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Dr. Kirsty Duncan, a 34-year old, Adjunct Professor at the University of Toronto, and formerly Associate Professor at the University of Windsor, completed a degree specializing in geography and anthropology with a minor in psychology, in 1989. She graduated with distinction and went on to complete her doctoral degree in geography at he University of Edinburgh in 1992. She has taught meterorology, climatology, and climate change, and teaches medical geography at the University of Toronto. Kirsty Duncan lives in Toronto, where she trains for marathons in her spare time.

  • Read a review of Hunting the 1918 Flu: One Scientist's Search for a Killer Virus

The Spanish Influenza of 1918 The guns fell silent at the eleventh hour of the eleventh day of the eleventh month of 1918. One in ten of those soldiers who had fought in Europe died in the service of his country; an even greater number were wounded in deadly trench warfare. The final cost of the war will never be known.

However, estimates of 12 million people dead, 7 million of them soldiers, are almost certainly too low. A total of 3 million people may have died in Russia alone, rather than the usual estimates of 1.7 million there. 1-6The war to end all wars was over.

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'In one wonderful and joyous explosion, the world went mad.' In most countries, shops closed; throngs of boisterous, jubilant people celebrated in streets; whistles blew, and bands played hit songs such as 'World Peace' - 'From now on, there'll be peace, / They'll wage no war again.' And exhilarated and intoxicated crowds set off fireworks, ignited bonfires, and revelled late into the night. In London, King George V and Queen Mary greeted the crowds from the balcony at Buckingham Palace. The King spoke gratefully, 'With you, I rejoice. Thank God for the victories the Allied armies have won, which have brought hostilities to an end. Peace is in sight.'

Three Waves of Influenza As the world's peoples were celebrating the end of war, the end of dying, and a fresh beginning, the second and most virulent of three waves of a new killer, 'Spanish influenza,' raged with a ferocity greater than all the killing power of the previous four years of war, killing tens of millions.

The Spanish Influenza of 1918

Although Spanish flu was new, influenza as such was not. The name 'influenza,' derived from the Italian word for 'influence,' had been used to describe disease beginning in the Middle Ages, when it was believed that illness came from the influence of the stars. The highly contagious, acute respiratory illness known as influenza, however, appears to have afflicted humans since ancient times; Hippocrates recorded one such epidemic in 462 BC. Pandemics of influenza were not new either. They raged in 1732-3, 1775, 1782, 1833, 1836-7, 1847-8, and 1889-90.

The pandemic in 1889-90 infected 40 per cent of the world's population, and thousands died. 9 Yet the first wave of Spanish influenza had largely gone unnoticed in the spring and summer of 1918. In fact, the spring wave of the disease did not even receive mention in the index of the 1918 volume of the Journal of the American Medical Association. 10 The disease had been mild, the mortality was not unusually high, and the world had been preoccupied with a fifth year of war.8,10 However, influenza was brewing quietly, with localized outbreaks in U.S. military camps in early 1918.

On 11 March, 107 American servicemen became ill at Camp Funston, Fort Riley, Kansas. By the end of the five-week training camp, 1,127 had been stricken, and 46 had died of pneumonia following the flu. Camps Doniphan, Fremont, Gordon, Grant, Hancock, Lewis, Logan, Kearney, McClellan, Oglethorpe, and others also reported epidemics in March and April. 10

By April the disease had spread to France - perhaps carried there by American troops.8 And by the end of April, influenza had reached Spain, where the disease was widely publicized. Neutral Spain had no censorship of its press, unlike countries at war.

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Spain made the first public announcement of the disease. Madrid cabled London: 'A strange form of disease of epidemic character has appeared in Madrid.' 7,8

By May it had reached Greece, Macedonia, Egypt, and Britain. In England, 10,313 sailors of the Royal Navy developed flu and were unable to leave port. And the Royal College of Physicians labelled the disease 'Spanish influenza,' 7,8 and the inaccurate name stuck in history.

In Britain the disease had been called 'Flanders Grippe'; in Spain, 'Naples soldier'; in Germany, 'Blitz Katarrh,' or lightning cold; and in Switzerland, 'La Coquette,' because it 'passed its favours around so freely.' In Poland it was the 'Bolshevik Disease,' and in Ceylon it was 'Bombay Fever.' In Hong Kong, it was termed 'too much inside sickness.' Perhaps the name 'Spanish flu' persisted because neutral Spain was unpopular with both warring sides, which were hit equally by 'a foe that cut down troops and sent them behind the lines to first aid stations and hospitals.' 8

Throughout the spring, there had also been outbreaks on the other side of the world. Influenza had been reported in China and in March in the Japanese Navy. By May it was widespread in Asia.7 Most of the deaths there were among the elderly, but there were an appreciable number of deaths among those 20-40 years old. 9

Second Wave

In the autumn the virus probably mutated, and a worldwide epidemic, or pandemic, of unprecedented virulence exploded in the same week in three port cities, thousands of miles apart - Freetown, Sierra Leone; Brest, France; and Boston, United States. Were they manifestations of a single mutation of the virus? Did the disease originate in one of three ports and travel almost instantaneously to the other two? Or were there different, simultaneous mutations? 10 To date, we have no answers to these important questions.

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The three epidemics launched the autumn wave of Spanish flu and the most devastating disease outbreak in recorded history in terms of total mortality. In September, the disease swept Europe. Returning troops carried flu home. In North America, servicemen disembarked from crowded ships at Atlantic ports only to board trains that would take them, along with flu, inland to cities, villages, and farms from Newfoundland to California. 8

The second, deadly autumn wave of Spanish flu lasted about six weeks in each city and then died down. In November, nine days after the war ended, Cockermouth, England, reported that almost every family in town was infected following a service of thanksgiving to peace in the church. A week after the war's end, the number of deaths in Britain soared to more than 19,000, and the U.S. state of Louisiana reported 350,000 new cases.

By December, a million were sick in Java, Dutch East Indies, 1,200 were dying daily in Barcelona, Spain, and 250,000 had died in India's Punjab. 7 Finally, the world took notice. Major nations reported flu in newspapers. One Canadian woman reported that the 'fear was so thick that even a child could feel it.' 8 Despite the world-wide alarm, most people developed only a mild flu.

Even in the severe autumn wave, 80 per cent of patients suffered only the usual three-to-five-day illness - initially a cough and stuffy nose, but later a dreadful ache in every joint The Spanish Influenza of 1918 9 and muscle - leaving them feeling as if they 'had been beaten all over with a club,' with a temperature as high as 40°C.

If the illness progressed no further, the victim was usually 'back to normal' within a week. 7-11 But pregnant women recovered more poorly. The prognosis was said to be 'severe' for women who aborted or went into premature labour. One study showed that a total of 26 per cent of 1,350 female victims suffered miscarriage, stillbirth, or premature labour. 9 Approximately 20 per cent of all influenza patients developed pneumonia. Half of those died. The pneumonia often developed rapidly, with some patients experiencing a 'heliotrope colouration of the lips and face.' 'Men literally choked to death with pulmonary oedema (swelling), the lungs so swamped with blood, foam and mucous that the faces were grey and the lips purple.'

A grey victim might cough up as much as two pints of yellow-green pus per day trying to clear his or her lungs; in so doing, one patient was reported to have ruptured the muscles in his rectum. The purple-black skin was terrifying to doctors, nurses, and family alike. Dr Albert Lamb of New York's Columbia Presbyterian Hospital described the new arrivals as 'blue as huckleberries and spitting blood.' 7 Cyanosis (a bluish discolouration of the skin caused by oxygen deficiency) nearly always meant death within 24-48 hours. 8

Doctors and scientists from around the world reported a wide range of symptoms. French flu victim Gilberte Boulanger experienced severe nasal haemorrhage - for more than a week, and up to thirty times per day, blood spurted, as if under high pressure, from her nostrils. Other victims, however, complained of a 'burning pain in the diaphragm,' a frontal headache (reminiscent of typhoid fever), and congested and inflamed conjunctivae (the mucous membranes that cover the front of the eyes and line the inside of the eyelids). 7

The sickness seemed to affect so many organs of the body usually untouched by influenza that Dr Charles Sundell of Britain's Medical Research Council recorded: 'No part of the body is exempt.' Sometimes, for example, the disease was thought to resemble encephalitis, as patients lapsed into coma for three weeks at a time. And sometimes it appeared to mimic nephrosis, as patients, with puffy faces and swollen ankles, passed only ten ounces of blood-streaked urine each day.

But the chief of laboratory services at Camp Sherman, Ohio, thought of an attack by chlorine gas - each time a man moved on his pillow, serous fluid poured from his mouth and nose. Still other doctors reported 'silent lungs' - an absence of breath so complete that it was thought that the stethoscope had failed to function. 7 Perhaps it was 'silent lungs' that sometimes caused a state of 'apparent death.'

In Cape Town, South Africa, Kate Le Roux witnessed a wagon loaded with coffins pull away from her friend's house. As she watched, the truck bumped over a pot-hole, and the top-most coffin smashed to the ground, violently releasing its contents. To Kate's horror, the 'corpse' screamed and then scrambled shakily to his hands and knees. In New Mexico, Frank Garundo begged an undertaker to keep his wife Clara's grave open in order that two of his three children, expected to die before the day was over, might be buried with their mother. When baby Helen died, Frank shakily rose from his own sick bed and made the journey to the cemetery. Once there, the griefstricken man asked that his wife's coffin be opened so that he might take one last look. To his horror, his wife was lying face downwards, with her long black braids twisted in her fingers - testimony to her agony as she tried to escape burial alive. 7

Just as rumours, stories, and legends abounded of live burials, so, too, did stories of lightning-speed deaths. Charles Lewis of Cape Town boarded a train for his parents' home in Sea Point, only three miles away. The conductor signalled the train's start and immediately died on the platform. Within minutes, a passenger had fallen dead, and the train stopped to unload the body. And then another traveller collapsed. In total, five people were struck down, and five times the train stopped to unload the dead on the pavement for collection by the municipality. And then, with only a quarter of the distance left to travel to Sea Point, the engineer slumped forward and died. Lewis, thrilled to be alive, gladly walked the rest of the way to his destination. 7 In the United States, a healthy New York woman boarded a subway train for home. When the train pulled into her station forty-five minutes later, she was dead. 10

In Quebec, Canada, a hearse driver infected with Spanish flu toppled from the horse-driven carriage, as if 'struck by lightning.' The man was dead even before he touched the ground. A lone policeman tied a rope to the horse's neck and led the hearse to the cemetery. 7

In Ontario, Canada, two girls sharing a room attended a lecture together one evening when the epidemic was at its height. In the morning, Claire Hunter called to her friend in the same room, 'Vera, I'm going downstairs for breakfast.' There was no response. After breakfast, Claire returned to her room to get her purse and again called The Spanish Influenza of 1918 11 to her roommate. No answer. This time, Claire pulled back Vera's sheets. Vera was dead. The doctor said that she had died at about two in the morning. 8

In many cases, there was no chance for doctors or nurses to intervene. Practitioners were in short supply and overworked, as the war had already siphoned off thousands - 40,000 of 140,000 American doctors had enlisted. 7 When there was a possibility of helping, doctors without therapeutic drugs could turn only to their 'time-honoured cures of rest, liquids and a great deal of hope' to cure very ill patients. 8

Dr Robert Parry of the Middlesex Hospital in London complained that doctors did little more than direct traffic; physicians simply 'guided people to the emergency wards or to the mortuary.' 7 As thousands of people died, more and more buildings were pressed into use as hospitals. Gymnasiums, chapels, and canteens were all commandeered as temporary hotels for the sick and dying.

In Queensland, Australia, the church hall served as the hospital. In Montego Bay, Jamaica, the hospital was the 'Northern News,' and in Enderline, Nebraska, a run-down railway hotel served as the hospital. In St John's, Arizona, the hotel for the sick was the abandoned county jail. Nor was it the only jail to serve; world-famous Sing Sing Prison, 25 miles up the Hudson River from New York City, also did time as a hospital. 7

In 1918, the medical profession did not know what caused Spanish flu. And because it did not know the cause, it did not know how to prevent the disease. Practitioners rightly assumed that the disease could be spread through the air by coughing or sneezing. Therefore many governments at all levels and on all continents enforced the closure of public areas where people might come into close contact with one another. They closed dance halls, schools, and libraries. Some North American cities shut YMCAs, ice-cream parlours, shoeshine parlours, candy stores, furniture stores, and churches. Some churches did remain open, but their ministers were cautioned to refrain from spitting from the pulpit. 7,8 Some governments practised quarantine and placarded infected households. 7

In Canada, the Department of Agriculture had administered Quarantine Service from 1867 to 1918, and subsequently the Department of Immigration and Colonization ran it. Unfortunately, Parliament had prorogued on 24 May 1918, and did not resume until 20 February 1919; as a result, there was no central source of advice or 12 Hunting the 1918 Flu control measures. 8

Other governments regulated the wearing of gauze masks. Many masks were decorated: in Rockford, Illinois, they sported a skull and cross-bones. 7 Police in many cities had orders to enforce the wearing of masks and to charge offenders, who were fined. 8 In New York City, huge signs bore the words 'It is Unlawful to Cough and Sneeze' and warned of a $500 fine or a year in jail. Within days, more than 500 New Yorkers had been caught and hauled in front of the courts. 7 Futile emergency precautions abounded across the continents.

In New Zealand, sanitary inspectors, evoking memories of the Black Death, launched a city-wide rat hunt. In Dublin, and in Nottingham, England, mobile water carts poured hundreds of gallons of disinfectant down street gutters. In San Francisco, the law courts were transferred to the open air. In Venice, California, health officers fumigated both animals and performers of the Al. G. Barnes Circus with coal, tar, and formaldehyde. And some townships enforced fumigation of everything from newspapers to tram tickets. Newspapers printed tips on how to keep well: avoid getting chilled; keep hands clean; sleep and work in clean, fresh air; avoid alcoholic stimulants; do not worry; and do not kiss anyone.

The U.S. surgeon general recommended avoiding tight clothes, tight shoes, or tight gloves. 7,8,10 Large numbers of ordinary citizens became afraid to venture outside. Many closed their doors to the outside world in order to stay alive. Instead of visiting friends and family, they communicated via letter. But prior to opening their mail, careful recipients often baked the envelopes to kill any incoming germs. 7,8 Telephones, still relatively new in 1918, also maintained family ties and friendships. Requests for connecting new lines increased rapidly in Canada. Installers were clearly at risk of exposure to sick families and therefore wore cheesecloth masks soaked in formaldehyde. If the danger seemed especially great, the workmen fastened the phone to a board and pushed it through the house window of a flu-stricken family. 7, 8 If people did venture outdoors to help friends and relatives, they often risked their own safety and that of their families.

Therefore some physicians in Canada and elsewhere recommended one of the many 'vaccinations' against Spanish flu available on the market. All such preventives had their advocates, all had their detractors. 8 Some households, however, had their own methods. Some families wore cotton bags holding camphor or moth balls around their necks to ward off the threat. 13

Others drank violet-leaf tea, inhaled salt water up the nose, or carried hot coals sprinkled with sulphur or brown sugar through the house to avert the danger. 8 Doctors, in addition to recommending vaccines, made home visits to the sick and dying. They travelled by car, sleigh, horseback, bicycle, and even snowshoe - by whatever means they had available.

One medical team left Vancouver Island, British Columbia, in a 12.2-m boat with a large, one-cylinder engine and fought 6.1-m tides on their 136.8- km journey to tend a lumberjack camp. 8

Poultices of goose-grease, bran, and lard and turpentine and compresses of fir-tree spills, mutton tallow, and mustard were among the concoctions applied to the chests of the sick. Drinks of warm milk, ginger, sugar, pepper, and soda soothed the ill. 7,8 And cough elixirs were administered to strengthen, heal, and make the flu-stricken well. One wholesale drug company that normally sold 6,000 bottles of cough medicine per week now faced a demand of 3,000 per day.8

Spanish flu killed an estimated 5 million people in India; in Punjab, the streets were littered with the dead, and trains had to be cleared of dead and dying passengers. In England and Wales, the disease killed an estimated 200,000. Spanish flu wiped out some 550,000 Americans. 7 It killed 19,000 in New York City alone. In Philadelphia, 521 people died in one day, and, at the height of the crisis, 4,500 died in just one week.

The local morgue was built for only thirty-six corpses; as a result, several hundred bodies were piled three and four deep. Every room and corridor was packed with the dead - covered with dirty, blood-stained sheets. Before flu disappeared, Philadelphia was forced to open five supplementary morgues to hold the victims.10

Canada lost between 30,000 and 50,000. Fourteen thousand perished in Quebec. In Montreal, the demand for transporting coffins was so great that trolley cars had to be converted to hearses which could carry ten coffins at a time. Eight cabinet-makers worked around the clock in Hamilton, Ontario, to keep up with the demand for coffins. Undertakers would take one casket to the cemetery and would hurry back to the church to pick up the next. In Toronto, funerals were allowed on Sunday; white hearses for children became a common sight. So too were sashes on doorways: a white sash for a child; grey for a middle-aged person; and purple for a senior citizen.8

Elsewhere in the world, coffins and undertakers were in equally short supply. Many families buried their dead in plain, unvarnished boxes, often fashioned from doors and floorboards. In many countries, however, the dead were interred in cardboard boxes, blankets, or paper shrouds, and piled in mass graves. In Rio de Janeiro, one householder pleaded with the fire brigade, conscripted as undertakers, to remove his dead brother. They refused, adamant that there was no room on the death cart. However, the desperate brother continued to plead, as the corpse was five days old. The firemen relented; they would take the brother, but in return they would leave a stranger who had died more recently. 7

In some places, the mortality was much higher than for the world as a whole. For example, in Samoa, 25 per cent of the population died. 7 In Alaska, some villages were wiped out completely, while others lost only their adults; in Nome, 176 of 300 Inuit died of the disease. 10 The Native population of Okak, Labrador, was equally hard hit: only 59 of 266 people survived. In one home, a man, his wife, and two of their children had died, leaving behind an eight-year-old girl, who survived on her own for five weeks.

The Moravian Mission described her ordeal: 'The huskies now began to eat the dead bodies, and the child was a spectator to this horrible incident. So mad the beasts became, upon tasting human flesh, that they attacked the child herself, biting her arm.' 7-8, 12 The surviving men at Okak dug a pit in the permafrost to bury their dead. It took about two weeks to produce a pit 9.8 m long, 3.1 m wide, and 2.4 m deep. The men dragged the corpses to the excavation. They laid 114 bodies to rest and sprinkled disinfectant over them. Finally the survivors piled rocks on top of the dead to prevent the dogs from tearing at the bodies. 7-8, 12 At Hebron, Labrador, only 70 people remained of a community of 220. This time there was no pit, and the bodies were simply consigned to the sea. The men quickly cut holes in the ice, weighted the bodies with rocks, and then dropped the corpses through the frozen surface. 7

During the 1918 pandemic, numerous questions were raised. What caused the 1918 pandemic? Was Spanish flu the same as previous pandemics of influenza? What was the difference between it and the common cold? And what made it so deadly? Medical practitioners talked of airborne Pfeiffer's bacillus, Pneumococcus, Staphylococcus, Streptococcus, malnourishment, and the crowding together of the world's peoples under conditions of great misery - conditions ideal for an outbreak of infection. 10 Some members of the public, however, explained the pandemic in terms of the weather, cosmic influences, electricity, open windows, closed windows, unclean pyjamas, even sabotage - fish contaminated by the Germans and 'flu germs' released by German U-boats. 13

Numerous autopsies were performed on the dead, all in the vain hope of locating some identifiable organism - perhaps Pfeiffer's bacillus or Streptococcus. Autopsies themselves could be a 'pathological nightmare.' Lungs, saturated with fluid and resembling 'melted red currant jelly,' might be up to six times their normal weight. 7 Sometimes 'bloody fluid oozed out of the lungs sectioned for examination,' and as rigor mortis set in, fluid often poured from a corpse's nose and stained the body wrappings. 9

Other organs, such as the liver, spleen, and kidney, often showed abnormalities, and a few cases even showed swelling of the brain. If a patient did survive, recovery was often long, slow and painful. One Norwegian nurse, Margit Moller, recalled treating a patient who had lain so long on a pile of newspaper - his only bedding - that flu obituaries for weeks past were imprinted on his buttocks. 7

In Alberta, Canada, Benjamin McKilvington required twenty-one days of recuperation before he could sit up on the edge of his bed. He needed another three weeks to gain enough strength to go outdoors. Still later, he visited the doctor's office, where he was promptly weighed. He weighed only 84 pounds - though wearing two pairs of underwear, two top shirts, a sweater, pants, a heavy overcoat, huge mittens, two pairs of woollen socks, moccasins, and a fur cap - a 'far cry' from his normal 137 pounds. 18

Throughout the world, those who survived Spanish flu were often left with respiratory weakness. Robert Gain of Quebec City, was hospitalized with flu in December 1918. His wife contracted the disease on New Year's Day, while visiting him at the hospital, and died two weeks later. She left behind five children, aged 18 months to 9 years. Gain's recovery was very slow, and when he returned home in March he lacked the strength to feed himself. He was unable to walk until June. 8 Whole families disintegrated. Young adults perished and left behind small helpless children, who were often forced into orphanages - 2,000 children in Cape Town and 500 in Stockholm. If young girls were deemed old enough to take over from their dead mothers, they assumed the care of their younger siblings and bore the burdens of adulthood. 7,8 Throughout the world, losses to businesses were staggering.

Flu chants suffered because customers were too ill to shop and staff were absent with flu. Theatres, pool halls, and restaurants all lost heavily. 7,8 But it was the insurance companies that were perhaps the hardest hit. In London, England, the Prudential Assurance Company paid out twice as much in flu claims as it had in war claims. One agent complained: 'It was just as though another large battle was going on in addition to the fighting on all fronts.' 8

Third Wave

On the tail of this mass destruction came the third and final, less severe wave of Spanish flu. All three waves were over within a period of twelve months in any one country. In some communities, people affected by the first or second wave turned out to be immune to attack in subsequent waves. 10 In summary, Spanish flu raged in every continent but Antarctica. It infected over half the world's population. Spanish flu killed Prince Erik of Sweden and the dowager queen of the Tongan Islands. Flu also killed General Louis Botha, first premier of the Union of South Africa; Sir Charles Hubert Parry, composer of 'Jerusalem'; and Edmond Rostand, author of Cyrano de Bergerac. 7 Survivors included King George V, Crown Prince Max of Baden, the imperial chancellor of Germany, Franklin Delano Roosevelt (U.S. assistant secretary of the navy), and 'Canada's own sweetheart,' actress Mary Pickford. 7

Deadliest Plague in History

The 1918 influenza is estimated to have killed between 20 million and 40 million people,14 but not all deaths would have been reported. Many countries had no medical statistics; even in countries that did have figures, physicians were not required to report influenza cases to their boards of health. Not until 1918 was influenza considered sufficiently serious to require recording of cases and deaths. Furthermore, many overworked doctors and nurses may have been too busy and exhausted to keep full reports.7-10 New estimates suggest that the pandemic may have killed 100 million people. 15

Almost half the deaths occurred among those aged 20-40 years - an age group already devastated by war. 'Spanish influenza killed the prime specimens of those in the prime of life'; 10 Spanish flu killed Harry Elionsky, America's strongest swimmer, who had once swum 90 miles non-stop. 7 An acting surgeon general of the U.S. army reported that the infection, like the war, 'kills the young, vigorous, robust adults.' 10

Yet despite its predilection for healthy young people, Spanish flu showed virtually no preference regarding social class or profession. Has any other plague ever wrought such havoc as Spanish flu?

The Black Death, or bubonic plague, which is caused by Yersinia pestis, a bacterium carried by fleas that reside on rodents, broke out in 1345, on the steppes of Mongolia. It decimated China's population and rapidly made its way across Asia. From Asia, it marched across Africa and Europe. Daily death rates were staggering: 400 in Avignon, France; 1,500 in Givry, France; 800 in Paris, France; and 500 in Pisa, Italy. In Vienna, the city buried or burned 600 bodies per day. 13 The disease reached Britain in 1348.

Bubonic plague swept from east to west across Europe and then returned from west to east through a new generation of susceptible children. Some people developed pneumonia, which enabled the bacteria to spread by respiratory contagion, killing more than half the population in some cities. London, England, with a pre-plague population of 60,000, was reduced to 35,000; half of Hamburg's population perished, and two-thirds of Bremen's. 13

In total, the 'Destroying Angel' killed an estimated one-quarter to one-third of the population of Europe (20 million to 30 million people) over more than five years.

In the late twentieth century, a new plague - acquired immunodeficiency syndrome (AIDS), caused by the human immunodeficiency virus (HIV) - began spreading rapidly around the planet. The virus spreads through sexual contact with an infected person; through exposure to blood, blood products (for example, through blood transfusion or needle sharing), or tissues of an infected person (for example, through organ transplantation); or by transmission from mother to fetus.

As of December 1999, AIDS is thought to have killed 16 million people. In summary, Spanish flu remains the deadliest disease in recorded history. It killed more people than the bubonic plague of the Middle Ages and more people than AIDS has to date, and, unlike the latter, the 1918 influenza did its killing in only one year. Possible Connections? Encephalitis Lethargica

In addition to Spanish flu, another worldwide, devastating scourge was raging unabated - encephalitis lethargica - and after a decade of Hunting the 1918 Flu research I still wonder if there are connections between the two.

The disease was depicted in the U.S. movie Awakenings (1990) based on the pioneering work of Dr Oliver Sacks, as recorded in his book of the same name.16 Encephalitis lethargica, known also as von Economo's disease, epidemic encephalitis, and sleeping sickness,16 appeared suddenly in Austria and France, perhaps as early as 1915, and rapidly picked up momentum.

By 1918, it had spread throughout Austria, France, England, Germany, and the United States. By 1919, it had spread over Europe, Canada, Central America, and India. And by 1920, it had diffused throughout the world. 17 The pandemic reached a climax in 192518 and rapidly disappeared, as mysteriously as it had appeared, sometime between 1927 and 1930. 19

Its reign of terror had claimed or ravaged the lives of an estimated 5 million people. 16 The disease began like other types of encephalitis (inflammation of the brain), with fever, headache, stiff neck, and drowsiness. 20 Its symptoms were so varied that few patients ever presented the same picture: 'it was a hydra with a thousand heads.' 16 Some people experienced a dramatic onset, while others were unaware even that they were ill.19 One child walking home from a concert suddenly developed a headache and then fell into a deep sleep; she died 12 days later without ever waking. 'Roland P.' (not the patient's real name) in Awakenings was stricken suddenly at age two-and-a-half by a virulent attack. Overnight, he became intensely drowsy, and he remained so for eighteen weeks.

And one 35-year-old woman developed all the signs of post-encephalitic Parkinsonism but could not recall any preceding illness at all. 16 Some victims experienced narcolepsy, stupor, coma, extreme wakefulness, or sleep reversal (they slept through the day and remained awake through the night). 17 Sacks's 'Frances D.' suffered intense insomnia, often resting only two or three hours a night, during her six-month illness. A third of those affected died in the acute stages of sleeping sickness, 'in states of coma so deep as to preclude arousal, or in states of sleeplessness so intense as to preclude sedation.' 16

Patients who survived an extremely acute attack of somnolence or insomniac illness often 'failed to recover their original aliveness.' If left to themselves, they fell asleep while sitting, standing, walking, or eating. If roused, they woke up quickly and could answer questions or respond to requests. Such patients were like 'extinct volcanoes.' 'They would be conscious and aware - yet not fully awake; they would sit motionless and speechless all day in their chairs, totally lacking energy, impetus, initiative.' 16

Survivors also suffered from a wide variety of complaints. Parkinsonism (a progressive disease of the nervous system that produces tremor, muscular rigidity, and slowness and imprecision of movements) was perhaps the most common disorder. Many patients became 'living statues - totally motionless for hours, days, weeks, or years.' Other encephalitis disorders included involuntary jerks, spasms, and tics; catatonia; and compulsive actions, such as yawning, coughing, sniffing, gasping, panting, staring, and yelling.

Encephalitis lethargica usually spared the higher faculties of 'intelligence, imagination, judgment, and humour.' 16 Patients were then unwilling witnesses to their own horrifying demise. Child victims suffered less from Parkinsonism than did adults, but they frequently experienced abrupt changes of character. Their sudden disobedient, quarrelsome, and destructive behaviour often led to their expulsion from school. Temper tantrums, stealing, fire-setting, swearing, exhibitionism, and sexual aggression were common. Many children complained that they felt compelled to act badly and as a result were often labelled 'moral imbeciles.' 21

Some children threatened to kill their friends and families, and a few actually committed murder. One young boy stabbed his mother and threatened 'to cut up' his brother and take a hatchet to his sister. Another youngster, expelled from school for severe behavioural disorders, later broke into uncontrollable fits of rage, attacking and threatening to kill those around him. During his later military service he was frequently punished for his conduct and in fact was sentenced to death (but later reprieved). 22

Despite the severity of encephalitis lethargica, many patients seemed to make a complete recovery from sleeping sickness and were able to return to their former lives. Their symptom-free recovery period was often followed by post-encephalitic disturbances, with Parkinsonism the most common. 16 Thirty per cent of victims developed Parkinsonian features after three years of recovery, and 50 per cent of victims after five years. 23

In 1969 Dr Oliver Sacks administered the miracle awakening drug, laevo-dihydroxyphenylalanine, or L-DOPA, to his post-encephalitic patients. In his 1973 book, Awakenings, he described his patients' response to the drug: 'For a certain time, in every patient who is given L-DOPA, there is a beautiful, unclouded return to health; but sooner or  later, in one way or another, every patient is plunged into problems or troubles.

Some patients have quite mild troubles, after months or years of good response; others are uplifted for a matter of days - no more than a moment compared to a life-span - before being cast back into the depths of affliction.'16 Sacks awakened 'Mrs. Ida T.,' who, when stricken in Poland by sleeping sickness as a young mother at the age of 20, trebled her weight in just one year. At the same time she had also become increasingly stiff, slow, and violent. Her family shipped her off to the United States for treatment. During her voyage from Poland, she became completely motionless and speechless. On arrival in the United States, she was taken directly to hospital. And for the next 48 years she lay 'rigid, mute, motionless, and glaring.' 16

In 1969, Sacks administered L-DOPA to Mrs T, 'seal-shaped' and weighing almost 500 pounds. Her body 'suddenly cracked,' and the jubilant woman began walking and talking - 'Wonderful, wonderful! I'm moving inside,' she proclaimed over and over. In 1970, Mrs T. was reunited with her daughter, who had come to the United States in the 1930s. The daughter had never attempted to find her mother because her family had told her that she was dead. It was not an easy reunion, but by 1971 a 'deep mutual relation had been forged.' By 1973, Mrs T. was experiencing some complications - rigidity and stuttering - from the continued use of L-DOPA. However, she was doing very well, considering that she had been catatonic for 48 years. 16

During the pandemic of encephalitis lethargica, numerous questions arose. Was the disease new, or had it occurred earlier in human history? What was its cause? Was it related to the 1918 influenza?

Baron Constantin von Economo, who first described encephalitis lethargica in 1917 after seeing numerous patients with a strange variety of symptoms at a clinic in Vienna, believed that the disease had probably occurred repeatedly before the Great War. A serious epidemic, described as 'febris comatosa,' had broken out in London, England, between 1673 and 1675. And a severe epidemic, followed by persistent slowness of movement and a lack of initiative in victims, had affected Tubingen, Germany, in 1712 and 1713.

Sacks himself has suggested a 2,000-year history. 16 Von Economo had warned that the causative agent 'was not extinct but only in a dormant or non-virulent form from which it would invariably re-emerge as it has done innumerable times since the dawn of recorded time.' 23 The Spanish Influenza of 1918 21 He was right. Occasional cases have been reported since the 1950s.24-8

Their significance is, however, not clear, and it is not known if they are caused by the same pathogen. No causative agent was identified during the pandemic, but since its clinical and pathological features were typical of a viral infection, medical practitioners immediately questioned whether sleeping sickness was related to Spanish flu.

 The recently examined brains of six people who died from encephalitis lethargica have shown antigens for the influenza A viral strains WSN and NWS, indicating exposure to these particular strains. 23 There is some good circumstantial evidence linking the Spanish flu and sleeping sickness. 29 Both pandemics were globally distributed and were closely related in time. Local, regional, and national epidemics of Spanish flu invariably preceded 'similar-sized' outbreaks of encephalitis lethargica. 30 Both diseases showed a preference for young, healthy people. Deaths were greatest in the 20-40-year age groups for Spanish flu and in the 20s-50s for sleeping sickness. 23 A large number of victims of encephalitis lethargica had had influenza in 1918.

And finally, past pandemics of encephalitis have been recorded in close association with other influenza epidemics; for example, the great influenza epidemic of 1889-90 preceded the notorious 'nona' - a severe somnolent illness that was followed by Parkinsonism in almost all survivors. 30 Deniers of links between the two diseases would, however, probably plead that von Economo himself found no relationship. In 1931, he wrote, 'The first cases (of encephalitis lethargica) occurred as early as 1915 and settle once and for all the fact that encephalitis appeared certainly two and possibly three years before the first appearance of the influenza epidemic.' 23

Furthermore, influenza was highly communicable from person to person, whereas encephalitis was remarkably noncommunicable. Nor did all cases of encephalitis lethargica have a history of preceding influenza infection. Finally, not all influenza epidemics are associated with epidemic encephalitis. 30

Despite the arguments, the balance of circumstantial evidence suggests that the two diseases may be related. Summary The second and third decades of the twentieth century experienced two great plagues, which remain mysteries even today: Spanish flu, the deadliest disease in recorded history, and encephalitis lethargica. 22

Hunting the 1918 Flu

The two claimed the lives of millions worldwide, and both changed families and the course of history. Following the two crises, scientists doggedly studied the pandemics and tracked their paths of destruction. More important, they continued to search for causes in hope of preparing for the next influenza pandemic - perhaps one that could prove as lethal as that of 1918 - and the next outbreak of sleeping sickness.

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