Abrahams and his colleagues conducted their research at Aldershot entirely independently from Bradford and Hammond, with the researchers only realizing that they were dealing with the same disease when both published papers in The Lancet in summer and autumn 1917. Abrahams came to the conclusion that the disease was more widespread than he had envisaged, and, more disturbingly, that it would continue to flourish during the winter months, increasing the need to develop a form of prophylaxis.17
If, as Abrahams suggested, purulent bronchitis was more widespread than had been realized, the question arises as to how it was transmitted. Had Harry Underdown contracted purulent bronchitis earlier in his military career, becoming infected at Aldershot, or Bagthorpe? In his bid to stay in the army, and keep fighting despite his own poor health, had Harry inadvertently transmitted the prototype of the deadly disease across the Western Front? It is tempting to conclude that Harry Underwood, who lies buried at the military cemetery in Étaples, might have been the original ‘Patient Zero’, but in fact Harry’s fate represented that of many like him who joined up and died, not in battle, but from the deadly disease that would become known as ‘Spanish flu’. The origins of the disease itself and the virus that caused it proved to be far more complex.
Perhaps the answer lies in Étaples itself, a massive military base which is a strong contender for the birthplace of Spanish flu. A small town in the Pas-de-Calais, some fifteen miles south of Boulogne, Étaples Base embraced port facilities, railway yards, stores, hospitals, prisons, training areas and all the encumbrances of an army at war. In addition, there were infantry depots, training grounds, a firing range, cemetery, laundry and two post offices.18 As horses still played a significant role in combat, there were stables for the thousands of horses that needed veterinary attention during the conflict.19 For food, there were piggeries, ducks, geese and chickens. The coexistence of animals alongside humans had been a familiar feature of warfare for hundreds of years. Little did doctors suspect, during the First World War, that ducks operated as a ‘reservoir’ for bird flu viruses, littering the soil with faeces that were then snorted in by pigs grubbing for food, and that the pigs would subsequently incubate avian viruses and combine them with the human flu viruses acquired through contact with people.20 It would not be until the last decades of the twentieth century that virologists such as Professor John Oxford and Jeffery Taubenberger discovered that avian flu could leap the species barrier and mutate into an influenza virus capable of infecting and killing humans.21
* * *
ANOTHER ELEMENT ADDED to this deadly petri dish was the presence of Chinese labourers, who were brought over to support the war effort. Recruited by the British in Northern China, their task was to ensure the smooth running of the Allied forces by ferrying munitions and food from the Channel ports to the camps. The presence of the animals, and the Chinese labourers, at Étaples was simply a familiar aspect of army life. At the time, the presence of the labourers was not regarded as a health issue, despite the Manchurian pneumonic ‘plague’ of 1910–11 which had killed between 43,000 and 60,000 people, the equivalent of the death toll during London’s great plague of 1665. In hindsight, virologists such as Dr Kennedy Shortridge of Hong Kong University have identified China as ‘the epicentre for influenza epidemics’,22 due to the ingrained Chinese habit of living at close quarters with their animals, keeping vulnerable piglets in their homes, for instance. ‘The ingredients are here – ducks, pigs, people, in close contact,’ he said.23
Conditions – ducks, pigs, people – were similar at Étaples, and were combined with the infectious diseases that beleaguer all military camps. Étaples consisted principally of a series of Infantry Base Depots (IBDs), gathered on the rising ground to the east of the railway that runs north–south beside the town. Drafts from England for numerous infantry divisions passed through the IBDs where, according to unit, they were regrouped, put through a period of training, and sent forward to the Front.24 Also in the depots were to be found men transferring to other theatres of the war or consigned to the category of ‘Temporary Base’ after hospital and convalescence.25 These included the interminable convoy of sick and injured Tommies and German prisoners of war from the Front nursed by a young Englishwoman, Vera Brittain, and her comrades in the Volunteer Aid Detachment or VAD at No. 24 General Hospital.
Étaples was a bleak spot at the best of times. Lady Olave Baden-Powell, wife of the founder of the Scouting movement and Chief Guide in 1918, volunteered in the YMCA huts at the base and dismissed Étaples as ‘a dirty, loathsome, smelly little town’.26 While officers managed to escape from the base camp to the smart beach resort of Le Touquet, the troops encountered oppressive conditions, with no rest for the weary. At the ‘Bull Ring’, as the training grounds were called, soldiers barely discharged from hospital and men who had seen much service in the trenches were put through the same training as the latest drafts from England.27 A course in gas warfare and two weeks at the Bull Ring was the usual programme; two weeks of marching across the dunes, supervised by officers and NCOs (non-commissioned officers) of the ‘blood on the bayonet’ school.28 The NCOs in charge of the training, known as the ‘canaries’ on account of their yellow armbands, also had a reputation of not having served at the Front, which inevitably created a certain amount of tension and contempt.29 While conditions were poor, marching to and from the Bull Ring, and the training itself, took up the entire day. Although Étaples was a permanent base, the men were confined to tents and the main meal of the day consisted of two slices of bully beef, two biscuits and an onion. One officer remembered the training as ‘demoralising beyond measure’30 while another man recalled that the Bull Ring was like ‘passing through hell for two weeks’.31 One corporal encountered several men returning to the Front with wounds that were far from healed. ‘When I asked why they had returned in that condition they invariably replied: “To get away from the Bull Ring.”’32
Conditions and morale deteriorated to such an extent that there was a mutiny at Étaples on Sunday, 9 September 1917. Vera Brittain recalled an atmosphere of rumour and secrecy, with female personnel locked up in their hospitals for their own safety, and concluded that the mutiny had been the result of harsh conditions.33
The war poet Wilfred Owen, based at Étaples at the end of 1917, held an equally jaundiced view of the base, describing it in a letter home to his mother on New Year’s Eve:
Last year, at this time, (it is just midnight, and now is the intolerable instant of the Change) last year I lay awake in a windy tent in the middle of a vast, dreadful encampment. It seemed neither France nor England, but a kind of paddock where the beasts are kept a few days before the shambles. I heard the revelling of the Scotch troops, who are now dead, and who knew they would be dead. I thought of this present night, and whether I should indeed – whether we should indeed – whether you would indeed – but I thought neither long nor deeply, for I am a master of elision. But chiefly I thought of the very strange look on all faces in that camp; an incomprehensible look, which a man will never see in England, though wars should be in England; nor can it be seen in any battle. But only in Étaples. It was not despair, or terror, it was more terrible than terror, for it was a blindfold look, and without expression, like a dead rabbit’s.34
For all its disadvantages, Étaples was the perfect spot for a military hospital. The base was close to the railway lines running south to Abbeville and the Somme, making it easy to bring the wounded in from the battlefield and send them back to the Front as soon as they were ready to fight again. Étaples was also close to Boulogne, offering a short hop across the Channel to England, an important consideration with German submarines patrolling the Channel.
Vera Brittain, who had abandoned her studies at Oxford University to volunteer as a nurse, first arrived at No. 24 General Hospital on 3 August 1916. Vera described Étaples poetically as lying ‘between the sand hills and the sea’,35 with ‘vivid light’ hanging over the marshes.36 The officers and men, with a
blunter turn of phrase, referred to Étaples as ‘the sandheap’.37
The camp seemed more like a small town than a military base, extending as far as the eye could see, with row after row of tents for the doctors and huts for the nurses stretching across the fields on either side of the railway line. No. 24 General Hospital itself, which had enough beds for 22,000 patients, consisted of twelve long wooden huts covered with nasturtium plants and chintz curtains at the windows. But with the distant sound of gunfire, there was no escaping the purpose of the hospital and the constant atmosphere of tension. ‘Everyone and everything’ at Étaples was ‘always on the move; friendships were temporary, appointments were temporary, life itself was the most temporary of all’.38
No. 24 General Hospital at Étaples had been built to cope with the huge number of casualties from the Western Front, and the diseases that accompany war. Initially, these were the traditional wounds of warfare, although these grew increasingly worse as the war progressed due to innovations in weaponry, including high-explosive shells and machine guns. Vera’s duties, when she first arrived, consisted of nursing prisoners of war housed in damp, overcrowded marquees, changing dressings and draining wounds in temperatures of 90° F. By September, as the weather remained unseasonably warm, the nursing staff developed a gastric bug, which they named ‘Etaplitis’.39 With men packed so closely together, there was a real danger of dysentery and typhoid. The next problem was sepsis, and the danger that wounds sustained in the trenches would fester. The men also suffered from trench foot, a hitherto unknown condition in which the men’s toes developed gangrene and dropped off, and trench fever, later discovered to have been transmitted by a louse, Pediculus humanus.40 There was also another new condition known as ‘war nephritis’, which presented with headache, fever and kidney damage, and the consequences of mustard gas, which led to chest infections, pneumonia and the dreaded ‘pulmonary bronchitis’ that had killed Harry Underdown and his comrades. Demoralized by war, their immune systems weakened, the convalescent troops were weak and vulnerable.
These conditions, new and old, were sufficient to keep the medical teams working flat out for the duration of the war. On any given day, there were 10,000 medical personnel at Étaples, male and female, while a hundred trains a day pulled into the camp’s railway sidings, bearing casualties from the Front. Stretched to capacity, the medical staff could scarcely cope, and many of them fell victim to illness and disease themselves, Vera among them. When Vera received a letter from her brother Edward on 12 January 1918, asking her to accompany him on leave in England, she understandably seized the opportunity.
But two days later, having arrived in Boulogne too late for the boat across the Channel, Vera found herself spending a feverish night at the port, aching all over and with a splitting headache. Next morning, a rough crossing and a freezing train journey from Folkestone did nothing to improve her condition and she reached the family home in Kensington ‘in a state of collapse’.41
The following morning, Vera woke with a temperature of 103 degrees, and was advised to prolong her leave until she had recovered. Vera appeared to be suffering from ‘PUO’ (Pyrexia [fever] of Unknown Origin) also known as ‘trench fever’,42 a catch-all for many wartime afflictions. Vera’s symptoms are also consistent with the early onset of Spanish flu, although she mercifully escaped the latter symptoms of purulent bronchitis, cyanosis and air-hunger. Had Vera already been exposed to an early form of the virus while nursing, and acquired immunity?
Whether Vera had been infected at Étaples, or been exposed to the virus during her voyage back to England, we shall never know. Unlike Private Harry Underdown, she survived and went on to record her experiences in Testament of Youth, one of the most compelling memoirs of the Great War. The destinies of Private Underdown and Vera Brittain were, like their lives, very different, but both their stories serve to illustrate the medical mysteries surrounding the origins of Spanish flu.
CHAPTER TWO
‘KNOCK ME DOWN’ FEVER
ONE FREEZING NIGHT in February 1918, Dr Loring Miner was called out to a patient in Haskell County, Kansas. Dr Miner had been informed that the old lady was suffering from ‘knock me down’ fever, the traditional name for fever, coughing and chills. For most patients, influenza was a fitful fever that passed within days. Only the very young and the very old had reason to fear it, since complications were lethal for the vulnerable. Seizing his leather bag, Dr Miner climbed into his horse-drawn buggy and headed for the remote farmstead. A craggy figure with a distinctive handlebar moustache, Dr Miner was much loved in this harsh rural outpost. It was said that Dr Miner’s patients would rather have Dr Miner drunk than any other doctor sober.1
Dr Miner was shocked by what he found when he reached the farmstead. The patient, an elderly woman, had developed ‘heliotrope cyanosis’, and was turning blue from lack of oxygen. Fighting for her life, she was racked with coughing fits and struggling to breathe; her family crowded round with bowls and towels as she suffered one catastrophic haemorrhage after another, blood frothing up from her lungs. Dr Miner immediately diagnosed pneumonia, following the initial onset of influenza, but never before had he witnessed such virulent symptoms. The patient died in agony soon afterwards. Over the following days, Dr Miner scarcely had time to record his patient’s unusual symptoms, for he was rushed off his feet by a flurry of similar cases. Night and day, local families knocked at the door of Dr Miner’s house or appeared in his drugstore begging for help. Many of the victims were previously fit and healthy, farm boys and young women struck down without warning. Influenza, potentially fatal for infants and the elderly, seemed to be targeting the healthiest folk in the community. Fascinated and appalled, Dr Miner threw himself into solving the riddle of this mystery affliction. He even administered diphtheria and tetanus injections to stimulate his patients’ immune systems. But there was little time for research, as Dr Miner chased the influenza the length and breadth of Haskell County. Although he had an automobile, one of the first in the county, he relied on his old horse-drawn buggy. He was frequently so exhausted that he fell asleep in the buggy, leaving his horse to find the way home.2 On rare breaks between house calls, the doctor consulted medical textbooks, wrote to other physicians and analysed blood and urine samples from his patients in a search for a cure. He suspected, but could not prove, that the outbreak had something to do with animal husbandry, due to the frequency of outbreaks in remote farmsteads, but he was battling in the dark. In 1918, our modern concept of a virus was unknown to medical science. It was understood that particles existed that were smaller than bacteria, but it would not be until 1938, with the invention of the electron microscope, that scientists would begin identifying viruses.3
While scientists were already researching bacterial vaccines for many diseases including smallpox, anthrax, rabies, diphtheria and meningitis, bacterial vaccines for influenza were of limited availability. Doctors could only rely on the classic treatments for influenza: bedrest, opium to suppress coughing and relieve pain, and quinine, an extract of tree bark. Traditionally used to treat malaria, although no longer recommended for this purpose, quinine was thought to aid recovery by enabling the patient to sweat out infection. Many patients turned to folk remedies, some more palatable than others. While lemon, whiskey and garlic were traditional ‘cure alls’, along with herbal remedies, more bizarre suggestions included castor oil and kerosene on a sugar cube.
As Haskell County held its breath and feared for its loved ones, the local newspaper, the Santa Fe Monitor, performed its traditional task of informing readers about the day-to-day activities of its readers: ‘Mrs. Eva Van Alstine is sick with pneumonia’, the paper announced, and as if by way of consolation: ‘Her little son Roy is now able to get up.’4 A day or two later came the announcement that ‘Ralph Lindeman is still quite sick. Goldie Wolgehagen is working at the Beeman store during her sister Eva’s sickness.’5 Readers were also informed that while ‘Homer Moody has been reported quite sick, Mrs J S Cox is
some better but is very weak yet’, and ‘Ralph McConnell has been quite sick this week.’6 The Monitor concluded that ‘most everybody over the county is having lagrippe or pneumonia’.7
These blunt descriptions downplayed the impact of the influenza outbreak in Haskell County. Descriptions such as ‘sick’ or ‘weak’ did not do justice to the sheer terror experienced by patients and their families, the speed with which the influenza outbreak took hold, and the appalling symptoms of cyanosis, haemorrhages and the sinister ‘air-hunger’ that left patients clawing at the air and gasping for breath.
Within weeks, the influenza outbreak in Haskell County subsided as quickly as it had begun, but Dr Miner refused to forget the experience, which had begun with the death of the elderly lady on the farmstead. The doctor had lost three patients to secondary pneumonia, a common complication of influenza, and was deeply concerned about the prospect of another outbreak. He wrote to the government in Washington, warning them about the outbreak in Haskell County and recommending precautions against an epidemic, but he was largely ignored. Influenza was not a ‘notifiable disease’, meaning that it had to be reported to the public health authorities, and the government was preoccupied with the war effort. This would be the first occasion when the government suppressed warnings of a lethal influenza virus for the sake of national morale. Dr Miner’s reports were eventually published, tucked away from prying eyes within the unsensational pages of a professional journal, the Public Health Reports for 5 April 1918: ‘INFLUENZA Kansas Haskell On March 30, 1918, the occurrence of 18 cases of influenza of severe type, from which 3 deaths resulted, was reported at Haskell, Kans.’8
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