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Royal Stuart

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Stuart Townend at Prom Praise at the Royal Albert Hall

Medical progress and the influenza pandemic of 1918.


The influenza outbreak of 1918 spread around the world and left
millions of people dead. This
 /pan·dem·ic/ ()
1. a widespread epidemic of a disease.

2. widely epidemic.

Epidemic over a wide geographic area.

 was both a crisis for human life
and a crisis for medical professionals attempting to combat the disease.
During a period when medicine had become thoroughly professionalized and
had made numerous advances in medical treatment, medical professionals
perceived their field to be rapidly and consistently progressing, and
many believed that there was little medicine could not overcome. Success
against such diseases as
yellow fever
 acute infectious disease endemic in tropical Africa and many areas of South America. Epidemics have extended into subtropical and temperate regions during warm seasons.
 fed the idea that science and
rational thought could conquer society's ills drove medical
professionals' efforts. However, these modern ideas of progress,
perfectibility, and medicine's pending triumph over disease
adversely affected the medical profession's ability to deal
effectively with the
influenza pandemic

 of 1918. Physicians'
efforts had not prevented a serious outbreak, and once it had exploded,
they could not control it. Looking specifically at the British medical
profession's struggle with the pandemic, as it coursed through both
Britain and Britain's armies abroad, this paper examines
physicians' own writings and investigates both their initial
confidence in the face of disease and their disappointment, fear, and
lack of clear direction as the pandemic exploded. In the aftermath of
the pandemic, their confusion, dearth of understanding, and pressure to
fill the void in knowledge are evident. This paper, then, discusses how
confidence affected their
 or mind-set
1. A fixed mental attitude or disposition that predetermines a person's responses to and interpretations of situations.

2. An inclination or a habit.
 when they confronted the pandemic, and
how the pandemic, in turn, affected their concept of progress, the
ability of medicine, and their duty thereafter.


Recently, the advent of the H1N1 virus has brought renewed
attention to influenza's potential to cause lethal epidemics even
in medically advanced areas of the world. In the years, and even
decades, prior, influenza was no longer typically perceived as a

tr.v. ter·ri·fied, ter·ri·fy·ing, ter·ri·fies
1. To fill with terror; make deeply afraid. See Synonyms at frighten.

2. To menace or threaten; intimidate.
 disease. It arrived every winter and infected many people;
however, in most places, it rarely seemed to kill anyone except perhaps
the very young or the very old, portions of the population already
weakened by other circumstances. Yet, as the H1N1 outbreaks exemplify,
influenza is not always a harmless affliction. It has erupted into
several epidemics and pandemics and has been responsible for the deaths
of millions of people. During such outbreaks, influenza, and the myriad
of other complications that can accompany it, can become deadly.

Though the H1N1 outbreaks provide an interesting example of
influenza's ability to become pandemic, aided in its spread by the
increased ease and volume of world travel, the largest and most
devastating influenza outbreak occurred in 1918. That pandemic, erupting
as World War I was ending, is estimated to have killed between twenty
and fifty million people worldwide with many millions more being
sickened (McNeill 1998, 292). World War I gathered together soldiers
from across the globe. As they dispersed from the war, creating
conditions similar to current practices of world travel, they carried
influenza with them. This influenza pandemic was so virulent and out of
the ordinary compared to influenza under regular conditions, that some
had questioned whether it was actually influenza at all, yet no one
doubted that this pandemic was exceedingly deadly (Edinburgh
Medico-Chirurgical Society 1919, 46).

The influenza pandemic of 1918 represented both a crisis for human
life and a crisis for medical professionals attempting to combat the
disease. In the period before influenza's catastrophic outbreak,
the medical profession had been experiencing a particular surge of
confidence. The medical field had been thoroughly professionalized with
new and increased educational requirements and licensing procedures for
practicing physicians and had made numerous advances in medical
treatment. Many physicians sincerely thought that there was little
medicine could not overcome, given the proper study and a populace
willing to follow medical advice. The medical profession was submerged
in the prevalent ideas of modern progress and faith in scientific
advances (Byerly 2005, 41). In several cases, their faith in science and
progress was rewarded by success; in some cases, however, this faith
caused them to underestimate the disease they were fighting (Byerly
2005, 4). Previous successes, coupled with already prevalent ideas of
continued progress toward perfectibility, caused doctors to become
progressively confident, perhaps over confident, in their abilities to
prevent and control disease (Byerly 2005, 4-7). Therefore, when
influenza grew to pandemic strength, leveling significant portions of
both military and civilian populations, medical professionals were at a
loss. They had not prevented a serious outbreak, and once it had
exploded, they could not control it.

This paper will specifically look at the British medical
profession's struggle with the influenza pandemic of 1918 by
examining the writings of physicians and public health officials. As it
coursed through both Britain and Britain's armies abroad, British
medical professionals sought to control, treat, and explain the
influenza. In their own writings, their initial confidence is evident.
As the pandemic exploded and spread, their disappointment, fear, and
lack of clear direction is evident. And, in the aftermath of the
pandemic, their confusion, dearth of understanding, and pressure to fill
the void in knowledge are evident. Through examining their writings, one
can trace the meeting of their confidence in progress and pandemic
influenza. Their confidence affected their mindset when they confronted
the pandemic, and the pandemic, in turn, affected their concept of
progress, the ability of medicine, and their duty thereafter.

The Disease of Influenza

Today, much more, but by no means everything, is understood about
influenza. Though often described in the medical literature surrounding
the 1918 pandemic as being caused by a
 , any rod-shaped bacterium or, more particularly, a rod-shaped bacterium of the genus Bacillus. Some bacterium in the genus cause disease, for example B.
, influenza is a virus
and exists in several strains, which are grouped into three main
categories of A, B, and C (Stuart-Harris, Schild, and Oxford 1985, 1).
The viruses are classified as A, B, or C based on their internal
ribonucleoprotiens. They are further classified by the host which serves
as their source, the location where they were first known to originate,
and the year in which they were first isolated and cultured
(Stuart-Harris, Schild, and Oxford 1985, 1). The virus is prone to
mutations and as new, mutated strains are discovered, they are added to
the catalogue of known influenza viruses competing with each other for
new hosts.

Influenza can infect not only humans, but also a variety of
animals, such as pigs, horses, and various birds. Virus type A appears
to be the most prevalent type and also the most likely to
intr. & tr.v. mu·tat·ed, mu·tat·ing, mu·tates
To undergo or cause to undergo mutation.

[Latin m
new stains. Precisely how new strains originate and the triggers that
cause mutation are not entirely certain. Additionally, type A viruses
are likely to be the causes of both human influenza epidemics and animal
influenza epizootics, or outbreaks (Stuart-Harris, Schild, and Oxford
1985, 1-2). Though much less is presently known about types B and C
viruses, type B viruses appear similar to those of type A, but seem only
to infect humans. Type C viruses were formerly thought to infect only
humans as well but are now known to he able to infect some animals.
Nevertheless, type A viruses receive the most attention, as they seem to
cause most epidemics and epizootics and have the widest range of
possible hosts (Stuart-Harris, Schild, and Oxford 1985, 1-2, 7-8).
Influenza in itself is not typically very dangerous; however, the attack
of the
influenza virus

Any of three viruses of the genus Influenzavirus designated type A, type B, and type C, that cause influenza and influenzalike infections.
 leaves the victim vulnerable to other
complications, which then work with influenza to pose serious dangers.
The most common complications are those involving the lungs, especially
bronchitis and pneumonia; however, complications involving the heart and
nervous system can also occur (Stuart-Harris, Schild, and Oxford 1985,

An influenza attack confers immunity against the particular strain
involved onto survivors through their production of antigens custom-made
to fight the infection the next time it arrives. As the virus

Undergoes a spontaneous change in the make-up of genes or chromosomes.

Mentioned in: Antiretroviral Drugs
however, the antigens produced from the initial infection may no longer
be effective. If the mutations are small enough, the strain only drifts
away from its original form, and immunity may not be lost. If the
mutations are large, however, they may constitute an antigenic shift,
wherein the new strain is so different from the original that those
previously infected with the first strain are not immune to the second
(Hope-Simpson 1992, 95-96). It seems that one or more large mutations
occurred in 1918, thus entirely negating any previously conferred
immunity against influenza (Hope-Simpson 1992, 96). Additionally,
although it is not entirely certain, recent theory holds that three
different A viruses and a B virus may have been involved in the 1918
pandemic (Hope-Simpson 1992, 27).

The State of Medicine Leading up to World War I

At the time of World War I, however, influenza was not perceived as
a threat. It was common in winter and was not a cause for alarm (Byerly
2005, 71). Though influenza had been causing periodic epidemics in
Europe from at least the 16th century onward, it did not warrant receive
much attention (McNeill 1998, 293). Medical professionals focused their
attention on warding off other, more threatening diseases during the

When the war started, the medical profession knew that the task
ahead would be both difficult and vital. It was well known that wars and

epidemic disease

 accompanied one another. Medical officers expected
disease to break out both among troops collected in Europe and among the
civilian populations. As one medical inspector noted, "soldiers
have rarely won wars. They more often mop up after the barrage of
epidemics. ... The epidemics get the blame for defeat, the generals the
credit for victory. It ought to be the other way round" (Zinsser
1934, 153). To this war, however, medical professionals brought a host
of medical advances to combat many well-known wartime diseases.
Additionally, all branches of the medical profession worked together in
an effort to combat disease both among military and civilian
populations. Medical scientists, practicing physicians, and public
health officials were closely aligned in their work, and medicine was
much more integrated than it was
tr.v. com·part·men·tal·ized, com·part·men·tal·iz·ing, com·part·men·tal·iz·es
To separate into distinct parts, categories, or compartments:

Since Robert Koch's 1876 discovery 1876 that germs, or
specific microorganisms, were responsible for producing diseases,
scientists had made headway in identifying and culturing the
1. Functioning as an agent or cause.

2. Expressing causation. Used of a verb or verbal affix.

 agents of several diseases (Drinkwater 1924, 12). As Koch, Pasteur, and
others made further discoveries, medical professionals combated diseases
in new ways and attained successes never before possible. One especially
notable success was that against yellow fever. Once the cause was
identified, and mosquitoes were recognized as the carriers, doctors
instituted methods of mosquito control that almost completely
obliterated the disease in areas under their control by 1906 (Byerly
2005, 18-19). Other advances also spurred the medical profession to
heights of confidence in its abilities. When the bacillus that caused


 was identified, doctors and wartime sanitation officers could
use this knowledge to detect the presence of the bacillus in water and
food supplies, thereby cutting down significantly those affected with
the disease (Drinkwater 1924, 53). Cholera was reduced in the same way.
Once the
 common name for members of either of two distinct orders of wingless, parasitic, disease-carrying insects. Lice of both groups are small and flattened with short legs adapted for clinging to the host.
 was identified as the carrier of
 any of a group of infectious diseases caused by microorganisms classified between bacteria and viruses, known as rickettsias. Typhus diseases are characterized by high fever and an early onset of rash and headache.
, medical
officials could institute delousing and washing programs to prevent that
disease among soldiers. Additionally, new vaccines were continuously in
the works for use among soldiers, and anti-tetanus and typhoid
vaccinations became especially important (Byerly 2005, 20-22).

During World War I, public health and field practitioners put their
advances to a great test. In the beginning of the war, many epidemic
diseases routinely associated with wars were conspicuous by their
relative absence (Byerly 2005, 4). Even in the earlier stages of the
war, medical officers had observed the links between sanitation and
health and were pleased and were pleased with the results of their
efforts thus far. "Modern methods of sanitation have done much
toward preventing the spread of army pestilences, not only in peace, but
also in war ... Whatever. attitude we may assume toward the question of
whether war can ever be wholly abolished, we must all agree that, if war
has once broken out, all possible means must be employed to prevent the
spreading of
 /pes·ti·lence/ () a virulent contagious epidemic or infectious epidemic disease.pestilen´tial

 within the armies" (Prinzing 1916, 3).
Civilian physicians and military medical officers alike were confident
that, by diligently employing modern methods of sanitation and disease
control, they could mitigate or even entirely prevent the spread of
disease both in peacetime and in wartime.

As the war progressed, medical and sanitary professionals sought to
further refine their sanitation methods based on what the war had taught
them thus far. Military medical professionals thought hygiene important
and strove to improve it as much as possible within their domains. They
advocated particularly the intake of fresh air, promoted better
ventilation, and pushed for at least forty square feet of space per man
in order to reduce both the onset and spread of disease (Kenwood 1916,
1083-1085). They recognized that their efforts were not completely
effective and that improvements must continuously be sought and
implemented; however, they were undoubtedly excited by what they had
accomplished. They saw, revealed in the war, a tremendous capacity for
organization, and envisioned, in peacetime, this capacity could be put
to use in constructing a policy of greater public health that would even
stem the tide

 of disease (Kenwood 1916, 1083-1085).

Medical officers took their responsibilities seriously and fought
to keep the soldiers under their care as free of disease as possible. As
they constantly looked for ways to improve sanitation and hygiene, they
found that such matters were not always in the forethoughts of
commanding officers focused on winning battles. Military officials
issued sanitary orders as guidelines to help medical officers in their
roles. Often, these orders called for measures that were not expedient
as troops marched and dug into trenches, yet the medical officers knew
that they had a great responsibility to follow the orders, and
furthermore, the arduous task of making the men follow the orders (Bayly
1917, 930-932). Medical officers attached to specific units of soldiers
saw themselves as the last barriers of defense against disease. Science
had determined what could be done to prevent and contain disease, and
British government administration had determined what should be done to
implement the decrees of science, yet it was left to the medical
officers to see to it that the precautions were actually carried out
(Bayly 1917, 930-932). These orders included regulations about where and
how latrines could be made, how trenches should be set up, what to do
with those taken ill, and how to keep and prepare food and

 (Bayly 1917, 930-932). Through attentive implementation of these
directives, medical officers felt confident they could keep their
soldiers safe from disease outbreaks. They believed they had the tools
for disease prevention and control at hand. All that was needed was
their proper implementation.

Thus, medical professionals entered World War I, and worked through
its beginning and middle years, knowing that disease outbreaks were a
serious threat. They knew disease traveled with soldiers and had
devastated armies in the past. However, they felt that by their
vigilance and use of medical advancements, they could hope to avoid such
catastrophic outbreaks in this war.

  Medical science is now endeavouring, by means of systematic procedure
  and splendid organization, to guard soldiers against the danger of
  infection; good drinking water is provided, the men and the rooms in
  which they live are kept clean, persons suffering from infectious
  diseases are isolated, all rooms and articles used by patients are
  disinfected, infected divisions of troops are quartered by
  themselves, germ-bearers are watched for and discovered, (Stc. The
  success of such measures is well known. (Prinzing 1916, 329-330)

Such measures for prevention were implemented as far as possible in
both British armies and the armies of other combatants.

Medical professionals knew they would continue to struggle with
disease. They even knew they could not, at this time, eradicate all
disease, but they believed that the knowledge medicine had gained was
thoroughly able "to confine pestilences within much narrower limits
than was formerly possible" (Prinzing 1916, 330), provided the
knowledge was actively heeded. With proper preparation and constant
vigilance, the medical profession sought to prevent as much as it could
and deal with whatever else came about in light of the advances already
achieved and continuing to be made. At the outset of the war, they
thought themselves well prepared to handle the health of the armies.

  It was a fortunate thing for the country that the Army Medical
  Service was well organized and efficient. Many of the problems which
  would confront us had been foreseen and their solution thought out.
  In particular the pathological branch of the service was well
  developed and excellently officered by a staff trained in the
  well-equipped laboratories of the Royal Army Medical College.
  (Andrews 1917, 829)

Even as the war progressed, they maintained this confidence.
Disease was not gone, but they felt it was much more controllable.
Furthermore, as medical officers did struggle against disease during the
war, they noted the lessons they had learned and the further progress
they had accomplished.

War Time Medicine--Successes and Failures

Medical professionals had to admit that they were at a loss on some
problems; however, even then, they expressed a confidence that it would
be worked out sufficiently and effectively by further research and
effort. This confidence is especially evident with regard to views of
early influenza outbreaks among the soldiers. Though able to
significantly cut down on parasitic infections due to contaminated food
or water supplies, medical professionals were not yet able to conquer
respiratory infections (Byerly 2005, 7). The war created ideal
conditions to foster and spread such infections,

 men, poor
ventilation, damp, cold trenches. Medical professionals felt that they
could control
respiratory disease

, especially pneumonia, if given the
right set of conditions; however, these were difficult to produce in
training camps, trenches, and transports (Byerly 2005, 15). Yet, when
mild outbreaks of influenza did occur in the spring of 1915 and in 1916,
few thought them very serious or worthy of much mention. Death rates
during these outbreaks, either due to influenza itself or its following
complications, were not much higher than during regular, seasonal
periods of influenza infection (Newsholme 1918, 691).
Special measures

 to combat influenza were seen as unnecessary at this time. Influenza had
last been epidemic in 1890, and though some remembered that epidemic, to
most physicians, influenza was a common and non-threatening

A physical or mental disorder, especially a mild illness.

Some medical professionals did, however, believe that the influenza
that broke out in larger than normal, though not catastrophic,
proportions in 1915 and 1916 appeared to be changed (Shera 1917,

  For instance, the older physician scarcely recognizes the modern type
  of influenza as his old friend the 'knock-me-down-fever,' and
  therefore is apt to overlook it, if not to despise it as unworthy of
  much attention. Yet, I venture to state, and herein hope to show,
  that the clinical and bacteriological phenomena associated with this
  complaint are a study worthy of much attention and as yet largely
  unfathomed, in spite of the enormous literature on the subject.
  (Shera 1917, 450-452)

As medical professionals observed the courses of influenza
outbreaks, both in Europe and in the
United States
 officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.
, it appeared that
influenza took different forms depending upon whether it occurred
sporadically, epidemically, or pandemically (Ritchie, Matthews, and
Goodall 1917, 31). In sporadic, or seasonal forms, the disease was well
known to physicians; however, in pandemic form, influenza's
"clinical characteristics vary widely" (Ritchie et al. 1917,
31). Yet despite the uncertainty of manifestations, pandemic influenza
was noted to have a high incidence rate, with around fifty percent of
all people in a given sample contracting it, and was far more virulent
than common, sporadic influenza (Ritchie et al. 1917, 31).

In addition to drawing increased attention to the apparent
difference between what common influenza accomplished and what pandemic
influenza could do, the milder outbreaks of influenza that preceded the
pandemic also raised some questions regarding medical
professionals' knowledge about the disease in general. Three types
of influenza were recognized, respiratory, cardiac, and
gastro-intestinal, based both on symptoms and the secondary
complications that could accompany them, yet beyond this classification,
knowledge of influenza became more muddled. It was commonly accepted
that the cause of any type of influenza was a bacillus identified by
Pfeiffer in 1892, or B. influenzae (Drinkwater 1924, 54), yet some were
not certain that this bacillus was the true cause and others disagreed
entirely (Ritchie et al. 1917, 31). Debate over the exact role of
Pfeiffer's bacillus would continue throughout the pandemic. Doctors
were also uncertain of how influenza was transmitted to humans. Some
believed that it was passed to humans from animals, while others had
reservations. Still further debate surrounded which kinds of animals
could transmit influenza to humans. All of these uncertainties led some
medical professionals early on to call for much greater exploration of
these "pathological depths" (Shera 1917, 450-452).

As the outbreaks of 1915 and 1916 subsided, however, so did any
focus on influenza. Medical officers had more dangerous diseases and
infections from which to protect their troops, and they focused on
continually improved methods of containing them. By 1917, the war had
been going on for three years, and British medical officers could review
the medical progress they had made during that time. The catalogue was
Enteric fever

1. See typhoid fever.

2. See paratyphoid fever.

A term that is sometimes used for either typhoid or paratyphoid fever.

Mentioned in: Paratyphoid Fever
 had been significantly and amazingly reduced
by both quarantining known carriers and preventative vaccination
(Andrews 1917, 829).
 , inflammation of the intestine characterized by the frequent passage of feces, usually with blood and mucus.
 had also been reduced, though the defeat
was not as spectacular as that over enteric fever. "Prevention has
therefore been reduced to

1. Of or relating to hygiene.

2. Tending to promote or preserve health.

3. Sanitary.
 precautions and to the search for
carriers, and on the Western front these measures have hitherto sufficed
to prevent any serious outbreak of dysentery, in spite of the return to
France of large bodies of troops from the Mediterranean area"
(Andrews 1917, 830). Among those troops serving in the Mediterranean and
Mesopotamian areas, the incidence of dysentery was still high, yet
medical professionals were working on treatment and prevention with
results that encouraged them (Andrews 1917, 830). Both cholera and
typhus excited medical professionals with their absence from the troops.
Their elimination marked a
v. re·sound·ed, re·sound·ing, re·sounds

1. To be filled with sound; reverberate:

 and important success (Andrews
1917, 830).

Medical professionals also found success in their treatments of
wounds inflicted through actual fighting in the war. Advances in
antiseptics and in the administration of
  or  acute infectious disease of the central nervous system caused by the toxins of Clostridium tetani.
 inoculations led to
reduced secondary infections among the wounded. "In the early days
of the war tetanus of a severe type was common amongst the wounded, and
the control of this disease by the prompt administration of a

 /pro·phy·lac·tic/ ()
1. tending to ward off disease; pertaining to prophylaxis.

2. an agent that tends to ward off disease.

 dose of

1. Neutralizing the action of a toxin or poison.

2. Of, relating to, or containing an antitoxin.

adj having the capacity to render bacterial toxins inert.
 serum to all wounded men will rank as one
of the triumphs of preventative medicine in the present war"
(Andrews 1917, 831). Also, segregating wounded soldiers from those
suffering from diseases in hospitals decreased further infection.

The affliction of
trench foot

A condition of the foot resembling frostbite, caused by prolonged exposure to cold and dampness and often affecting soldiers in trenches. Also called immersion foot.
, at first a common and

Causing a loss of strength or energy.

Weakening, or reducing the strength of.

Mentioned in: Stress Reduction
 problem for soldiers in the trenches, was also largely conquered by
scientific progress. Trench foot, a minor state of frostbite which could
end in
 local death of body tissue. Dry gangrene, the most common form, follows a disturbance of the blood supply to the tissues, e.g., in diabetes, arteriosclerosis, thrombosis, or destruction of tissue by injury.
, was more or less eliminated from the trenches with the
introduction of special coverings worn on the
feet and legs

See also anatomy; body, human; walking.


any invertebrate of the phylum that includes insects, arachnids, crustaceans, and myriapods with jointed legs.
 to prevent
the continuous wet and cold from seriously harming the soldiers'
extremities (Andrews 1917, 832).

With other diseases, the medical professionals experienced less
success. Cerebro-spinal fever,
trench fever
 see rickettsia.
, and trench
 , inflammation of the kidney. The earliest finding is within the renal capillaries (glomeruli); interstitial edema is typically followed by interstitial infiltration of lymphocytes, plasma cells, eosinophils, and a
 remained relative mysteries and continued to
tr.v. af·flict·ed, af·flict·ing, af·flicts
To inflict grievous physical or mental suffering on.

[Middle English afflighten, from afflight,
 troops. However,
physicians and researchers remained confident that their mysteries would
be solved, and the diseases would be similarly reduced (Andrews 1917,
830). On the whole, medical professionals and government officials were
both impressed with the achievements of science and their application to
the war effort. The successes against so many diseases, despite limited
successes against others, led some to declare that "the health of
the army at present might be considered satisfactory", and that
"nothing in this war was more striking than the triumph of science
over disease, wholly upsetting the experience of former wars"
("Medical Notes in Parliament: Mr. Foster's Tribute to the

Army Medical Services

: The Triumph of Science Over Disease" 1917,

The Onset of Pandemic Influenza

As 1917 drew to a close, however, so did a period of relative
security against disease. In March and April of 1918, cases of
undetermined fever, or influenza, began to appear in United States'
army training camps. Increasing numbers of soldiers reported to army
hospitals with symptoms such as severe headache, high fevers, pains in
bones and muscles,
 /pros·tra·tion/ () extreme exhaustion or lack of energy or power.

heat prostration  see under exhaustion.

, cough, nausea, and rash. In hospitals,
medical officers consigned the patients to bed, fed them light foods,


 aspirin for pain, and tried to prevent the secondary
complications that were much more dangerous than influenza itself
(Byerly 2005, 70). By April, influenza outbreaks emerged among the
troops in France, signaling an
influenza epidemic

. Eventually, this
would be recognized as the first wave of the 1918 influenza pandemic
(Byerly 2005, 70-71).

Medical officers were worried about these outbreaks of influenza.
They tried to investigate and contain them, but containment proved
impossible. With new troop transports continually arriving in Europe
from United States, with the crowded conditions in training camps, and
with life in trenches, influenza quickly spread amongst the soldiers and
was soon present all over Europe, among the belligerents of both sides
and neutral countries as well. Medical professionals progressively
realized that this outbreak, unlike others they had faced, was spiraling
out of their control. On both sides of the war, medical officers were
quiet about the outbreaks as they were not willing to reveal to any
enemy a possible weakness in their armies; therefore, when reports of
influenza outbreaks came out of neutral and less
 also tight-lipped  
1. Having the lips pressed together.

2. Loath to speak; close-mouthed. See Synonyms at silent.
 Spain in
May of 1918, the epidemic was named the "
Spanish Influenza

Influenza that caused several waves of pandemic in 1918-1919, resulting in over 20 million deaths worldwide.
(Byerly 2005, 88).

In Europe, throughout April, May, June and July, tens of thousand
of soldiers in the British, French, German, Austrian, Italian, and
American armies sickened and required hospitalization every day (Byerly
2005, 73). As alarming as the rate of morbidity was, and as damaging as
that was to armies attempting to maintain a viable
fighting force

relatively few cases were actually fatal ("The Influenzal
Pandemic" 1918, 39). Early on in Britain, some asserted that this
outbreak may have been caused by an "aberrant bacillus," but
the only treatments then called for were bed rest, aspirin, and good
ventilation. For prevention, medical officers chiefly advocated the
covering of mouths when coughing to prevent influenza's spread from
person to person through spitting and coughing the disease into the air
("The Influenzal Pandemic" 1918, 39). These methods of
treatment and prevention did not differ from those used to fight
influenza under regular, seasonal conditions. They relied on the best
methods they had and hoped for these methods to conquer influenza while
they took notes on the results.

As the first wave progressed, British medical officers observed the
effects as it hit each camp. In one camp, 1,439 cases were admitted to
the hospital between June 21 and July 10. The average stay at the
hospital was five days, with one or two days needed for the fever to
break (Averil, Young, and Griffiths 1918, 111-112). Medical officers
kept careful tabs on the complications they all knew could develop after
an influenza attack. Of the 1,439 cases mentioned above, only sixteen
developed pneumonia, and of those sixteen, seven died. The low rate of
complications was heartening, however, once complications developed, the
high death rate was a cause for alarm (Averil, Young, and Griffiths
1918, 111-112).

As stories of infection and fear became rampant, British medical
officials sought to issue some guidelines and to make an authoritative
statement about influenza to stem the alarm at least partially (The

Royal College of Physicians

 1918, 546). Officials admitted that while
they knew something of influenza, there was still quite a bit about its
nature that remained uncertain. Nevertheless, they tried to make some
statements to influence people positively in the fight against
influenza. The main call was for the avoidance of overcrowding at all
costs, the maintenance of well-ventilated, airy rooms, and the wearing
of warm clothes to avoid being chilled (The Royal College of Physicians
1918, 546). Officials also stated the need for good, nourishing food to
prevent against influenza while maintaining that war rations were more
than adequate to accomplish goal.

Upon feeling sick, officials recommended a person to
 /gar·gle/ ()
1. a solution for rinsing mouth and throat.

2. to rinse the mouth and throat by holding a solution in the open mouth and agitating it by expulsion of air from the lungs.
disinfectant (liquer sedae chlorimatae) and water every four to six
hours and to flush the nose out with salt water. Once actually ill, bed
rest was the only sure treatment as no drug had yet been shown to either
cure or prevent influenza and vaccines against it were still in their
uncertain, testing stage (The Royal College of Physicians 1918, 546).
Doctors and patients alike were advised that the period of enfeeblement
that often followed during
 /con·va·les·cence/ () the stage of recovery from an illness, operation, or injury.

 from influenza was not to be
taken lightly, as it could mask a potentially fatal complication. Beyond
these measures and recommendations, officials stressed the need to
isolate the sick from the healthy to prevent spread and urged
individuals to take up their responsibility to try to protect
themselves, and thus their communities, from influenza (The Royal
College of Physicians 1918, 546).

Such was the advice given to both military and civilian
populations. These measures could be sufficient if no serious
complications developed; however, as the number of those taken ill
exploded, there were often not enough physicians to care for all the
sick as they would have been cared for in peacetime. Military physicians
had the arduous task of caring for thousands of soldiers. Military
populations often suffered from shortages of both doctors and nurses.
Civilian physicians also faced a difficult task in caring for the
remaining civilian population. Many physicians offered their services to
the military during the war, which left relatively few at home.
Additionally, many medical personnel would have been among the most
susceptible to influenza, suffering constant exposure and being fatigued
from over work and other wartime demands. Thus, both military and
civilian medical professionals had extreme workloads on their hands.

At its height, the first wave affected 30 to 40 percent of children
under ten and 20 to 30 percent of adults (Stuart-Harris, Schild, and
Oxford 1985, 119). By the end of July, however, influenza cases had
significantly dropped off, and the outbreak was subsiding in Britain
(The Royal College of Physicians 1918, 546). Influenza hit a summer
lull, and the first wave fizzled out. Many had sickened, few had died,
and medical officers remained concerned lest influenza return (Byerly
2005, 73). Indeed, the retreat of influenza was only temporary and by
September 1918, the second wave had begun.

The Second Wave of Influenza

During the second wave, influenza became exceedingly virulent, and
victims were far more likely to experience dangerous complications.
Though the exact factors that caused influenza's increased
virulence were ultimately unknown, many speculated, albeit vaguely, that
"The bacillus itself may have become more virulent, or there may
have arisen some conditions favouring its growth and producing a very
large increase in its numbers" (The Influenza Committee of the
Advisory Board to the D.G.M.S., France 1918, 505). Wartime
circumstances, such as rationing, cold, damp conditions in trenches, and
exposure to
poison gas
 any of various gases sometimes used in warfare or riot control because of their poisonous or corrosive nature. These gases may be roughly grouped according to the portal of entry into the body and their physiological effects.
, could have contributed to the devastating
virulence. Influenza's
incubation period

1. See latent period.

2. See incubative stage.

 appeared to be between two
and four days, and the onset of the disease was usually sudden (The
Influenza Committee 1918, 505).

Influenza could manifest itself in various forms, depending upon
its severity and the complications resulting from it. It could range
from a "simple three-day fever, to various pulmonary infections, to
something resembling malaria, to a gastric infection, to rare but fatal


blood poisoning
 see septicemia.
 or even cerebral infections (Small 1920,
16-24). It was the complications, however, that often killed. Though the
symptoms of influenza during the first wave caused alarm in medical
professionals, the symptoms exhibited in the second wave were far worse.
Patients were often admitted with fevers of 105 or even 106 degrees
Fahrenheit. Some experienced bleeding from the nose and ears. Many
coughed up bloody, foaming
 /spu·tum/ () [L.] expectoration; matter ejected from the trachea, bronchi, and lungs through the mouth.

sputum cruen´tum  bloody sputum.
. Some were

Of, suffering from, or characteristic of delirium.
, lethargic,


Affected with nausea.
, or

1. Lacking normal voluntary control of excretory functions.

2. Lacking sexual restraint; unchaste.
 (Byerly 2005, 7778). One of the most striking
and terrifying symptoms was that of
 , bluish coloration of the skin, mucous membranes, and nailbeds, resulting from a lack of oxygenated hemoglobin in the blood.
, or blueness of the skin
due to lack of oxygen. Patients exhibiting this symptom often died
within hours, suffocating as their lungs filled with sputum (Byerly
2005, 78).

Even if one survived the initial attack of influenza, he found
himself weakened and susceptible to a host of opportunistic secondary
infections. The most common complication suffered was pneumonia, which
caused inflammation of the lungs, fever, cough, chest pain, and
difficulty breathing (Byerly 2005, 81). The second wave produced an
unusually high number of pneumonia cases in adults aged 20 to 40, and
once pneumonia was contracted, the
fatality rate

See death rate.

fatality rate

see case fatality rate.
 was about 50 percent
for this age group (Stuart-Harris, Schild, and Oxford 1985, 119). Other
complications included bronchitis,
spinal meningitis

Inflammation of the membranes enclosing the spinal cord, especially a usually fatal form that affects infants and young children and is caused by a strain of gram-negative bacteria (Hemophilus influenzae).
, infections of the
kidneys, heart, or ears,
pulmonary emphysema

See emphysema.
, gangrene of the lungs,

 , persistent purulent discharge into a cavity such as the pleural space or the gallbladder. Empyema results as a complication of bacterial infections such as pneumonia and lung abscess.
 (consolidation of

Containing, discharging, or causing the production of pus.

Consisting of or containing pus

Mentioned in: Lacrimal Duct Obstruction


containing or forming pus.
 matter in the lungs), and heart
failure (Byerly 2005, 81). Medical professionals were alarmed and
stunned by the unusually high number of sufferers who developed
secondary infections. Furthermore, they found that the secondary
infections seemed more deadly than normal. Military and civilian doctors
monitored and recorded case after case of death from bronchitis and
various types of pneumonia with horror (The Influenza Committee 1918,

Like the first wave, the second wave of influenza was also
particular in its unusual propensity to attack those aged 20 to 40.
Typically, influenza most affects the very young and the very old and
thus produces a U-shaped mortality curve. In the second wave, a W shaped
mortality curve ensued. The very young 'and the very old were still
seriously affected, but so were those in the middle years of life. The
second wave was in fact most deadly for those aged 20 to 40, and not
only for those previously sick, but also for those previously healthy
(Byerly 2005, 5). In London alone, 44 per cent of influenza deaths and
37 per cent of those from influenza, pneumonia and bronchitis were in
adults aged between 20 and 45" (Stuart-Harris, Schild, and Oxford
1985, 119).

Efforts of Containment and Treatment

In Britain, medical officials were
tr.v. as·ton·ished, as·ton·ish·ing, as·ton·ish·es
To fill with sudden wonder or amazement. See Synonyms at surprise.
 at the rates of
sickness, the symptoms, 'and the fatalities. Influenza ravaged both
the military and civilian populations and left medical professionals
scrambling to find viable preventative and treatment measures at a time
when hospitals were both exceedingly
v. o·ver·crowd·ed, o·ver·crowd·ing, o·ver·crowds
To cause to be excessively crowded:
 due to illness rates
and exceedingly understaffed due to a relative shortage of doctors and
nurses (Small 1920, 15). In these efforts, committees and boards, such
as the Ministry of Health and the Royal Society of Medicine, as well as
independent medical professionals worked constantly both to treat
influenza and study it ("A Ministry of Health" 1918, 139).
Bacteriologists searched for the causes of influenza and epidemiologists
searched for explanations as to how and why the pandemic erupted. Those
actually treating patients, though overwhelmed with caring for the sick,
also took copious notes on their work, seeking to find effective
treatments and to explain the pandemic.

With regard to prevention, medical professionals had to admit that
they were powerless to halt the spread of influenza, both in the
military and at home. "We are at present unable to prevent the
spread of influenza by communal means, and the experience of every
family invaded by influenza demonstrates the difficulty, amounting
almost to impossibility, of preventing the spread of infection in the
domestic circle" (Newsholme 1918, 692).

Prevention efforts were also hindered by the war, as the following
passage illustrates:

  There are national circumstances in which the major duty is to "carry
  on," even when risk to health and life is involved. This duty has
  arisen as regards influenza among the belligerent forces, both our
  own and of the enemy, milder cases being treated in the lines; it has
  arisen among munition workers and other workers engaged in work of
  urgent national importance; it has arisen on a gigantic scale in
  connexion with the transport during 1918 of many hundreds of
  thousands of troops to this country and to France from overseas. In
  each of the cases cited some lives might have been saved, spread of
  infection diminished, great suffering avoided, if the known sick
  could have been isolated from the healthy; if rigid exclusion of
  known sick and drastic increase of floor-space for each person could
  have been enforced in factories, workplaces, barracks, and ships; if
  overcrowding could have been regardlessly prohibited. But it was
  necessary to "carry on," and the relentless needs of warfare
  justified incurring this risk of spreading infection and the
  associated creation of a more virulent type of disease or of mixed
  diseases. (Newsholme 1918, 692)

In every aspect of wartime life, military and civilian populations
sought to "carry on" despite influenza. Crowded conditions in
trenches and on transport ships and the confluence of soldiers from all
over the world made it difficult, if not impossible, to carry out
recommended preventative measures such as ample space for each soldier,
good ventilation, and the isolation of the sick from the healthy. Among
the civilian population, the urge to "carry on" often caused
people to go back to work before fully recovered, thus inviting the
onset of serious complications and possibly spreading influenza to
others. With the war's help, influenza spread rapidly and
uncontrollably among military and civilian populations despite the
concerted efforts of medical professionals and public officials. The
government issued warnings, and doctors gave advice, yet none of it
hindered influenza's progress.

With regard to treatment, in addition to the regular bed rest and
good ventilation orders, many other varieties of medicines and measures
were advised by different physicians; however, each one only treated
symptoms (The Influenza Committee 1918, 507). Some symptomatic
treatments of influenza served simply to make the patient more
comfortable, alleviate pain, allow for sleep, and so forth, but others
were meant to ward off the secondary infections. Yet, preferably,
because these secondary infections were particularly deadly, medical
professionals sought to prevent them if at all possible. "And it is
well to enforce the warning that wisdom lies in considering any case at
its period of invasion potentially a severe one, not to say potentially
a desperate one. If this principle were followed, both by the patient
before he seeks advice and by the doctor after he has first given it,
the disease would lose much of its terrors" (Horder 1918, 694).
Most efforts to ward off complications consisted of keeping the patient
warm to prevent pneumonia and allowing proper time for convalescence
(Horder 1918, 694).

The treatments prescribed differed from physician to physician.
Some relied on techniques that others denounced. Some found certain
drugs very helpful, while others found that no drugs seemed to help. In
their efforts to find effective treatments, physicians tried a host of
drugs and other remedies, some of which included
 /per·man·ga·nate/ () a salt containing the MnO4- ion.

Any of the salts of permanganic acid, all of which are strong oxidizing agents.
being sprayed down in a chamber with disinfectant, washing Out the nose
and throat with acroflavine solution or salt water, inhaling steam
vapors, poultices, aspirin,
 , white crystalline alkaloid with a bitter taste. Before the development of more effective synthetic drugs such as quinacrine, chloroquine, and primaquine, quinine was the specific agent in the treatment of
camphor oil

The oil obtained by steam distillation from the wood of the camphor tree and used to produce natural camphor.

 /hy·dro·chlo·ride/ () a salt of hydrochloric acid.

A compound resulting from the reaction of hydrochloric acid with an organic base.
 solutions, alcohol, and even heroin. Bed rest and proper ventilation
seemed to be the only treatments everybody could agree on without

The Development of an
Influenza Vaccine
 Flu vaccine A vaccine recommended for those at high risk for serious complications from influenza: > age 65; Pts with chronic diseases of heart, lung or kidneys, DM, immunosuppression, severe anemia, nursing home and other chronic-care

Many medical professionals placed their hopes for effective
treatment in the future development of a vaccine against influenza.
During the pandemic, vaccines were used by many doctors to treat or
prevent influenza; however, at that time, influenza vaccines were
untested, and doctors used them experimentally. Nevertheless, given the
ineffectiveness of other preventative and
 /cur·a·tive/ () tending to overcome disease and promote recovery.

1. Serving or tending to cure.

 measures, the vaccine
seemed the most hopeful possibility.

Much disagreement surrounded the use of vaccines against influenza
during the 1918 pandemic, both among medical researchers and general
physicians. Though most medical professionals looked forward to the
development of vaccines, not all thought it wise to administer them in
the present pandemic. Some thought that proper vaccines could not be
made because the causative agent of influenza was not definitively and
agreed upon

 (The Royal College of Physicians 1918, 546).
Others desired more information before employing vaccines (Edinburgh
Medico-Chirurgical Society 1919, 51). A minority believed the vaccine,
or at least the ones available during the pandemic, gave no benefits in
fighting off or preventing influenza (Edinburgh Medico-Chirurgical
Society 1919, 53). For the most part, however, desperate researchers and
practitioners developed vaccines and used them in treatment, despite the
lack of testing. They recorded their results, and often found the
vaccines to be successful, either cutting an influenza attack short or
preventing one from ever occurring at all (Pennell 1919-1920, 209).

The production of an influenza vaccine in 1918 was largely
guesswork, and several vaccine formulas circulated. Many formulas
consisted of a mix of pneumococci,
n. pl. staph·y·lo·coc·ci
A spherical gram-positive parasitic bacterium of the genus Staphylococcus, usually occurring in grapelike clusters and causing boils, septicemia, and other infections.
, B. influenzae, and

 , any of a group of gram-positive bacteria, genus Streptococcus, some of which cause disease.
 /ba·cil·li/ () plural of bacillus.


see bacillus.
. Some advocated a mix because the
actual causative agent of influenza was still a matter of speculation,
while others hoped the mix would

1. To introduce a serum, a vaccine, or an antigenic substance into the body of a person or an animal, especially as a means to produce or boost immunity to a specific disease.

 against all likely infections
(Wynn 1920-1921, 111). Even if most vaccines contained the same
organisms, the dosage varied. Some physicians thought it dangerous to
inject too many bacilli into a patient, fearing damage to the kidneys,
and kept their dosing small (Pennell 1919-1920, 209). Others, however,
felt that the higher the possible dosage, the more effective the vaccine
would be, even if the reaction of the patient was a little more
unpleasant. Some found a fair compromise to be giving three or four
smaller doses instead of two larger ones (Wynn 1920-1921, 110-111).

On October 14, 1918, Britain's War Office held a conference to
develop a preventative vaccine for influenza, and thus, end both the
pandemic and the squabbling of physicians. The committee, like many
medical professionals, expressed doubt as to whether Pfeiffer's
bacillus was really the cause of influenza. They agreed that it was
somehow significant to influenza, but thought that the real causative
agent might still be undiscovered. The committee's findings were
subsequently summarized as follows:

  After discussing the available evidence as to the bacteriology of the
  present epidemic, the majority of those present were agreed that
  there was considerable doubt as to the primary etiological
  significance of the Bacillus influenzae of Pfeiffer, and considered
  that the existence of some as yet undiscovered virus must be regarded
  as possible. They had, however, no doubts as to the very frequent
  presence of Pfeiffer's organism in this epidemic, nor as to the great
  importance of the part which it played in the production of the
  symptoms and complications
  of the disease. The organisms most frequently associated with the B.
  influenzae, and in their opinion, chiefly responsible for the gravity
  of the secondary pulmonary complications, are pneumococci and
  streptococci. ("The Utilisation of Vaccine for the Prevention and
  Treatment of Influenza" 1918, 565)

Because B. influenzae, pneumococci, and

A genus of spherical-shaped anaerobic bacteria occurring in pairs or chains. Sydenham's chorea is considered a complication of a streptococcal throat infection.
 bacilli were
commonly found in influenza victims, the later two responsible for
producing secondary infections, the committee composed its vaccine of
several different strains of all three organisms. It recommended that
vaccines be administered in two doses, with the second dose containing
twice as many bacilli as the first dose. The doses were to be given in
intervals of ten days ("The Utilisation of Vaccine" 1918,
565). The committee also outlined guidelines for administering vaccines
in special cases, namely children,
colonial troops

, Native contingents,
and those already suffering from subacute or chronic influenza. For
children over the age of three and those already suffering from
influenza, the dosage was reduced. They recommended that children under
the age of three not be vaccinated at all. For colonial troops and
Native contingents, three doses were recommended. The committee decided
that those already suffering from a severe case of secondary
broncho-pneumonia should not be vaccinated because of the
"dangerous rapidity and severity of many of these cases"
("The Utilisation of Vaccine" 1918, 565). However, should
physicians decide to

To inoculate with a vaccine in order to produce immunity to an infectious disease such as diphtheria or typhus.

 these patients anyway, the committee
suggested that the dosage be much reduced.

Finally, "In order to ascertain the degree of protection given
by the vaccine," the committee strongly recommended "that the
necessary administrative steps be taken to secure statistical record
dealing the with following matters:--

  (a) The reactions following the inoculations.

  (b) The occurrence of any cases of severe illness within 48 hours of

  (c) The incidence of the disease among the inoculated and

  (d) The incidence of complications among the inoculated
  and uninoculated" ("The Utilisation of Vaccine" 1918, 566)

Even when setting out guidelines for the use of vaccines, medical
professionals knew that not enough testing and research had been
completed to make sure statements. The committee on vaccination made
recommendations because of the emergency, not because it had concluded
anything definitive about the use of vaccines against influenza.

The committee's recommendations gave many medical
practitioners a definite guideline to follow and caused them to feel
more confident in administering vaccinations. Some, however, felt that
the committee had been too cautious with its dosage recommendations, and
advocated larger doses (Wynn 1920-1921, 113). They thought that larger
doses created a higher benefit and did not cause undo stress on those
inoculated. In the end, the question of vaccine formula remained a
matter of debate and development. Nevertheless, British medical
professionals placed their hopes in the success of the anti-influenza
vaccines. "It appears to us that the only practical measure which
is likely to be effective to control the present epidemic is a
prophylactic vaccine treatment" (Fildes, Baker, and Thompson 1918,


Intimately connected with the vaccine debate was the debate over
the actual causative agent of influenza. Though some British medical
professionals still clung to the idea that Pfeiffer's bacillus was
the actual cause of influenza, by the second wave, most had at least
some doubt as to its actual role, and many believed that a still
undiscovered organism was actually to blame. Medical professionals
continuously attempted to settle the debate during the pandemic by
producing evidence of B. influenzae in patients suffering from
influenza. Initially, this evidence proved difficult to produce. Only
small amounts of the bacillus were found in patients and only
inconsistently. However, as medical professionals developed new
techniques for culturing microorganisms, they began to find the bacillus
much more regularly and in larger numbers, both ante-mortem and

 (Fildes, Baker, and Thompson 1918, 699). These findings showed
that the bacillus was important to influenza.

  When now these bacteriological findings, ante- and post-mortem,
  are reviewed as a whole, taking into consideration the essentially
  superficial nature of many of the examinations and the difficulties
  met with in the preparation of a very delicate medium, it appears
  justifiable to us to suggest that B. influenzae is very frequently
  present in the respiratory passages before death, and is present in
  the lungs and sometimes the blood after death so frequently as to
  suggest that the disease is constantly associated with and due to a
  B. influenzae infection. (Fildes, Baker, and Thompson 1918, 699)

However, other organisms, specifically pneumococci and
streptococci, were also consistently present in influenza patients,
especially those suffering complications, and the exact relationship
among them remained uncertain to medical professionals. Despite improved
evidence of B. influenzae's presences in the pandemic and the
presence of other, known organisms, many wondered if influenza was
actually due to a filter passing organism as yet unknown because it was
so small that it passed through the filters used to catch and identify
microorganisms (Russell 1919, 402).

During the pandemic, medical professionals had to settle for
uncertainty regarding the causative agent, though, as they realized,
this unknown further hindered their ability to combat the disease. To be
as safe and effective as possible, they tended to act, for the time
being, as if all the organisms present, and perhaps ones unknown, worked
together to produce influenza (Russell 1919, 402).

The Third Wave

By the middle of November 1918, the second wave of influenza began
v. re·lent·ed, re·lent·ing, re·lents

To become more lenient, compassionate, or forgiving. See Synonyms at yield. Obsolete
 in Europe. With their heads still spinning, British medical
professionals watched as, through no great success of their own,

morbidity and mortality

 rates fell to within normal levels during the
remainder of the winter. As the war ended as well, it seemed that
medical professionals would have some time to study what had just
occurred and gain insight into the influenza epidemic. However, by the
spring of 1919, influenza returned in a third wave. This third wave,
stretching from January into the middle of 1919 but with a concentration
in February and March, was also pandemic. Though it was less destructive
overall than the second wave, it was still deadly, seemingly composed of
the same virulent causative agents as the second wave (Byerly 2005, 7).
Like the second wave, it caused a high incidence of deadly pneumonia and
was also prone to attacking those between 20 and 40 years of age
(Stuart-Harris, Schild, and Oxford 1985, 119). By the middle of 1919,
however, it was over; it burned itself out, perhaps because it could
find no more susceptible human hosts to infect (Byerly 2005, 7).
Influenza would continue to break out in epidemic form after the third
wave; however, for the next, decade, these outbreaks were of decreasing
severity (Hope-Simpson 1992, 27).

The Aftermath of the Pandemic

In the aftermath of the pandemic of 1918, medical professionals
faced many unanswered questions about what had happened. In their
writings after the pandemic, medical professionals of all kinds
expressed shock at influenza's powerful onslaught, dismay that they
were powerless to halt its advances, but also determination to discover
what had allowed it to happen and how it could be defeated, should it
occur again. The meetings and discussions doctors engaged in regarding
influenza during the pandemic did not stop once it was over. They
continued to discuss it, both to share their dismay and better their
knowledge. They also wrote copious articles describing their experiences
during the pandemic, setting down research gathered both in the
laboratory and in practice, and attempting to draw conclusions from it.
They did not put their failure during the pandemic behind them, but
instead examined and confronted it. The memories their discussions drew
up were painful. "All here will, I think, agree with me when I say
that the influenza epidemics of the autumn of last year and the spring
of this year were the most brain-racking as regards causation, and the
most heart-breaking as regards course and treatment, of any medical
experience we have ever had in our lives" (Edinburgh
Medico-Chirurgical Society 1919, 46).

Despite their
broken hearts

, and perhaps egos, medical
professionals knew they had work to accomplish. They searched for the
identification and cause of the pandemic. Throughout the pandemic, there
had been some debate as to whether this outbreak was similar to or
fundamentally different from earlier outbreaks. Though this pandemic
seemed like influenza, medical professionals did not accept that it was
the same disease they had faced in previous generations. "The
unbiased reader cannot but form the conviction that the recent epidemic
was essentially different from any that preceded it; and that the
element of pneumonia in the epidemic far outweighed the element of
simple influenza in bringing about the magnitude of the outbreak and its
unprecedentedly high mortality" (Dewar 1919, 308). For British
medical professionals, this pandemic towered over "all previously
recorded epidemics of similar nature" and "proved the most
fatal epidemic of disease of any form" that had occurred within any
recent memory (Dewar 1919, 30.3).

As they decided the pandemic was different from any other influenza
outbreak, they searched for explanations for its occurrence. Though they
would find nothing concrete as to the causes of the pandemic, they did
identify the war as a critical factor in its development. "Although
no satisfactory explanation is known of the causes exciting either the
minor or the major epidemics of influenza, there can be no doubt that
the movements of the recent war have been responsible on a large scale
for its increased virulence" (Newsholme 1918, 693). The confluence
of troops from all over the world, the crowded conditions on ships, in
training camps, and in trenches, the influence of weather and fatigue,
the constant movement of troops back and forth from the front, and
finally, the return of soldiers to their homes, all helped create the
conditions in which influenza thrived and spread all over the world.
Additionally, necessities of war mobilization diverted resources away
from dealing with the pandemic, and the imperative of military secrecy
regarding outbreaks of influenza further hindered efforts at control
(Newsholme 1918, 693).

In the search for its cause, medical professionals could not
separate the pandemic from the war itself. Only the war could have
provided the proper conditions and allowed the explosion. For some, the
pandemic and the war became connected even on a metaphorical level.
Searching for the organism that produced the infection was necessary;
however, that organism had been producing that infection as long as
anyone could remember. What this time had made the results so
catastrophic? For them, blaming the pandemic on a causative organism was
tantamount to blaming the war on "bullets and poison gases"
(Crookshank 1920-1921, 104). The causes of the pandemic were deeper than
merely an organism producing an infection, and if epidemics were really
to be prevented, deeper causes must be identified and ameliorated. The
following passage illustrates this mindset:

  We, then, who are concerned to prevent, if possible, the vast
  epidemics that we call influenza, amongst others, must study the
  ultimate causes of these periodical disorders of the health of
  communities, just as the intelligent statesman, who would prevent
  war, should be less occupied with problems of artillery than with
  the causes that lead to conflicts. ... Our business, then, is to
  enquire why pestilences occur; to seek a way, if way there be, of
  foretelling their imminence; and to consider how far they may be
  prevented or modified by the means at our command.

  The inoculation, for example, of individuals during an epidemic,
  and the adoption of measures to limit contagion are undoubtedly
  valuable, but they can no more prevent a pandemic of influenza than
  can gas masks and steel helmets prevent a war. (Crookshank
  19201921, 104)

For the moment, however, medical professionals, specifically
bacteriologists and clinical physicians, would focus on identifying the
elusive causative agent of influenza. The hopeful believed that the
pandemic would spur greater and more successful research into treatments
and prevention of respiratory diseases. For them, "The present
pandemic will not have been suffered in vain if intensive investigation
is pursued on

 diseases in general, and if these great cause of
national disability and mortality are brought more nearly under
control" (Newsholme 1918, 693).

The pandemic did spur greater research. As early as 1919, new work
was being done on filter passing organisms in the hopes of identifying
the root cause of influenza (Logan 1919, 128). Scientists felt they
almost had to start over in their search for influenza's causative
organism, and laboratories both in the United States and in Europe
engaged in this activity (Olitsky and Gates 1923, 100). For years,
scientists conducted research both on animals and on volunteer humans,
with limited success. For over a decade, epidemic influenza and its
causative agent remained a mystery. Yet, medical scientists were
convinced that a filter passer must be the cause. They could not deny
that Pfeiffer's bacillus was present in influenza infections;
however, they believed that a filter passer paved the way for
Pfeiffer's bacillus, causing the initial infection and then being
destroyed by subsequent infections (
 breed of large, agile working dog developed in Scotland during the 17th and 18th cent. It stands from 22 to 26 in. (55.9–66 cm) high at the shoulder and weighs from 50 to 75 lb (22.7–34 kg).
 1933. 144).

In 1930, a filter passer was isolated and identified as the cause
of influenza in swine. Three years later, another filter passer was
isolated and identified as a cause of influenza in humans when a ferret
infected with it sneezed in scientist's face and passed the
infection on to him (Hope-Simpson 1992, 3435). Yet, even with this
discovery made, medical professionals had a long way to go in uncovering
all of influenza's intricacies, a task still incomplete today.


The pandemic of 1918 caused a crisis in medicine. It laid bare the
weaknesses of the profession and devastated the world as medical
professionals looked on helplessly. Medicine had accomplished great
advances in the prevention, treatment, and control of disease,
accomplishments of which it could be, and was, surely proud. However,
with World War I providing conditions ripe for the weakening of
populations and the onset of epidemic disease, medical professionals met
a disease they could not conquer. Though the profession was deeply
emotionally harmed by its failure, the hurt it felt spurred it forward
to continue working to fight diseases, to gain new knowledge, and
develop new treatments, such as a vaccine. Previous to the pandemic, the
medical profession could bask in its accomplishments against yellow
fever, enteric fever, typhoid, typhus, and others, but influenza brought
medicine's shortcomings to the fore, forcing doctors and scientists
to face them. Though after the pandemic, medical professionals would
continue to revel in their successes, it was their great failure with
influenza that pushed them to learn more about it. Common, seasonal
influenza outbreaks had never drawn much of the medical
profession's attention. It was the greatest known pandemic of
influenza that made them take notice. Additionally, more recent
epidemics, such as H1N1, and other seemingly unconquerable diseases,
serve as reminders that medicine is not invincible and will face
failures. Yet in these failures, like that of 1918, the medical
profession is pushed toward further innovations in the fight against


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 or  see Sara.


(flourished early 2nd millennium BC) In the Hebrew scriptures, the wife of Abraham and mother of Isaac. She was childless until age 90.
Wayne State University
 at Detroit, Mich.; state supported; coeducational; established 1956 as a successor to Wayne Univ. (formed 1934 by a merger of five city colleges).

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