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Among my many weaknesses, none is worse than my appetite for chicken soup. When I was a child, I looked forward to my mother serving it on Friday nights. To this day, it brings back memories of growing up in London, and its long and rainy winter nights. For centuries, chicken soup has been seen as a folk remedy for coughs and colds, fevers and chills—all the symptoms of the flu. My mother would remind me to finish my serving so that I wouldn’t become ill over the winter. It was the most delicious preventive medicine imaginable.
Many years later, while at medical school in London, I came across a study suggesting that chicken soup might actually be the real thing. The article was published in 1978, in the journal Chest, and its title is almost as delicious as the soup itself: “Effects of Drinking Hot Water, Cold Water, and Chicken Soup on Nasal Mucus Velocity and Nasal Airflow Resistance.”
In the study, pulmonologists paid healthy volunteers to drink either hot water, cold water, or hot chicken soup, and then they measured any changes in congestion—or, as the title suggests, how fast mucus and air moved through the nasal cavity. The researchers concluded that while hot water is good to help clear your stuffy nose, chicken soup has “an additional substance” that does the job better. No one’s clear on what this secret ingredient is, but researchers have theorized that the key to the soup’s restorative powers is the nourishing partnership of vegetables and chicken.
Dr. Stephen Rennard of the University of Nebraska Medical Center has studied chicken soup for more than a decade, and in 2000 he found that the recipe from his wife’s Lithuanian grandmother reduced upper respiratory cold symptoms by inhibiting the circulation of certain white blood cells that react to infection—meaning that chicken soup is a kind of anti-inflammatory.
“There’s little doubt that, one hundred years from now, probably everything else that I’ve done will be forgotten because it’ll be irrelevant and out of date,” says Rennard in a YouTube video shot in his kitchen as his wife cooks. “But the chicken soup paper probably will still be cited.” Doctor tested, grandma approved.
Sometimes age-old wisdom yields clinical success. I wish I could say the same for other remedies that have been tried for treating the flu. Enemas. Mercury. Tree bark. Bloodletting. Methods to boggle your mind and turn your stomach. Be glad you weren’t born in the 1900s. Today, no reputable doctor would prescribe these treatments, but just over one hundred years ago they were state-of-the-art therapies. Perhaps the only thing more shocking than the crudeness of these “cures” is the fact that our state-of-the-art methods in the twenty-first century aren’t wildly more advanced.
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Not three years after he resigned as the first president of the United States, George Washington was on his deathbed. As a last-ditch effort to save him, doctors opened his veins to thwart the infection ravaging his throat. Washington endured four rounds of bloodletting, the last one only a few hours before he succumbed.
“I am just going,” Washington said to his secretary, Tobias Lear, at that point.
“He died by the loss of blood and the want of air,” said a family friend and doctor, William Thornton—who suggested that Washington could be reanimated by a transfusion of lamb’s blood.
Bloodletting is the practice of draining the body of blood—and therefore, in theory, of toxins and disease—and was mainstream medical practice for more than two thousand years. In the eras before any useful medications or treatments, bloodletting was pretty much all there was. It dates back to at least the fifth century BCE, and is mentioned in the writings of the second-century Greek physician Galen, who taught that it was an important tool that could heal the sick. Bloodletting is frequently mentioned in the Talmud, a work recording the debates about Jewish law and ethics that was finalized around 600 CE, and was widely practiced during the Middle Ages and beyond. One of the most respected medical journals in the world is named after the main tool used in bloodletting: Lancet.
Bloodletting never worked. In fact, it was terribly dangerous—just ask George Washington—but it continued to be prescribed for influenza into the first decades of the twentieth century. And not just by fringe practitioners. It was recommended by military doctors who were on the front lines during World War I and saw another enemy—a microbial one—outflanking the ranks. What’s more, these doctors wrote about their experiences of bloodletting in important medical journals, including, poetically, the Lancet.
Three British doctors serving in northern France in December 1916, about two years before the outbreak of pandemic influenza, described a disease that swept through the army camps with catastrophic results. It was as if the influenza virus were doing a sort of dry run, preparing to unleash even more destruction later. The doctors were certain that the disease, which they called “purulent bronchitis,” was caused by the influenza bacillus, and they described their efforts to treat the poor servicemen who were taken ill. They were failing.
“So far,” they wrote, “we have been unable to find anything that has any real influence on the course of the disease.” And then this: “Venesection has likewise failed to benefit the patient for more than a very short time, though possibly we have not resorted to this treatment sufficiently early.”
You could almost miss this if you were reading the paper quickly. But it’s there. The British physicians had tried venesection, the medical term for bloodletting, and it had not worked—perhaps, they thought, because they tried it too late in the course of the disease. Two years later, at the peak of the flu pandemic, other British military physicians reported bloodletting their patients, too, only this time they reported that it worked, at least in some cases.
It wasn’t only the British who were still bleeding their patients in the twentieth century. In 1915 Heinrich Stern, a physician in New York, published his Theory and Practice of Bloodletting. While Stern was critical of bloodletting for most medical conditions, he did believe it could be helpful in some instances.
“I am an advocate of the conditional employment of this ancient method,” he wrote, “and I believe it unnecessary to state that I do not consider it a panacea.”
Stern was somewhat ambivalent in recommending it as a primary therapy for the flu, but almost a decade later, in America’s leading medical journal, doctors were still advocating bloodletting to treat pneumonia, convinced—without a shred of evidence—that it would get results when “our more conservative methods fail.”
Bloodletting to cure influenza eventually went out of fashion in the twentieth century, but other wild and suspicious treatments were still part of the medical repertoire.
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In 1913 a small book with a black cover was published by a doctor named Arthur Hopkirk. Its title was etched in gold: Influenza: Its History, Nature, Cause and Treatment. Hopkirk recommended a series of bizarre treatments for influenza. For fevers, the good doctor recommended “a purge,” meaning a laxative, such as the delightfully named “effervescent magnesia.” Severe cases of flu required a heavy-duty laxative like calomel, which is made with mercury chloride. Mercury, of course, is highly toxic.
Hopkirk’s 1914 recommendations did contain some nuggets of sound advice here and there. For example, alongside the poisonous mercury laxative he recommended aspirin, derived from the bark of the willow tree. (Of course, aspirin is still used, though today you are more likely to take Tylenol or Motrin.) But even that recommendation may have done more harm than good, because doctors didn’t yet know how to safely dose the drug. Symptoms of an aspirin overdose start with ringing in the ears, followed by sweating, dehydration, and rapid breathing. A severe overdose results in fluids pouring into the lungs, mimicking the actual symptoms of the flu. Fluids then enter the brain and it swells, resulting in confusion, coma, convulsions, and death. People were not just dying of the flu during the Spanish flu pandemic; they were also dying of aspirin overdoses.
During the pandemic, aspirin was widely used, but many physicians seemed oblivious to its dangers. In Delhi, senior physicians were concerned that younger doctors in Bombay and Madras were misusing the drug, while in London one physician who practiced from Harley Street, London’s fanciest medical address, encouraged its use. He recommended that the patient be “drenched with aspirin at a dose of twenty grains an hour for twelve hours, and then every two hours thereafter.” That is six times greater than the maximum safe dose. It’s an insane amount of aspirin.
Because it was given in highly toxic doses, it may have been the aspirin that killed so many during the pandemic, and not the influenza itself. This is an unsettling thought, but it might help explain the deaths of a disproportionate number of otherwise healthy young adults—the very population that today rarely suffers from serious flu infections.
Hopkirk also suggested that for pneumonia, a patient take “a teaspoonful of Friar’s balsam, or a small handful of eucalyptus leaves” with a pint of water. Friar’s balsam, in case you were wondering, contains benzoin, a resin that comes from the bark of several different trees. I used benzoin all the time in the emergency department; I’d dab it around a wound before placing a dressing over the top. Benzoin makes the dressing stick much better. But it’s of no use in treating the flu.
Hopkirk, like many physicians of his day, also prescribed quinine to treat the flu.
“In quinine,” he wrote with great certainty, “we have a drug that not only controls fever-producing processes allied to fermentations, but also exerts a definite anti-toxic action on the specific virus of influenza itself.”
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Bark again. Quinine comes from the cinchona tree, found in South America. There it was used by the indigenous peoples to treat malaria, and by the middle of the seventeenth century it was imported into Europe, where it became known as Jesuits’ powder (named for the religious order that brought it to Italy). Until only a decade ago, quinine was used as the first-line treatment for malaria, and it continues to play an important role in eradicating that disease. So how did it end up being used to treat influenza?
The answer is simple. Malaria causes fevers, just like influenza does, and quinine reduces the frequency and severity of fevers. If quinine cured the fever associated with malaria, why not use it to treat all fevers? And so quinine became a standard weapon in the arsenal to fight influenza. At the outbreak of the pandemic it was used in England, the United States, and the European continent. Grove’s Tasteless Chill Tonic was the most popular quinine product. As a treatment for malaria it had made Edwin Wiley Grove rich in the 1870s, and now it was being marketed for the flu. In newspaper ads across the country, it was claimed that the tonic would “fortify the system against colds, grip and influenza.” It improved the appetite, brought color to the cheeks, restored vitality, and purified the blood, “making it rich.” You would soon feel its “strengthening invigorating effect” and, as an added bonus, Grove’s tonic did not upset your stomach, or cause “nervousness or ringing in the head.”
But quinine does not directly reduce fevers in the way that aspirin does, and so it had no effect on the fevers caused by influenza. Worse still, in high doses it causes vision problems or even blindness, ringing in the ears, and cardiac arrhythmias. Overall, quinine is a dangerous and useless drug for influenza.
Still, it wasn’t all toxic mercury and tree sap for Hopkirk’s hapless patients. For nausea and vomiting, which are common symptoms of the flu, he recommended small doses of dry champagne.
“There is no finer pick-me-up after an attack of influenza,” he wrote, “than good ‘fiz.’ ”
If this all sounds a little much, it was. Even a hundred years ago, the medical community thought Hopkirk’s advice was peculiar, at best. An anonymous reviewer writing in the Journal of the American Medical Association could not hide his contempt:
Foreign physicians, especially British, may find such a book tolerable and perhaps instructive, but for Americans the ordinary text-books will probably furnish an equal quantity of useful information without induction of nausea by the persistent recommendation of nostrums. The astonishing thing is that Scribner’s would allow their imprint on such a book.
Astonishing indeed. But Hopkirk’s remedies were not as unusual as you might think. In fact, they appear to have been pretty mainstream (even in America, much to the chagrin of that cranky reviewer).
One of my favorite examples of how we fought the flu comes from the 1936 nursing records of an influenza patient, which were saved as a family heirloom and published seventy years later. Over a period of three weeks he was treated with a punishing battery of balms: mustard plaster (a home remedy rubbed on the skin), aspirin (for fevers), codeine (for cough), phenolphthalein (a cancer-causing laxative), cough medicine, camphorated oil, seven enemas (seven!), rectal tubes (don’t ask), milk of magnesia (another laxative, God help him), urotropine (a bladder antiseptic), and tincture of benzoin. The patient received at least five prescribed doses of whiskey and fourteen doses of castor oil. Actually, his seven enemas may have been medically necessary, because he was given at least thirty-nine doses of codeine, which suppresses coughing, but also causes constipation.
Now remember, this was two decades after the great influenza pandemic, and yet patients were still being treated with Friar’s balsam and castor oil. What we can conclude from Hopkirk’s 1914 book—and the nursing records of this poor overtreated patient—is that doctors attacked influenza with a number of folk remedies that were at best useless and at worst poisonous.
Some were at least organic: burning orange peels, or dicing onions to sterilize a room. Many doctors had concocted potions and medicines of their own, and advocated for their use with statistics that are hard to believe. In February 1919 a Dr. Bernard Maloy of Chicago claimed that he had treated 225 patients with pneumonia, and had not lost a single one. He used a tincture of two plants, aconite and Veratrum viride, in a regimen of ten doses. We do not know the concentrations of each ingredient, but aconite (also called monkshood) and Veratrum viride (called false hellebore or Indian poke) are plants that are—you guessed it—poisonous. In sufficient doses they cause nausea, vomiting, and a precipitous drop in blood pressure. They may even be fatal. Maloy’s mixture must have been carefully titrated to prevent these side effects, and let us not forget that many modern drugs are also toxic in high doses. Still, his claim that the mixture prevented or perhaps aborted pneumonia with a success rate of 100 percent suggests that his patients had been carefully selected, and that those with severe cases of influenza or pneumonia had been excluded from his protocol.
Some people were so desperate during the 1918 pandemic that they found their own perilous means of treatment, without the aid of a misguided doctor. As the flu roared through the coastal towns of southwestern England, the villagers of Falmouth were taking their sick children not to the hospital but to the local gasworks—to inhale the fumes. Parents thought that exposing their children to poisonous gases would reduce their symptoms.
A sanitary officer, Captain A. Gregor, set off to investigate this claim scientifically by looking at the rates of influenza across different groups in Falmouth. At a naval patrol base, he noted a 40 percent rate of influenza. A local army battalion of 1,000 troops had a rate less than half of that. And at a local tin works where workers were exposed to the noxious fumes of nitric acid, the influenza rate was half the rate at the army battalion: a mere 11 percent. Some workers at the tin works were exposed to explosives and gunpowder, and for those lucky enough to inhale these fumes, the influenza rate was lower still; only 5 percent of them came down with influenza.
The popular belief that many “colds in the head” could be cured by fumes “has some foundation of truth,” Gregor concluded in the British Medical Journal in 1919, as the influenza pandemic petered out. He was not the only one to make this observation. Another physician reported that it was “abundantly clear that poison gas workers were practically immune from influenza.” Mercifully, no one—not even the mercury-friendly Dr. Hopkirk—was actually recommending breathing toxic fumes as a way to prevent influenza.
There is no way of knowing if Gregor’s observations really had anything to do with the exposure of the workers. Chlorine does kill the avian flu virus, and it probably did the same to any pandemic flu viruses floating around those gasworks, but remember, chlorine gas was also used to kill scores of soldiers in the most excruciating way during World War I.
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Not all physicians practiced like quacks during the pandemic. James Herrick, a doctor who worked in Chicago, studied medicine at Rush Medical College in Illinois, and was by all accounts a brilliant physician. In 1910 he was the first to describe what was later called sickle cell disease, although at the time he was stumped to explain the cause of the condition. Two years later he published an important review of diseases of the coronary arteries in which he argued, against the prevailing wisdom, that those arteries may become blocked without causing immediate death. Based on his experiences, he was able to describe the clinical manifestation of such blockages a century before cardiac imaging became available. In doing so he laid the foundations of modern cardiology. In addition, he published on pneumonia, leukemia, and a host of other diseases, including influenza.
Herrick was among the very first to challenge the potions and folk remedies that were actually harming and killing patients who had influenza. Herrick had treated the flu during two pandemics, 1890 and 1918, and his plea was simple: doctors should stop using nearly all the medications in their arsenal. There was no evidence that any of them worked.
It took a lot of courage to write that in the summer of 1919, when the United States and the rest of the world were recovering from the worst pandemic in history. Most doctors who treated the flu, Herrick wrote, did so on the basis of “superficial observation and limited experience.” They ignored the fact that the disease is self-limiting, meaning that it usually cures itself.
“So many conclusions are crude,” Herrick wrote, “and so many are reached by a mental process in which an optimistic credulity takes the place of the more desirable scientific skepticism.”
Herrick balked at the variety of bogus treatments, which ranged from the inane to the lethal. A shot of mercury? Enormous doses of quinine? “Certainly,” he wrote with a characteristic understatement, “some one has blundered in reaching conclusions.”
Instead of prescribing these worthless medications, Herrick said, let’s try more practical methods that really do work: isolation, for example, and masks to prevent infection, with plenty of fluids to keep the patient hydrated. And rest. Lots and lots of rest. His regimen was squarely in the conservative mainstream. Several weeks of bed rest, partly outdoors, and plenty of fresh air, quiet, and sleep.
Of course, Herrick was also a man of his time, so it’s not surprising that he, too, addressed the use of laxatives, and insisted that “the bowels should be opened fully at the beginning of the illness and not allowed to become sluggish at any time.” But let’s give him a pass on that one, because of all the other marvelous and commonsense things he had to say:
One of the hardest things to do in the treatment of a serious, self-limited, infectious disease is to refrain from prescribing drugs merely because the diagnosis has been made. The self-restraint of the level-headed physician is likely to be swept aside by the thought of the possible grave consequences of the malady, and his accustomed good judgment is apt to be smothered in the semihysterical atmosphere of alarm that pervades the community during the visitations of the epidemic. He forgets that a large proportion of patients with influenza do not need a single dose of medicine. There should be no routine treatment according to which certain drugs are given at stated periods, whether or not there is a clear indication for their use. The treatment is really expectant, symptomatic and individualistic.
That last sentence is gold. It should be ingrained in the brain of every medical student in every medical school in the country. Wait and see what happens, treat the symptoms, and think about your patient and the individual profile she fits.
Fortunately, there were other physicians who also believed that the vast majority of the interventions for flu were flawed, at best. In November 1918, one doctor stationed with the Canadian troops at Camp Bramshott in England wrote that from the large number of agents used to treat influenza, “their comparative futility is obvious.”
While treatments have changed over millennia, and indeed from decade to decade, the patient in some ways remains the same. It’s the same type of virus, after all, that afflicted the ancient Greeks, that sent unlucky souls to Dr. Hopkirk, and that still knocks out your spouse, your child, or yourself. So what now?
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Well, none of my colleagues will offer you a laxative, at least. We won’t order bloodletting either. But you might be surprised at how little the treatment of influenza has advanced.
Here is a typical rundown of what happens more than 31 million times each year in the United States. It is late fall and you start to feel unwell one Friday evening. You are tired and don’t feel like eating. Your lower back and legs start to ache. Then you get an episode of chills and begin to sweat. You take your temperature. It’s 102 degrees Fahrenheit. Now you really start to feel awful. The chills get worse. Your throat gets scratchy, then sore. You start sneezing. By Saturday morning you have a runny nose and a cough, and now your entire body aches. You have influenza.
How you react to this very common scenario varies. You may stay home and reach for Tylenol or Motrin to keep the fever down and ease the aches. You may stay in bed, drifting in and out of sleep. If you are lucky, you’ve got someone to check in on you and bring you water or a hot drink. After a couple of days, the fever finally abates, and your strength starts to come back. It’s now Monday, so you call in sick, but you can finally drag yourself into the shower. Although you have little appetite, you drink some soup. By Tuesday your fever has gone, and your appetite slowly returns. It’s all over by Wednesday, and you are back in the office.
That’s what happens to most otherwise healthy people when they get the flu. Most. But certainly not all. At the first sign of a fever or body aches, some will call their primary care doctors, who will tell them to stay home and drink plenty of fluids, or to go to the emergency room if their condition does not improve. The last thing your doctor wants you to do is come into her office and infect her, her staff, and the other patients. I’ve treated hundreds of patients with the flu in the ER, and many were there in the very early stages, or with symptoms that were so mild that all I could do for them was send them home with the kind of advice my mother would have given: have some chicken soup.
Some patients, though, are in mortal danger when they get the flu. They may be elderly or have an immune system compromised by HIV, chemotherapy, or steroids. They may have an immune system that functions perfectly well but they just happen to have a particularly nasty bout of influenza. They may not have drunk enough water, or they couldn’t stay hydrated because of vomiting and diarrhea. These are the more serious cases of flu, the ones that often end up in the ER. Most arrive by car or cab, and some by ambulance.
However you get there, the first person you’ll meet on arriving in the ER is a triage nurse. She’ll ask you for a quick medical history. Then she will take your pulse and blood pressure, check your temperature, and put a little probe on your finger to measure the oxygen content of your blood. If these four measures, known collectively as your “vital signs,” are more or less normal, you’ll be given a mask to cover your mouth and nose and asked to sit in the waiting room until a bed opens up. As you sit there, you may see three or four other masked patients, also in their pajamas with overcoats draped over their shoulders, waiting, just like you. The sickest patients go into the ER first; if you can stand but another patient is too weak to walk, he gets moved in front of you.
If the flu season is especially severe, there will be many patients with symptoms just like yours, clogging up the waiting room. If you arrive in the afternoon or early evening, peak times for most ERs, your wait will be longer. If you are treated in an urban ER, you will likely spend longer waiting than if your ER were in the suburbs. Fridays and Mondays are often the busiest days of the week; federal holidays and the early-morning hours are usually quiet. On the day after a federal holiday, the ER is terribly busy. Remember, too, that medical teams are likely to be at their slowest at the end of their shifts. Putting this all together means that if you have a bad case of the flu and need to be seen in the ER, your best bet is to turn up at seven a.m. on Christmas morning. Just don’t tell them I sent you.
Once a bed opens up for you, you’ll be poked and prodded. An IV goes into your veins. Blood samples come out. All before a doctor sets eyes on you. When the doctor arrives, she will ask you about your illness: start time, symptoms, and so on. The doctor has two goals. First, she wants to make sure that you don’t have a serious condition like pneumonia that could require antibiotics or admission. Second, she wants to figure out if you require any interventions, like additional intravenous fluids. If you do indeed have the flu, and you don’t need IV fluids, you will be sent home with nothing more than some Tylenol (and, in the U.S., a rather large bill).
So how does the doctor know that you actually have the flu? I have to admit that even after five years of medical school, another four years of residency, and several thousand hours of seeing patients, most of us in the ER just intuit it. Of course, we rule out other conditions by asking important questions like “Have you traveled to Africa?” or determining whether you’ve had any exposure to carbon monoxide. That last question is really important. If it doesn’t kill you immediately, carbon monoxide poisoning will cause symptoms that mimic the flu. Since flu outbreaks peak in the fall and winter—the very period in which people are running their heaters and furnaces—carbon monoxide exposure is often misdiagnosed as the flu.
Several years ago, I appeared in court as an expert witness in a tragic malpractice claim in which a husband, wife, and son were found dead in their Philadelphia home from carbon monoxide poisoning. It turned out that the wife had visited her local ER with headaches, nausea, and vomiting. Twice. On neither occasion was the question of carbon monoxide poisoning considered. Instead, her symptoms were assumed to be caused by the flu. The jury awarded the estate nearly $1.9 million in damages.
Once a flu diagnosis has been made, the discussion of treatments begins. If you have a fever, you will be given a medicine to lower it. That’s what every ER doctor in the country will do, including me. But it’s good to ask if we should, in fact, reduce the fever associated with influenza.
For nearly everyone, fevers are not dangerous in any way. But they are rather unpleasant, and so we treat them. There is evidence that a fever is actually beneficial, and the reason is simple: the immune system fights infections better when the body is hotter. White blood cells are released in greater numbers from the bone marrow, and the cells do a better job of fighting the infection. Fever also improves the efficacy of another group of blood cells called natural killer cells, and it increases the ability of macrophages (“big eaters” in Greek) to ingest and destroy the invading cells.
Since the body does a better job of fighting infection when it is a few degrees hotter, might reducing the fever lead to a worse outcome for the patient? A group from McMaster University in Canada looked at what happens in a large group of people when some of them—infected with, say, influenza—take medicine to reduce their fever. Once they feel better, patients with the flu get out of bed and start to socialize, spreading the virus. On a population level the effect is rather drastic. The McMaster group concluded that the practice of frequently treating fevers with medication enhances the transmission of influenza by at least 1 percent. I know that doesn’t sound like a lot, but remember that as many as 49,000 people die from the flu each year in the United States. If you plug the McMaster estimates into these flu numbers, almost 500 deaths per year in the U.S. (and perhaps many more elsewhere) could be prevented by avoiding fever medication during the treatment of influenza.
In the ER, I would always give medicine to a flu patient with a fever. And so, I believe, would every ER physician I know. It’s partly because that’s how I was trained, and partly because fevers are just not pleasant. But it’s also because of patient expectations. People expect their fever to be treated. It’s just not worth the time and effort to explain the McMaster paper to a sick and achy patient who desires relief.
Another intervention I often provide for flu patients is intravenous fluids. For dehydrated patients this is extremely important. After a bag or two of IV fluid—which contains sterile water, salt, and a bunch of electrolytes—patients often feel remarkably better. I’ve seen countless patients with the flu arrive at the ER by ambulance, too weak to stand. An hour later, and with two bags of fluid on board, they are able to walk out of the ER and return home.
Blood tests are usually not necessary, and a chest X-ray exposes the patient to needless radiation. This is important for two reasons. First, because you may be the kind of person who arrives at the ER with a mild case of the flu and expects the doctor to order blood tests and an X-ray. And second, because if you’re not that kind of person, you may find it hard to believe that there are indeed those who want this kind of testing done as a matter of routine. Leave it up to your doctor. Don’t request a blood test or X-ray. They serve no purpose other than to add a large charge to your bill. I almost never order them, but there are exceptions. Some patients will just look very sick, be extremely dehydrated, or have complicating chronic conditions. Some may be heavy smokers, and some may have developed pneumonia. They might be out of breath. When I listen through my red stethoscope to their lungs, I hear crackles and wheezes (or “rales” and “rhonchi,” as doctors mysteriously refer to them). In these patients, a lung X-ray is vital, because it will show if there are signs of pneumonia. A blood test will show high numbers of white cells, signaling a serious infection. One of the first ways I can help is to give such patients pure oxygen to breathe, through a clear plastic mask placed over their nose and mouth. In our lungs are thousands of tiny sacs called alveoli, through which oxygen passes into our bloodstream. In lungs that are ravaged by influenza and pneumonia, these alveoli are filled with fluid and pus. That means less oxygen is getting into the blood, leading to shortness of breath. Blood with enough oxygen is bright red. Blood without it turns darker. When the oxygen levels get critically low, the lips and ears turn a dusky blue. This is called cyanosis, and it’s a sign that the patient is very sick. It was one of the hallmarks of severe illness in the 1918 pandemic. To treat cyanosis or a low oxygen level, I give pure oxygen. This can relieve distress in just a few minutes.
These sick patients must then be admitted to the hospital. They will be treated with antibiotics to fight the bacteria that have taken hold in the lungs. They will get IV fluids to keep them hydrated, and will continue to breathe pure oxygen that is fed to them through plastic tubes attached to the wall. Most need only a few days in the ward to improve, but if the damage to the lungs is severe and widespread, they will be transferred to the intensive care unit. There, each patient is looked after by a single nurse, attentive to every change in their condition. If their illness gets even worse, they will be sedated and connected to a machine that takes over the work of breathing. A tube about nine inches long and the width of your index finger is slipped carefully into the trachea and past the larynx. It is attached to a ventilator, and with each cycle the patient’s chest expands and contracts. Now all we can do is wait.
If all goes well, the pneumonia is beaten into submission and the inflammation caused by the influenza virus slowly recedes. After a few days, the breathing tube can be removed and the sedation is slowly reduced. The patient awakens, oblivious to the life-and-death battle that has been raging. That’s if things work out. But sometimes the pneumonia is so virulent and aggressive that it cannot be stopped. First the lungs will fail, then the kidneys and the liver. Multiple organ failure. And influenza takes another life.
I don’t mean to be too morbid here. Of the millions who typically come down with the flu each year, fewer than 1 percent will die. For those who visit the ER, most need only to be reassured that time is all that is necessary to heal. One of the great current misconceptions is that antibiotics are needed for all ailments. If you are a healthy person with run-of-the-mill flu, you should not ask for antibiotics, and your doctor should certainly not prescribe them. Antibiotics don’t fight viruses, and so they are completely ineffective against the flu. If, however, you have a complication and your viral flu has evolved into a bacterial pneumonia, you should certainly be treated with them. But, and it’s worth repeating, antibiotics do nothing against the flu virus. You would be amazed at how many patients ask for antibiotics when they clearly have a viral infection, and are disappointed when I decline to prescribe them. Doctors are largely responsible for this huge problem. The best data we have suggests that about half of all patients with viral infections like influenza get a completely useless antibiotic.
Bloodletting, enemas, champagne, toxic fumes, and castor oil. It’s hard to believe we once thought these were state-of-the art treatments for the flu. We’ve come a long way over the last hundred years. Or so you might think. But despite all the benefits that modern medicine provides, curing the flu remains beyond our reach. We are still threatened by the virus and worry that another pandemic like 1918 is just around the corner. To understand why a cure remains so elusive, we need to take a closer look at the virus itself.