A Short History of Disease

by Sean Martin

  But typhoid was not just afflicting military personnel by the time the British army sent thousands of vaccinated men to the front in 1914. One of the most celebrated cases was that of the Irish cook, Mary Mallon, better known as Typhoid Mary. Mallon (1869–1938) was arrested in 1907 on suspicion of causing a number of typhoid outbreaks in the families she had worked for as a cook in and around New York City. These had resulted in several deaths. After examination, it was found that Mallon’s gallbladder was riddled with typhoid bacteria, although Mallon herself was in perfect health; due to some quirk of her immune system, the microbes did not affect her. She was kept in quarantine in Riverside Hospital on North Brother Island in the East River, before being released in 1910 on the condition that she gave up being a cook.

  Despite her ordeal, Mallon believed that she didn’t have anything wrong with her, and went back to her former profession. History repeated itself. More outbreaks followed, but each time the authorities tried to track Mallon down, she had left her employers (who were often in hospital by that stage) and had gone to ground, only to reappear working under false names elsewhere. She was eventually re-arrested in 1915 and sent back to Riverside Hospital, where she spent the last 33 years of her life in quarantine. Given the number of aliases she had used, the precise number of Mallon’s victims remains unknown, but she could have been responsible for up to fifty deaths. Mallon was what is known as an asymptomatic carrier, the first known to medical science. The precise nature of her immunity is still being researched.

  The Spanish Lady

  Ironically, quarantine could have saved Mary Mallon’s life. On 11 August 1918, a Norwegian ship, the Bergensfjord, entered New York City’s harbour. Eleven of her crew and ten passengers were sick with a new, and very deadly, form of influenza.367 Other ships followed in the coming weeks, bringing what became known as the Spanish Flu with them. As the First World War entered its final, bloody months, soldiers and civilians alike were struck down in the deadliest pandemic the world has ever seen. Up to fifty million people died, more than had perished in the Great War. Perhaps due to war fatigue, perhaps due to shock, people stoically accepted the devastating losses and, by the end of 1919, it was all over. There were no memorials, no eulogies, no parades of remembrance.368 It has become ‘a global calamity the world forgot’.369 As Mark Honigsbaum notes, ‘Why this should be so puzzled commentators at the time and has continued to puzzle historians ever since. “Never since the Black Death has such a plague swept over the face of the world,” commented The Times in December 1918 “[and] never, perhaps, has a plague been more stoically accepted”’.370

  No one knows exactly where the pandemic began. It could well have had several points of origin. Spain was the first country to report outbreaks, in May 1918. As she was a neutral country, her news was not censored, and so the epidemic became known as the Spanish Flu, or the ‘Spanish Lady’. Some think it might have begun on the Western Front, where it was known as ‘Flanders grippe’ among the British; the Germans dubbed it Blitzkatarrh. China or Hong Kong have also been proposed as points of origin. Other theories hold that it began in American army camps in the midwest in the spring of 1918, when America was preparing to send troops to Europe.

  The earliest report seems to have come from Camp Funston, a newly built training facility in the grounds of Fort Riley, in central Kansas. On 4 March, Camp Funston’s cook, Albert Gitchell, reported sick. ‘Today many scientists believe that Gitchell was the Great Flu’s patient zero.’371 If so, Gitchell didn’t have to wait long for others to join him in the sick ward. By noon the same day, 107 men had fallen ill. Within weeks, it had spread to other American camps, and when American Expeditionary Force troops landed in France in April and May 1918, they brought the flu with them. There were initial outbreaks in Brest, Marne and Vosges.

  Places like the huge British army field hospital at Étaples demonstrated how closely troops and microbes mingled on a continual basis, and could well have played a part in spreading the flu. Despite ostensibly being a hospital, Étaples was rife with tetanus, dysentery and typhoid, as well as conditions particular to the Western Front, such as trench foot and trench fever. Trench foot was the result of prolonged exposure to cold mud, and causes the toes to become gangrenous until they rot and fall off. Trench fever was a form of relapsing fever transmitted by a louse, Pediculus humanus, that was endemic to the trenches. Other soldiers were suffering the effects of mustard gas attacks. Add to this panoply of infections the sheer number of men in the camp – more than a million soldiers passed through Étaples between June 1915 and September 1917 – and the presence of horses, chickens and pigs, and you have ‘the perfect conditions for the emergence of pandemic influenza.’372

  There were three waves of flu. The first occurred in the spring and early summer of 1918, being active in Europe by April, but also appearing in China the same month. In Spain, the first country able to report on the epidemic, up to one third of the population was affected (about eight million people). People taken ill included the King, the Prime Minister and the Minister of Finance. The Times reported that 700 people had died in Madrid in May and that the disease had ‘passed the joking stage’.373 In May, influenza appeared in India, although there is almost no way it could have reached there from Europe in so short a time. Over the course of the summer it reached Australia, Southeast Asia and South America.

  Its initial effects seemed to have been military. The pandemic quite possibly crippled the major German spring offensive, which ground to a halt just 40 miles from Paris before the numbers of soldiers falling sick forced them to turn back. The Allied Powers were not in much of a position to exploit the German weakness: by June, the American Expeditionary Force was experiencing ‘phenomenally high’ rates of illness. It was not unknown for battalions to have 80 to 90 per cent of their fighting men incapacitated by the flu, while 5,500 British troops died in the pandemic’s first wave, and a further 226,000 were taken ill.374 In addition, around ten per cent of the British navy was sick. Many of those returning home to recuperate spread the disease on the home front.

  Attacks could be very sudden. Initial cold-like symptoms could suddenly deteriorate into full-blown pneumonia. People died quickly, often within 48 hours, drowning in their own phlegm. Doctors performing autopsies on dead servicemen noted that the victims’ lungs were like ‘red currant jelly’ they were so destroyed by the virus. Victims could also bleed from the nose, ears and lungs. Some literally dropped dead in the street without warning. It was not unknown for people to go out wearing tags that bore their names and addresses and those of their next of kin, in case they never returned home.

  In many cities in Britain, America, and elsewhere, public gatherings were temporarily banned, and the wearing of white cotton face masks advised. (Although they weren’t terribly effective against flu germs, it was better to be seen doing something rather than nothing.) Spitting was banned in New York City; while in Prescott, Arizona, even shaking hands became a criminal offence. In Britain, soldiers sent home to convalesce were banned from public places such as cinemas and concert halls. Similar troop bans and quarantines were enforced in other countries, too. Industry suffered. The Times reported that a textile house in Lancashire, employing 400, had 100 off sick. One third of Wigan mine workers fell ill, and in Newcastle collieries, the absentee rate was 70 per cent.375 It’s possible that these rates were so high because people in these areas were already suffering from ill health caused by the effects of industry. In the US, industrial cities such as Pittsburgh suffered similarly high rates of illness.

  The second wave of the pandemic struck in the autumn of 1918. Normally a typical winter wave of flu will hit the old and children hardest, but the Spanish Lady’s second visit was unusual in that young adults between the ages of 20 and 40 also proved highly susceptible. The flu was also no respecter of social class or position: British Prime Minister Lloyd George was bedridden in September, and ‘he was ill to such an extent that his valet, Newnham, considered it
“touch and go” as to whether he would survive.’376 The Prime Minister’s illness was kept out of the papers in the name of the war effort.

  Schools and factories were closed. Public services were affected: in Philadelphia, the telephones were knocked out because most of the operators had contracted the flu. There were too few police to patrol the streets in some cities, and streets became choked with uncollected refuse. Letters went undelivered. Temporary hospitals were set up in schools, town halls and other municipal buildings; doctors and nurses were in constant demand. In India, ‘rivers became clogged with corpses’377 because there was so little firewood left available for funeral pyres. In Enfield, one funeral director had to turn work away, due to having 97 funerals to conduct in one week.378 In Sheffield, people lay dead at home for up to 10 days sometimes, due to the lack of hearses. In Philadelphia, the dead were collected in taxis.379 In Central Africa, villages of 300–400 families were ‘completely wiped out, the housing having fallen in on the unburied dead.’380

  Despite the rising death toll in the autumn of 1918, people tried to carry on regardless. Schoolchildren made light of the calamity with a playground rhyme:

  I had a little bird

  Its name was Enza

  I opened the window

  and in-flu-Enza.

  Even when the war ended in November – itself an event possibly hastened by the pandemic – people still celebrated by throwing parties and attending dances, despite the fact that these celebrations continued to spread the virus. 1918 was the first year on record in which the death rate in Britain exceeded the birth rate.

  Numerous folk remedies were tried against the flu. Potatoes and cucumbers were thought to possess medicinal properties. Other folk remedies included garlic, sulphur, Lifebuoy soap, Oxo stock cubes, incandescent gas burners, aspirin, quinine, opium, ammonia, camphor, eucalyptus, iodine, creosote, turpentine, snuff, cinnamon, salt water, tobacco, beef tea, cocoa, disinfectant and alcohol. (Champagne was very popular in France in this respect.) Among the most bizarre was bathing in cat’s urine.

  Such folk beliefs are part of an age-old tradition of quack medicines whose ancestors may have made an appearance every time influenza did. The disease itself is certainly age-old, although there seem to be no definite identifications prior to the sixteenth century. What is known for certain is that influenza is an ancient zoonotic virus: Dorothy Crawford notes that flu has been with us ‘ever since the Chinese domesticated water fowl and pigs some 9,500 years ago.’381 It was unknown to Hippocrates. Mary Dobson suggests the first European epidemic occurred in 1173, and that Columbus and his men might have caused an epidemic on Hispaniola in 1493, a form of swine flu which the natives are thought to have caught from the ships’ pigs.382

  Flu produces several pandemics every century, and the 1510 European outbreak is the most reliable early date we have for its appearance. Due to its apparent ability to appear everywhere, it was thought to be caused by malign astrological influences, hence the name influenza, from the Italian. The English physician Thomas Willis (1621–75), whom we met thrashing patients in Bedlam in Chapter 5, remarked of the 1658 epidemic that it was ‘sent by some blast of the stars’.383 Another epidemic began in 1557, when it was referred to in Edinburgh as ‘the newe acqayntance’ that had affected Mary Queen of Scots, and which

  passed also throughe her whole courte, neither sparinge lordes, ladies nor damoysells, not so much as ether Frenche or English. It ys a plague in their heades that have yt, and a sorenes in their stomackes, with a great coughe, that remayneth with some longer, with others shorter tyme, as yt findeth apte bodies for the nature of the disease. The queen kept her bed six days. There was no appearance of danger, nor manie that die of the disease, excepte some olde folkes.384

  The next epidemic, in 1580, spread from the Mediterranean to the Baltic and ‘deserves the title of pandemic’.385

  The 1781–82 epidemic, known as ‘la Russe’ due to its supposed origins in Eastern Europe, even reached the Americas. That influenza could produce high fatality rates among Native Americans, as it did during the seventeenth and eighteenth centuries, is a strong indicator that the virus originated in the Old World. Lower mortality in Europe, Africa and Asia suggests the populations of those continents had developed some degree of immunity due to repeated exposure to the virus over many centuries. These were also the parts of the world where the domestication of animals was practised longest, another significant factor when the virus in question is a zoonosis. By the time la Russe struck, it also had the industrial revolution to help it on its way. As Alfred Crosby remarks, ‘It was the most impressive of the early examples of what population growth and improving transportation systems could do in extending the reach of influenza.’386

  ‘Russian’ flu returned again in 1889–90. Originating in Bokhara in Tsarist-controlled Uzbekistan, it spread westwards via railways and commercial and diplomatic travellers. It killed an estimated quarter of a million people in Europe, and probably several times that in total. 27,000 people died in Britain, which did force the authorities to regard it as something more than a nuisance. But, as FB Smith notes in regard to this epidemic, ‘[British] government action was precluded by the uncertainties in early diagnosis and the cost and resistance to official meddling with everyday business to contain what the public regarded as a minor illness.’387 Being such a ‘minor illness’ – it was an annual visitor each winter – meant that the Russian flu didn’t elicit the same kind of panic in Britain that the 1831 approach of cholera had done. Familiarity had clearly bred contempt. Also, such had been the success of medical science that, ‘By the 1890s many Britons had lulled themselves into thinking that the wonders of medical science could vanquish any foe, no matter how microscopic. In Germany Robert Koch had isolated the bacilli of tuberculosis and cholera while in Paris Louis Pasteur had developed vaccines against anthrax and rabies and discovered the process of pasteurisation. But, for all their achievements, neither had the least notion of what a virus was.’388

  Notions about what a virus was had not progressed when the Spanish Flu appeared in 1918. A third and final wave swept the world in the spring of 1919, but by May, it had run its course. A study conducted in 1927 thought the pandemic had killed 20 million people, more than had died in the Great War, which ‘only’ claimed 15 million lives. But the figure for the Spanish Flu is now thought to be around 50 million, making it the deadliest pandemic in history. Some experts even think that figure is far too low, and that the true death toll may be around 100 million.389 Around 675,000 Americans died; in the UK, the death toll was 228,000. In India, 12 million died – around ten per cent of the population.

  What caused the Spanish Flu to be so virulent is still a matter for research. One of the reasons for influenza’s success as a disease is that it mutates after every pandemic. So far, the 1918 strain, a variant of the H1N1 flu virus, has not reappeared, despite great efforts to find it. Bodies of victims who died on Spitsbergen and in Alaska in 1918–19 have been exhumed from the permafrost of their Arctic graves in the hope that their bodies may still contain the virus that killed them. So far results have not been conclusive. Other theories posit a link between the Russian and Spanish Flus. Could survivors of the former have been immune to the latter? Again, without evidence in the form of preserved tissue samples, the theory remains unproven. Or was the Spanish Flu a form of swine flu? Before the outbreak at Camp Funston in Kansas, local farms had experienced an outbreak of swine flu which disappeared in mid-March, around the time the first human cases were reported. Or had the Spanish Flu virus in fact been around for a number of years before 1918, with the pandemic being triggered by an unfortunate combination of events?390 (Army doctors at the British field hospital at Étaples, for instance, thought they had seen similar flulike symptoms in 1916.391) Latest research suggests it was a form of bird flu that by-passed pigs and other susceptible hosts entirely, going straight into humans. Scientists fear that the Spanish Flu – or a variation of it – will ret
urn (see avian flu and SARS, below).

  Perhaps the suddenness of the pandemic, and people’s seeming acceptance of it, makes it unique. As Andrew Nikiforuk notes, ‘The flu’s impeccably modern persona (brief, global and anonymous) made it a simple event to accept. A quick and easy death is a twentieth century ideal and the flu, so familiar and so fast, performed to expectation.’392 But its reputation as a catastrophe the war-weary world wanted to forget continues. When Mark Honigsbaum was researching his book on the pandemic in 2005, he found one of the few remaining British survivors, 93–year-old Ada Darwin. ‘Tragically, both Darwin’s baby brother and both parents died in the pandemic but nearly 90 years on she still had perfect recall, telling me she could “see” the triple funeral cortege passing by a street near her school “like a film” in her head.’393 Ada Darwin’s memories sound for all the world like a piece of forgotten newsreel that no one has seen in a very long time.

  Medical Advances

  Newsreels of a very different sort were seen by cinema audiences at the end of the Second World War in Europe. On 12 April 1945, before British forces liberated the Nazi concentration camp at Bergen-Belsen, they were met by a German officer, who warned them of conditions inside. A typhus epidemic had been raging in the camp since February, and thousands of inmates had died. A quarantine zone around the camp was established, with white flags and signs reading Danger – Typhus. The Germans surrendered, and the British entered the camp. When BBC journalist Richard Dimbleby sent his report back to London, his superiors at Broadcasting House didn’t believe him. They were sure conditions at Belsen couldn’t possibly be as bad as he had claimed. As one eyewitness wrote of the liberation, ‘Even the most hardened warriors were crying, vomiting and cursing at this never-imagined depth of human depravity.’394