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Public Health Perspective
Howard Markel, MD, PhD
Medscape Public Health & Prevention. 2006;4(2) ?2006 Medscape
Posted 11/16/2006
Influence of the Heavens
In recent months, there has been a lot of talk about the threat of an influenza pandemic but, in my opinion, not nearly enough considered contemplation of past events that ought to give us pause, if not the outright shudders.
Many laypersons overuse the term "flu" to characterize just about every type of upper respiratory infection they encounter. In recent decades, even gastrointestinal viruses have been inappropriately linked to influenza with such medically inaccurate terms as "stomach flu."
But in reality, health professionals are aware that true influenza -- the syndrome caused by a strain of influenza A or B virus -- is far worse than the average common cold and is marked by high fevers, muscle aches, intense fatigue, and a relentless, painful, productive hacking cough. Even after recuperation from the acute symptoms, there is the well-documented postviral depression patients often encounter for weeks afterward, as well as continued breathing difficulties and painful chest wall muscles.
No wonder, then, that the Italian Renaissance physicians who first coined the term "influenza" for the terrible epidemics that appeared roughly every 30 years explained the illness's powerful ravages as being due to supernatural influences. Indeed, this is what influenza means in Italian -- influenza coeli [influence of the heavens or stars] or influenza del diavolo [influence of the devil].
But as bad as a bout of real, seasonal influenza is, the human encounter with the H1N1 strain -- the version of influenza that literally swept the world in a matter of weeks to months during the 1918 pandemic -- was far worse. This version of flu was amazingly virulent, and inspired a virtual immunologic storm. It had an attack rate of 25% to 50% and killed 2% or more of those stricken. Compare that to a roughly 5% to 20% attack rate of seasonal influenza with a mortality rate usually lower than 0.1%.
Moreover, seasonal flu typically affects the elderly, very young children and infants, and those with preexisting medical conditions such as heart disease, lung disease, or immunocompromised conditions. But in 1918, the elderly were not nearly as drastically affected as in years past, and there was a huge spike in cases and deaths among previously healthy teenagers and young adults.
The Flu Pandemic of 1918
To better understand the individual experience of a case of influenza in 1918, let's begin at the end rather than at the beginning. The great internist and pathologist Sir William Osler once called the autopsy table medicine's "final court of appeals." A century ago, in an era preceding the miraculous imaging techniques and laboratory tests that now allow us to glimpse at pathologic processes long before they actually kill their victims, the physician's earliest opportunity to understand disease often occurred long after it was relevant to the individual patient.
By all accounts, doing an autopsy on an individual patient who succumbed to the 1918 flu was a harrowing experience. Pathologists of the 1918 era were stunned to discover how influenza defiled the lungs of their patients. Most conspicuous were the enormous quantities of bloody, frothy fluid that emerged from the tiny, diaphanous air sacs, or alveoli, of the lungs. Indeed, so fluid-filled were these dissected lungs that instead of floating in water, as you would expect a balloon-like entity to do, they plummeted to the bottom of buckets with a resounding thud. Even the larger airways, the bronchioles, bronchi, and the trachea of these poor patients, were fluid filled, suggesting that the body had attempted to mount a battle of immune cells, cytokines, chemotoxins, and macrophages against the virus that had invaded it but, alas, often lost miserably.
All of this explains the intense air hunger many of the 1918 flu victims experienced and the bluish, purple tinge [cyanosis] of their skin. Many of these poor men, women, and children died awful deaths -- frequently within 24 to 48 hours of developing symptoms of the flu -- because they were basically suffocating. But all of the flu victims, whether they succumbed or not, experienced profoundly painful muscle and joint pains, exhaustion, delirium, and remarkably high fevers, sometimes as high as 105 degrees F, leading many who survived to remark that during their illness they felt as if they had beaten all over the body with a club.
One of my favorite medical observers of the 1918 pandemic was the stately, plump pathologist and medical doyen, Dr. William Henry Welch. In 1918 he was one of the world's leading experts in microbiology and pathology and was well acquainted with just about every cutting-edge medical advance of the early 20th century. One of the founders of the famed Johns Hopkins Hospital and a bona fide medical mover and shaker, he was internationally known as the Dean of American medicine. No wonder, then, that President Woodrow Wilson asked Dr. Welch to orchestrate a medical response to the rapidly spreading influenza epidemic sweeping the nation, and especially the military camps where men preparing to go overseas to fight in World War I were dying in droves before they ever saw or heard a gun shot.
When the newly commissioned Colonel Welch and his medical team visited Camp Devins, just outside of Boston, in late September 1918, the sight was chilling to say the least. In the autopsy suite, Welch turned pale at the sight of the cadavers' blue, fluid-filled and swollen lungs. It was hardly the gruesome sight of scores of flayed-open bodies that made Dr. Welch so queasy. In his long career, he had presided over tens of thousands of postmortem examinations. Rather, Welch realized that he was on the ground floor of what he could only categorize as a "new and terrible plague." One long-time assistant -- the brilliant physician and leading influenza expert Rufus Cole, later recalled that it was the only time he ever saw the imperturbable Welch really worried and distraught.[1,2]
Another remarkable medical observer of the incredible power of the pandemic on the human body was Welch's colleague -- the eminent dean of the University of Michigan Medical School, Victor C. Vaughan. Equally rotund at a weight of over 300 pounds, Dr. Vaughan was almost in the same league as Welch in terms of medical statesmanship. A founder of the National Board of Medical Examiners and a past president of the American Medical Association, he was one of the principal architects of the modern medical educational and research system that is still in place to this day. Vaughan was also an internationally acclaimed expert in public health, microbiology, and epidemic control who helped stem the tide of typhoid epidemics that swept through army camps during the Spanish-American War of 1898. Asked to join the influenza commission by Dr. Welch, Dean Vaughan recalled the carnage of influenza in his memoirs published nearly a decade later:
In the memory chambers of my brain there hang many pictures. Some are the joy of my life, too sacred and too personal to describe to any save my most intimate friends. But there are also ghastly ones which I would tear down and destroy were I able to do so, but this is beyond my power. They are part of my being and will perish only when I die or lose my memory. . . [the largest canvas details the 1918 flu pandemic]. I see hundreds of young, stalwart men in the uniform of their country coming into the wards of the hospital in groups of ten or more. They are placed on the cots until every bed is full and yet others crowd in. The faces soon wear a bluish cast; a distressing cough brings up the blood stained sputum. In the morning the dead bodies are stacked about the morgue like cord wood. This picture was painted on my memory cells at the division hospital, Camp Devins, in 1918, when the deadly influenza demonstrated the inferiority of human inventions in the destruction of human life.[3]
Perhaps one of the most eloquent descriptions of how influenza tore family life asunder -- through the eyes and emotions of a young girl during the pandemic of 1918-1920 -- was recorded by the lovely writer Katherine Anne Porter. Born in Texas, Porter's tuberculosis led her to the supposedly healing air of Denver, Colorado. In 1918, she was well enough to pen a column for the Denver Post, for which she covered one of the nation's hardest-hit urban centers in terms of flu mortality, a staggering death rate of 711 per 100,000 citizens, including the city's mayor. Her magisterial novella, Pale Horse, Pale Rider, transforms this worldwide tragedy into a work of art and should be required reading for all who wish to know something about the social impact and personal impact of contagious disease.[4]
Set in the midst of what we now call the first world war, the novella charts the progress of a young woman, Miranda, in her influenza- and fever-induced delirium. Near death and hard-hit by the flu, Miranda hallucinates her way through a physical examination:
The second young interne, still quite fresh and dapper in his white coat. . . was leaning over listening to her through a stethoscope. . . from time to time he tapped his fingers smartly with two fingers, whistling.
Miranda observed him for a few moments until she fixed his bright busy hazel eye not four inches from hers. "I'm not unconscious," she explained, "I know what I want to say." Then to her horror she heard herself babbling nonsense though she could not hear what she was saying.[5]
Nevertheless, Miranda makes a harrowing recovery from her grave illness, thanks to the attentive care of her nurses and physician, only to learn that her newfound love, Adam, died of influenza. Yet in a wonderfully optimistic declaration, typically denied to anyone over 20, Miranda concludes:
No more war, no more plague, only the dazed silence that follows the ceasing of the heavy guns; noiseless houses with the shades drawn, empty streets, the dead cold of tomorrow. Now there would be time for everything.[6]
Hope for the Future?
But is there time for everything? The threat of a human pandemic avian influenza essentially represents the first pandemic in human history that we have had some semblance of advance warning -- and hence, the opportunity to prepare. With the advances in virology, surveillance, rapid communications, modern computing, and epidemic modeling, many of us share the exciting hope that we can apply all of these methods to a pandemic's rapid mitigation, if not containment or outright prevention. But will we get our epidemiologic ducks in a row to ensure some semblance of public health protection if our worst fears about avian flu really do come true? As historians love to say: only time will tell. Yet, like Katherine Anne Porter's Miranda, I remain ever hopeful that there will be time for everything -- including productive, ethically, and socially appropriate strategies that mitigate the microbial threats that inevitably loom on our horizon.
References
Flexner S, Flexner JT. William Henry Welch and the Heroic Age of American Medicine. New York, NY: Viking Press; 1941: 376-377.
Crosby A. America's Forgotten Pandemic: The Influenza of 1918. Cambridge, Mass: Cambridge University Press; 1989: 3-11.
Vaughan VC. A Doctor's Memories. Indianapolis, Ind: Bobbs-Merrill, Co.; 1926: 382-384.
Porter KA. Pale Horse, Pale Rider. Three Short Novels. New York, NY: The Modern Library; 1939: 249.
Porter KA. Pale Horse, Pale Rider. Three Short Novels. New York, NY: The Modern Library; 1939: 245.
Porter KA. Pale Horse, Pale Rider. Three Short Novels. New York, NY: The Modern Library; 1939:p. 264.
Howard Markel, MD, PhD, George E. Wantz Professor of the History of Medicine, Professor of Pediatrics and Communicable Diseases, Director of the Center for the History of Medicine, University of Michigan, Ann Arbor; author of When Germs Travel: Six Major Epidemics and the Fears They Have Unleashed (Pantheon Books)
Disclosure: Howard Markel, MD, PhD, has disclosed no relevant financial relationships.
Howard Markel, MD, PhD
Medscape Public Health & Prevention. 2006;4(2) ?2006 Medscape
Posted 11/16/2006
Influence of the Heavens
In recent months, there has been a lot of talk about the threat of an influenza pandemic but, in my opinion, not nearly enough considered contemplation of past events that ought to give us pause, if not the outright shudders.
Many laypersons overuse the term "flu" to characterize just about every type of upper respiratory infection they encounter. In recent decades, even gastrointestinal viruses have been inappropriately linked to influenza with such medically inaccurate terms as "stomach flu."
But in reality, health professionals are aware that true influenza -- the syndrome caused by a strain of influenza A or B virus -- is far worse than the average common cold and is marked by high fevers, muscle aches, intense fatigue, and a relentless, painful, productive hacking cough. Even after recuperation from the acute symptoms, there is the well-documented postviral depression patients often encounter for weeks afterward, as well as continued breathing difficulties and painful chest wall muscles.
No wonder, then, that the Italian Renaissance physicians who first coined the term "influenza" for the terrible epidemics that appeared roughly every 30 years explained the illness's powerful ravages as being due to supernatural influences. Indeed, this is what influenza means in Italian -- influenza coeli [influence of the heavens or stars] or influenza del diavolo [influence of the devil].
But as bad as a bout of real, seasonal influenza is, the human encounter with the H1N1 strain -- the version of influenza that literally swept the world in a matter of weeks to months during the 1918 pandemic -- was far worse. This version of flu was amazingly virulent, and inspired a virtual immunologic storm. It had an attack rate of 25% to 50% and killed 2% or more of those stricken. Compare that to a roughly 5% to 20% attack rate of seasonal influenza with a mortality rate usually lower than 0.1%.
Moreover, seasonal flu typically affects the elderly, very young children and infants, and those with preexisting medical conditions such as heart disease, lung disease, or immunocompromised conditions. But in 1918, the elderly were not nearly as drastically affected as in years past, and there was a huge spike in cases and deaths among previously healthy teenagers and young adults.
The Flu Pandemic of 1918
To better understand the individual experience of a case of influenza in 1918, let's begin at the end rather than at the beginning. The great internist and pathologist Sir William Osler once called the autopsy table medicine's "final court of appeals." A century ago, in an era preceding the miraculous imaging techniques and laboratory tests that now allow us to glimpse at pathologic processes long before they actually kill their victims, the physician's earliest opportunity to understand disease often occurred long after it was relevant to the individual patient.
By all accounts, doing an autopsy on an individual patient who succumbed to the 1918 flu was a harrowing experience. Pathologists of the 1918 era were stunned to discover how influenza defiled the lungs of their patients. Most conspicuous were the enormous quantities of bloody, frothy fluid that emerged from the tiny, diaphanous air sacs, or alveoli, of the lungs. Indeed, so fluid-filled were these dissected lungs that instead of floating in water, as you would expect a balloon-like entity to do, they plummeted to the bottom of buckets with a resounding thud. Even the larger airways, the bronchioles, bronchi, and the trachea of these poor patients, were fluid filled, suggesting that the body had attempted to mount a battle of immune cells, cytokines, chemotoxins, and macrophages against the virus that had invaded it but, alas, often lost miserably.
All of this explains the intense air hunger many of the 1918 flu victims experienced and the bluish, purple tinge [cyanosis] of their skin. Many of these poor men, women, and children died awful deaths -- frequently within 24 to 48 hours of developing symptoms of the flu -- because they were basically suffocating. But all of the flu victims, whether they succumbed or not, experienced profoundly painful muscle and joint pains, exhaustion, delirium, and remarkably high fevers, sometimes as high as 105 degrees F, leading many who survived to remark that during their illness they felt as if they had beaten all over the body with a club.
One of my favorite medical observers of the 1918 pandemic was the stately, plump pathologist and medical doyen, Dr. William Henry Welch. In 1918 he was one of the world's leading experts in microbiology and pathology and was well acquainted with just about every cutting-edge medical advance of the early 20th century. One of the founders of the famed Johns Hopkins Hospital and a bona fide medical mover and shaker, he was internationally known as the Dean of American medicine. No wonder, then, that President Woodrow Wilson asked Dr. Welch to orchestrate a medical response to the rapidly spreading influenza epidemic sweeping the nation, and especially the military camps where men preparing to go overseas to fight in World War I were dying in droves before they ever saw or heard a gun shot.
When the newly commissioned Colonel Welch and his medical team visited Camp Devins, just outside of Boston, in late September 1918, the sight was chilling to say the least. In the autopsy suite, Welch turned pale at the sight of the cadavers' blue, fluid-filled and swollen lungs. It was hardly the gruesome sight of scores of flayed-open bodies that made Dr. Welch so queasy. In his long career, he had presided over tens of thousands of postmortem examinations. Rather, Welch realized that he was on the ground floor of what he could only categorize as a "new and terrible plague." One long-time assistant -- the brilliant physician and leading influenza expert Rufus Cole, later recalled that it was the only time he ever saw the imperturbable Welch really worried and distraught.[1,2]
Another remarkable medical observer of the incredible power of the pandemic on the human body was Welch's colleague -- the eminent dean of the University of Michigan Medical School, Victor C. Vaughan. Equally rotund at a weight of over 300 pounds, Dr. Vaughan was almost in the same league as Welch in terms of medical statesmanship. A founder of the National Board of Medical Examiners and a past president of the American Medical Association, he was one of the principal architects of the modern medical educational and research system that is still in place to this day. Vaughan was also an internationally acclaimed expert in public health, microbiology, and epidemic control who helped stem the tide of typhoid epidemics that swept through army camps during the Spanish-American War of 1898. Asked to join the influenza commission by Dr. Welch, Dean Vaughan recalled the carnage of influenza in his memoirs published nearly a decade later:
In the memory chambers of my brain there hang many pictures. Some are the joy of my life, too sacred and too personal to describe to any save my most intimate friends. But there are also ghastly ones which I would tear down and destroy were I able to do so, but this is beyond my power. They are part of my being and will perish only when I die or lose my memory. . . [the largest canvas details the 1918 flu pandemic]. I see hundreds of young, stalwart men in the uniform of their country coming into the wards of the hospital in groups of ten or more. They are placed on the cots until every bed is full and yet others crowd in. The faces soon wear a bluish cast; a distressing cough brings up the blood stained sputum. In the morning the dead bodies are stacked about the morgue like cord wood. This picture was painted on my memory cells at the division hospital, Camp Devins, in 1918, when the deadly influenza demonstrated the inferiority of human inventions in the destruction of human life.[3]
Perhaps one of the most eloquent descriptions of how influenza tore family life asunder -- through the eyes and emotions of a young girl during the pandemic of 1918-1920 -- was recorded by the lovely writer Katherine Anne Porter. Born in Texas, Porter's tuberculosis led her to the supposedly healing air of Denver, Colorado. In 1918, she was well enough to pen a column for the Denver Post, for which she covered one of the nation's hardest-hit urban centers in terms of flu mortality, a staggering death rate of 711 per 100,000 citizens, including the city's mayor. Her magisterial novella, Pale Horse, Pale Rider, transforms this worldwide tragedy into a work of art and should be required reading for all who wish to know something about the social impact and personal impact of contagious disease.[4]
Set in the midst of what we now call the first world war, the novella charts the progress of a young woman, Miranda, in her influenza- and fever-induced delirium. Near death and hard-hit by the flu, Miranda hallucinates her way through a physical examination:
The second young interne, still quite fresh and dapper in his white coat. . . was leaning over listening to her through a stethoscope. . . from time to time he tapped his fingers smartly with two fingers, whistling.
Miranda observed him for a few moments until she fixed his bright busy hazel eye not four inches from hers. "I'm not unconscious," she explained, "I know what I want to say." Then to her horror she heard herself babbling nonsense though she could not hear what she was saying.[5]
Nevertheless, Miranda makes a harrowing recovery from her grave illness, thanks to the attentive care of her nurses and physician, only to learn that her newfound love, Adam, died of influenza. Yet in a wonderfully optimistic declaration, typically denied to anyone over 20, Miranda concludes:
No more war, no more plague, only the dazed silence that follows the ceasing of the heavy guns; noiseless houses with the shades drawn, empty streets, the dead cold of tomorrow. Now there would be time for everything.[6]
Hope for the Future?
But is there time for everything? The threat of a human pandemic avian influenza essentially represents the first pandemic in human history that we have had some semblance of advance warning -- and hence, the opportunity to prepare. With the advances in virology, surveillance, rapid communications, modern computing, and epidemic modeling, many of us share the exciting hope that we can apply all of these methods to a pandemic's rapid mitigation, if not containment or outright prevention. But will we get our epidemiologic ducks in a row to ensure some semblance of public health protection if our worst fears about avian flu really do come true? As historians love to say: only time will tell. Yet, like Katherine Anne Porter's Miranda, I remain ever hopeful that there will be time for everything -- including productive, ethically, and socially appropriate strategies that mitigate the microbial threats that inevitably loom on our horizon.
References
Flexner S, Flexner JT. William Henry Welch and the Heroic Age of American Medicine. New York, NY: Viking Press; 1941: 376-377.
Crosby A. America's Forgotten Pandemic: The Influenza of 1918. Cambridge, Mass: Cambridge University Press; 1989: 3-11.
Vaughan VC. A Doctor's Memories. Indianapolis, Ind: Bobbs-Merrill, Co.; 1926: 382-384.
Porter KA. Pale Horse, Pale Rider. Three Short Novels. New York, NY: The Modern Library; 1939: 249.
Porter KA. Pale Horse, Pale Rider. Three Short Novels. New York, NY: The Modern Library; 1939: 245.
Porter KA. Pale Horse, Pale Rider. Three Short Novels. New York, NY: The Modern Library; 1939:p. 264.
Howard Markel, MD, PhD, George E. Wantz Professor of the History of Medicine, Professor of Pediatrics and Communicable Diseases, Director of the Center for the History of Medicine, University of Michigan, Ann Arbor; author of When Germs Travel: Six Major Epidemics and the Fears They Have Unleashed (Pantheon Books)
Disclosure: Howard Markel, MD, PhD, has disclosed no relevant financial relationships.
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