Pandemic 1918
Page 8
Returning to work at the MRC just as the first wave of influenza hit northern France, Fletcher’s subsequent role consisted of overseeing the research being carried out in France at the hospital pathology labs. The research laboratories in France demonstrated ‘the decisive role of British military medicine in shaping official strategies against the pandemic’.13 Through the spring and autumn of 1918, the War Office, the Army Medical Services (AMS) and the Medical Research Committee (MRC), which had coordinated mobilization of British medical science, jointly produced official knowledge and epidemic strategies. Prior to the epidemic, these authorities had worked together to create a system of military pathology, which linked pathological laboratories to base and field hospitals in France and Flanders. This system was organized to collect, isolate and identify pathogens from the battlefield, and to facilitate production of vaccines and antisera, a blood serum containing antibodies against specific antigens, injected to treat or protect against specific diseases. Military pathology delivered therapeutic and preventive measures against a range of battlefield diseases, and its planners trusted that it could do the same with influenza.
Combined efforts between the army and the medical researchers were aided by the fact that both organizations had many points of similarity. Medicine was traditionally organized along military lines in terms of discipline, organization, rank and uniform, relying on teamwork and specialization.14 For this reason, medical research fitted comfortably into the war machine. Large-scale communication linked Casualty Clearing Stations (CCS) at the Front to field and base hospitals attached to each army division. Field hospitals were supported by ‘territorial’ hospitals in mainland England, which were connected to major London and provincial teaching hospitals and run by consultants who were given temporary ranks in the RAMC and paid part-time salaries.15
At the heart of this were the pathology laboratories, inspired by the success of bacteriology in civilian medicine and the development of public health.16 The forward-looking RAMC had been training its doctors in pathology and bacteriology since 1903, while the pathology labs which developed during the war were justified by Fletcher as vital for the ‘efficiency of the fighting forces’.17
For this reason, as soon as an influenza epidemic broke out in the army in spring 1918, the War Office, the Army Medical Service and the Medical Research Committee took the view that if the influenza germ could be identified, a preventive vaccine could be developed to protect soldiers and military interests.18
The military pathology laboratories had been established by Sir William Boog Leishman (1865–1926), a career military pathologist, specialist in tropical medicine and founding member of the MRC. Leishman was instrumental in spearheading the integration of pathology into military medicine.19 In October 1914, Leishman had been appointed Advisor in Pathology to the Director-General of the AMS and detailed to establish pathological laboratories in France and Flanders. Leishman oversaw the deployment of almost one hundred pathologists at eighty-five hospital labs in France and Flanders, the development of a fleet of twenty-five mobile labs and provision of pathological services at the Front, and the creation of a central research lab in Boulogne.
The pathology department at the Royal Army Medical College in Millbank, London, was the hub of the operation, training pathologists, and developing preventive and therapeutic techniques and vaccines for cholera, plague and dysentery. These vaccines, developed in peacetime, had even greater significance during the war. As a result of developments in vaccination, fewer soldiers died of infections than in any previous war.
The AMS’s central pathology laboratory at Boulogne was headed up by Sir Almroth Wright (1861–1947), the MRC’s leading pathologist. Wright’s two young assistants, Alexander Fleming and Leonard Colebrook, worked alongside him on wound infections and antiseptics, and the Boulogne laboratory had links with Wright’s Inoculation Department at St Mary’s Hospital, Paddington.
Many historians have claimed that the British Military had attempted to conceal the epidemic of killer flu, by delaying reports of the outbreak and claiming that it was of Spanish origin. Historian Michael Bresalier, however, takes the view that this was less a matter of censorship, and more a consequence of the fact that military doctors were genuinely confused about the identity of this new strain of influenza.
Up until 1918, influenza had been assumed to be a bacterial disease caused by Pfeiffer’s bacillus. Richard Pfeiffer (1858–1945), a leading German bacteriologist, had isolated what he believed to be the causative agent of influenza in 1892. According to Pfeiffer, the disease was caused by ‘a small rod-shaped bacterium’ that he isolated from the noses of flu-infected patients. He dubbed it Bacillus influenzae (or Pfeiffer’s bacillus), which was later called Haemophilus influenzae. Pfeiffer’s discovery was not questioned, chiefly because other human diseases, such as cholera and plague, had been shown to be caused by bacteria.20
This theory dominated the official strategy when the influenza epidemic hit the British Expeditionary Force in France and Flanders in March 1918. Working on the assumption that the epidemic of spring and summer 1918 was influenza, the AMS pathologists tried to isolate B. influenza from sick soldiers’ sputum, nasal passages and blood, and from the lesions of the few cases that ended up on the autopsy table.21 The doctors believed that if they could develop a vaccine based on Pfeiffer’s bacillus, they could inoculate against flu, in the same way that inoculation had been developed against other diseases.
But, in the absence of Pfeiffer’s bacillus, many doctors questioned whether they were dealing with influenza at all. Lacking a satisfactory definition of the disease, pathologists, as noted earlier, had classified it as ‘Pyrexia [fever] of Unknown Origin’ or ‘PUO’, also referred to as ‘Three Day Fever’, because, as Colonel Soltau of the Army Medical Service had observed, the disease consisted of ‘three days’ incubation, three days’ fever, and three days’ convalescence’.22 Both these definitions were, like ‘trench fever’, ‘clumsy catch-alls, for which neither specific causal agents nor pathognomonic signs could be determined’.23 All through the summer of 1918, arguments raged across the pages of the learned journals as to the nature of the disease and the validity of a vaccine.
While the British Medical Journal claimed that ‘the general consensus of opinion seems to indicate Pfeiffer’s Bacillus Influenzae as the infecting agent despite the reports in the same journal’,24 The Lancet ‘doubted whether the epidemic was influenza’.25
During the course of summer 1918, two loosely defined camps of pathologists clashed over the causal agent and identity of the epidemic. While the ‘Pfeiffer School’ argued that the epidemic was influenza, and said the failure to find the bacillus was due to technical problems, the ‘anti-Pfeiffer’ brigade suggested that either the disease was not influenza or the disease was caused by another organism.
The majority of military pathologists were familiar with Pfeiffer’s bacillus. From as early as 1915, its isolation was used to distinguish the various atypical respiratory conditions encountered on the battlefield and local outbreaks of influenza in France. The bacillus had come to general military attention in late December 1916, when it was isolated from an epidemic of ‘purulent bronchitis’ at Étaples by Hammond and Rolland.26 Purulent bronchitis was said to be the ‘primary condition’ in 45 per cent of all pulmonary autopsies performed in the hospital during February and March 1917,27 with the majority having died of ‘lung block’ resulting from the accumulation of fluid and pus in the lungs, causing emphysema and cyanosis in an estimated 50 per cent of deaths.
What struck investigators was that in smears and cultures of sputa and lung samples from twenty cases they tested, Bacillus influenzae appeared to be the primary agent, even though the symptoms were different. Reports by a team of medical experts at Connaught Hospital at Aldershot Command in September 1917 supported this observation. The Aldershot team identified B. influenzae as the primary agent in the eight cases they tested and other well-known respiratory germ
s – particularly pneumococci, Micrococcus catarrhalis, and streptococci – as secondary infections. Like their counterparts at Étaples, the Aldershot group concluded that the isolation of B. influenzae from the majority of cases of purulent bronchitis indicated a ‘serious form of influenzal infection’.28 Pathologists and physicians working at the No. 3 Canadian General Hospital at Boulogne, who carried out a full clinical, pathological and bacteriological study of purulent bronchitis, supported this conclusion. From all but one of the nine cases, they were able to grow B. influenzae in pure culture, which they interpreted as a key indicator that the bacillus caused the disease.
However, not all researchers were able to isolate B. influenza. Failure to do so was put down to inadequate technique, as the bacteria were notoriously difficult to culture.29 Arguments raged as both sides accused the other of professional incompetence. In the meantime, Pfeiffer himself remained silent.
Despite the high rate of infection, the spring and summer epidemics of 1918 were regarded as mild. While the influenza had made a massive impact on Allies and Germans alike, the majority of those infected had recovered. Some experts, however, were already predicting a second wave, which would prove deadlier than the last. Walter Fletcher believed that it was not a matter of whether there would be a recrudescence, but when, as did Fletcher’s colleague, Major Greenwood.
Major Greenwood (Major being his forename, not an army rank) was the son of an East End doctor, and originally studied mathematics at University College, London, before training as a doctor at the London Hospital in Whitechapel. Already equipped with first-class skills in mathematics and medicine, Greenwood switched to the Lister Institute, where he was employed as a statistician. At the Lister Institute, Greenwood was inspired by Karl Pearson, whose Grammar of Science was to inspire a new generation of epidemiologists interested in the emerging discipline of biometrics.30 Enlisting in the RAMC at the outbreak of war, Greenwood studied fatigue and industrial wastage for the Ministry of Munitions before turning his attention to the first wave of influenza in the summer of 1918.
Having been shocked by the high rate of hospitalization for influenza in the army, Greenwood plotted a graph showing the increase in cases and compared them with the onset of the Russian flu epidemic of 1889–90. During that epidemic, the first wave had occurred in the winter, not in the summer, but Greenwood observed that the outbreaks revealed near identical ‘curves’ showing a rapid increase followed by a steep decline, like an inverted V.31 Judging by these results, Greenwood feared that the summer influenza epidemic indicated a second, more deadly wave, which would hit Britain in the autumn or winter of 1918. This period of the year, when resistance was at its lowest, was the worst possible time for respiratory diseases.
Although they did not work directly together, Fletcher shared Greenwood’s fears that a second, more deadly wave of influenza was poised to hit Britain in the latter months of 1918. Fletcher subsequently commented that ‘it is natural to expect secondary waves with great confidence and as the primary wave came in the early summer, it was not a bad guess that a secondary wave with its dangerous pneumonia would come at the approach of winter’. He added that the MRC would ‘err on the side of caution’ and prepare for a second wave, whether it came earlier or later.32
Unfortunately, the War Office did not share Fletcher’s concerns. Despite the high rate of influenza in France and Flanders over the spring and summer, the army was more concerned about the daily realities of gangrene and sepsis, lice and trench fever than the prospect of another influenza epidemic. Nevertheless, Fletcher stuck to his guns. He urged Sir Arthur Newsholme to help investigate the cause of the summer outbreak in Britain and prevent further outbreaks later in year, writing that he would be grateful for any help investigating the epidemic. One solution, Fletcher suggested, would be to control the numbers travelling by public transport, which had to be playing a part in spreading influenza across the entire country. But Newsholme remained indifferent to Fletcher’s pleas. In a speech of self-justification later that year, Newsholme conceded that public transport constituted ‘prolific sources of infection’ but maintained that, given the vital importance of the war effort, ‘the vast army of workers must not be impeded by regulations as to overcrowding of vehicles in their efforts to go to work and to return home’.33
On 5 August 1918, Fletcher sent a memorandum to the British Medical Journal and The Lancet calling on pathologists and practitioners to prepare for a second epidemic. He asked for the results of the bacteriology research to be sent to the MRC. His aim was to ensure that laboratory and clinical work was well organized and centrally administered. But Fletcher was soon overtaken by events. Reports were already reaching the MRC that the dreaded second wave of influenza had been detected in France and at bases on the British mainland.
CHAPTER SEVEN
THE FANGS OF DEATH
BY SUMMER 1918, just as the Allies had begun to feel victory was within their grasp, Spanish flu succeeded where the Germany army had failed and effortlessly conquered Europe. The comforting routines of daily life were abandoned as the Spanish Lady strode across the continent. Trains were cancelled, businesses collapsed and trials went unheard as legal proceedings were suspended. The Kaiser himself was not immune. On 11 July, the New York Times reported that the Kaiser ‘has fallen victim to the influenza which has been so prevalent in the German army … he had gone home from the French front because of an attack of the Spanish grippe’.1 Kaiser Wilhelm’s subjects suffered with him, at least 400,000 Germans dying of Spanish flu. As the disease raged through her adoptive country, Princess Evelyn Blücher, an Englishwoman married to a German aristocrat, witnessed ‘the awful reality of influenza. Hardly a family in the country was spared.’2
‘From our housekeeper at Krieblowitz I hear that the whole village is stricken with it, and the wretched people are lying about on the floors of their cottages in woeful heaps, shivering with fever and with no medication or any one [sic] to attend them.’3
In Hamburg, four hundred were dying each day and furniture vans had to carry the bodies to the cemetery. ‘We are returning every day to the barbarism of the Middle Ages in every way,’ wrote Princess Evelyn. ‘I am often astonished that there are no religious fanatics nowadays to run through the streets, dressed in sackcloth and ashes, and calling on the people to repent their sins.’4
In Paris, 1,200 people died in one week. Elsewhere in France, 70,000 American troops had to be hospitalized, nearly a third of them dying. J. S. Wane, a Cambridge undergraduate who had signed up as an army clerk, found all the soldiers at the Normandy village of Goury sleeping in the open air, by order, because of the influenza epidemic.5
In August, Private A. J. Jamieson, 11th Battalion Royal Scots, was holed up in a small barn at Meteren, near the Belgian border:
Our signal section was occupying a small barn and due to move into the line on the day that illness struck. One after another, the occupants were carried out and meanwhile my head felt like a threshing machine. I wondered how many would be left to march off that night and resolved to stick it out as long as possible. Finally I joined ‘A’ company for the line and several times I staggered forward with my steel helmet catching the man in front in the small of the back. Ultimately, I lay down on a mattress in the cellar of a ruined farmhouse, checked that all my telephone connections were in order and knew nothing more until I was rudely shaken by the company commander who asked me if I knew that, for a soldier on duty sleeping at his post, the sentence was death. I explained my condition which he apparently understood and that was the end of it and of my Spanish ’flu.6
From Europe, the Spanish Lady had travelled remorselessly across the globe in four short months, crossing oceans and mountain ranges and infiltrating Scandinavia, Greece, Egypt and India. The first wave of influenza hit Bombay on 10 June 1918, when seven police sepoys (Indian soldiers serving under British orders), including one who worked the docks, were admitted to hospital suffering from a non-malarial fever.7 Betwee
n 15 and 20 June, victims included dockyard workers, and the employees of a shipping firm, the Bombay Port Trust, the Hong Kong and Shanghai Bank, the telegraph, the mint and the Rachel Sassoon Mills.8 Mortality rose and mass absenteeism became common in banks and offices. Health Officer J. A. Turned observed that Bombay in June was like a huge incubator, equipped with all that was necessary to cultivate infection: an overcrowded city with a large working-class population living in conditions which lent themselves to the spread of disease. From a daily mortality of 92 on 3 June, the figures rose to 230 by 3 July. According to The Times of India, ‘nearly every house in Bombay has some of its inmates down with fever and every office is bewailing the absence of clerks’.9
Turner believed that the outbreak had originated with the crew of a ship that had docked in Bombay at the end of May, while the Indian government claimed that the sailors had caught Spanish flu in Bombay due to what it called the ‘insanitary condition’ of Indians.10 Turner responded that the epidemic had been inevitable since 1915, as Bombay was a port of arrival and despatch for troops, and accused the Health Officer of Bombay Port of failing to report cases. The Bombay Chronicle argued that Bombay and indeed the whole of India had paid ‘dearly’ for this neglect, while The Times of India was outraged by the perceived failure of the Health Department, despite the lakhs (thousands) of rupees spent on it. Rumours also circulated that outbreaks of Spanish flu on military vessels had been suppressed.10