But Spanish flu, by contrast, was far more aggressive and fast acting. During the devastating second wave of the epidemic, which began in the summer of 1918, victims collapsed in the streets, haemorrhaging from lungs and nose. Their skin turned dark blue with the characteristic ‘heliotrope cyanosis’ caused by oxygen failure as their lungs filled with pus, and they gasped for breath from ‘air-hunger’, like landed fish. Those who died quickly were the lucky ones. Others suffered projectile vomiting and explosive diarrhoea, and died raving as their brains were starved of oxygen. Those who recovered were often left with a lifetime’s legacy of nervous conditions, heart problems, lethargy and depression. Doctors and nurses worked heroically to care for the sick, often falling ill themselves. Dr Basil Hood, medical superintendent of St Marylebone Infirmary, London, left a devastating account of conditions at his hospital, which he described as ‘the most distressing occurrence of my professional life’.27 On the Western Front, nursing staff had to cope with an endless stream of corpses, dark blue and putrescent within hours of death,28 in addition to treating combat injuries.
On the battlefield, both Allies and Germans sustained massive losses. Out of the 100,000 casualties suffered by the US military, 40,000 troops died from Spanish flu. As troop movements dispersed influenza to every corner of the globe, the Spanish Lady travelled alongside innocent doughboys, from the United States to France. On one such journey, the doomed voyage of the USS Leviathan in September 1918, over ninety-six men succumbed to Spanish flu in hellish conditions while dozens more perished once they disembarked.29
Life on Civvy Street was no better, with entire families struck down in their homes. Children starved to death as their parents lay helpless in their beds; deranged men murdered their children, convinced that their offspring would starve without them. In South Africa, the bodies of dead and dying mine workers were thrown from trains and left along the trackside.30 In New York, 600 children ended up in orphanages. Across the globe, entire cities became ghost towns as daily life ground to a halt. In Washington and Cape Town, undertakers ran out of coffins, while in Philadelphia a shortage of burial space meant the city council resorted to excavating mass graves with steam shovels.31 As the spectre of the Spanish Lady conjured up visions of the Black Death of 1348, the great plague of 1665 and the terrible waves of cholera and typhus that devastated Europe in the 1840s, some speculated that this was not influenza at all, but plague itself, and feared that the human race would be wiped out. As the American epidemiologist Dr Victor C. Vaughan pointed out in 1918, the doctors of the day ‘knew no more about the flu than fourteenth-century Florentines had known about the Black Death’.32
Combatants and civilians on both sides of the divide now discovered that Death was the new enemy. As isolated outbreaks formed into the terrible pattern of a pandemic, the world responded as if at the mercy of some alien invasion; Spanish flu became reminiscent of H. G. Wells’s science fiction classic War of the Worlds.
Another disturbing feature of Spanish flu was the age of the casualties. Normally, it is the very young, the very old and patients with compromised immune systems who are most susceptible to dying of influenza. But the majority of victims in the Spanish flu epidemic were healthy young men and women, wiped out in their prime. Pregnant women were particularly vulnerable, Spanish flu killing both them and new mothers and their babies. In Massachusetts, one midwife helped a young woman deliver her premature baby, only to have both die within hours.33
Between spring 1918 and summer of 1919, the Spanish Lady continued her dance of death, attacking without warning, and seemingly at random. As if in a disaster movie, there was no telling which members of the worldwide cast would live or die. Those who survived included Franklin D. Roosevelt, who arrived in New York after a near fatal voyage on the unlucky USS Leviathan;34 British Prime Minister David Lloyd George also almost lost his life to influenza, a death which would have caused dreadful loss of morale to the Allies;35 it was thought that Mahatma Ghandi wouldn’t survive, and Kaiser Wilhelm suffered alongside his subjects. The great American novelist John Steinbeck recovered, as did the author Mary McCarthy, film star Lillian Gish, and Groucho Marx and Walt Disney. The experience of Spanish flu appears to have had a significant psychological impact; writers in particular noted the changes. It is said that Steinbeck’s perspective was forever changed by the experience,36 while Katherine Anne Porter, author of the Spanish flu memoir Pale Horse, Pale Rider, regarded the disease as an epiphany that altered the direction of her life.37 Thomas Wolfe, one of the greatest American novelists, left a spellbinding and compelling account of his brother’s death from Spanish flu in his most famous novel, Look Homeward, Angel.38
Spanish flu presented the wartime medical profession with its greatest challenge: how to tame the epidemic through cure, control and containment. Given the huge impact of the disease on both sides, much of the research was conducted by the military. While the civil authorities dismissed influenza as a distraction when all thought should be of the war, military doctors in Britain and the United States began to look for a solution based on their existing research into other epidemic diseases such as typhoid and cholera; but their hands were tied. They did not know exactly what they were dealing with. With the benefit of hindsight, we know that influenza is caused by a virus; but in 1918 scientists believed it was a bacterial disease, characterized by the presence of Pfeiffer’s bacillus. Ultimately, the research conducted during these dark, terrifying times would lead to great scientific breakthroughs, such as the recognition that influenza can affect humans, birds and pigs, and the classification of the three subtypes of the influenza virus as type A (Smith, 1933), type B (Francis, 1936) and type C (Taylor, 1950).39 But back in the autumn of 1918, as medical scientists struggled to develop a vaccine with their colleagues dropping dead around them, it must have seemed a desperate race against time.
Apart from the Spanish Lady herself, the most distinctive image of Spanish flu is the mask. While the mask itself provided little protection from the disease, it has become the icon of the epidemic. Generally white and fastened behind the head, the mask graduated from medical staff to the civilian population; in many towns and cities it became an offence to go outside without one. Policemen directed traffic in masks, entire family groups were photographed in their masks, including their cats and dogs; a honeymooning couple in San Francisco shyly confessed to their doctor that they wore their masks and nothing else when making love.40 Surreal and haunting, the photographs of masked figures from this period resemble scenes from a science fiction film.
One of the most contested aspects of the Spanish flu epidemic remains its origins, as researchers and historians continue to debate the causes of the epidemic and indeed the very nature of Spanish flu. While some still argue that Spanish flu originated in the battlefields of France, as a mutation from animal flu,41 others claimed that Spanish flu was not influenza at all but a strain of bubonic plague from China which travelled to the United States and Europe with the Chinese labourers supporting the Allied armies.42 War is a great time of conspiracy theories so it comes as no surprise that many believed the flu to be man-made in origin, with claims being made that it had been distributed by German U-boats on the Eastern seaboard or circulated in Bayer aspirin packs.43 In highly religious communities, Spanish flu was even seen as divine punishment for humanity’s sinful nature in general and in starting a war in particular.44 Many survivors and eyewitnesses speculated that the original cause was the millions of corpses rotting in No Man’s Land, combined with the lingering effects of mustard gas.45 These explanations continue to be discussed to this day.
One aim of Pandemic 1918 was to examine the impact of Spanish flu from the point of view of those who witnessed it, either famous or obscure. To this end, I present the memories of East End schoolgirls, Mayfair debutantes, Boston schoolboys and Italian immigrants. In this book you will find Lady Diana Manners, ‘the most beautiful woman in England’,46 and her fiancé Duff Cooper, overwhelmed with desp
air on Armistice night;47 the war poet Robert Graves losing his mother-in-law to Spanish flu after a night at the theatre; Vera Brittain of the Volunteer Aid Detachment, and author of Testament of Youth, surviving what seems to have been an early attack of Spanish flu,48 and countless other nurses battling to cope with influenza cases at the Front. Here too are the forgotten heroes, Dr James Niven, Chief Medical Officer of Manchester, whose advice spared the lives of many, but not enough, in his own view; the medical researcher Walter Fletcher, who devoted his life to finding a solution to influenza; and Major Graeme Gibson, the doctor who became a martyr to his own research. But while Spanish flu killed many famous individuals, including the Austrian painter Egon Schiele, the majority of its victims remained unknown and unmourned outside of their immediate families, my own grandparents included. In numerous parts of China, Africa, India and Russia (in the maelstrom of revolution) the lack of accurate records meant that many millions of victims went unrecorded, their stories lost in the horror of the pandemic. For this reason, I have chosen to focus on the personal stories that have been preserved and handed down through family memories, documents, memoirs and the lives of more famous individuals. As the majority of these have been drawn from the British and American experience of Spanish flu, the emphasis of this book is unavoidably Western, although I have attempted to touch upon the impact of Spanish flu in British India, South Africa and New Zealand.
In the last chapters of the book, I explore research into the H1N1 virus carried out by Jeffery Taubenberger, the ill-fated excavation in Norway to extract samples from the bodies of Norwegian miners buried in the Arctic permafrost and the horrifying implications of the 1997 Hong Kong bird flu outbreak during which six people died including two children. I also attempt to take a glimpse into the future and consider the disturbing possibility that the Spanish Lady might stage a return visit, albeit in a different guise.
Finally, I would like to explain just why I have chosen to use the term ‘Spanish Lady’ as a description of the fatal virus that killed over 100 million people during the period 1918–19. As the first wave of Spanish flu broke across Europe in June 1918, cartoons and illustrations appeared depicting the disease as ‘the Spanish Lady’. Spanish flu was personified as a death-headed, skeletal woman in a black flamenco dress, complete with mantilla and fan. The subtext of this gothic creation implied that the ‘Spanish Lady’ was a prostitute, free with her favours, and infecting everybody at the same time. Often parodied in political lampoons, the Spanish Lady became an iconic symbol of the influenza epidemic (the other being the face mask), featuring in countless publications across the globe throughout the epidemic. The Spanish Lady lost none of her power to fascinate decades later, when she lent her name to the title of Richard Collier’s excellent history, The Plague of the Spanish Lady.
When I first came to write about the 1918 influenza pandemic, I rejected the description ‘Spanish Lady’ as an unhelpful concept, little more than a weary misogynistic cliché. But as the months went by, I began to appreciate the Lady for what she was; a fictional creation who enabled the world to make sense of its suffering at some subconscious level. The Lady has her origins in the world of Greek mythology, as an avenging goddess, a Eumenides; there is something of Kali, the Hindu goddess of destruction, about her, too. In Christian iconography, the Spanish Lady is the shadow side of the Madonna, a mater dolorosa, an exterminating angel punishing the world for its destructive acts of war. She is also a classic femme fatale, a woman in black. She is our lady of sorrows, the Spanish Lady, our torment. As a cultural phenomenon, she is impossible to resist. And this is her story.
CHAPTER ONE
A VICTIM AND A SURVIVOR
AS DAWN BROKE over a military hospital in northern France, another young soldier was pronounced dead. Sadly, this was a common occurrence at 24 General Hospital, Étaples, the biggest field hospital in France. Hundreds of men had already died here, from disease or wounds. When Private Harry Underdown, a farmer’s son from Kent, died on 21 February 1917, he appeared to be just one more statistic. Even the words on Harry’s death certificate seemed commonplace. At twenty years old, Harry was the latest victim of ‘widespread broncho-pneumonia’, a complication following an attack of influenza,1 but he may also have been one of the first victims of the disease that would morph into the terrifying entity that was Spanish flu.
Harry’s short life was tragic but unremarkable; yet another young man among the millions killed during the First World War. Born near Ashford, Kent, in 1897, Harry grew up on the family farm, named ‘Hodge End’.2 When war was declared, Harry initially chose to stay on at Hodge End, later describing his occupation as that of a ‘hay trusser’.3 But then, at the end of 1915, Harry changed his mind and decided to enlist. At just 5 feet 1½ inches tall, and 132 pounds in weight, Harry was passed fit for military service and joined the Army Reserve, under a scheme whereby he was ‘required to serve one day with the Colours and the remainder of the period in the Army Reserve … until such time as you may be called up by order of the Army Council’. 4 So, although he now formed a part of the Army Reserve, Harry returned to his farm. In April 1916, Harry was called back to the army, and, as a private in the 12th Battalion, Queen’s (Royal West Surrey) Regiment, he was sent for training at an army depot. But within four months he had fallen ill, and was hospitalized with tonsillitis. Harry appeared to recover, then came a relapse, and he was not finally ‘discharged cured’ until 5 August 1916.5
Almost immediately, Harry was sent over to France. Within a few weeks, he became a casualty, after being buried in debris when a shell exploded nearby. Although not physically harmed, Harry was invalided home, suffering from shell shock, the Great War’s euphemism for combat stress. At Bagthorpe Military Hospital in Nottingham, Harry was found to be ‘very shaken’, with ‘loss of speech and memory’.6 ‘Rest & bromides’ formed the course of treatment prescribed.7
Despite these misfortunes, Harry was determined to stay in the army. In November 1916, he left hospital and returned to his regiment. After being detained in England for a few weeks, Harry crossed back to France in February 1917. Within a fortnight he had been struck down by ‘widespread broncho-pneumonia’, as it was named by Lieutenant J. A. B. Hammond of the Royal Army Medical Corps.8 Lieutenant Hammond observed Harry’s condition with sympathy and intense professional interest; he had witnessed similar symptoms in previous patients at Étaples, none of whom had recovered.9
At first, Hammond noted that Harry’s symptoms seemed consistent with ordinary lobar pneumonia, ‘with the sounds of crackling rales [popping sounds] clearly audible at the root of the patients’ lungs’.10 What was different, however, was the amount of purulent pus Harry produced, together with a terrible breathlessness that made him visibly distressed, panicking and attempting to leap out of bed. There was worse to come; as Harry’s condition deteriorated, his skin began to acquire a ‘dusky heliotrope type of cyanosis of the face’ due to lack of oxygen.11 Harry Underdown died soon afterwards.
Noting that this was the twentieth fatal case of ‘widespread bronchial pneumonia’ since the year began, Lieutenant Hammond and his colleagues became intrigued and concerned by this development, speculating that it was an unusual condition and might perhaps be war related. Lieutenant Hammond conducted a study of the condition with army pathologist Captain William Rolland and Dr T. H. G. Shore, the officer in charge of the Étaples mortuary and laboratory. Hammond’s findings were eventually published in The Lancet in July 1917.12 The article came to the attention of Sir John Rose Bradford RAMC, consultant physician at Étaples. Bradford, a future president of the Royal College of Physicians, was ‘an enthusiastic advocate of laboratory based research’13 and had been sent out to Étaples to do his part for the war effort. At first, Bradford had found himself frustrated by the lack of professionally interesting medical cases, freely admitting the fact in letters home to his wife. But the emergence of ‘widespread bronchio-pneumonia’ piqued his curiosity; the disease that killed Harry Un
derdown had eventually caused the death of 156 soldiers at Étaples during February and March 1917.14 Bradford recruited Hammond to conduct further research into the condition.
One aspect of the disease only became evident after death. During autopsy, in a case of lobar pneumonia, pathologists would expect to find damage to one of the lobes of a patient’s lungs. However, in the case of these patients, there was widespread bronchitis. On being sliced open, the smaller bronchi oozed thick yellow pus and in some cases contained H. influenzae and other bacteria.15 Of the 156 soldiers who had been diagnosed with and died of purulent bronchitis in the winter of 1917, 45 per cent had purulent excretions blocking the smaller bronchi. As ‘the disease assumed such proportions as to constitute almost a small epidemic’ at Étaples, Hammond decided that these features constituted a ‘distinctive clinical entity’ and named the disease purulent bronchitis in a paper for the British Medical Journal published the following year.16
The most disturbing aspect of the ‘purulent bronchitis’ outbreak of winter 1917 was its resistance to treatment. Doctors resorted to every conceivable type of approach, including oxygen therapy, steam inhalation, even blood-letting, but without effect.
While Hammond and his team were investigating the phenomenon of purulent bronchitis in Étaples, a similar outbreak occurred at an army barracks in Aldershot, England. RAMC Major Adolphe Abrahams, older brother of the Olympian champion Harold Abrahams, was in charge of the Connaught Hospital at Aldershot during 1916 and 1917, where a series of patients had presented with purulent bronchitis in the winter months. The symptoms which these patients presented were disturbingly similar to the ones witnessed at Étaples, including coughing up yellow pus and cyanosis, and the disease was resistant to every form of treatment and had a high fatality rate.
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