Open-Air Treatment During the “Spanish Flu” Pandemic

by Rishma Parpia

Published April 12, 2020 | Medicine, History

Story Highlights

• The 1918 influenza pandemic known as the “Spanish flu” was caused by an H1N1 influenza virus and was the most deadly pandemic of the 20^th
• Open-air treatment was used to treat patients and is believed to have reduced the number of deaths as well as transmission of infection among medical staff.
• Historically, sunlight and open-air treatment has been used as an effective treatment for depression, war wounds, jaundice, Rickets and more.

Almost exactly a century ago, a new H1N1 influenza A strain known as the “Spanish flu” caused a global pandemic.¹ Although there is no consensus regarding the origin of the novel influenza virus, it appeared suddenly and spread globally between 1918 and 1919.² Estimates of the exact number of deaths caused by the virus vary according to different sources but it is thought to have infected a third of the world’s population and killed at least 50 million people, making it the deadliest infectious disease pandemic in modern history.³ Morbidity was high ranging from 25 percent to 90 percent and the fatality rate was between one to three percent.¹
The conventional view during the Spanish flu pandemic, which occurred before antibiotics were widely available to treat bacterial pneumonia complications, was that nothing could be done to stop the spread of the H1N1 virus and that no treatment options were available at the time. However, there is evidence that some interventions did alter the course of the infection for some people.1

1918 Pandemic Influenza Overwhelmed Medical Facilities

Since the Spanish flu pandemic occurred during World War I, two of the most affected populations were soldiers living in military barracks and sailors on warships. Due to overcrowding and poor ventilation, soldiers and sailors were at high risk of contracting the influenza virus and other opportunistic infections, such as bronchitis and bacterial pneumonia, that can cause serious complications leading to death.⁴
When the pandemic reached the east coast of the United States in 1918, the city of Boston, Massachusetts was especially affected.⁴ With so many people infected with the virus and so many dying within a few weeks, the burden on medical facilities, medical staff and funeral homes was overwhelming. The 1918-1919 influenza pandemic also resulted in significant economic and social disruption.¹
Public health authorities in the United States initiated measures that were used to control infectious disease epidemics during medieval times when populations suffered significant loss of life, such as during the Bubonic Plague.⁵ Their mitigation strategies aimed to reduce the transmission of the virus by preventing physical contact between the infected and the uninfected.
Orders issued by public health officials were based on what was known at the time in terms of understanding of how the influenza virus spread through the air by coughing and sneezing.⁵ After physicians concluded that the virus was transmitted through the air, efforts to control contagion were organized to prevent those infected from sharing the same air space as the uninfected. Public gatherings and close contact was seen as the primary avenue for quick transmission of the disease.⁵

U.S. Military Doctor Saves Lives with “Open Air” Treatment

The Massachusetts State Guard established an emergency hospital known as Camp Brooks Open Air Hospital at Corey Hill in Brookline near Boston, where sick sailors were hospitalized.^{1 4} Major Thomas F. Harrington, the hospital’s medical officer in charge, had studied the history of his patients and observed that sailors were housed in poorly ventilated rooms in the ships prior to hospitalization.¹ He recommended that sick sailors be placed in tents to maximize their access to fresh air. In sunny weather, they were taken out of the tents and put into open air.4 Patients were kept warm in their beds at night with hot-water bottles and extra blankets and were fed every few hours.¹
A combination of fresh air, sunlight, high standards of hygiene and reusable face masks appear to have substantially reduced deaths among some patients and reduced transmission of infections among medical staff.¹
From when the hospital opened on September 9, 1918 until its closure a little more than a month later on October 12, a total of 351 patients were admitted, one third of whom were diagnosed with pneumonia. In total, 36 of the 351 sailors admitted to the hospital died.¹
Out of all the hospital’s medical staff that included 15 doctors, 45 nurses and aides, 20 sanitary corps men and 74 sailors acting as orderlies, only six nurses and two orderlies developed influenza.¹ In five of these cases, exposure to the virus was reported to have taken place outside the hospital. A few types of medicine were used to relieve the patients’ symptoms and help their recovery but these were considered less important than were regular meals, warmth and lots of fresh air and sunlight.¹

Fresh Air and Sunshine Used for Tuberculosis

Dr. Arthur Ransome (1834–1922), a leading investigator on tuberculosis, emphasized the importance of fresh air in the disinfection of rooms occupied by tuberculosis patients and also in the disinfection of patients themselves. He said, “…abundant fresh air, together with sunshine, acts antiseptically upon both the bodies and the clothing of patients, destroying all organic impurities which may emanate from either, and so purifying the air that enters the respiratory organs.”⁶
Open-air therapy was a treatment that was widely used until 1950 when antibiotics were introduced.⁶ In addition, during the 1950s, chemotherapy replaced open-air treatment and belief in the therapeutic and germicidal properties of outdoor air diminished.⁶

Opposition to Open-Air Therapy

Despite opposition to open-air therapy, the surgeon general of the Massachusetts State Guard, Dr. William A. Brooks, was confident that open-air methods were effective in treating patients at the hospital.¹ Many medical professionals believed that patients would reap the same benefits if the windows of a conventional hospital ward were open or the patients were put in a hospital “sun parlor.”¹
However, Dr. Brooks held the position that patients did not do as well in an ordinary hospital, regardless of how well ventilated, as they did outdoors. His argument was that patients in indoor sun parlors were not exposed to direct sunlight all day as they were when they were outdoors.¹ He reported that in one general hospital with 76 cases, 20 patients died within three days and 17 nurses became sick.
In contrast, the open-air treatment adopted at the Camp Brooks Open Air Hospital reduced the fatality of hospital cases from 40 percent to about 13 percent. Dr. Brooks said, “The efficacy of open air treatment has been absolutely proven, and one has only to try it to discover its value.”¹

Sunlight and Infection Control to Prevent, Treat Disease

Studies have shown that ultraviolet radiation inactivates influenza virus and other viral pathogens and that sunlight also kills bacteria.¹ Historically, exposure to the sunlight is known to facilitate healing in many conditions such as septic war wounds.¹ There is also evidence to show that heart attack patients have a better chance of recovery if they are placed in sunlit wards.⁷ Psychiatric patients suffering from depression do better if they are exposed to sunlight while hospitalized⁸ and so do premature babies with jaundice.⁹
One of the major advantages of placing patients outside in the sun is that they can better synthesize vitamin D in their skin, which is not possible to do indoors behind glass1. Rickets, a childhood disease caused by vitamin D deficiency has always been associated with respiratory infections. Several studies have hypothesized that low levels of vitamin D increases susceptibility to influenza, which may explain the increased incidence of respiratory infections in patients with Rickets.¹
According to a 2018 study published in International Journal of Molecular Sciences, the author Beata Gruber-Bzura writes that:

The studies clearly show that vitamin D is, undoubtedly, part of the complex factors which affect the immune response. So, assessing vitamin D status and maintaining optimal serum levels in all aging adults and children, and micronutrients should be regarded as one of the essential factors which improve our health condition overall and also support our fight against diseases.¹⁰

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