ideal burrowing ground for the influenza virus due to an enzyme there that, once connected to a cell, allows the virus to "split one of its proteins during teh manufacturing of new virus particles."  (1, page 27-28)

Figure 2 -- Chart showing mortality from 1918 influenza
pandemic in the U.S. and Europe (published 2006)

So there were some wacky theories postulated as to what caused the Spanish flu.  One theory was that a so called Pfeiffer's bacillus caused it.  At Chelsea Naval Hospital north of Boston the Pfeiffer's bacillus was present in the throats of 80 percent Spanish Flu victims autopsies.  It was the accepted theory, even though other victims didn't have the bacillus.  (4, page 271)

The Pfeiffer bacillus was first discovered by the man who named it, Richard Friedrich Johannes Pfeiffer, in 1892.  It was a small rod-shaped bacteria that he found in the upper respiratory tract of patients infected with influenza.  With the germ theory being well known by this time, many didn't doubt the claims of Pfieffer. (Wikepedia, will find a reliable reference later)

Figure 8 -- Burying flu victims, North River, Labrador (1918)

We now know Pfieferr's bacillus as Haemophilus Influenzae.   Later studies confirmed it's a bacteria that it normally lives in humans without causing disease, although in the right circumstances is known to cause a variety of diseases, such as eppiglotitis.  (Wikepedia)

While the cause was being debated, the Spanish Flu continued to make it's way around the world, aided by the ignorance of the populace.  It was transferred from one person to another when it was exhaled, coughed or sneezed into the surrounding air, and inhaled by another person.  This surreptitious killer was a new and powerful strain of influenza.

Influenza was the last thing on anyone's mind, mainly because it was considered minor ailment, and it had been more than twenty years since the last pandemic.  The flu was considered a "minor inconvenience" compared with the smallpox or yellow fever.  It was so minor that the government didn't require new victims to be reported, and so there was no way of knowing a new pandemic was raging, until the bodies started to stack up. (3, page 5)

Figure 3 -- Men in an Alberta field wear masks during the Spanish flu,
Fall 1918, Canada.  Masks were made of gauze or cloth

It was called the Spanish flu because it was believed to have started in Spain. Although the truth is no one knows where it started.  In Spain it was called the "three day fever."  The rest of the world called it the Spanish flu, probably because Spain was a neutral state, and it was among the few European nations "that did not censor its news reports."  Yet before long the flu had spread to all of Europe, Asia, and the United States.  (1, page 10)

It hit hard.  While the flu normally kills 1.5 percent of its victims, mainly the very young and the very old with weakened immune systems, the Spanish flu was different: it killed men and women with fully developed immune systems:  people who we think of as being healthy and strong enough to fight off the virus; people strong enough to fight in a war

Figure 4 -- Patient's at Walter Reed Hospital are separated by sheets.  Nurses
wear cloth masks over mouth and nose (circa 1918 or 1919)

It was normal for the flu to spread fast through military barracks, prisons and schools.  But the Spanish flu was aided by a war, with thousands of troops huddled together in trenches.  These men traveled all over the world, carrying the virus with them.

Within 2-3 days of contact with the virus, they started showing the typical signs of flu: headache, fatigue, sore throat, aches and pains, dry cough, fever and chills.  Yet these typical signs progressed in some victims to chest discomfort, pneumonia, and then cyanosis of the fingers, toes and then face.

The pneumonia caused bleeding in the lungs, and the victims would cough up blood.  Their faces turned dark blue, and their toes black.  These were ominous signs that usually resulted in death from suffocation.  And unlike regular pneumonia, death from pneumonia caused by the Spanish flu was quick, sometimes in less than 48 hours. (3, page 8)

Perhaps it was the helpless feeling of watching these people suffocate that provided one of the reasons why many studies were performed during WWI on oxygen therapy, and oxygen equipment greatly improved.  By the 1920s oxygen was available in hospitals to treat diseases that caused hypoxemia, although to the victims of the Spanish Flu in 1918 this was of little help.

Figure 5 -- Spanish Flu public notice from 1918

The Center for Disease Control (CDC) provides us with the following statistics regarding the Spanish Flu (2):

• A third of the worlds population (500 million persons) were infected
• Greater than 2.5 % of those infected died, as compared to the average flu virus killing 1.5%
• Total deaths are estimated anywhere from 50 million to 100 million

The most significant statistic is the last one there: over 50 million people died.  This made the Spanish Flu the worst pandemic in the history of the world.  Compare that with the following (1, page 7):

• 11.7 million died in the first 25 years of AIDS
• 9.2 million died in combat deaths in WWI
• 15.9 million died in combat deaths in WWII

Figure 6 -- Policemen wearing masks provided by the
American Red Cross in Seattle, 1918

Basically, the only remedy was to wait it out and hope you, or the ones you loved or were taking care of, survived.  A remedy tried was to inoculate "troops with vaccines made from body secretions taken from flu patients or from bacteria that they thought caused the disease.  They made them men spray their throats each day and gargle with antiseptics  or alcohol.  They hung sheets between beds, and at one camp they even hung sheets in the centers of thh tables at mess halls.  At Walter Reed Hospital, soldiers chewed tobacco each day, believing that it would ward off the flu."

While the origin of the Spanish Flu is unknown, some have developed conspiracy theories that postulate that the governments attempt to prevent the flu by giving such vaccinations were what caused the deadly strain in the first place.  We have heard stories of worse things being done by the Germans later, in the 1930s.  Yet such an attempt may have been performed in just about any country, including the United States.  Yet such conspiracies were never proven, and probably never will be.

Figure 7 -- A street car conductor iSeattle in 1918
refusing to allow passengers aboard
 who are not wearing masks

Another attempt to prevent the spread of the Spanish flu was to require people to wear masks made of gauze or cloth.  The problem with this is these masks often gave people the courage to go out into public places, and the virus was so resilient that it would make it's way right around the masks.  It was airborne, tiny enough, and wicked enough to do such a thing.

The Spanish flu went away as fast as it arrived, probably because it infected all the people who were vulnerable.  Eager to forget the dreadful events that just occurred, many newspapers refused to publish anything about the flu.  People were eager to put it behind them, and move on with their lives

Yet the Spanish flu had a major effect on society.  It interrupted society and economies all over the world, where people stayed home to care for their friends and relatives, and to keep themselves from getting the flu.

It also impacted the health care industry, whereas the government from then on required new epidemics of the flu to be reported.  Much of the way the influenza virus is kept in check today is based from researchers and scientists studying the outbreak of 1918.

Later, during the 1930s and 40s antibiotics and sulfa drugs were discovered to prevent and treat bacterial infections.  This made it so people who developed pneumonia as a complication of the flu could be treated and cured.  These medicines made the influenza bug less likely to be a killer.

Today we also have the ability to create an influenza vaccine and have it ready to give to people at high risk, if the strain can be isolated soon enough.  The problem that continues to plague scientists is there are many strains of the flu, and to inoculate against all of them wouldn't be cost effective.

Figure 9 -- "Demonstration at the Red Cross Emergency
Ambulance Station Washington, D.C.,during the
influenza pandemic of 1918."

So for this reason scientists must continue to be vigilant.  When new cases are reported, they are monitored.  Each year the "suspected" strain of influenza is readied in a vaccine and recommended for anyone at high risk, which generally are the very old, very young, and caregivers.  Although, as the Spanish Flu reminds us, sometimes those at risk aren't the typical victim.

Further reading:

1. Spanish flu creates the 'living room'

References:

1. Kolata, Gina, "Flu," 1999, New York, Farrar, Straus and Girouxx
2. Taubenberger, Jeffrey, David Morens, "1918 Influenza: the Mother of All Pandemics," Emerging Infections Diseases, Centers for Disease Control (CDC), http://wwwnc.cdc.gov/eid/article/12/1/05-0979_article.htm, accessed 11/26/12
3. Crosby, Alfred, "America's Forgotten Pandemic: The influenza of 1918," 2003, United Kingdom, Cambridge University Press
4. Wikepedia: all the photos for this post are from Wikepedia: The free online encyclopedia.  

400-1743: The first use of the term influenza

In the ancient world all diseases were attributed to the wrath of the "diety." If a Pandemic ravaged a village, town or nation, it was attributed to an angry god or spirit.  Both the ancient Greek poet Homer (800-701) and Hippocrates (460-370) described pandemics during their lifetimes.  It's probable some of these were attributed to the influenza virus.

Homer describes how Zeus used his thunderbolt to "punish impiety," and "for vengeance for an insult offered to his priest, the shafts of the Sun-god carried sickness into the Argive camp, destroying first the dogs and mules, and then thousands of warriors," writes Arthur Hopkirk, in his 1914 book "Influenza."  (1, page vii and viii)

In reality these warriors may have died of a pandemic caused by a virus or bacteria, such as influenza.  Although the ancients had no clue about the internal workings of the human body, nor about invisible invaders of the human body.  It was easier for them to believe in fake gods and attribute them when bad things like plagues happened.

"On mules and dogs th' infection first began;

And last, the vengeful arrows fix'd in man."

Those described as having sweats and chills (signs of a fever) were the most likely to succumb to the disease.  In man's desire to help his fellow man, the following were the remedies tried (1, page 15-16):

• Purging
• Venesection
• Bleeding by the ranal vein
• Emetics

And sometimes the remedy wreaked more havoc than the plague.  If ruthless venesection was performed, this in and of itself could have been the killer.  Yet the plague was blamed nonetheless.

The plague struck again and again.  In 412 B.C. the following was written regarding a plague in Rome (1, page 16):

“A plague, however, which broke out at that time and gave more alarm than it proved destructive, diverted the people’s attention from the forum and political disputes to look after their families and take care of their health. The city was all over oppressed with sickness, though no great mortality ensued.”

It struck again (or so historians think) in (1, page 20-26)...

• 827 A.D. in France and Germany
• 876 in Italy
• 889 in Germany
• 927 in France and Germany
• 996-97 in England
• 1173 in Germany and Italy (it was called "a dense fog" in Italy, first authentic outbreak)
• 1239
• 1311
• 1323 in Italy and France
• 1327-28
• 1357
• 1287 in France and Germany
• 1403 in Paris, France
• 1404
• 1410-11 in France
• 1413-14 in France
• 1427 in France caused a "Poisonous air."
• 1438
• 1482
• 1505
• 1510

The following quote comes from 1323 (3):  

In the year, 1323, and in the month of August, there was a pestilential wind, which caused nearly all the inhabitants of Florence to fall sick of cold and fever, and the same thing took place throughout almost of whole of Italy.

And the following from 1327 (3):

In the said year and month, there was throughout the whole of Italy an infection fever caused by cold; but few people died of it.

Regarding the 1387 outbreak, the following was written (4):

There came a general pestilence in the whole country, with cough and influenza, so that hardly one among ten remained healthy. 

Regarding the 1427 outbreak, an anonymous chronicler from St. Albans wrote (1, page 25-6):

In the beginning of October, a certain rheumy infirmity which is called 'mure' invaded the whole people, and so infected the aged along with the younger, that it conducted a great number to the grave. 

The remedy for the 1387 pandemic, which took few lives, was "decoctions of chamomile and coriander berries, sweetened with syrup and poppies; clymasta; diaphoretics; and low diet." (1, page 23)  This would have been a more pleasant remedy compared to what the ancient Greeks treated the symptoms.  

Many of the deaths that resulted occurred on the fifth or sixth day, and Hippocrates notes that death usually occurred on the seventh day.  Later, in the first century A.D., Galen agreed with Hippocrates that death usually occurred on the seventh day.  (1, page 17)

At some point in our history, sometime in the ancient world, the concept that little creatures in the air may be responsible for spreading some diseases was postulated, although who postulated this theory, and when, remains a mystery.

Hopkirk says the first to write of this concept may have been the Greek "polyhistorian" Varro (117-36 B.C.), who wrote the following:

It is to be observed that wherever there are marshy districts certain most minute animals will grow, which cannot be discerned by the eye; but, carried by the air, reach the body through the mouth and nostrils, causing serious disease." (1, page x)

Varro was referring to the malaria plague in "Corfu when Pompey was there with an army and fleet."  Although the same concept may be applied to other contagious diseases, such as influenza.  Varro recommended the following to prevent the spread of the disease malaria: (1, page x)

• Isolation
• Ventilation
• Destruction of insanitary dwellings
• Etc.

Influenza is known to cause much grief for those afflicted with it, although it causes only a few deaths.  Usually those who die from it are over the age of 65 or have some chronic underlying medical condition that is complicated by influenza.

Prior to the 16th century influenza was referred to by various names, depending on the geographic region of the person describing it.  Sometimes it was simply referred to as a pest, pestilence, or plague.  Historians determine if the "plague" was influenza by descriptions of the symptoms, a high morbidity, yet low mortality rate.  If many deaths resulted, chances are that particular plague was not influenza. (1, page 4-5)

The term influenza may actually have come from a misinterpretation of the Italian word influence.  The idea here is that around 1357 people believed the position of the stars "influenced" outbreaks of the disease.  Although how this term superseded all the other terms and made it's way into medical nomenclature remains a mystery.  (1, page 6)(2, page 31)

The following are just a few other names used to describe various pandemics or endemics most historians figure were influenza (1, pages 8-9):

1. Burzelen:  1307 in Germany (meaning to stumble?)
2. Le tac or le horion:  1411 in France
3. Tonawasches Fieber:  1414 in Germany (Because occurred in Danube district)
4. Coqueluche: 1414 in France (Caused oppressive pain in the head)(Victims wore cap on head)
5. Ladendo:  1427 in France
6. Schafkrankheit or Schafhusten:  1580 in Germany (Sheep's disease, cough)
7. Galanteriekrankheit or Modefieber: 1709 in Germany (Galant malady, fashionable fever)
8. Le Grippe:  1743 in France (from "agripper," meaning to sieze quickly and cause sore throat
9. Petite poste or petite courrier:  1762 in France
10. Zamporina:  Brazil in 1780
11. La Coquette:  France 1780-81
12. Russische Krankheit (lightning catarrh):  1782 in Germany (due to its sudden onset)
13. Corcunda (hunchback disease):  Brazil in 1816.  Violent cough made you hunch your back
14. Polka Fever:  1846-7 in Brazil

In Great Britain during the 14th and 15th centuries, common names were faucht and slaodan.  Creatan was a word derived from creat (chest), and was another common name.  In 1562 it was called "the newe acquayntance.  In 1580 "the gentle correction."  It was also referred to as "the jolly rant," "the new delight," "the Dunkirk rant," and "the knock-me-down fever." (1, page 9)

An outbreak in Britain in 1485 was described as "English Sweat." It was so back that "King Henry VII had to postpone his coronation," according to Evelyn Kelly and Claire Wilson in their 2011 book "Investigating Influenza and Bird Flu."  "The disease was treated with tobacco juice, lime juice, and bloodletting." (2, page 32)

Finally, in 1743, the term influenza was used to describe influenza.  No one knows why, but this is the term that stuck, and has since made it's way to medical nomenclature.  The only exception was in Germany, where the Grippe was the term commonly used as of 1743.  

While the names varied through early history, the "grip" the disease held on it's victims were similar:

• Catarrh:  Inflammation of the respiratory tract (nasal congestion)
• Fever:  Usually over 100 degrees
• Chills:  Associated with the fever
• Headache:
• Body or muscle aches: Especially of the back, arms and legs
• Dry cough: Helps spread the disease from one victim to the next
• Fatigue and weakness:  General feeling of tiredness
• Suspended Business: Many stopped working to take care of their families

It's generally the commonality of symptoms described, the high rate of morbidity, and low mortality, that has allowed historians to feel confidence these epidemics and pandemics were probably influenza.  

References:

1. Hopkirk, Arthur F., "Influenza: It's History, Nature, Cause and Treatment," 1914, New York, Charles Scribner and Sons
2. Kelly, Evelyn B., PhD and Claire Wilson, "Investigating influenza and Bird Flu: Real facts and real lives," 2011, Enslow Publishers, U.S., Chapter 2, "The History of Influenza," pages 29-47
3. Hopkirk, op cit,Gluge, "in the course of his argument, quotes the following passages from Buoninsegni’s Istoria Fiorentina, Florence, 1580." The passages are recorded on page 21 of Hopkirk's book.  
4. Hopkirk, op cit, from Jakob von Konigshoven Stassburg Chronicles, of 1387, as recorded by Hopkirk on page 22 of his book

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