Le Infezioni in Medicina, n. 3, 392-402, 2024

doi: 10.53854/liim-3203-14

INFECTIONS IN THE HISTORY OF MEDICINE

An examination of the influenza pandemic in early 20th century in Crete through the lens of the 1918 editions of Nea Ephimeris, a Cretan newspaper

Gregory Tsoucalas

Department of the History of Medicine and Medical Deontology, School of Medicine, University of Crete, Heraklion, Greece

Article received 28 March 2023, accepted 25 July 2024

Corresponding author

Gregory Tsoucalas

Email gregorytsoukalas@uoc.gr.

SummaRY

Crete, strategically situated at the crossroads of three continents, was historically embroiled in incessant conflicts between colonisers and Greek revolutionaries, as well as recurrent battles against disease. In 1918, the island faced a novel adversary: influenza. In response, the state, local authorities, and medical professionals on the island mounted a formidable defence. Hospitals, health centres, and the military all contributed to the effort. Essential provisions of medicine and food were distributed to support the populations in areas most inflicted.

The Heraklion-based newspaper Nea Ephimeris played a crucial role in documenting these events. Through its articles, reports, interviews, and reviews of the influenza situation, it disseminated vital information that helped the public understand both preventive measures and the necessary actions to combat the spread of the virus. This study examines the coverage by Nea Ephimeris from January 1918 to January 1919, assessing how the newspaper informed, supported, and uplifted the urban and rural populations of Crete.

The data collected reconstruct the events of that period and demonstrate how historical pandemics offer lessons that can prepare health professionals for future challenges.

Keywords: Kingdom of Greece, Heraklion, Ioannis Mourellos, social distancing, quinine.

INTRODUCTION

The 1918 flu pandemic profoundly impacted the global population, resulting in such high mortality rates that it nearly left physicians without patients; the effects on the population were tremendous. Historically, all subsequent pandemics have been measured against the 1918 outbreak [1].

Crete had been integrated into the Kingdom of Greece since 1913, a mere five years before the pandemic began (Figure 1). The island was administratively divided into four prefectures: Chania, Rethymno, Heraklion, and Lasithi (Agios Nikolaos) [2]. The withdrawal of foreign troops from Crete compounded public health challenges as the military hospitals previously operated by Italian, Russian, and French forces in Chania, by the Russians in Rethymno, and by the British in Heraklion ceased their operations [3, 4]. This led to a significant gap in healthcare provision, just as the island was grappling with the pandemic.

Figure 1 - Celebrating the Union of Crete with the Kingdom of Greece at Phirca Fort in Chania on 1 December 1913. Present at the event were Eleftherios Venizelos and King Konstantinos of Greece.

Although many state documents from the Cretan Politeia [Κρητική Πολιτεία, state] were destroyed by fire, leading to the loss of much data regarding the island’s administrative structure, various archives and some newspapers have been preserved [5]. These illustrate the efforts made to tackle the 1918-1919 pandemic [6]. The Greek population first learned about the flu pandemic through the reporting of prominent journalists from the newspaper Thessaly in central Greece. Cases were initially reported in Patras in July and by autumn, the pandemic had spread across the entire Kingdom [7].

The pandemic has been characterised as the most severe ‘disease holocaust’ of modern history, with illness rates affecting 25 to 40 percent of people in impacted communities simultaneously [8, 9]. In Crete, which was navigating its new status as an integrated part of the Kingdom of Greece, the population had already been hard-hit by various viral outbreaks prior to this pandemic [2].

During 1918, a succession of outbreaks was also reported. The Kingdom, its local government, municipal authorities, the military, the Church, private doctors, and philanthropists all endeavoured to manage the catastrophic effects of an epidemic unprecedented in scope [5]. The influenza pandemic exacted a heavy toll on lives. This recurrent visitor has, since antiquity, been responsible for numerous recorded epidemics of influenza-like diseases worldwide, with Greece among the affected nations [10].

This historical analysis utilises documentary research to examine the newspaper archives housed in the Vikelaia Municipal Library of Heraklion, focusing on the 1918 editions of Nea Ephimeris (Greek: Νέα Εφημερίς). To enhance understanding of the era, this study also incorporates references from other local Cretan newspapers, as well as state and municipal documents, and various treatises from the second and third decades of the 20th century, all relating to Crete and the influenza pandemic.

The Cretan newspaper Nea Ephimeris

Ioannis Mourellos (1886-1962) (Figure 2), born in Choumeriaco Merabellou, is believed to have descended from a Venetian family that had assimilated into Greek culture. From the age of 19, Mourellos embarked on a distinguished career in publishing, which earned him widespread acclaim in the nascent Kingdom. A staunch supporter of Eleutherios Venizelos’ government, he founded a newspaper to inform the local populace. In 1911, using modern printing equipment imported from Italy, he launched Nea Ephimeris (English: New Newspaper) (Figure 2B). This publication quickly became a prominent voice for Venizelos’ policies. However, due to financial difficulties, the editor, publisher and merchant of books, advertising brochures etc., Mourellos, lost control of the newspaper in 1924 [11, 12].

Figure 2 - The publisher Ioannis Mourellos, from Moudatsakis’ work The Printing Offices of Heraklion (left side); B. The front page of the 1918 issue of the newspaper Nea Ephimeris, from the Vikelaia Municipal Library of Heraklion (right side).

Nea Ephimeris was pivotal in reporting on the Balkan Wars and the influenza epidemic at a local level, detailing outbreaks, health measures, the deployment of physicians, and fatalities [5]. Subsequent business ventures failed, and Mourellos turned to the field of Greek literature, publishing various magazines and historical treatises. His legacy still endures as a significant figure in Greek philosophical literature [11, 12].

Infectious outbreaks in 1918 Crete

At the dawn of the 20th century, Crete, newly annexed to the Kingdom of Greece, was plagued by various infectious diseases that frequently escalated into deadly epidemics (Figure 3) [5]. Malaria, in particular, was the most prevalent infectious disease across the early 20th-century Kingdom, largely due to its extensive marshlands, conducive to mosquito breeding, and the prevailing weather conditions [13]. Various geohydrological and soil factors, coupled with widespread malnutrition and poor living conditions, led to recurrent malaria outbreaks on Crete, which were regularly reported in the daily news [5].

Figure 3 - Infectious outbreaks, reports from Nea Ephimeris. Areas infected to the Map of Crete by Aubyn Trevor Battye, 1913.

To combat this endemic threat, Greece established the Greek Anti-Malaria League in 1905 under the patronage of Konstantinos Savvas (1861-1929), Professor of Hygiene and Microbiology at the School of Medicine of the National Kapodistrian University of Athens, and the paediatrician Ioannis Kardamatis (1859-1942). The League was notable for its diverse and pioneering membership, including professors of medicine and pharmacy, members of parliament, journalists, pharmacists, physicians, bankers, clergy, civil servants, and businessmen, who joined forces to ensure a comprehensive approach to combating malaria across the nation [13].

The state, leveraging research on quinine that began in 1893-1894 and was substantiated by various scientists by 1917, established a centralised network for distributing quinine to municipalities, hospitals, and physicians - a system that was also implemented in the Cretan prefectures [5, 13, 14]. To prevent price surges, the Ministry of Economics regulated the cost of quinine. Additionally, a series of socio-hygienic initiatives, such as the drainage of swamps, were undertaken to improve environmental conditions. The prefect was responsible for overseeing these projects, and there was an instance where he had to intervene publicly, announcing that although the project engineer had received the necessary funds, the works were not completed, leading to an outbreak of disease in the Messara area (Figure 4) [5].

Figure 4 - Text excerpts from Nea Ephimeris: On the left, an announcement by the Heraklion Prefect Emmanouil Lydakis reports that engineer Evangelos Kyriazis received 1.2 million drachmas but failed to complete the drainage of the swamp lands in the Messara area, leading to an epidemic among the local population. On the top right, the Ministry of Internal Affairs declares that the Ministry of Economics was responsible for the distribution of quinine in Crete. The bottom right details an announcement from the Ministry of Economics about the pricing of quinine, set at 2.75 drachmas per small box, which was distributed at local soup kitchens for the poor.

Epidemic typhus emerged in the city of Heraklion, exacerbated by demographic shifts and the influx of immigrants which further degraded living conditions, particularly in the poorer districts. Concurrently, cases of meningitis were reported in Heraklion, Pyrgos Monophatsiou, Skalani Pediadas, and Shoinias. The prison in Heraklion experienced multiple instances of the disease, necessitating ongoing disinfection efforts, and similar issues were observed in local refuges. Both the military and rural communities near Heraklion were also affected. All identified cases were treated with injectable therapeutic approach at the Pananeion Municipal Hospital of Heraklion.

Scarlet fever was reported in Chania. Additionally, an outbreak of anthrax occurred in Sternes Monophatsiou, where a calf died, while an unidentified zoonotic disease led to fatalities among domestic cows in Kalo Chorio Pediadas. In both cases, municipal authorities took measures swiftly. In Sternes, the affected livestock were slaughtered, incinerated, and buried, and the village was quarantined under the supervision of the local police station officer. In Kalo Chorio, the response measures were overseen by the local agronomist (Figure 5) [5].

Figure 5 - Text excerpts from Nea Ephimeris: On the top left, a report on a meningitis case involving a 14-year-old girl who passed away at 5 am. On the bottom left, a soldier is described as being treated by the head physician, Stylianos Meliaras, at the Pananeion Municipal Hospital of Heraklion. The centre bottom text announces an epidemic of typhus. The top right section reports an outbreak of scarlet fever in the city of Chania. The centre right text details an anthrax case in Sternes that resulted in the death of a calf owned by villager Stergios Maravelakis. On the bottom right, there is a report of an unknown zoonosis in Kalo Chorio Pediadas, where cows succumbed within 20 days of the epidemic’s onset.

The 1918 flu in Crete

In 1918, the influenza pandemic reached the island of Crete. Nea Ephimeris extensively covered the outbreak (Figure 6), starkly noting that the island had been flu-free during 1917 but warning that “Not a single corner of the island will remain uninfected” (Figure 7). The pandemic affected both urban and rural communities, causing widespread suffering and numerous fatalities. To illustrate the severity of the situation, during December 1918 and January 1919, Nea Ephimeris dedicated a section to daily flu reports, meticulously recording the number of deaths, often distinguishing among the Hellenic and Muslim populations and refugees in Heraklion (Figure 8).

Figure 6 - Text excerpts from Nea Ephimeris concerning the flu pandemic: On the left side, Minister of Care Spyridon Simos issues directives to the Prefecture of Heraklion to implement measures combating the pandemic. In the centre, Heraklion city physician Ioannis Drakopoulos provides information on the flu, including measures, treatments, behaviours, and sanitation practices. On the top right, the prefecture calls for enhanced efforts from the municipal Department of Sanitation and Cleanliness to improve the city’s daily conditions. The bottom right section contains a death report for the 25th and 26th of December 1918, categorising fatalities separately among Christians, Muslims, refugees, and residents from other municipalities.

Figure 7 - Influenza reports for the island of Crete from Nea Ephimeris 1918-January 1919. Areas infected on the Map of Crete by Aubyn Trevor Battye, 1913.

Figure 8 - Death reports sourced from the Municipal Archives of the City of Heraklion and published by Nea Ephimeris, covering the period from 16th December 1918 to 16th January 1919. The data illustrates a significant de-escalation in flu-related fatalities, decreasing from 10-13 deaths per day to 0-1in a month.

The poorer districts of Heraklion, along with refugee settlements and prisons, were particularly hard hit, with reports of hundreds falling ill. The epidemic also spread extensively in the agricultural areas surrounding Heraklion during the late autumn, as the olive harvesting season exacerbated the situation. The outbreak in the Aharnai area was described as devastating, overwhelming the terrified local population and “sending many to Hades”, with over 600 people afflicted at one time. The flu was compared to cholera and the plague.

The epidemic unleashed its most ferocious onslaught in the Vianno region, mercilessly claiming the lives of the young. In Meramvellon, the second largest city in the Lasithi prefecture, there were reports of 1,500 individuals affected simultaneously, many of whom “found shelter in the wings of death”. The village of Thrapsano experienced a markedly high mortality rate, while in Selinou, 21 fatalities were recorded among 500 affected villagers [5]. It is important to acknowledge that these figures are based solely on reports by Nea Ephimeris, and it is highly probable that cases in prefectures outside Heraklion were significantly underreported.

Influenza, commonly known as the flu, was recognised as a contagious and primarily airborne disease. Transmission was noted to occur through saliva when an infected person coughed, sneezed, or kissed. The microbes expelled by the mouth contaminated the air surrounding the patient. Additional transmission routes included handshakes, handkerchiefs, clothing, and water. The flu typically presented as a mild acute infection, but could also be fatal in some instances. Individuals with underlying heart diseases, young children and the elderly were deemed more vulnerable to the infection. Common symptoms reported were significant mood changes, fever, weakness, cough, angina, pneumonia, bronchopneumonia, pleuritis, headaches, and gastrointestinal issues.

There was uncertainty about the cause of the pandemic, although many experts believed that the Pfeiffer bacillus was to blame. Other bacteria such as streptococcus pyogenes, pneumococcus, pneumobacillus, and staphylococcus were identified as contributing to the severity of the disease, leading to complications like severe pneumonia, pericarditis, meningitis, nephrotic syndrome, and multi-system failure syndrome.

To alleviate the distress, Nea Ephimeris published a poem about the flu, predicated on the belief that art can soothe the mind. Released just before Christmas and signed with a ‘D’, speculation remains whether this initial stood for Ioannis Drakopoulos, the city physician, or was simply a pseudonym. The author’s identity remains unknown (Figure 9) [5].

Figure 9 - A poem reflecting on the flu pandemic, published in Nea Ephimeris just before Christmas in December 1918. Free translation:

“With the flu, we’re all in dire straits;

It spares neither young nor old,

Seeking to bury us alive.

Everywhere you look, the flu dominates thought.

Fear has taken hold of everyone,

And those who cough are marked as afflicted.

Cursed be this damnable flu, my God;

Better it were if the flu did not exist at all.

As if wars were not sufficient,

You, above all, have burdened us with this plague.

Our physicians prescribe remedies,

But hearses are filled day and night.

They have no time even for bread,

Lost, without knowing where to turn.

Pharmacists, too, overwhelmed,

Fear errors in their haste.

The flu recruits the young,

Men and women alike, indiscriminately.

It claims the elderly as though they were young,

A spectacle for the living.

And should it claim me,

Friends and kin, shed no tears but remember:

‘and pray God grants me peace.”

D.

Infrastructure, measures and treatment

Public municipal hospitals were established in the major cities of Crete. In Chania, a hospital served both Christian and Muslim communities (Figure 10). A similar facility was present in Rethymno (Figure 11). Heraklion boasted two hospitals, each catering to one of the population groups, while a newer one, the Pananeion Hospital was constructed in late 19th century (Figure 12) [2].

Figure 10 - The 1st Municipal Hospital in the City of Chania, housed on the last two floors of the old Municipality, picture from Ereisma Magazine published in 2018.

Figure 11 - The Municipal Hospital of Rethymno built by the Russian troops in 1898, published by Nikolaos Andriotis in 2020.

Figure 12 - The Pananeion Hospital of Heraklion in an early 19th century postcard, published by R. Behaeddin.

A network of local public health stations existed across major towns and villages, complemented by health departments at both the prefecture and municipal headquarters [5]. While various monasteries such as the Monastery of Agia Triada in Chania, the Monastery of Dioskouriou in Mylopotamos, the Monastery of Agarathou in Pediada, and the Monastery of Saint Panteleimon in Fodele offered health services in the late 19th century, their involvement during the 1918 pandemic remains uncertain [2].

In Chania, the 1st Hospital of Chorophylakis, initially an army corps facility from 1908 with 40 beds, was transformed in 1913 into the 1st Military Hospital of the City of Chania, becoming the largest on the island (Figure 13). In Neapoli Meramvellon, a military sanatorium provided care primarily to military personnel. In 1913, Heraklion established a Military Hospital with 62 beds, according to a 1920 survey. Various military health stations were organised in remote areas [17, 18].

Figure 13 - The Palace of Chalepa that housed the 1st Military Hospital of the City of Chania in 1911-1913, as published by A. Kladou-Mpletsa in her work The city of Chania outside its walls in 1998.

The Minister of Care (Greek: Περιθάλψεως), Spyridon Simos (1868-1935) (Figure 14), alongside the Iatrosynedrion (the State Congress of Health), mandated all physicians to exert their utmost efforts in combating the flu epidemic (Table 1). During this period, physicians were categorised into various roles including state, municipal, prefectural, county, rural, hospital, remote health station, school, legal, prison, military, private, among others.

Figure 14 - Minister of Care Spyridon Simos, photo portrait of 1929, Musée Albert Khan in Boulogne-Billancourt, France.

Table 1 - Physicians reported inside Nea Ephimeris during 1918 related to pandemic.

Local authorities were instructed to focus on sanitary conditions and hygiene in urban areas. Principles of individual responsibility and non-harm to society were emphasised for the first time. Preventative measures included the closure of schools from November to February, social distancing, and avoiding crowded venues such as coffee shops, theatres, and cinemas which were identified as potential transmission hotspots.

Personal hygiene practices and the avoidance of damp environments that could affect the mucosa of the mouth and nose were advised. At the onset of symptoms such as cough, quinsy, or fever, patients were instructed to rest in bed, consume hot milk, and a physician should be called for further care. Workers displaying flu symptoms were to be excluded from their workplaces.

All prescribed measures were to be publicly displayed by local authorities to ensure widespread compliance. Pharmacies were ordered to operate on a 24-hour schedule under military supervision. Additionally, improving the living conditions of refugees and the poor was recognised as a crucial strategy [5].

Patients were to be quarantined in their own rooms, and their clothing and cutlery sterilised by boiling for at least twenty minutes. Caregivers were instructed to wash their hands thoroughly. For prophylaxis, gargling with borax or other physician-recommended medications was advised.

In an influential article in Nea Ephimeris, the City of Heraklion’s physician, Mr Drakopoulos, recommended a regimen of continuous, small doses of quinine – a common global practice at the time –along with aspirin, rest, ample sleep, milk, and gargling treatments. The use of expectorants, cardiotonics, and laxatives was also suggested. The consumption of wine, cognac, and other alcohols was discouraged.

Facilities housing patients were required to be disinfected daily with a formalin solution. Prisoners exhibiting severe symptoms were to be immediately transferred to municipal hospitals. Throughout the pandemic, public health responses included the redeployment of public and military physicians to highly affected areas and the organisation of missions to supply food (sugar, flour) and medications.

The regions forming the triangular areas of Heraklion-Messara-Pediada and Mallia-Vianno-Ierapetra, which were severely impacted by the flu epidemic, received the most substantial aid (Figure 15). The prefecture, municipalities, and the army were tasked with the official recording of fatal cases [5].

Figure 15 - Health infrastructure, deployment of health professionals and supply missions during the 1918 pandemic in Crete, from Nea Ephimeris 1918-January 1919. Areas depicted on the Map of Crete by Aubyn Trevor Battye, 1913.

The church sought to provide support, with frequent processions of the icons of various Saints across the island. A notable instance was the procession of the icon of Saint Barbara around the city of Rethymno, which was believed to have contributed to a milder transmission of the flu among locals [16].

Charitable organisations and the Red Cross assisted greatly during the epidemic. In an unusual advertisement in Nea Ephimeris, a local perfumer in Heraklion even promoted his cologne as a means to combat the flu [5].

DISCUSSION

The press played a crucial role in disseminating information about the flu during the 1918 epidemic [5]. Although the Pfeiffer bacillus, referred to as influenza B, was identified as the primary cause of the epidemic, various studies suggested the involvement of mixed infections and a potentially lost virus strain that may have initiated the outbreak [19]. The fundamental principles of sanitation and hygiene were well-understood, similar to current standards. The mechanisms of transmission were also recognised. Social distancing measures were implemented in a manner akin to those adopted in today’s epidemics. However, one notable absence was the use of face masks. While reports and instructions for making face masks were globally circulated in the press, there is no evidence of such guidance in Crete during 1918 [5, 20]. Fortunately, Greece was familiar with epidemic measures, having faced various outbreaks since gaining its freedom in the mid-19th century. The eminent Greek politician Ioannis Kapodistrias (1776-1831) was among the early advocates for such health measures [21].

The flu began spreading across Europe in April 1918, though the initial wave seemed relatively mild in Crete, with only few cases, which either went unrecorded or were deemed insignificant. However, reports intensified by late autumn, with the epidemic peaking between November 1918 and mid-January 1919 [5, 10].

In his 1919 review, Rondopoulos noted that while the first wave -from June to July 1918 - was mild, the subsequent wave starting in October in Greece resulted in a significantly high mortality rate, ranging from 15.5% to 24.23%, and even as high as 50.7% in army hospitals (22). That same year, Filtzos in his report for the American Consulate attributed the high mortality rates to the abnormal living conditions - both mental and physical-, scarcity of food, excessive labour, and the ongoing war. He confirmed the mortality rate at 50% and observed that treatments such as colloidal silver administered intravenously or subcutaneously showed promising results, though vaccinations had not been administered [23].

The term “hospital” became synonymous with fear, as nearly half of those admitted succumbed to the illness. Factors like overwork and environmental conditions, including moisture and dust, were also significant contributors to the high mortality rates [24].

In Crete, both living and working conditions were identified as factors contributing to increased mortality rates. However, a notable difference in total mortality was observed. In the year 1917, Heraklion recorded 544 deaths, while in 1918, the number slightly increased to 570. Given a population of 27,000 residents (excluding refugees), this increment of 26 individuals suggests that the mortality percentage was not as high as some reports indicated.

The impact was more significant among the Christian population, partly because approximately 2,500 refugees living in substandard conditions experienced a higher death rate, as reported by Dr. Drakopoulos. Although cases were reported in prisons, no comprehensive records were maintained.

The prefect of Heraklion, Emmanouil Lydakis, in an interview, confirmed the low mortality figures for the city, but did not provide numbers for rural areas. He merely noted that the epidemic initially hit the areas of Messara and Mallia that were already afflicted by malaria, which further compromised the residents’ health. Factors such as overwork in the fields and with olive trees, humidity, and food scarcity contributed to the increased death toll. Colloidal silver was not mentioned as a treatment option in Crete, where quinine was primarily used [5].

The 1918 pandemic had such a profound impact globally that any subsequent flu outbreaks were often dismissed as “an invention of the penniless to attract charity and attention, or a disease of physicians without clients”, due to the comparatively fewer people affected [1].

Epilogue

In 1918, Crete was an ailing island. Having only recently become part of the Kingdom of Greece, the island’s infrastructure was poorly organised. Despite this, concerted efforts led to a lower mortality rate than in other regions of the state. The press, notably Nea Ephimeris, played a crucial role in informing the public with continuous updates about the flu situation. Journalists proactively urged local authorities to take more robust actions than they initially considered possible.

Missions to supply necessities and the deployment of physicians bolstered the more vulnerable rural areas, while municipal hospitals cared for the urban population, refugees, and prisoners alike. Measures such as social distancing and targeted treatments improved the situation. In the years that followed, Crete not only recovered but also drew valuable lessons that laid the groundwork for a more systematic approach to combating future viral outbreaks.

Conflict of interest

The author declares no conflict of interest.

Funding

The author declares no source of funding.

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