Commemorating the First World War Centennial in Kansas

Aspirin, the Flu Pandemic, and WW1

In 2009 Karen Starko, MD, published a paper where she suggests that aspirin may have played a significant role in the death of people suffering from the 1918 flu.

It wasn’t until the 1960’s that pharmacologists began to seriously study how aspirin worked.  It is a very complicated drug.  In 1968 a graduate of Nebraska School of Pharmacy told me that if Aspirin were to come on the market today it probably would not be over-the-counter.

Today we understand that aspirin has some serious side effects and it can be toxic if given in large doses. We know that those having major surgery must stop aspirin therapy a week or more before surgery. Children don’t get aspirin in flu like situations because it can cause Reyes syndrome, and those with Von Willebrand’s disease are very sensitive to aspirin caused bleeding. For aspirin today the maximum suggested dose per 24 hour period is 4,000 mg.

In 1918 and before, not much was known about aspirin. It was beneficial to reduce fever, aid in relief of arthritic pain, the relief of headaches pain, and relief from somatic pain. However, toxic effects of aspirin were not really understood.

In 1899 Aspirin was patented by Bayer, a German chemical company.  In February 1917 that patent expired.  By 1918 many generic drug companies jumped on the aspirin bandwagon to make a profit in the aspirin market.

So during WW1 this is what we have:

1.  Aspirin was inexpensive.  It was produced in large quantities and sold world wide.
Because aspirin had become generic, India had inexpensive aspirin (see Starko’s previously mentioned article for more info).  The people of India suffered from the flu in great numbers.  Death rates were high. Karen Starko was challenged by three physicians to explain this high death rate since it was thought India did not have access to aspirin due to the expense. Dr. Starko responded in a 2010 follow-up that India did have inexpensive aspirin as everyone did, and they used it as a tablet to be swallowed. They also used aspirin in some unusual ways such a gargling.

2.  People were afraid of the 1918 flu, and aspirin offered help by reducing the fever and the pain.  It made them feel better even if they weren’t.

3.  Physicians did not understand aspirin, and the officially prescribed doses of aspirin in 1918 are considered toxic today.

In 1918 there were no guidelines on management of aspirin toxicity.  There were few directions on the aspirin bottles about doses, and there were no recommendations for the amount of aspirin prescribed. One physician prescribed a handful of aspirin every hour. Another gave 1300 mg hourly.   The American Medical Association recommended 1000 mg every three hours or until symptomatic relief was achieved.  The bottom line; daily doses prescribed were 8,000 mg to 31,200 mg.  Considerably higher than the 4,000 mg recommended today.

In addition there is today a known variable involving aspirin (not known in 1918 ) in that individual responses to normal aspirin doses can vary significantly which can result in toxic doses. Also low doses of aspirin given for many days may in some people accumulate to a toxic dose.

4.   Aspirin was heavily advertised in August of 1918, and the American Medical Association, the U.S. Surgeon General and the U.S. Navy all recommended aspirin in high doses.

5.   Aspirin sales doubled and sales peaked just before the death rate increased from the flu.  This seem to be so overlapping and similar that it strongly suggests a direct relationship between aspirin sales and death from flu.  The death rate increased sharply in the United States.  It peaked first in the Navy in late September. It peaked in the Army in early October.  The general population peaked in late October.

6.   Holistic medical personnel did not seem to have deaths related to the flu.  Aspirin was considered a poison and it wasn’t prescribed. It was said that those patients who died in their practices were those that came to them after they had already taken aspirin.

7.  The very young did not die from aspirin linked to the flu, because the pediatric textbook’s recommendations for fever management was cold water baths.

During the 1918 flu pandemic two types of conditions were described. The first was considered an early death that upon postmortem revealed a “wet” look. A person dying in this situation exhibited lung congestion, purpuric rash (usually means bruising and/or bleeding) and no bacteria.  Some pathologists described the situation as unusual.  One pathologist described the amount of lung tissue involved with pneumonia “too little to explain death”. The pathology reports noted thin, watery and bloody liquid in the lungs, like the lungs would exhibit on a drowned victim.

The second condition has been described with those who died “late”.  It was often referred to as a “Superinfection”.  Those people who were sick for several days usually died of a bacterial infection.

The pathology noted above has been described with people who died from the flu in 1918,  and it is also noted to be consistent today with death due to aspirin toxicity.

The salicylates can cause lung toxicity.  The pathology of aspirin toxicity demonstrates pulmonary edema, hemorrhagic lungs, and petechial changes in the lung. Salicylate can produce increased lung fluid, increased protein levels and reduce mucocilary clearance.  Increased lung fluid and increased protein levels aid in bacterial growth.  The ciliary fibers in the respiratory tract help to remove foreign material and keep it out of the lungs. When ciliary fibers don’t work correctly this aids in bacterial growth in the lungs. In addition the immune system’s effectiveness has been reported to be reduced with aspirin toxicity.

Dr. Karen Starko quotes several different sources in her article that describe pathology associated with only aspirin toxicity. Cyanosis, pulmonary congestion, alveolar hemorrhage, subplural and subepicardial hemorrhage, petechiae, etc. are all noted in aspirin toxicity.

The point Dr. Starko makes is the pathology noted on autopsy in the 1918 flu pandemic is very similar to that found on autopsy from those who died from known aspirin toxicity.

The actual number of people who had a negative effect with aspirin therapy in their treatment for the flu will never be known.   Dr. Karen Starko, however, does make a very compelling case that aspirin had a significant impact of the outcome of people suffering from the 1918 flu pandemic,  which may have contributed to the high number of deaths.


“Salicylates and Pandemic Influenza Mortality, 1918–1919 Pharmacology, Pathology, and Historic Evidence”  in Clinical Infect Dis (2009) 49 (9): 1405-1410.

“Questioning the Salicylates and Influenza Pandemic Mortality Hypothesis in 1918–1919” in Clin Infect Dis (2010) 50 (8): 1203-1204 ( Dr. Starko’s answer to aspirin use in India)

Perry Walters is a life long resident of the Tonganoxie, KS area. He graduated from Kansas University with a BS in Education with a minor in history and an AB in Science. He received a DDS degree from the University of Missouri at Kansas City. He joined the Navy and served two years on active duty. One year was with the Fleet Marines in Okinawa. He retired from the Naval Reserves. He later received a Masters Degree in Periodontics and directed a graduate program in periodontics. Later he directed a hospital based dental clinic. After retirement he and his wife became active in the Tonganoxie Historical Society where he is the editor of their newsletter. He also films and edits movies of local people who know history.

1 Comment

  1. Amanda

    Loved this. Thanks!

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