INTRODUCTION
Try to imagine a time when the most terrifying sound you could hear was not the rattle of machinegun fire or the whistle of falling artillery shells, but the sound of a sneeze. The Influenza pandemic of 1918 and 1919 killed an estimated 50 million people worldwide – more than the First World War – and yet we still know little about how or where it started and why it was so lethal.
There is no memorial to the victims of influenza, except for those who died in service and are remembered in the cemeteries and on the memorials of the CWGC. As many as one million service personnel across all the combatant nations lost their lives to the disease.
The memory of the disease was largely overshadowed by the end of the war and it is only recently that the 1918 pandemic has been reconsidered in the light of modern medicine. In many ways it is the forgotten fight of the First World War.
Learn how the CWGC’s records memorialise those who died and are helping to inform modern understanding of the disease and approaches to pandemics today.
WHAT was SPANISH FLU?
Influenza is a respiratory virus that spreads between persons through the air and by direct contact. It was a well-known disease, with the last major pandemic occurring in 1889-1891
The crowded conditions of trenches, troop ships and trains, or barracks promoted all respiratory infections but this was particularly true for influenza.
Most people infected in 1918 had ordinary “flu” consisting of several days to two weeks of fever, weakness and cough. This was militarily important because of the large numbers of soldiers who could not fight because they were ill with influenza.
During the last German offensives on the Western Front in early 1918, Allied headquarters were extremely concerned that insufficient soldiers would be available to stop the German advance.
Because of military secrecy associated with troop numbers, information on influenza was suppressed and the first reports actually came from Spain due to their lack of censorship.
It became known as “Spanish flu” not because of the origin of the virus but due to where it was first reported.
Influenza and the First World War
Influenza is a common disease that was present throughout the war.
Small localised outbreaks of lethal pneumonia occurred in soldiers in the UK and France as early as 1914, which may have been fore-runners of the 1918 pandemic. Experienced doctors reported some cases of very severe pneumonia, which in retrospect they stated was similar to what they later saw in 1918.
The vivid blue cyanosis of soldier’s faces and their tendency to bleed from nose and throat were typical of these severe pneumonia cases.
Experts are still divided over where the disease originated. Some think China or the United States, while others have suggested the vast military complex at Etaples on the Western Front – which is home today of the largest CWGC cemetery in France.
Since influenza viruses are all ultimately derived from waterfowl, the exact origin of the virus is less important than the war-time conditions that greatly promoted its global spread.
The war did not cause influenza but it is likely that the First World War enabled the 1918-19 pandemic’s rapid evolution and spread through the many disrupted war-time populations.
For reasons unknown, influenza returned in a particularly lethal wave of infections from August 1918, building to a peak in November 1918. The late 1918 influenza killed at a much higher rate than any influenza epidemic on record.
For most soldiers, influenza was an ordinary illness that made them unfit for duty, but in 1918 a larger number than usual (1-3%) went on to develop bacterial pneumonia – which was highly lethal in the era prior to antibiotics.
Why the 1918 influenza virus was highly lethal and why it specifically killed young adult males is still not understood. No influenza virus since 1918 has ever approached the same mortality rate.
THE MEDICAL RESPONSE
The doctors and nurses of the First World War were used to massive casualties following major battles, such as the Somme, but influenza was different.
Huge numbers of sick soldiers appeared suddenly from all units, not just those in the trenches, with a disease that no one was expecting or understood.
As you might imagine, doctors and nurses were particularly hard hit by infections contracted from their patients, which stretched the remaining well medical personnel beyond human limits. But the death rates in doctors and nurses was very low, except for those who had just joined the military, such as emergency service nurses (VAD).
The medical technology of the early 20th Century had little to offer soldiers whose lungs were failing from influenza as this predated antibiotics and mechanical ventilation support. Just trying to control fevers and provide fluids for the massive numbers of incapacitated soldiers was about all that could be done.
This was very discouraging for doctors and nurses who had made such progress against war wounds and epidemics such as typhoid, to suddenly find themselves faced with an infectious disease that seemed more like a medieval “plague” than a modern disease.
“I shall never forget the sight of the mortuary tents. There were rows of corpses, absolutely rows of them, hundreds of them, dying from something quite different. It was a ghastly sight, to see them lying there dead of something I didn’t have the treatment for.”
Geoffrey Keynes
How different was Influenza in 1918 from today?
In most ways, other than its extreme lethality, the 1918 influenza pandemic was the same as influenza before and since.
Usually it is the very young and very old that die of influenza. For unexplained reasons young adults, particularly males, died at much higher rates in 1918 than any other influenza pandemic for which records exist. This had obvious military implications during the First World War.
In mid-1918 there was a wave of influenza that caused great numbers of sick soldiers, but killed very few. Sick soldiers cannot fight and there was great concern in different headquarters that insufficient manpower would be available to fight the war.
Both the military and influenza situation stabilised as the war continued and then suddenly the lethal wave of the 1918 influenza virus arrived.
Initially the late 1918 wave of influenza appeared no different than what had been seen before. However, more of the infected soldiers with influenza went on to develop pneumonia, caused by an additional infection from bacteria living in their nose and throat.
Pneumonia was a highly lethal infection, with one in three dying, prior to the discovery of antibiotics during the Second World War. The difference between the “ordinary” influenza seen in mid-1918 and the lethal influenza seen from late-1918 was the number of soldiers developing secondary pneumonia that then went on to die.
There were, however, two clinical aspects that were widely noticed by military medical officers that have been largely restricted to the 1918 pandemic; bleeding phenomenon (especially nose bleeding) and a very distinctive form of deep blue skin colouring (cyanosis).
Nose bleeding was noted in more than 10% of some military groups with influenza. It was often severe, requiring packing of the nose in order to stop the flow of blood.
The dark blue cyanosis seen in conscious influenza patients was so remarkably different from anything seen before that the British Army Medical Corps brought in an artist from the Royal Academy to graphically capture the distinctive colour, which was described as “heliotrope cyanosis” after a deep blue flower (lavender).
Heliotrope cyanosis was regarded as a very poor sign, with 95% of soldiers showing such signs going on to die - usually within a single day.
The CWGC contribution
Equality of Sacrifice and remembering the victims of Spanish Flu
Most of the Commonwealth servicemen and women commemorated by the CWGC for the First World War died during, or as a result of, combat operations but many thousands also died of accident or infectious disease.
For CWGC, provided you were still in service (in uniform and not discharged from the military), cause of death is irrelevant because of the far sighted principle, established in 1917, to treat everyone equally.
The First World War is often stated to be the first war where combat deaths outnumbered disease deaths, largely due to the lethal industrialisation of the war. It is difficult to determine the impact of infectious diseases due to the way casualties were recorded.
It is an unfortunate fact that disease deaths were often underappreciated compared to combat deaths, despite the obvious fact there was an awful equality in death from any cause.
Although combat deaths were carefully recorded and particularly recognised if honoured by posthumous awards, disease deaths were obscured with terms like “died on active service”. It was as if a soldier dying of disease had somehow let the team down by not resisting the infection.
During the 1918 influenza pandemic, healthy men were suddenly medically evacuated only to die a few days later of an illness no one understood at the time. The utter randomness of mortality robbed the ultimate sacrifice of meaning.
There are particular reasons why influenza deaths never formed distinct memories for the survivors of the First World War despite the pandemic’s massive global impact:
- The lethal wave of influenza occurred at the end of war and blurred into memories of the Armistice.
- Influenza killed the soldiers who had just joined the military when they were either still anonymous recruits or unknown new men in the unit.
- Death from disease happened in hospitals away from the front line, unlike combat deaths which often occurred in frightening proximity to survivors.
- Influenza deaths did not occur instantly, so the news of a comrade’s death often did not reach friends in his unit until long after the fact.
- Funerals for combat casualties were conducted by unit chaplains, sometimes with their friends in attendance, close to where they died. Funerals for disease deaths were conducted in the same manner, but occurred in large cemeteries (e.g. Etaples) associated with military hospitals with few if any friends in attendance.
- Combat deaths occurred in distinct units whereas disease deaths were lumped into larger groupings and labelled as personnel “wastage”, important mostly due to the need for replacements.
Look at the photo below of a small infantry unit (B company, 29th Battalion Australian Imperial Force, Australian War Memorial photo E02790) as the officer calls the roll at the end of battle on 8 August 1918.
The first thing to notice is that although this is an infantry company (usually about 100 men), attrition has reduced it to barely the size of a platoon (10-20 soldiers).
Because the photographer recorded the names of each man in order, one can reconstruct what happened to each of them by the end of the war, which was only three months into the future.
Four would die during combat in those three months. It is also known that five (in blue) became ill enough to be hospitalised during the influenza pandemic and one (in red) of those soldiers died of influenza. This is not untypical of the attack rates experienced in late 1918.
Mortality was a common in the trenches of the First World War. Survivors inevitably had more memories of combat deaths while disease deaths occurred out of sight in military hospitals.
The sacrifice of those dying during the 1918 influenza pandemic was exactly equal to those who perished in combat. We do not discount any soldier’s sacrifice during the war.
Using CWGC Records to understand the disease
We estimate that some 13,000 of our casualty records indicate a primary or secondary cause of death that can be linked to the 1918-19 influenza pandemic. It is highly likely the true figure is much higher but not every record contains cause of death detail.
Even so, this information, and the fact that CWGC can help link such deaths to a geographical location, is useful to modern day researchers into the disease. Analysis of our records has helped track the spread of the disease and even inform casualty rates among particular units.
It gives scientist a geographical location – based upon the grave of the individual – from which to track the impact and course of the disease. Our records also allow those deaths to be examined by force and by age.
Perhaps strangely, some of this information can be used to calculate likely mortality and survivability rates among particular sections of society and even profession.
The Human Cost
Ultimately, the influenza pandemic of 1918-19 is a story of human tragedy. At a time when the most costly war in human history was finally drawing to a close – when families were finally reunited and people’s thoughts were turning to a more positive and hopeful future – an invisible virus brought loss and heartbreak to millions.
In the UK as many as a quarter of the population contracted the disease and an estimate 220,000 people died. Other Commonwealth nations were hit even harder. In South Africa the disease left behind an estimated 900,000 orphans.
Here are just a few personal stories of some of those who died and are remembered by CWGC.
Major The Hon. Charles Lyell
Major The Honourable Charles Lyell of the Royal Garrison Artillery, died of pneumonia in the USA. He was 43 years old. Charles is buried in Arlington National Cemetery, USA.
Charles was born in 1875 and educated at Eton and New College, Oxford.
In 1910 he became the Liberal party Member of Parliament for South Edinburgh and in 1911 he was appointed as Private Secretary to Herbert Asquith, the Prime Minister.
In 1917 Charles resigned his seat and joined the forces. He was working in Washington as the Assistant Military Attaché to the British Embassy when he caught pneumonia and died.
Able Seaman Albert Edward McKenzie VC
Able Seaman Albert Edward McKenzie VC was just 19 when he was awarded the Victoria Cross for his actions during the Zeebrugge Raid.
The raid was one of the most celebrated episodes of the First World War as the Royal Navy attempted to block the Belgian port and prevent the German navy from using it. More than 200 sailors and marines were killed and over 300 wounded. Albert’s comrades chose him to receive the award for his bravery.
He was presented with his medal by King George V at Buckingham Palace while, still recovering from his wounds. In October of 1918 he became a victim of the influenza pandemic and was buried in Camberwell Old Cemetery, South London.
Major Reginald Oscar Schwarz
Major Reginald Oscar Schwarz was born in South London and has the unusual distinction of playing International rugby for England and Test cricket for South Africa.
Reginald’s three England caps came at fly half in 1899 and 1901, but he was on the losing side on each occasion. Greater fortune came his way at cricket.
In 1903 he went to work on the Johannesburg railway. He played in 20 test matches for South Africa and between 1905 and 1912 in four series against England.
He was a leading exponent of the googly and in all took 55 test wickets at an average of just over 25. Such was his skill that he was named Wisden Cricketer of the Year in 1908.
At the outbreak of the war he joined the South African army and served in German South-West Africa. By early 1916 he was in France, where he was awarded the Military Cross. He then served in a number of posts but, with increasing poor health, was transferred to the salvage corps in early 1918. Seven days after the Armistice he died of pneumonia. He is buried in Etaples Military Cemetery.
Bertha Bartlett
Bertha was born in Brigus, Conception Bay, Newfoundland, on 14 November 1894.
In 1916, aged 21, she volunteered to serve overseas with the Canadian Voluntary Aid Detachment of the British Red Cross.
She arrived in England in December 1916 and was posted to the 4th Northern General Hospital in Lincoln. The hospital occupied the old buildings and fields of the former Lincoln Grammar School. It had bed space for 41 officers and 1,126 other ranks. Over 45,000 men were treated in the hospital during the war.
Bertha worked in Lincoln for seven months until July 1917, when she was moved to Bermondsey Military Hospital in London.
Bertha was working in Bermondsey at the height of the Spanish Flu pandemic and in late 1918 she contracted the illness. She died on 3 November, eight days before the Armistice, and 11 days before her 24th birthday.
She was laid to rest in Wandsworth (Earlsfield) Cemetery, London. Upon her headstone are inscribed the words, ‘She died for those she loved’.
Husband and Wife
At Etaples Military Cemetery in France are buried a husband and wife – both of whom died during the influenza pandemic.
Mrs Florence Grover, aged 21, is buried in Plot I, Row C, Grave 1 of Etaples Military Cemetery. Her husband, Private Albert Grover, aged 23, who died three weeks later, is also buried there.
One of the nursing sisters Mary McCall, recalled: “One particularly tragic case I remember was a little girl, a very young bride, who’d been brought out to see her wounded husband. She had probably caught the infection before she left, because not long after she arrived in the ward she collapsed and was taken to the Sick Sisters’ quarters with influenza. She died a day or two later and it was terribly tragic for the poor husband. Then later he caught it and died too.”
Credits:
IWM, CWGC Archive, NCP, CDC, & Library of Congress.