The Spanish flu of 1918 was the greatest pandemic in recorded history.
Recent estimates suggest that this flu claimed as many as 50 million lives around the world
between 1918 and 1919, killing more people in a single year than the entire “Black
Death” of the 14th century. As the world confronts a new pandemic, it is worth remembering
the history of the “Spanish” flu and how it set us on the path towards our modern flu vaccine.
When the first cases of the influenza A (H1N1) pandemic broke out in 1918 during the final year of World
War I, the origins of this deadly pandemic were unknown. Contemporary explanations in
the Allied nations ranged from fears of a new form of biological warfare to a by-product
of trench warfare resulting from the use of mustard gas.
The Spanish flu is also misnamed. The idea that the pandemic began in Spain relates to
reports in the press of cases of influenza in the summer of 1918, where as many as eight
million Spaniards succumbed to the disease. Even the King of Spain, Alfonso XIII, caught
influenza in 1918. However, the first cases actually broke out
months earlier in a military camp in Kansas where few noticed the signs of the pandemic
to come amid the ongoing war. On March 4, 1918 company cook Albert Gitchell, possibly
patient zero, reported sick with a fever of 104º Fahrenheit at Camp Funston, part of
Fort Riley, where 54,000 men were gathered for basic training. Within days, 522 soldiers
reported sick and by the end of the month 1,100 soldiers were admitted to hospital with
influenza. The wartime context for the pandemic is especially
important: not only did the flu claim more lives than the war itself and prolong the
suffering brought about by the First World War, but the pandemic also followed the movement
of soldiers around the globe. The American Expeditionary Forces (AEF), which deployed
out of Kansas to France, were likely carrying the flu with them in the spring of 1918 as
the Allies rushed deployments to halt the German Ludendorff Offensive. The first British
cases occurred in mid-April as well, spreading out of ports and Scottish dockyards.
Still, little attention was paid to what contemporary physicians described as a quote three-day
fever endquote that was circulating in Europe in late spring and early summer 1918.
In this first phase of the pandemic most patients recovered quickly; their fevers broke after
two days and most were fit for work within a week. Only a minority of patients suffered
complications, such as pneumonia, that led to fatalities. Moreover, by June 1918 the
number of cases in Europe and North America began to steadily decline leading to a belief
that the flu pandemic was over. In late August, however, the flu reemerged
suddenly across the globe with much greater lethality.
This second phase of the pandemic began almost simultaneously in Brest on August 22, in Freetown
on August 24 and in Boston on August 27—all major military port cities. Over the course
of the next four months, flu circled the globe infecting approximately 500 million people.
Hospitals were overwhelmed. Doctors and nurses disproportionately fell victim to the pandemic
while treating an unprecedented number of patient-cases. Pulmonary complications appeared
more frequently, contributing to a mortality rate twenty-five times higher than a normal
influenza outbreak. Fatalities peaked in November 1918.
Military officials were often the first to realize the severity of the flu, but they
did not understand the nature of the illness. The Royal Army Medical Corps began bacteriological
examinations of soldiers for “Pfeiffer’s bacillus”. The German physician and bacteriologist
Richard Pfeiffer had incorrectly identified “Pfeifer’s bacillus” as the causal microbe
responsible for the flu in 1892. In the United States, William H. Welch, former
president of the American Medical Association and a member of the Johns Hopkins Medical
School, studied the epidemic in military camps in September 1918, employing state-of-the-art
medical research techniques to treat Pfeiffer’s bacillus. Welch and his team tried a host
of antiserums, vaccines, and medical compounds—all to no avail. Their microscopes could not see
something as small as a virus. Meanwhile, civilian public health programs
remained conflicted about how to respond to the pandemic.
Arthur Newsholme, head of the British Local Government Board, the government organization
responsible for the oversight of domestic public health campaigns, told Britons simply
to quote carry on endquote. To impose quarantines necessary to contain the pandemic would have
been too detrimental to the war economy. Parliament did not impose any sort of public health legislation
until November 1918, and these laws only limited the duration of public gatherings and access
to cinemas. In the United States, the American Public
Health Association (APHA) was more proactive in its efforts to prevent the spread of the
flu and reduce the severity of the pandemic. The APHA recognized that the disease was extremely
communicable and sought to break the channels of infection. It initiated respiratory-hygiene
education campaigns about the dangers of coughing, sneezing, and the careless disposal of nasal
discharge. The gauze mask was another important preventive
tool. The face masks consisted of a half yard of gauze, folded like a triangular bandage
covering the mouth, nose, and chin. Some cities, like San Francisco, legislated that everyone
should wear a gauze mask in public. A popular rhyme was created to remind people of the
city ordinance: Obey the laws, And wear the gauze, Protect your jaws, From Septic Paws
Ultimately, very little succeeded to effectively control the pandemic. By winter 1918, the
pandemic suddenly dropped off, although a third, final, and milder phase would resurge
in the spring of 1919. It too passed naturally. Physicians and medical researchers could ultimately
do little about the flu’s onslaught because they did not understand what was causing it.
For years physicians wanted to quietly forget their inability to combat the pandemic. Yet,
the 1918 global influenza pandemic left an important legacy in the history of medicine.
Beyond shocking tolls, the pandemic inspired a surge in biomedical research.
In 1919, doctors attempted to vaccinate patients against influenza, developing a vaccine for
Pfeiffer’s bacillus that proved completely ineffective. After the pandemic had passed,
biomedical researchers began to reevaluate the etiology of influenza with the goal of
preventing a future pandemic. Between 1935 and the early 1960s the influenza virus was
the most studied virus infecting humans. In 1936, H1N1, the strain of the influenza responsible
for the pandemic, was isolated in the laboratory. This began the path towards a vaccine, which
was first tested, again in the context of war, on U.S. soldiers during World War II.
Today, we are regularly vaccinated against the H1N1 strain of influenza in our annual
flu shot so that, with hope, we do not have a repeat of the 1918 pandemic. It was a human
catastrophe that should never have been forgotten.