In the winter of 1917-1918, patients with a particularly harsh form of influenza began appearing in the office of Dr. Loring Miner, a physician in Haskell County, Kan. They presented with high fevers, headaches, body aches and coughing. Dozens of healthy people suffered, and some died. Were these cases harbingers of the worldwide pandemic to come?
In August 1917, some 200 miles away, new U.S. Army recruits began pouring into Camp Funston at Fort Riley, Kan., as the United States geared up to enter World War I. Crowded troop trains from all over the country brought soldiers to Camp Funston, the largest army training facility in the country. Over 40,000 men could be housed there at one time. Without doubt, some of those recruits had journeyed from Haskell County.
The two-story barracks held 300 men each. The camp also had theaters, infirmaries, schools and workshops—all places where large numbers of soldiers congregated. Spitting on sidewalks and floors was a common behavior. As many as 200 men washed mess kits in the same water barrel before it was changed.
In addition, all these troops came to Kansas and left on crowded trains. From January to November 1918, 6.5 million men traveled this way, over 1 million in July of that year alone. And because Kansas City was a major shipping point for livestock, large numbers of hogs and chickens found their way to animal pens at Camp Funston before being slaughtered. Conditions were perfect for a virus to spread rapidly.
Between March 4 and March 29, 1918, over 1,100 men appeared at the base hospital with various symptoms ranging from fevers to head and muscle pain and coughing. These “normal” flu symptoms were often followed by a pneumonia, and this one-two punch produced much of the 5% future mortality in both military and civilian populations.
From Funston to the World
The 1918 pandemic swept through the United States in three phases: One happened in Camp Funston that March; another happened in the civilian population from August through November 1918; and the final smaller outbreak happened in early 1919. This flu appeared in Boston in August 1918, then in Philadelphia and elsewhere the following month. The worst U.S. casualties occurred in October and November 1918.
Estimates of those casualties worldwide range from 20 to 100 million, but the real total can never be known. By Easter Sunday of 1919, some 550,000 had died in the United States alone. In October 1918, around 11,000 died in Philadelphia.
What did the public health and medical communities do to fight this onslaught of cases? Some cities quickly adopted various public health measures: mandatory isolation of the sick and their contacts, school closures, and bans on public gatherings. Campaigns against spitting and other behaviors were widespread. Masks were widely worn and even mandatory in San Francisco, although those measures proved to be problematic. Some masks were too thick to allow comfortable breathing; others were too thin to be effective.
Cities such as San Francisco and St. Louis—where these measures were adopted quickly—generally had fewer cases and deaths. Philadelphia was a city that lagged behind, and the populace suffered. The first case appeared there in early September 1918, and officials warned about coughing and sneezing in public. Even so, the city still sponsored a Liberty Loan Parade, which was attended by 200,000 people; within two weeks there were 20,000 influenza cases.
Developing the First Flu Vaccine
Meanwhile, the medical community also tried various treatments. Patients were bled or given oxygen. Some patients were given blood transfusions from people who had recovered from the flu, an intervention that seemed to help in a percentage of cases.
Of course, the race was on to develop a vaccine. In 1892, German physician and bacteriologist Richard Pfeiffer found a bacterium in the nose of influenza patients in “astonishing numbers,” and he declared it to be the cause of that disease. Pfeiffer was a giant in the field of infectious diseases, and had been searching for the cause since the 1889-1890 pandemic. Working with Robert Koch, he had developed the concept and proved by experiment the existence of endotoxins and their roles in infectious diseases. He was also a pioneer in typhoid vaccination.
Not everyone accepted Pfeiffer’s claim, but many did. After all, bacteria had already been shown to be the cause of anthrax, cholera and plague. Drug companies promoted vaccines already available for other diseases. Doctors made batches of “vaccines” mostly by using inactive microorganisms, and they often distributed them to other doctors to inject in their patients or to be tried in asylums and orphanages. Accusations of price gouging and kickbacks were common.
Enthusiastic claims of success were made, but no regulation or control groups for these “trials” existed. The U.S. surgeon general and the American Medical Association were skeptical of those claims. Meanwhile, numerous articles about vaccines appeared in the medical literature in 1918 and subsequent years. JAMA even published one by George McCoy, of the U.S. Public Health Service, and his colleagues titled “The Failure of a Bacterial Vaccine as a Prophylactic Against Influenza” (1918;71[24]:1997. doi: 10.1001/jama.1918.26020500023006i). Some researchers suspected a virus, but virology was just beginning to develop. This research chaos eventually led to the criteria for vaccine trials.
The march of vaccine development began with Edward Jenner’s work on smallpox in 1797. A wave of discoveries occurred in the 1880s and 1890s for cholera, rabies, tetanus, typhoid fever and bubonic plague. Another wave in the 1920s covered tuberculosis, diphtheria, pertussis, yellow fever and tick-borne encephalitis.
The search for an influenza vaccine continued after 1918, but not until 1933 did scientists isolate the influenza A virus in ferrets. Other work in 1936 revealed that the virus could be grown inside embryonated chicken eggs, another important step. In 1938, Jonas Salk and Thomas Francis developed a vaccine using a fertilized chicken egg and successfully inactivated influenza A. U.S. soldiers received this vaccine during World War II, and its use for civilian populations was approved in 1946. A single vaccine for both types A and B was first developed in 1942, and since these milestones many others have followed in the fight against influenza. But as we have recently learned, those viruses are incredibly versatile.
—A.J. Wright, MLS
The author served as a librarian in the Department of Anesthesia at the University of Alabama at Birmingham, from 1983 to 2015.
The book and journal literature on medical, public health and social aspects of the great 1918 flu pandemic is vast. A good starting point is John Barry’s classic account, “The Great Influenza: The Epic Story of the Deadliest Plague in History” (Penguin Books; 2005). He covers in wonderful detail all of those layers.