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1918 Influenza Pandemic: U.S. Army Perspective
In the fog of the influenza pandemic of 1918, Dr. Victor C. Vaughan, head of communicable diseases for the U.S. Army training camps, cautioned shaken observers that a full accounting of the pandemic required time and further study. (1) Surgeon General M.W. Ireland and Lieutenant Colonel Joseph F. Siler, M.D., prepared and delivered that final accounting in their 600-page tome titled The Medical Department of the United States Army in the World War: Communicable and other Diseases (1928). (2-4) Major Milton W. Hall, M.D., prepared the 110-page chapter on the respiratory disease outbreaks.
This work on the influenza pandemic and other disease outbreaks among American soldiers between April 1, 1917 and December 31, 1919 is based on massive amounts of actual data analyzed and interpreted by clinicians, medical epidemiologists, and scientists for use by posterity (us). The book is the most detailed, comprehensive, complete, reliable, valid and useful description of the 1918 influenza pandemic available today, in this author’s opinion. Its scientific approach contrasts with the social historical approach common to many books available today on the 1918 influenza pandemic. What did the physician authors of The Medical Department of the United States Army in the World War: Communicable and other Diseases learn from the medical data collected during the Great War? What can people living a century later (us) learn from their work?
During World War I in the U.S. Army camps, many diseases flourished. There are individual chapters in The Medical Department of the United States Army in the World War: Communicable and other Diseases on the typhoid and the paratyphoid fevers, inflammatory diseases of the respiratory tract, tuberculosis, cerebrospinal meningitis, anthrax, diphtheria, the venereal diseases, the diarrheal group of diseases, chickenpox, scarlet fever, measles, mumps, German measles, encephalitis lethargica, infectious jaundice, typhus fever, trench fever, Vincent’s disease, the malarial fevers, intestinal parasites, diseases of the skin, and neurocirculatory asthenia. Of these myriad diseases afflicting soldiers in the U.S. Army during World War I, the respiratory diseases dominated in quantity and severity. (4) Dr. Hall declared, “[T]he serious and fatal inflammations of the respiratory tract…formed by far the most important factor in the sickness and death records of the Army during the World War.” (5)
The total mean strength of the U.S. Army (officers and enlisted men, henceforth, soldiers) from April 1, 1917, to December 31, 1919, was 4,128,479. (6-7) Of these 4,128,479 soldiers, 3,515,464 (85%) reported sick for admission. [!] (6) This number of sick soldiers is astounding. The total number of soldiers admitted for respiratory diseases was 1,125,401, which calculates to 27% of all soldiers in the U.S. Army and 32% of U.S. soldiers reporting sick for admission. In other words, one out of three soldiers developed respiratory disease requiring sick admission at some time between 1917-1919 and one out of three soldiers reporting for sick admission carried a respiratory disease diagnosis. Note that the respiratory disease diagnoses in the respiratory disease category employed by Dr. Hall were limited to influenza, bronchitis, bronchopneumonia and lobar pneumonia. Each of these disease entities affects the lower respiratory tract. Upper respiratory disease categories such as pharyngitis [sore throat], tonsillitis, and sinusitis were not included in Dr. Hall’s respiratory diseases category. Of the 1,125,401 soldiers admitted for respiratory disease diagnoses, 791,907 carried the diagnosis of influenza, which calculates to 19% of all soldiers in the U.S. Army (1917-1919) and 23% of all soldiers who reported sick for admission (1917-1919). By contrast and by way of example, 67,026 (2%) soldiers reported sick for syphilis, 4,831 (0.1%) for cerebrospinal meningitis, and 1,529 for typhoid fever (0.04%). (2) Of the 791,907 soldiers diagnosed with influenza, 24,664 (3%) died. (8) There were so many deaths, logistical problems arose over managing the bodies, according to a congressional probe to which Secretary of War Newton Baker responded in three days of testimony in late January 25, 1918, available elsewhere. (9) The U.S. Congress was having difficulty obtaining information on U.S. Army camp operations because of censorship of the press by the Wilson administration, which did not want Germany to know, via U.S. media, of troubles affecting the raising of a U.S. army. Of the 791,907 soldiers diagnosed with influenza, 767,243 (97%) survived their illness. Of all the deaths charged to influenza, 99.4% were recorded as due secondarily to pneumonia (66.1% bronchopneumonia and 33.3% lobar pneumonia; the difference between the two types of pneumonias is not important here; rather the fact that the patients died a respiratory death is what is important). The total number of deaths from all diseases during the war was 58,119. Of the 58,119 deaths due to all diseases, the respiratory diseases accounted for 46,992, or 80.85%. (8) In other words, four out of five soldiers who died of disease died of respiratory disease (as defined by Dr. Hall, see above). At the beginning of 1918, most clinicians believed that the bacillus of Pfeiffer caused influenza. Dr. Richard Pfeiffer was an eminent German researcher and son-in-law of Dr. Robert Koch whose conclusions that bacteria caused influenza were based on work done late in the 1889-1892 cycle of the disease. However, noted Dr. Hall, “With the advent of the earlier recognizable waves of the 1918 outbreak it became evident that the bacillus of Pfeiffer was not uniformly present in the cases examined.” (10) Bacteriologists simply were not growing the Pfeiffer bacillus (today known as Haemophilis influenza) from sputum, blood, or other fluids of the gravely sick soldiers exhibiting signs of what was being called “influenza.” In fact, instead, bacteriologists were growing pneumococci and other “mouth” bacteria from sputum, which were under normal circumstances considered benign.
If Pfeiffer’s bacillus was not causing the clinical picture of influenza, then what was? Indeed, what constituted a case of influenza? Was it fever, headache, aches, pains, and sniffles that lasted around three days—or was it all of those things and bronchitis, bronchopneumonia, or lobar pneumonia—disease of the lower respiratory tract--which could be severe and even rapidly fatal for the patient. In other words, was lower respiratory tract involvement a complication of influenza or was it a manifestation of influenza itself? The distinction was important, because it governed how individual clinicians in individual army cantonments labeled the disease afflicting soldiers. For example, purists in some cantonments “refused to give sanction to the diagnosis of influenza unless it was possible to demonstrate the presence of the bacillus of Pfeiffer,” sniffed Hall. (10) Instead, the camp reported the case that seemed like influenza clinically, but did not demonstrate the Pfeiffer bacillus, as “other respiratory disease.” Furthermore, said Hall, “Unfortunately for the exactness of our records in this class of diseases, the clinical characteristics of mild influenza are such as to lead to its ready confusion with several of the milder so-called common respiratory diseases. Of these, bronchitis, tonsillitis, and pharyngitis are the leading diseases with which many of the earlier cases of influenza were confused. When the outbreak (September-November 1918) was at its height the uniformity of symptoms presented by large number s of cases made confusion almost impossible and at the time of an epidemic wave in the majority of instances the cases were correctly diagnosed.” (11) The point here is that a standardized case definition of influenza did not yet exist during the Great War. As a result, the U.S. Army data may be more difficult to interpret for some people. To work around this constraint, Dr. Hall grouped all the major (lower respiratory tract) respiratory diagnoses under the heading “inflammatory diseases of the respiratory tract” and delivered data under four diagnostic headings—influenza, bronchitis, bronchopneumonia and lobar pneumonia, as noted above. In this way, he captured, he believed, all of the cases that were influenza. For more detail on this matter, the interested reader is referred to Dr. Hall’s chapter. Earlier, it was noted 1,125,401 soldiers were admitted for “respiratory diseases” between April 1, 1917 and December 31, 1918. Of these 1,125,401, 791,907 (70%) received the diagnosis of influenza. How many received the three diagnoses in the respiratory diseases category? Hall noted that 255,148 (23%) received the diagnosis of bronchitis; 32,572 (3%), the diagnosis of bronchopneumonia; and 45,774 (4%), the diagnosis of lobar pneumonia (all percentages rounded). (12) Clinicians who directly managed the influenza epidemic in September, October, and November 1918 commonly noted its bizarre nature, frequently noting the clinical disease was unlike anything they had ever before encountered in their professional lives. In addition, Dr. Hall wrote, “Wherever a definite outbreak occurred the cases were so strikingly similar in their clinical manifestations as to leave no doubt as to their essential unity.” (13) Furthermore, the influenza clinical picture in fall 1918 was something very different from the first wave of influenza observed in the spring of 1918. The latter was generally mild, consisting of fever, headache, aches and chills, and lasting two or three days with complete recovery. What did the influenza patients in fall 1918 look like, clinically speaking? Friedlander, et al., at Camp Sherman, Chillicothe, Ohio, noted that uncomplicated cases of what they were calling influenza were characterized by “fever, coryza [head cold, i.e., nasal congestion and loss of smell], conjunctivitis [red eyes], [and a] dry hacking cough.” Lung sounds, however, were clear by stethoscope, suggesting absence of lower respiratory tract involvement, and blood smears showed a mostly normal white blood cell count. (14) This variation of what was being called influenza occurred frequently in the spring outbreak of 1918, for example, at Camp Funston, Kansas. The influenza disease, or what was being called influenza, changed when the second wave struck in fall 1918 (September, October, November). Dr. Hall listed the main symptoms and signs of the later more pernicious form of influenza from the records he reviewed, as follows. Dr. Hall noted that the appearance of the throat of the influenza patient was unusual: “The influenza throat showed a brilliantly red, glazed appearance of the pharynx and fauces without swelling or exudation [pus]. This appearance was most marked on the soft palate, and the sharp delimitation of the reddening at the margin of the hard palate was stressed. This throat condition was described not only in connection with the spring outbreak but with that of the fall as well. All patients complained of some degree of sore throat.” (13)
In addition, Hall said, “many patients exhibited a hemorrhagic [bleeding] tendency…It was most commonly manifested by epistaxis [spontaneous nosebleed without sores or other cuts], often recurrent, but hemorrhages from other mucous surfaces were not rare.” (13) “Epistaxis, which occurred in 10 percent or more of the cases, was of all degrees, but often severe, recurrent, and debilitating in the extreme. Purpura, intestinal and renal hemorrhages also occurred” (found at autopsy). (16) Hall said, “The first point to strike the observer was the universal occurrence of cyanosis. This condition appearing in an apparently uncomplicated case of influenza, if of a degree at all marked, usually presaged the onset of pulmonary inflammation.” (16) The color of the cyanosis was peculiar, “described by some as ‘heliotrope,’ occurred in more severe infections, especially in the fulminant cases and in those that later developed pneumonia.” (12) Heliotrope is a mineral also known as bloodstone.
Finally, Dr. Hall listed “extreme prostration, out of proportion to the degree of fever or the duration of the illness” as a generally recognized sign of influenza. So, too, was the slow return to normal in convalescence.” (13)
Dr. Solomon Strouse, at Chicago’s Michael Reese Hospital, noted his influenza patients’ “painfully congested conjunctivae”—as if the patients “had survived a sandstorm.” (15) Other clinicians noted a stunningly wide spectrum of the severity of primary infection. “At one extreme were the fulminant cases, resulting in death so promptly that secondary infection could hardly have had time to develop. At the other extreme were cases occurring in considerable numbers during an outbreak, and noted especially in the hospital personnel, in which the marked malaise and slight sore throat, with or without a little rise of temperature, were not regarded by the individual attacked as of sufficient importance to warrant relief from duty.” (13) Roy Grist, a member of the Camp Devens’ hospital surgical team, wrote to a colleague the following: These men start with what appears to be an ordinary attack of LaGrippe [sic] or Influenza, and when brought to the Hosp. they very rapidly develop the most vicious type of Pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible. (17-18) Clinicians turned to autopsy to try to discover the cause of the disease they were calling influenza. Dr. Hall drew his information from multiple sources available elsewhere. (19)
Autopsies by the hospital staff s at various army cantonments during the virulent second wave of influenza identified one group of cadavers with “wet, red lung” or “hemorrhagic pneumonitis,” noted Hall. (20) “It occurred typically in the earlier part of any given outbreak, and then usually in cases of less than average duration, often of only two or three days.”
“A second group, comprising a majority of deaths during an epidemic, showed various pneumonic lesions on a hemorrhagic background. These occurred in cases of somewhat less initial severity than those of the first group and life was prolonged sufficiently to allow the lesions of secondary infection to fully develop.” Secondary infection could be with Pfeiffer’s bacillus, pneumococci, as Friedlander and his colleagues discovered in the majority of their fatalities, or other bacteria. (14) “These cases [were] found in the greatest proportion during the height of the outbreak and showed an average duration decidedly longer than those of the purely hemorrhagic type, even as much as ten days or two weeks.” (20) Dr. Hall declared, “The wet red lung or hemorrhagic pneumonitis gave a picture almost pathognomonic of acute influenza pneumonia. The only comparable findings are those of pneumonic plague and those seen in acute death from toxic gas [e.g., mustard gas]. Hall continued, On opening the thorax the first point noted was the almost total failure of the lungs to collapse. On removal the lung retained on the table its natural size and shape. The pleurae [covering of the lungs] usually contained a little blood-tinged fluid, rarely any considerable amount. The pleural surface was usually smooth and glistening, though a thin layer of fibrin over areas of greater density was not rare. The pleural surface of the lung was brilliantly mottled throughout with different shades of red, from the pale pink of emphysema through the bright color of recent hemorrhage to the deep purple of venous blood. This mottling was lobular in distribution, contrasting colors often showing in adjacent lobules. There were usually considerable areas of definite emphysema, especially along the anterior borders. The posterior portions, especially of the lower lobes, showed the darkest coloration, but the changes described usually involved all the lobes to some extent. (21) On section of such a lung, large quantities of bloody serum escaped from the cut surface, usually containing small bubbles of air. It seems impossible to dry the surface by scraping. Portions cut from the lung usually barely floated in water; some sank…The entire tracheobronchial tree was intensely congested, of a deep velvety red, spotted here and there with foci of a darker or more intensely red color. The bronchi contained a thin seromucous bloodstained fluid and the bronchioles, especially peripherally, were distended and prominent…The extent to which the lung was involved in this hemorrhagic and edematous process was at times incredible and was plainly of itself incompatible with life. (21) Histologically (sections of tissue viewed under the microscope), the mucosa of the trachea was always destroyed to some extent and large areas were denuded of epithelium. Hall continued: “Such areas were covered by exudates composed of red blood cells, mucus, and small amounts of fibrin.” Everywhere in the passages of the lung existed a homogeneous mass “resembling colloid, sometimes as finely granular material, and sometimes containing strands of fibrin. Varying numbers of red blood cells are present in this fluid from a scattered few to densely packed masses indistinguishable from a recent infarct. In some cases large numbers of bacteria are found throughout; in others careful search fails to reveal their presence.” (22)
Dr. Holt carefully noted the involvement of the upper respiratory tract in influenza patients, as described above. “The nearly constant pharyngitis is emphasized clinically,” he said. “Involvement of the accessory sinuses of the nose, especially the sphenoidal, was reported with great regularity by pathologists who looked for the condition.” (23) “The early conjunctival inflammation [of the eyes] observed clinically is perhaps related to the upper respiratory tract infection or may possibly represent the atrium of infection,” he added. (24) Dr. Hall said the main aim of treatment in the uncomplicated early influenza case was the avoidance of pulmonary complications. (25) The best physicians could do at the time was institute treatment early. “Men who continued on duty after definite symptoms had developed were much more likely to develop pneumonia,” observed Hall. “The excellent morale of the combatant troops in the face of the enemy, which led many soldiers to refuse to report themselves sick until forced to do so, is believed to one great cause of the greater proportion of pneumonias and relatively high fatality shown by the troops in [France in] the American Expeditionary Force. The important elements of treatment, once the patient comes under medical care, were found to be rest in bed, warmth, and a light, hot diet….Drug treatment is of the palliative character. Aspirin was largely used for the pains of onset, though it was criticized by some as being depressant. Dover’s powder, or morphine, to promote rest; sprays, preferably oily, to relieve nasopharyngeal discomfort, and laxatives as needed comprise most of the drugs used. On report is available of the use of serum from convalescents in early cases.” (For more drugs used to treat patients with influenza in 1918, see note #26 below.) With this treatment, most physicians noted most of the soldiers were better in three days. Once a soldier with influenza developed the complication of pneumonia, however, physicians had even less to offer the patients. They could try antipneumococcus serum or certain bacterial vaccines given intravenously, which produced variable results. (27) Recall that no antibiotics were available until decades later. Dr. Hall acknowledged that clinicians looked forward to the day when scientists would discover the primary etiological agent of influenza so that therapies could be developed that would at least “limit the amount of pulmonary damage done by the primary disease and thus prevent the pneumonic complications” by opportunistic bacteria. (28) What can people living a century after the 1918 influenza pandemic learn from the experiences of clinicians in the U.S. Army during that pandemic? First, influenza case definition was challenging, because the disease seemed to change between the first wave in spring 1918 and the second wave in fall 1918, and laboratory findings were inconsistent. Clinicians finally settled on the idea of uncomplicated influenza (sore throat, coryza, headache, fever, muscle aches, fatigue), which lasted several days, and complicated influenza, which included involvement of the lower respiratory tract (pneumonia) by opportunistic bacteria common to certain geographic areas. For example, Pfeiffer’s bacillus (Haemophilus influenza) grew out of the lungs of patients in Germany during the 1889-1892 cycle of influenza pandemic), but pneumococcus (Streptococcus pneumonia) grew out of the lungs of soldiers in Sherman Camp in Ohio in 1918. Aggressive treatment of uncomplicated influenza was to prevent, to the degree possible, complicated influenza, which often was fatal in the era before antibiotics. Most of the influenza cases of spring 1918 were called (from the perspective of fall 1918 observers) uncomplicated and a dismaying portion of the influenza cases of fall 1918 were called complicated. Second, the vast majority of patients struck with influenza in 1918 (spring and fall waves combined) survived their illness ordeal. A great deal of modern attention is understandably directed toward influenza’s potential lethality influenza, particularly of the second wave that struck in September, October and November 1918. However, the actual data for soldiers who contracted influenza in the U.S. Army between April 1, 19197 and December 31, 1919, shows that 97% of them survived their illness. Third, nevertheless, a huge number of previously healthy soldiers (24,664) died horrific asphyxiating deaths from complicated influenza. Fourth, respiratory diseases during World War I were the killers, not gastrointestinal or other disease categories as with earlier wars. Fifth, hospital staff could do so little for patients stricken with influenza other than pulling them off duty and putting them into a warm bed with hot food. Various immune therapies were tried with variable success. Then newly available Bayer aspirin (made by and imported from Germany!) at least lowered the body temperature, which afforded relief for many ill soldiers. Sixth, the U.S. Army, because of poor planning, was not initially equipped to provide the surge capacity necessary to manage the sudden huge number of patients who required care. Notes:
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