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Comment by fxj | Hacker News Reader

Differences in health systems and infrastructure also matter. The Spanish flu hit the world in the days before antibiotics were invented; and many deaths, perhaps most, were not caused by the influenza virus itself, but by secondary bacterial infections. Morens et al (2008) found that during the Spanish flu “the majority of deaths … likely resulted directly from secondary bacterial pneumonia caused by common upper respiratory–tract bacteria.

Morens D. M., Taubenberger J. K., Fauci A. S. (2008) – Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness. J. Infect. Dis. 198 962–970.

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Continuing with that thought, the correct dosages of drugs like aspirin were still being worked out. Aspirin was common treatment for the Spanish Flu, but an overdose of aspirin causes a build up of fluid in the lungs making pneumonia worse.

https://www.sciencedaily.com/releases/2009/10/091002132346.h...

> The Spanish flu hit the world in the days before antibiotics were invented;

IIRC: Antibiotics and germ theory were invented. But the scientific community and the medical community weren't fully on board yet.

Germ theory goes back a lot longer. It was well accepted by 1918.

The Broad Street Pump in 1854 London was the thing that really got germ theory going.

Before that, people reasonably were suspicious of germ theory based on their understanding of chemistry. If you dilute a bad substance in the Thames, there is just no way it can be that deadly, dilution wins. They had no idea that the substance could self-replicate.

Dr. John Snow started out knowing nothing, but in a feat of science that still amazes, he helped the world learn a lot. His dogged persistence has saved billions of lives by now.

Fun Fact: After they realized London needed a proper sewer system, they knew that just digging up the streets would never again happen. So they built the sewer system at well above max capacity. Nearly 150 years later, London is now starting to think about improving that capacity.

Great overview here:

https://www.youtube.com/playlist?list=PL3jY7zdQgRU5EHJ_MMyEe...

People did know about self-replicating substances; they'd been using them for making beer and bread for millennia. The nature of yeast was a mystery, but the capacity of fermentation to spread through a nutrient medium was well-known. An edition of Cooley's Cyclopedia I read from around that time attributes fermentation to a particular kind of molecular excitation, which is only true in the sense that it's true of all physical processes on materials made out of molecules. He gives some recipes for producing yeast by spontaneous generation (or, as we now know, from airborne or foodborne spores).

Amusingly, among the numerous recipes for deadly medicines made from mercury, arsenic, and lead, Cooley also gives a number of quite effective disinfectant recipes. He rejects the "contagion" theory that infectious diseases require contact to spread, preferring the "miasma" theory.

I think Pasteur's experiments with the beef broth in the 1860s were what really convinced all philosophers of the germ theory. Snow already believed something similar (contagion from "morbid matter"), but the Broad Street Pump results did not convince the doubters quite as effectively.

A lot of the future-proofing and high quality of the work is due to Joseph Bazalgette. The decisions made and the reasons behind them are really interesting. The Great Stink, The Princess Alice Disaster, London’s lost rivers etc. https://en.m.wikipedia.org/wiki/Joseph_Bazalgette

You are confusing two things. AntiSEPTICS and germ theory were both well established by the Spanish Flu. AntiBIOTICS were not. In other words we knew how to prevent surgical infection but not how to treat a bacteria that had already settled into someone's body.

Louis Pasteur came up with and proved the germ theory in the 1860s. Joseph Lister proved in 1865 that carbolic acid would prevent infection in surgery. Adoption took many years, but by the 1880s antiseptic surgery was widely adopted and Lister was made a baronet in recognition.

The Spanish flu was 1918, decades after the widespread adoption of antiseptics.

The first antibiotic, penicillin, was discovered in 1928. But it did not enter medical use until 1942. This was not a result of doctors resisting a good idea though. Penicillin is created by a bacteria. How do you produce useful quantities of a substance that in concentration kills the very thing that produces it?

"Penicillin is created by a bacteria" - I think Penicillin is made by a fungus.

You are correct, my bad. But the production problem is what I described. The fungus is resistant but not immune to its own poison. It therefore proved very hard to produce commercially viable amounts. However once a mass production method was found, it was considered vital to the war effort and we quickly ramped up production.

> Penicillin is created by a bacteria

Mold, no?

Sulfonamides were used widely before penicillin was (1930's).

https://en.wikipedia.org/wiki/Sulfonamide_(medicine)

Yes, but the ones used at that point slow bacteria growt, but do not kill bacteria. They are therefore not considered antibiotics.

They were also discovered after the Spanish flu.

According to Wikipedia (https://en.wikipedia.org/wiki/Penicillin#Discovery):

"The effects of penicillium mould were finally isolated in 1928 by Scottish scientist Alexander Fleming"

...kind of like how today we have anti-virals, even for covid-19, which aren't being widely distributed.

Haven't many of the COVID-19 deaths also been due to pneumonia?

Yes, but this time its viral pneumonia.

Not only viral pneumonia though.

According to a professor, specializing in pandemics, I heard interviewed while the outbreak was still focused mainly in Wuhan, many ultimately get killed off by bacterial secondary infection. Encouraging in some ways, under the horrifying circumstances, with the catch that in many parts of the world that secondary infection will be caused by multiple resistance bacteria.

I'd say this pandemic is going to be by far the biggest single consequence post to date for the antibiotic resistance problem, despite being driven by a pathogen that was never sensitive to the antibiotics.

Yes, and isn't this cause for some optimism since many people have now received vaccines such as Prevnar-13 and Pneumovax-23?

The CDC still isn't recommending them for all adults. At this point I probably won't go to the doctor's office due to transmission risks.

I heard (from a doctor who just received an e-mail summarizing clinical results from Wuhan and Seattle) that actually the primary killer is cardiac arrest.

"This virus is way smarter than I'd imagined. Apparently people don't mostly die of respiratory failure, but of cardiac arrest. Doctors have noted that right as patients begin to recover from their ARDS (severe respiraotry failure requiring intubation), they suddenly develop acute heart failure (dilated cardiomyopathy with EF going from normal to <10% acutely, for the doctors on here) and go into VF/VT or asystole."

The mechanism for that is unknown, but apparently the virus is attacking the heart directly.

I heard that the virus isn't attacking the lungs or the heart, rather it's the immune systems response after the main infection has done it's business? Probably makes it more bizarre.

That's the "cytokine storm" theory, right? I've heard that but also heard conflicting and inconclusive evidence about it. Some evidence against it is that lymphopenia (abnormally low white blood cell count) is seen in 83% of patients and that patients with lymphopenia have significantly worse prognosis as far as death rates are concerned; this would seem to indicate that it's not the immune system doing the damage. It doesn't conclusively rule it out - you can develop cytokine storms with a depressed immune system, and Spanish Flu was another disease that also caused both lymphopenia and cytokine storms - but it does waggle its eyes suggestively in favor of looking for other causes.

Thanks!

Cardiac arrest was also reported for SARS (SARS-CoV-1): https://www.ncbi.nlm.nih.gov/pubmed/14633442

So much is still unknown about SARS and MERS that I wouldn't hold my breath waiting for credible answers regarding SARS-CoV-2/COVID-19. And MERS is still circulating (see https://www.who.int/emergencies/mers-cov/en/), so it's not like nobody is interested.

When I learned diaphragmic breathing years ago, there were some studies around suggesting that it helped clear the lungs, especially the lower lungs, of debris and fluid, which can help prevent bacterial pneumonia.

Anecdotes != data, but I've had 1 'chest cold' in the intervening years, whereas as a child and teen most of my colds were chest colds and clearing my lungs was a major step in every recovery.

I'm also curious about how many were due to a cytokine storm and multiple organ failure.

We can now treat bacterial pneumonia, but COVID-19 causes pneumonia directly, unfortunately.

can the system dispense as many as needed antibiotics in time? Or, I guess, they just drop them via helicopter...even if it means that some will be taken for no reason

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