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1918 Influenza Overview

influenza

The Big Event Nobody Talked About

After an eventful spring in aviation, and before an eventful fall in aviation, summer 1918 seems to have been mostly just war-as-usual. So now seems like a good time to discuss a subject which was bigger than the whole war, and then we'll go back to aviation, because that's what this blog is mainly about, and because we are not experts on the flu other than occasionally personally experiencing a lesser form of it. If you want to know more about the flu, there are many recent books about it, but not many contemporary accounts...as we will discuss.

Walter Reed Flu WardWe particularly recommend John M. Barry's book The Great Influenza:The Epic Story of the Deadliest Plague in History, which is the main source for information in this post. And, though it is not much of a source of information about the flu, number 8 in the Anne of Green Gables series, Rilla of Ingleside, was published right after the war and is dedicated to a friend who died on January 25th, 1919, of the flu.

Keep in mind as we talk over the next few weeks about the aviation events of fall 1918 that they were all against the background of the peak weeks of the flu. On the other hand, at the time nobody knew it as THE flu yet, and it was also not well-known how extensive it was other than that it was too close for comfort.

What Was Special About the 1918 Flu?

The ancestors of everybody now alive experienced the flu years. Not necessarily experienced the flu itself, but some surprisingly high percentage of everyone in the world got it, especially in the nations involved in WWI. It is hard to diagnose exactly who had what when at a century's distance, but estimates of how many died of the flu have risen, rather than fallen, since 1927. Of course, anything that kills so many so fast makes accurate records difficult; as Barry says, " The few places in the world that then kept reliable vital statistics under normal circumstances could not keep pace with the disease."

Far Worse Than War

It is estimated now that 50 to 100 million people (quite a range of uncertainty!) were killed by the flu, which is 5 to 10 times as many as WWI killed. And those deaths came fast. According to Barry, it appears that more than 5 percent of the world's population died, most during a twelve-week period in 1918. 

Worse Than the Black Death

Many compared the flu to the Black Death, but it actually killed more and faster; its main run was about 18 months as compared to a few years for the worst part of the Black Death. "Influenza killed more people in a year than the Black Death of the Middle Ages killed in a century."

Deaths of the Young and Healthy

The flu was notable not only for how many it killed, but for killing a different demographic than most flus. Most people consider a flu not much more than a major annoyance, an interruption in getting things done for a couple weeks, because flu is rarely deadly except to the very young, very sick, and very old. But the 1918 flu, while it certainly killed people in the earliest and latest years of life, also killed early middle-aged people disproportionately. The ages least likely to die were older children, teenagers, and younger grandparents.

The problem with killing middle-aged people is that this age group is the most likely to be raising children, who are then fatherless or motherless. And then there was the effect on pregnant women. "In thirteen studies of hospitalized pregnant women during the 1918 pandemic, the death rate ranged from 23 percent to 71 percent. Of the pregnant women who survived, 26 percent lost the child. And these women were the most likely group to already have other children, so an unknown but enormous number of children lost their mothers."

As Deadly as WWI Aircraft

One measure of the effect of the flu is to look at its effect on aviators from Cornell University. Cornell contributed more officers than any other institution to the war, and many went into aviation. In Cornell's "Roll of the Fallen" it is interesting to note that very few died in air combat. Most died (in a fairly even split) of either aircraft accident, or flu and its complications.

Imagine It Today

Over the course of the epidemic, 47% of all deaths in the US were related to influenza, and average life expectancy was depressed by more than 10 years. The "excess death toll", or those who died in addition to those who normally would have died over the period, was about 675,000. In comparison to the population of the US at the time, that would be like over 1.8 million "excess" deaths today over a year and a half.

What Was It Like to Have the Flu?

1918 Flu in OaklandApparently the reason for the unusual age distribution of deaths was a "cytokine storm". In the process of trying to fight off the flu, the body's immune system would go too far and cause irreparable damage to the body, especially the lungs, keeping the lungs from exchanging oxygen and suffocating the patient.

According to an army physician, "These men start with what appears to be an ordinary attack of LaGrippe or Influenza, and when brought to the Hosp. they very rapidly develop the most vicious type of pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white."

Disgusting Effects of Flu

Cyanosis came from a lack of oxygen to the tissues, turning people not just blue, but blackish, giving rise to rumors of a return of the Black Plague. Though the newspapers said it wasn't the plague, they had already lost credibility by dismissing or understating the spread of the flu, so as not to diminish morale for the war effort. Had the sufferers but known, they might have wished it was "only" the Black Plague!

From 5 to 15 percent of the men at US Army cantonments experienced bleeding from the nose similar to that caused by Ebola. Others hemorrhaged from the nose, stomach, intestines, and ears. Other effects were on the brain or spine, causing paralysis, depression, insanity, and other effects such as temporary or permanent inability to see or smell. It is suspected that the brain problems the people had in Oliver Sacks' book Awakenings (also a movie of the same name) could have been a result of the flu.

Immune System Vs. Its Host

"The virus was often so efficient at invading the lungs that the immune system had to mount a massive response to it." Cytokines attack invading viruses in many ways. One is to raise body temperature, causing fever. 

But cytokines themselves also have toxic effects. The typical symptoms of influenza outside the respiratory tract, the headache and body ache, are caused not by the virus but by the cytokines.
Routinely, the body fights off the influenza virus before it gains a solid foothold in the lungs themselves. But in 1918 the virus often succeeded in infecting epithelial cells not only in the upper respiratory tract but all the way down the respiratory tract into the innermost sanctuaries of the lungs, into the epithelial cells of the alveoli. This was viral pneumonia.
The immune system followed the virus into the lungs and there waged war. In this war the immune system held nothing back. It used all its weapons. And it killed. It killed particularly with 'killer T cells,' a white blood cell that targets the body's own cells when they are infected with a virus, and it killed with what is sometimes referred to as a 'cytokine storm,' a massive attack using every lethal weapon the body possesses. 

In  the attack, the alveoli were often damaged by the virus, the immune system, or both. The lungs could no longer exchange oxygen with the blood, and the patient died of lack of oxygen. "Or the victim can simply die from exhaustion: he or she must breathe so rapidly to get enough oxygen that muscles become exhausted. Breathing just stops."

Leaving you with this picture of the horrific nature of the 1918 flu, we will continue next week with the effects of the flu on the war, and the war on the flu.



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