By James Kennedy

The Spanish Influenza Pandemic also known as ‘La Grippe’ has been the most significant public health catastrophe in modern times. Its impact was both worldwide and local, and irrespective of social class, location or age. The scale of mortality has been difficult to assess, but global estimates extend to as many as one billion ill and 100 million dead [1]. In this article mortality in Scotland is outlined and the human impact is described, since often major world events are remembered through local experience. The pandemic typically occurred in three waves: the first between March and August 1918, followed by a more severe wave between September and early December 1919 and a further one between January and May 1919.

The earliest documented case of what was to become known as Spanish Influenza is associated with Camp Funston at Fort Riley in Kansas on 4 March 1918. ‘Patient Zero’ was Albert Gitchell a mess cook who by the time he became seriously ill had served food to hundreds of troops. However some question the American origins of the pandemic pointing towards the military camps in France where there were already reported infections, with a high mortality during the winter of 1916-17. This condition became described as a ‘purulent bronchitis’ and these reports came from the large British military camp at Etaples [2].

Butler and Hogg [3] suggest that the influenza epidemic can be traced to earlier than 1918, in the Shansai province of China where people often lived in close proximity to pigs and birds. They connect this with the role of Chinese labourers as part of the workforce who dug the trenches and graves in the Great War. Interestingly the Aberdeen Weekly Journal offered an alternative view from China: ‘the Chinese believe the disease is due to the contamination of the world atmosphere by the use of gas and other explosives in Europe’ [4].

The 1918 pandemic is commonly known as the ‘Spanish flu’ which is not related to the origins of the illness but because of the extent of influenza cases initially reported in Spain. Spain was a neutral country in the War and early reports in the British press were of a ‘mysterious illness’ emanating from the uncensored press in Spain in May 1918. By this time there seems little doubt that the pandemic was already rife on the western front and indeed cases were being recorded in Glasgow.

The British Medical Journal of 1 June 1918 was less than convinced about the nature of the mysterious illness and stated ‘pending further information it seems not improbable that this acute catarrhal disease is what we are accustomed to speak of as ‘influenza’ and that in Spain now the gastro-intestinal form is prominent’ [5].

The Numbers

In 1919 a supplement to the Annual Report of the Registrar General for Scotland was produced to report on the Influenza Pandemic[6] over the 10 month period, July 1918 to April 1919 inclusive. The supplement’s primary focus was the number of deaths based on death registers. It did not offer a view about the number of people who were affected by influenza. According to the report the first indication of an epidemic in Scotland was in the mortality statistics for Glasgow for May 1918 when the general death rate and the death rate from pneumonia increased. Glasgow’s role as a major seaport is the most likely explanation for these figures and this view is asserted by several authors [7]. This was the first wave of the pandemic occurring in Scotland.

This perspective on the development of the first wave was reinforced by Dr A McLean the Assistant Medical Officer of Health in Glasgow who stated that there was a small series of outbreaks in the late spring/early summer of 1918 followed by a significant increase in late September 1918. An alternative view was offered which stated that influenza was prevalent in epidemic form in China and Japan in March 1918 [8]. It has also been suggested that influenza reached Great Britain at the same time as reaching Spain and that vessels of the Grand Fleet at Scapa Flow and Rosyth were affected by the middle of April 1918 [9].

Ships bringing troops back to the UK and the railway network appear to have been significant factors in the spread of the virus across the country including Scotland. Mrs. J Oliphant [10] offered this perspective:

I was a VAD nurse stationed at the 4^th Scottish Military Hospital, Stobhill at that time. An American troop ship had arrived at the Clyde bearing hundreds of the flu victims. They were divided amongst all the military hospitals in Glasgow.

She explained that there was no time to disinfect or fumigate the wards. All the soldiers from the ship were kept on the same ward but when the white soldiers objected the beds had to be moved. As a consequence the white and black patients were nursed on opposite sides of the same ward. Over the following months the number of monthly deaths in Scotland fluctuated, reaching its maximum of 4272 in November. This reflects the arrival of the second wave. The figures fell in December and January but the third wave caused significant deaths in February and March 1919. The final number of deaths caused by the influenza virus was 17575 which exceeded the mortality of all previously recorded epidemics in Scotland.

The Registrar General suggested that these figures were probably an underestimate and that a mortality figure of 26199 was more likely in Scotland. There have been a number of further revisions of the scale of deaths especially by Johnson [11]. One of the reasons for these revisions is that a chronic condition Encephalitis Lethargica has been identified as being possibly associated with the 1918-19 influenza pandemic. Prior to 1918-19 this disease was unusual and rare but there was a significant increase in mortality from this condition in the 1920s. In addition many who survived were left with long term health care needs, sometimes requiring lifelong care [12]. The number of deaths recorded from Encephalitis Lethargica during the period 1920-1930 in Scotland was 1203 and once these are included Johnson suggests that a revised range of deaths associated with influenza in Scotland would be 29000 to 35000.

Distribution

The virus dispersed far and wide through human contact. Deaths were recorded in every county in Scotland and in all burgh and county districts with the exception of the Cumbrae District of Bute, and the Burghs of Abernethy, Culross, Anstruther-Wester and Kingussie. Recent research by this author using Scotland’s People data suggests otherwise for some of the above areas. In Cumbrae the County and Town numbers are combined so the situation cannot be established but certificates with a cause of death as influenza do exist for Abernethy, Culross, Kingussie and Insh. This means that Anstruther-Wester is the only area where with certainty no deaths from influenza were recorded in Scotland.

The number of deaths in what were defined as Principal Towns (with a population over 30000) were also outlined in the Registrar General’s Report [13]. Fig.5 shows the maximum weekly death rate of each of these towns as well as the date of each maximum rate and, for comparison, the yearly death rate of 1917.

This table provides an insight into the absence of any distinct geographical features regarding the pattern of spread of the pandemic. It also indicates that Scotland as a country was more significantly affected by the second and third waves and that by April 1919 the pandemic had begun to recede.

Age

The age incidence of influenza deaths in 1918-19 was completely different from that in previous epidemics and from the usual pattern of deaths associated with routine influenza. Comparisons have been made with the epidemics of 1889-90 and 1900. Generally the two earlier epidemics had a major impact on the young and the old whereas in the 1918-19 epidemic the largest mortality (over 50%) occurred between the ages of 15 and 44 and almost a quarter of the whole in the prime of life between the ages of 25 and 44.This is markedly different from all other patterns of death (Fig. 6). The major feature in 1900 was the relative high frequency of death in the older age groups. An interesting reflection was offered by Dr. Thomas Finlayson Dewar in 1919: ‘the magnitude of the events that occurred in France, Belgium and Germany, in Syria, Russia and the Balkan States during the latter half of last year and the first third of this tended to divert attention from the extraordinary and most grave epidemiological phenomenon that was then taking place at home’ [14].

Gender

Of the 17575 deaths, 47.8 per cent were the male 52.2 per cent female. The Report states ‘tabulations of the age distribution of male and female influenza deaths taken separately show no points of special interest’. However this author’s analysis of the local newspapers suggests that most local reporting focussed on returning soldiers and otherwise well-known local men. Individual deaths of women were more commonly found in the death columns of the relevant newspapers. Occasionally women featured in short news reports when other members of the family had also died.

Influenza Virus

There are four influenza virus types, A, B, C and D. Pandemics are associated with Type A, which has many subtypes, and infects humans, birds, pigs and some other animals. A pandemic strain may develop from an animal – mainly chicken, duck or pig-strain – by genetic change and adaption to humans, so that it can be transmitted between humans without any animal involvement. The virus is transmitted directly or indirectly from person to person via droplets through sneezing and coughing. Typically after a few days of incubation a sudden onset of fever occurs.

Spanish Influenza produced the usual range of influenza symptoms but often to a greater intensity than normal. The abrupt onset, with significant respiratory problems and a high fever, led to major problems. Mortality rates averaged 2.5% of those infected whereas usually the influenza mortality rate would be 0.1%. These symptoms are described by Dr. James Leask a GP from Wick: ‘Very significant epistaxis in comparison to the usual influenza, headache-more intense and less amenable to treatment, severe bronchitis and very significant muscular pain’.[15] Leask dealt with around 2000 cases from July 1918 onwards and also reflected that in his experience the level of fatality was highest amongst those aged 17-35; septicaemia was often present and that fear of the illness was ever present.  He also stated ‘no community is safe but those communities where the immigration of the individual is of daily occurrence, as by railway, are earliest infected’. He acknowledged that the outlying districts escaped the longest but ultimately became infected.

Treatment

Most doctors tried to treat the symptoms as best they could but were seriously hampered by a depletion of the medical and nursing workforce and with an especially lethal infection of sudden onset. Bedrest, hot baths, good quality food and nursing all featured in Leask’s treatment of individuals. He also described many victims as suffering from long term fatigue, depression and fear of recurrence. In one of his fatal cases, death was the result of suicide of a patient caused by post-viral depression and fear of a recurrence.

Public health measures were varied as at that time there was no National Health Service and the role of the Local Government Board was limited. It is considered by some to have been slow to react. However influenza was not a notifiable disease and therefore it is possible that there was a time lag between its arrival in an area and an understanding of the likely scale of its distribution and impact. Measures were nevertheless taken to try and control the epidemic [16]. These included the closure of schools, spraying streets with disinfectant and discouraging large gatherings of people. Picture houses in some areas were not allowed to admit children under the age of 14. They were also expected to fumigate their premises between performances. The military authorities were some of the first to stop soldiers attending picture houses

In some parts of the world face masks became the norm. An interesting perspective was offered in a newspaper report on 1 March 1919 [17] following advice from the Local Government Board. The focus of the article was on the use or otherwise of face masks. The article stated that ‘Sir James Crichton Browne regards them as about as useful as putting up a barbed wire fence to keep off flies’. The article goes on to recommend healthy living, well-ventilated rooms and the avoidance of crowded gatherings.

Newspaper Coverage

This section is based on an analysis of the Scotsman, the Glasgow Herald and a range of local newspapers in Aberdeenshire, Banffshire and Stirlingshire. Reporting of the influenza initially focussed on a ‘mysterious illness’ emerging from Spain. This was mainly through the national newspapers, with some local ones then picking up the theme. An assessment of local newspapers in a number of areas suggests that the reporting of the first wave in the summer of 1918 was fairly limited. The triggers for more reporting in the autumn and early winter of 1918 appear to be reports from local Medical Officers of Health followed by reports of soldiers having died of influenza, sometimes in Great Britain or indeed in Scotland. The return and burial of these soldiers featured significantly in local newspapers as had the deaths in action of Scottish and British soldiers throughout the war. Once it became known that the influenza was spreading, advertisements for treatments and cures became regular items. Cases more likely to be reported were those associated with the death of more than one family member; also reported were the difficulties that undertakers faced in dealing with the number of burials.

Memories of the Influenza

In his book The Plague of the Spanish Lady [18], Richard Collier described the impact of the influenza pandemic from October 1918 to January 1919. Collier was a British historian and author born in London in 1924. He joined the RAF at the age of 18 and later became a war correspondent. He wrote for numerous British and American magazines and his books include many focussing on war. In the early 1970s Collier and his research team sought out people with memories from their younger days. The massive response provides the basis of a global chronology of the epidemic. In the epilogue to the book the following quote is offered from HL Mencken:

The epidemic is seldom mentioned and most Americans have apparently forgotten it. This is not surprising. The human mind always tries to expunge the intolerable from memory, just as it tries to conceal it while current.

The original letters have been retained at the Imperial War Museum [19] and the collection includes over thirty letters from people who had been living in Scotland at the time of the epidemic. These form the basis of the following two sections, providing rural and urban perspectives. Additional information about the correspondents is provided in brackets.

Rural Perspective

George Arthur aged 11 or 12 during the pandemic and writing from Ayrshire on 11 May 1973. He remembers the school being badly affected, with fewer and fewer in the class until one day the teacher said ‘you can go home now, you will be told when to come back’.(George was born on 15 April 1907; his father was a police inspector. George was employed for much of his life as a fruit van salesman and lived to the age of 92).

Mrs AS Balreaves aged 17 during the pandemic, from Lumsden Aberdeenshire, writing on 8 May 1973. She remembers living in a remote village where almost every house had a sufferer and that there were several fatalities. She recalled a double tragedy as follows: ‘the policeman and his wife were both victims’. The policeman’s wife had gone into labour during her illness and fortunately their baby survived.

Vida Gray aged 9 during the pandemic and writing from Newmachar on 10 May 1973. She wrote vividly of the processions to the graveyards and that doctors carried the keys of the homes where everyone was laid up which meant that the doctor and district nurse were able to visit with medicine and the nurse would prepare food for the families. She also wrote: ‘No horror film I have seen as an adolescent or a grown woman has ever struck the same feeling of awe of those terrible days and the clamping of the horses’ hooves in the gloaming and at dawn again, will always haunt me’.

Dorothy Jack aged 10 and living on a farm in New Deer in East Aberdeenshire during the pandemic. Dorothy lived on a farm equidistant from Peterhead and Fraserburgh. Following the death of Dorothy’s father, her mother had continued to manage the farm with the help of two younger men and a maid.  One of the younger men had attended the Skippy Fair which was a horse market. He became unwell within a couple of days of returning. Influenza spread throughout the entire household in a matter of days and a number of neighbours looked after the farm animals and left cooked food at the doorstep. She wrote: ‘I can remember having a very high temperature and we were all delirious, having terrible nightmares … older people, people with bad chests or lungs and women who had babies died. It was an extension of all the sadness of the casualties of war’. (Dorothy in her adult life was a schoolteacher who never married and died at the age of 76 in Stonehaven, on 19 June 1985).

WBE Matthew, writing from Inverurie, Aberdeenshire on 11 May 1973. He had left school and was helping on the farm of his brother-in-law. He was considered to be one of the better farmers in the area. The farm was in the village of Torphins about 16 miles from Aberdeen. He recalls: ‘when the epidemic raged in Aberdeen people I understand died on the street and children in the playground’. He wrote that they felt better off in the rural area but when the infection spread there were quite a few deaths. He felt it was partly responsible for the decision he made to become a nurse. In 1921 there was another epidemic and a few nurses succumbed. He finished his letter: ‘I must have had immunity as I survived and continued nursing for approximately 46 years’.

Elizabeth Munro aged 19 during the pandemic and writing from Evanton in Ross-shire on 15 May 1973. Elizabeth was living on a farm and the doctor was based some six miles away. She remained well and it was her role to attend to the ill in their houses twice a day. She gave them special drinks, milked their cows and fed their animals. She had a strong Highland mare and rode from house to house. The doctor had given her a bottle of quinine tablets to take which she believed was why she remained well.

Marion Copland (née Simpson) aged 17 and in Fife during the pandemic, writing from Aberdeenshire on 13 May 1973. Marion remembers having a high fever for some 48 hours and suffering excruciating pain. She recalls that the pain suddenly lifted and she then broke out in a sweat. She said that she was lucky that she had a nose bleed and she believed it helped her recover. She says despite a good recovery her hair came out but it did grow again. She also recalls the scale of deaths as follows:  ‘People were dying in such numbers that there were not enough coffins for them, coffins being joiner made in those days. I remember a family of five sisters who all died from this flu’. (Marion lived in Stonehaven in Aberdeenshire in her adult days and married Albert Copland; she died on 24 September 1979 at the age of 78 by which time she was a widow but living with her daughter).

Urban perspectives

David Balbarnie writing from Dundee on 16 May 1973. David was aged 9 at the time and wrote that it was a period of great worry. He can recall a girl he knew inviting him to see her mother who had died the previous week. He describes visiting what he called ‘the poorest of houses’ and seeing a coffin with his friend’s dead mother in it. The father of the family had died the previous week meaning that his friend and her two brothers became orphans.

Elizabeth Simpson, née Campbell aged 11 during the pandemic and living in Dundee (her letter was undated). She wrote that most of her family became unwell with the exception of her oldest brother who looked after everybody else. When she returned to schools her friends said: ‘We thought you were dead, you must have been terrible’.

John Hellens, in South Queensferry, near Edinburgh during the pandemic, writing on 3 October 1973. John was the Officers’ Chief Steward on the battleship the Royal Sovereign, catering for a large room in the Officers’ Mess. Their battle ship was based at Rosyth and between sea-going patrols they came to anchor in the Firth of Forth. He recollection is as follows: ‘in our ship the best part of the ship’s company got it. I was confined to my bunk and unable to land for 5 days and the ship’s company were nearly all incapacitated with it …  thank goodness we had three very efficient Naval Doctors so did not have many casualties’.

Iain MacKinnon writing from Perth on 8 May 1973 about his experience in Aberdeen. Iain remembered information primarily passed on to him from his mother including about two spinster women who stayed nearby, one of whom returned on a Friday evening, became ill and went to bed. She was dead by the Monday.

George McLeod writing from Arbroath on 15 May 1973. George was a young soldier in June 1918 and could remember ‘soldiers dropping like flies on the Scots barrack square’. Just after the Armistice he received a telegram informing him that his parents and two brothers and sister were very ill. He was given a travel warrant and by the time he got back to Dundee the doctor told him that whilst his family had been very ill they had all responded well to treatment.(George worked as a clerical officer in Pensions and National Insurance and died on 17 January 1979 at the age of 78).

Eileen Sampson aged 5 and in Cherrybank near Perth during the pandemic, writing from Perth on 1 June 1973. Her father was an army officer and stationed in Edinburgh. However the family continued to live near Perth and Eileen remembers being kept away from her mother who had developed influenza. However this did not prevent Eileen from catching it: ‘I do remember being covered with a linseed meal poultice over the entire front of my body from throat to the bottom of my stomach and pleading with mum to take it off’. She was also given other medicines to help her recover including arrowroot milk pudding and a tonic called Robeline.

Sarah Simpson from near Aberdeen during the pandemic, writing from Aberdeen on 16 May 1973. She did experience influenza but felt that being from a farming family they were probably better off. She remembers the local doctor, Dr Cooper, being run off his feet and she referred to nose bleeds which at the time were considered to be a distinct feature of the influenza: ‘I had a relation who died from it and many others whom we knew, were in the obituary column. It was around about October 1918 when we were hit by it. We were told if you had no nose bleedings it would be fatal. My goodness my nose bled all one night on and off. It was really terrible and it seems to me now looking back that it was a plague that hit the whole country. Some people blamed the inferior food, we were getting just at the end of the First World War’.

Annabelle Mary Clarihew (née Spark) in Aberdeen during the pandemic, writing from Aberdeenshire on 10 May 1973. Annabelle had been a pupil at the Aberdeen Central School now known as the Hazelhead Academy and she was about to sit her exams when influenza struck. She remembers losing a lot of weight and also that her hair fell out. She also wrote ‘in delirium, I always saw my brother in his uniform at the foot of my bed. He was an officer in the Gordon Highlanders and had been killed in active service, in July 1917’.(Second Lieutenant AC Spark was a member of the 8^th/10^th Battalion of the Gordon Highlanders and was the son of William A Spark JP and Isabella Ogg Spark of Glenbuchat, Aberdeen).

Conclusion

This article offers an insight into a major event that was poorly reported. What is clear is that Scotland was affected as other parts of the world and that rurality did not afford any protection. Whilst the first wave in May and June 1918 appears to have had a limited impact the second and third waves led to high levels of mortality and illness. The virus slowly abated from March 1919 onwards but Scotland had experienced up to 35000 deaths in a one-year period. Inevitably the scale of death and destruction from the First World War dominated much of the media as well as individual’s lives. This may in some way explain the contemporary under-reporting as well as a desire by the government to maintain morale. Tragedy was added to tragedy by the high mortality in the younger generations in whom much of the post-war hope and aspiration was invested. The imminent return of a young soldier who had survived the war only to be fatally struck down by influenza, sometimes back here in Scotland, must have come as a massive body blow to parents and families. Hidden among the statistics are individuals and this is best reflected by the detailed and powerful testimonies of the survivors some fifty years later. This is also a subject which will lend itself to local research, combining the activities of local and family history groups.

Acknowledgements

This article forms part of a wider study. I would like to offer thanks for support provided by archive and local study services in Aberdeen, Moray, Falkirk and Stirling; and Special Collections at the University of Aberdeen. My thanks to Professor Niall Logan for advice on aspects of the influenza virus.

References

1    N Johnson, Britain and the 1918-19 Influenza Pandemic: a dark epilogue (Routledge, London, 2006), p.37.

2    JAB Hammond, W Roland and THG Shore, ‘Purulent Bronchitis: a study of cases occurring amongst the British troops at base in France’, The Lancet 190 (14 July 1917), pp.41-6.

3    AR Butler and JL Hogg, ‘Exploring Scotland’s Influenza Pandemic of 1918-23: lest we forget’, Journal of Royal College of Physicians of Edinburgh 37 (2007), pp.362-6.

4    Aberdeen Weekly Journal, 8 November 1918, p.5 col.5.

5    ‘The reported epidemic in Spain’, British Medical Journal,1 June 1918, p.627.

6    NRS GD 814/449 Report on the Mortality from Influenza in Scotland during the Epidemic of 1918-19: A Supplement to the Annual Reports of the Registrar-General for Scotland (HMSO, 1919).

7    Johnson, op cit, p.53.

8    G Marks and W Beatty, Epidemics (Charles Scribner & Sons, New York, 1976).

9    The Times, 15 January 1920, p.4 col.1.

10  Imperial War Museum Archives (hereafter IWMA), Richard Collier Basic Box List 63/5/1 SF Britain, France letters.

11  NPAS Johnson, ‘Flu: the Scottish Experience of Spanish Flu’, Scottish Historical Review 83(2) (2004), pp.216-26.

12  RCN Archives GB 1199 C751 Personal Papers of John Adams.

13  NRS GD 814/449 op cit p.7 table C showing Maximum weekly death-rate (all causes) during the Influenza Epidemic period in each of the sixteen principal towns.

14  TF Dewar ‘Influenza in Scotland’, Edinburgh Medical Journal 23(5)(1919), pp.303-8.

15  J Leask, Observations upon the Influenza Epidemic of 1918-19 as affecting the eastern parts of Caithness, unpublished PhD thesis, University of Aberdeen,1920.

16  Bridge of Allan Gazette, 1 March 1919 p.6 col.1.

17  T Royle, The Flowers of the Forest (Birlinn, Edinburgh, 2006), p.279.

18  R Collier, The Plague of the Spanish Lady (Macmillan, London, 1974).

19  IWMA.

James Kennedy has a background in nursing and health care management. He has had a long-standing interest in local history and is Chairman of Loch Ard Local History Group and a Trustee of Strathard Community Trust and of the Scottish Local History Forum.