In March 1916 England’s Local Government Board (LGB), then the highest medical authority in the country, forwarded a report to the Treasury calling for the creation of “a reserve of medical personnel for epidemics”.[1]
Sir Arthur Newsholme, the then head of the LGB, as well as leading civil servants, such as Robert Morant, were concerned that with a war raging in Europe and half the nation’s doctors and nurses on military service, local physicians would be unable to cope with the surge in demand for their services in the event of an epidemic that sickened a large proportion of the civilian population. It was widely recognised that the risk of such an epidemic had been exacerbated by the concentration of tens of thousands of Allied troops on the Western Front and the unsanitary conditions fostered by trench warfare.
Although diseases like dysentery and typhus were well-known to military doctors, the war had also seen the emergence of peculiar new broncho-pneumonic conditions, such as “purulent bronchitis”. The fear was that servicemen returning to England on furlough, or at the end of the conflict, might introduce these diseases to the UK’s civilian population, which would have little or no immunity to them.
“In the present abnormal circumstances there is exceptional danger of the introduction and spread of epidemic disease… and there is some ground for holding that a portion of the charge should fall on public funds,” wrote a Treasury official, summarising the LGB’s proposal.[2]
Despite having misgivings, the Treasury approved the LGB’s scheme. Its only proviso was that it be administered by the LGB rather than the National Insurance Commission, which had been established by the Chancellor of the Exchequer, Lloyd George, just five years earlier under the National Insurance Act.[3]
This example of what today we would call pandemic planning is just one of the remarkable documents contained in British Online Archives' new collection, Pandemics, Society, and Public Health, 1517–1925. This focuses on diseases that have had a significant impact on British society, namely cholera, smallpox, influenza, and plague. Arguably, the most significant disease that this digital collection surveys is influenza.
Britain suffered repeated epidemics of cholera and plague in the nineteenth century, and smallpox had been a domestic scourge since the twelfth century. Yet the deadliest epidemic to visit the British Isles was the 1918–1919 “Spanish influenza” pandemic, so-called because the first reports of the outbreak came from Spain, where press dispatches were not subject to the censorship of Allied countries.
Some 228,000 Britons perished in the pandemic—nearly as many as had died taking Passchendaele from the Germans in 1917. Worldwide, the novel influenza virus was responsible for the deaths of at least 50 million people, more than ten times as many as died fighting during the First World War. The result was that 1918 would be the first year since records began that Britain’s death rate exceeded its birth rate.
By bringing together digitised documents from the UK Treasury, Foreign Office, Ministry of Munitions, and Ministry of Health, whose establishment in 1919 was prompted in part by the influenza pandemic, Pandemics, Society, and Public Health, 1517–1925 makes it possible to trace discussions about influenza between the different arms of government, as well as the Army medical services and the War Office. Yet in order to make sense of these discussions it is important to understand medical conceptions of influenza at the time.
In 1916, when the LGB called for the establishment of a medical reserve for epidemics, the last thing Newsholme and other infectious disease experts expected was an epidemic of influenza. This was because influenza was a regular seasonal visitor to the British Isles and, unlike cholera and plague, it was not a notifiable disease. Nor was its mode of transmission fully understood, with old-school sanitarians and epidemiologists looking to “environmental influences” and followers of the German bacteriologist, Robert Koch, considering it a contagious bacterial disease spread by interpersonal contact. Moreover, only doctors who had been in practice during the 1889–1892 “Russian” influenza pandemic, so-called because the first reports emanated from St Petersburg, were familiar with the deadly pneumonias and the debilitating neurological conditions that were hallmarks of the pandemic form of the disease. Four million Britons were sickened in the first wave of the Russian flu and by 1892 some 110,000 had perished in this pandemic. Yet when, in the early summer of 1918, it was reported that the “Spanish flu” had arrived in the British Isles, most medical experts dismissed the threat. “With elementary precautions influenza is no more likely to spread than typhoid”, as one doctor informed his colleagues.[4] “When epidemics occur, death always happens”, declared the British Medical Journal.[5]
Newsholme, who had previously served as Medical Officer of Health for Brighton, and who had cut his teeth as a statistician, shared these prejudices. In Brighton, he had observed how sanitary reforms had made little difference to the prevalence of influenza and other entrenched respiratory diseases, such as tuberculosis. He was also suspicious of the claims made by bacteriologists and other laboratory researchers. As he informed a summit meeting on influenza at the Royal Society of Medicine (RSM) on 13 November 1918, while quarantines and border controls might be effective against contagious diseases such as cholera and plague, influenza’s mode of transmission was uncertain and the infection spread too rapidly. “I know of no public health measures that can resist the progress of pandemic influenza”, he stated.[6]
Medical historians have long debated the reasons for this “failure of expertise” on the part of the British medical profession.[7] As the documents relating to influenza in Pandemics, Society, and Public Health, 1517–1925 make clear, however, some doctors and scientists were alert to the dangers of an influenza pandemic and, following the relatively mild wave of “Spanish flu” in the summer of 1918, had been warning Newsholme and others to anticipate a more severe, secondary wave in the autumn.
Such concerned officials included Major Greenwood, an epidemiologist and student of the English mathematician and biostatistician, Karl Pearson, who was therefore schooled in the latest statistical methods; George Newman, the Chief Medical Officer of the Board of Education who, at the end of the First World War, would become the Chief Medical Officer of the new Ministry of Health; Morant, the key architect of Lloyd’s George’s national insurance reforms, who would help engineer Newsholme’s retirement from the LGB in 1918; and Walter Morley Fletcher, a Cambridge-educated biochemist and the head of the Medical Research Committee (later, the Medical Research Council), which had been sent up by Morant in 1914 to provide impartial scientific advice to the government.
When the war broke out, Fletcher had been appointed to the Army Pathological Committee where he worked closely with Sir William Boog Leishman, a tropical medicine specialist and Director General of the Army Medical Services. Confronted with sepsis, gas-gangrene, and other “diseases of war”, Fletcher found himself liaising with pathologists and bacteriologists in the Royal Army Medical Corp (RAMC). It was through these networks that Fletcher learnt of the high battalion hospitalization rates from influenza in the summer of 1918 and began co-ordinating laboratory research into the disease.
Despite uncertainty about the aetiology of influenza, a loose medical consensus held that the agent was a bacillus, first identified in the early 1890s by the German bacteriologist Richard Pfeiffer. However, Bacillus influenzae or Pfeiffer’s bacillus, as it was commonly known, was hard to culture and could not be isolated from patients with any regularity, raising doubts about whether it was the cause of the “Spanish flu”, or if the outbreaks seen in military camps and hospitals were true influenza. Nonetheless, when, in 1917, bacteriologists at Aldershot and Etaples, a large military camp in northern France, reported finding Pfeiffer’s bacillus in men hospitalized with peculiarly stubborn cases of bronchitis, and the bacillus also turned up in men hospitalized with influenza in 1918, Leishman pressed Fletcher to investigate. Thus, Fletcher began what, even in peacetime, would have been an ambitious task—coordinating research at military and civilian laboratories with the aim of producing a vaccine from Pfeiffer’s bacillus and the other bacteria commonly found in the nose and throats of influenza patients. These vaccines would have mixed results, however. The reason, as we now know, is that influenza is caused by a virus, not a bacterium, and while the bacterial vaccines may have helped with secondary infections, none of them were effective against influenza. Definitive proof that influenza was a viral disease only came in 1933, when researchers at the National Institute of Medical Research in Hampstead inoculated ferrets with throat washings from influenza patients and, having infected the ferrets, transferred the infection back to people, thereby fulfilling Koch’s postulates.
Fletcher had long suspected that influenza was a viral disease. In 1918, however, when he began coordinating laboratory research, he could not be sure and prosecuted the campaign for a vaccine on two fronts. First, he arranged for sera from American patients recently recovered from influenza to be forwarded to Haslar Military Hospital in Portsmouth. He likewise had sera from the Rockefeller Institute in New York transported to Liverpool Medical School. Second, he arranged for experimental animals to be sent to Abbeville, in northern France, where a group of RAMC bacteriologists had begun investigating the causal agent. This research team was headed by Colonel S. L. Cummins, adviser in pathology to the British Armies in France, but the experiments were conducted by a team led by Major Graeme Gibson. The results of these investigations are described in the MRC report, Studies of Influenza in British Army Hospitals in France, 1918.[8] Parallel studies were also conducted at Etaples, where in the winter of 1916 there had been an outbreak of “purulent bronchitis”, a disease that some experts believe may have been a precursor of “Spanish flu”.[9]
Rather than experimenting on human volunteers, Gibson passaged throat washings and from influenza patients in mice, rabbits, and monkeys. The rabbits and mice were relatively easy to come by, the monkeys less so. With a world war raging primates could not be shipped to northern France from the rain forests of Africa and Asia. Instead, Fletcher sourced monkeys for the experiments from zoos and private collections in England. Not all the monkeys were happy to cooperate, however: one unfortunate animal escaped from the Home Office and went walkabout in Whitehall where it was run over by a bus. By December 1918 Gibson had succeeded in infecting several test animals and was reporting that he was seeing lung lesions “similar to those seen in human cases” of influenza. Fletcher responded by urging him to go “all out” in the work. However, by now the war was over and the British were dismantling their camps in northern France, threatening both Gibson’s experiments and research at Etaples. [10]
With the second wave of influenza over, Fletcher was also struggling to sustain interest. As secretary of the MRC he commanded an annual budget of £57,000—about £4 million in today’s money—but the lion’s share was earmarked for tuberculosis research. With the war over Fletcher faced pressure to focus on this and other domestic health concerns.
Then, in February, came the news that Gibson had paid the ultimate price. According to a colleague, he’d been working long hours in the lab, repeatedly filtering serum from influenza patients to be sure it was free of bacteria and conducting passage experiments in mice when Fletcher reported he was attacked by the disease in its “severest form”.[11] He died soon afterwards.
According to Cummins, Gibson’s death was a “grievous loss” to medical science, as he had been on the point of completing his experiments into what he “believed to be the Filtrable Virus”.[12] Nevertheless, it was “such an end as a soldier would have chosen”, showing that “dangers resolutely faced are no less glorious in the laboratory than in the trenches”.[13]
Although the bacteriological studies were inconclusive and the vaccines were ineffective, Fletcher had good reason to fear that the mild summer wave of “Spanish flu” might herald a more severe secondary wave in the autumn of 1918. A key piece of evidence had come from Greenwood’s study of hospitalization rates from influenza in the Royal Air Force in the spring and early summer of 1918. Comparing these with the first wave of “Russian flu” in 1889–1890, Greenwood was able to show that the waves exhibited near symmetrical rises and falls, the only difference being that the first wave of “Russian flu” had occurred in winter. To Fletcher, this suggested it would be prudent to prepare for a second wave of “Spanish flu”. Newsholme was unimpressed with Greenwood’s statistical methods, however, telling the summit meeting at the RSM that no one could have anticipated a return of influenza in the autumn and bristling at suggestions that “more could have been done to avert the present pandemic”.[14]
To appreciate how Britain might have responded with different leadership, one only has to look at the precautions taken by the Ministry of Munitions. There, staff sickened by influenza were immediately sent home and contacts had their throats disinfected and painted with an iodine solution.[15] Other staff were instructed to gargle regularly with Cody’s fluid, a disinfectant made from permanganate of potash, and at lunchtime orderlies were instructed to open windows so that rooms could be ventilated.[16] These precautions appear to have been effective, with no severe pneumonia cases reported among the ministry’s 20,000 staff and the death of just one male employee.[17]
To this day, the origins of the “Spanish flu” pandemic—like the pandemic of Covid-19—remain a mystery. When scientists reconstructed the virus’s genome in 2005, they discovered that it had avian-like properties, suggesting that, like other influenza viruses, it had begun as a virus of birds. But when—or precisely where—it first gained a foothold in human populations is unclear, with some historians favouring a US point-of-origin and others arguing for northern France or China.[18] One thing is certain, however: the virus could not have been manufactured in a laboratory, as such technology did not exist at the time.
So, what insights and lessons, if any, should we draw from Britain’s wartime experience of influenza? Perhaps the best-known image of the 1918 influenza pandemic is the sketch made by W. Thornton Shiells showing an influenza patient in various stages of cyanosis.[19] This was a condition that occurred in the latter stages of a severe influenza infection as a patient’s lungs filled with choking fluids, resulting in oxygen leeching from their arteries. In the most extreme form, known as heliotrope cyanosis, a patient’s lips, cheeks, and ears would turn blue, followed by dark purple. First observed in the purulent bronchitis cases at Etaples and Aldershot in 1916 and 1917, and subsequently seen in soldiers hospitalized with “Spanish flu” in 1918 at army camps in northern France and North America, the condition was a hallmark of the pandemic form of the disease and usually indicated a very bad prognosis.
During the initial stages of the pandemic of Covid-19, doctors in Wuhan, in China, and Lombardy, in northern Italy, encountered similarly distressing cases of pneumonia as patients’ alveoli filled with pus and other fluids, rendering X-rays of their lungs a ghostly white colour. The difference today is that, if identified early enough, such cases can be treated before they become terminal. But in 1918, there were no mechanical ventilators to support a patient’s breathing when their lungs failed, or antibiotics to treat the bacterial fellow travellers of flu. Nor did Britain possess a national health service for treating those who could not afford private medical care, or intensive care units for treating severe pneumonic cases.
Nevertheless, the identification of unusual pathologies and symptoms, such as cyanosis, remains an important indicator for clinicians to this day that they may be dealing with a new pandemic pathogen. And while there have been considerable advances in laboratory diagnostics since 1918, tests for novel pathogens take time to develop and, as we saw during the Covid-19 pandemic, are often prone to error. Moreover, unlike in 2020, when vaccines for Covid-19 were fast-tracked in record time, on the next occasion we may not be so lucky. Nor, despite today’s sophisticated electronic reporting systems for monitoring unusual outbreaks across the globe, are we able to say precisely when and where the next pandemic virus will emerge. Hence, the importance of recognizing that pandemics are regular occurrences and being prepared and being ready to respond rapidly to the next pandemic.
Newman realized as much in 1919. One of his first duties as Chief Medical Officer at the new Ministry of Health was to compile a report on the pandemic for the Secretary of State, Christopher Addison.[20] In his report, Newman argued that if a reliable way could be found of predicting epidemics then their “ravages may be mitigated, perhaps altogether checked”.[21] The experience of “Spanish influenza” had underlined “the essential solidarity of all mankind in the matter of epidemic sickness”, he continued. Measures such as sanitary cordons and quarantines could only delay pandemics, not prevent them. Anticipating the establishment of the Health Division of the League of Nations, Newman argued that what was needed was a “supra-national system of preventive medicine”.[22] In the meantime, Newman made influenza a notifiable disease and appointed a standing committee of the medical heads of various Whitehall departments to share “intelligence” on diseases with epidemic and pandemic potential.[23]
Despite these innovations, however, Newman was “gloomy” about the prospects for pandemic prevention.[24] Influenza, he concluded,
simply had its way. It came like a thief in the night and stole treasure. That we have just passed though one of the great sicknesses of history… is an experience which should dispel any easy optimism of the kind. No instructed epidemiologist can say what the world may not have to endure during the next half century other plagues of the first order of severity.[25]
Those words, I would suggest, are as relevant today as in 1919.
Further Reading:
Bresalier, M. Modern Flu: British Medical Science and the Viralization of Influenza, 1890–1950. Palgrave Macmillan, 2023.
Eyler, John M. Sir Arthur Newshome and State Medicine, 1885–1935. Cambridge: Cambridge University Press, 1997.
Honigsbaum, F. “The Struggle for the Ministry of Health.” Occasional Papers on Social Administration 37 (1970). London: Social Administration Research Trust.
Honigsbaum, M. Living With Enza: The Forgotten Story of Britain and the Great Flu Pandemic of 1918. London: Macmillan, 2009.
Honigsbaum, M. “Imagining pandemics now, and then: a century of medical failure.” Interface Focus 11, no. 6 (2021): 20210029.
[1] London, The National Archives (TNA), T1/11919/8396, "Proposals of the Central Medical War Committee for Creation of a Reserve of Medical Personnel for Epidemics," available at https://microform.digital/boa/documents/42996/73754-b23#?xywh=-3513%2C-276%2C10183%2C5511.
[2] Ibid.
[3] Lloyd George was Chancellor of the Exchequer in Herbert Asquith’s Liberal government.
[4] Sandra M. Tomkins, “The Failure of Expertise: Public Health Policy in Britainduring the 1918–19 Influenza Epidemic,” Social History of Medicine 5, no. 3 (1992): 435–54, at 16.
[5] British Medical Journal, 9 Nov. 1918.
[6] Arthur Newsholme, “Discussion on Influenza,” Proceedings of the Royal Society of Medicine 12 (1919), 1–18.
[7] Tomkins, “The Failure of Expertise: Public Health Policy in Britainduring the 1918–19 Influenza Epidemic,” 435–54.
[8] TNA, FD 4/36, Medical Research Committee, Studies of Influenza in British Army Hospitals in France, 1918, available at https://microform.digital/boa/documents/42982/fd-436-studies-of-influenza-in-british-army-hospitals-in-france-1918#?xywh=-2364%2C-166%2C6608%2C3301.
[9] J. Hammond, W. Rolland, and T. Shore, “Purulent bronchitis: a study of cases occurring among British troops at a base in France,” The Lancet 190, 4898 (July 14, 1917): 41–46.
[10] TNA, FD 1/529, Fletcher to Cummins, 6 Dec.1918, cited in Mark Honigsbaum, Living With Enza: The Forgotten Story of Britain and the Great Flu Pandemic of 1918 (London: Macmillan, 2009), 116–118.
[11] Honigsbaum, Living with Enza, 119.
[12] TNA, FD 4/36, Medical Research Committee, Studies of Influenza in British Army Hospitals in France, 1918, 36, available at https://microform.digital/boa/documents/42982/fd-436-studies-of-influenza-in-british-army-hospitals-in-france-1918#?xywh=-2364%2C-166%2C6608%2C3301.
[13] Ibid.; Honigsbaum, Living with Enza, 120.
[14] Newsholme, “Discussion on Influenza”.
[15] The National Archives (UK), MUN 4/3702, "Aircraft Production Department Report," 13 March 1919, 2, available at https://microform.digital/boa/documents/42990/mun-43702-ministry-of-munitions-precautions-against-influenza#?xywh=-3024%2C-235%2C8680%2C4697.
[16] Ibid., 1–4.
[17] Ibid., 4.
[18] For a good overview of the different origin theories see Margaret Humphreys, “The Influenza of 1918: Evolutionary Perspectives in a Historical Context,” Evolution, Medicine, and Public Health 2018, no. 1 (2018): 219–229.
[19] A. Abrahams, N. Hallows, and H. French, “A further investigation into influenzo-pneumococcal and influenzo-streptococcal septicaemia: Epidemic influenzal “pneumonia” of highly fatal type and its relation to “purulent bronchitis,” The Lancet (4 Jan. 1919), 1–11 [illustrator: W. Thornton Shiells].
[20] George Newman, “Chief Medical Officer’s Introduction,” in UK Ministry of Health, Report on the Pandemic (London: HMSO, 1920).
[21] Ibid., iv–xxiii.
[22] Ibid.
[23] Ibid.
[24] Ibid.
[25] Ibid.