James F. Armstrong, RN, BSN, CCRN
I had a little bird and its name was Enza
I opened the window and
in-flu-enza – Children's jump rope rhyme heard nationwide during the height of the pandemic.
The Spanish Influenza of 1918 was the greatest, most lethal pandemic the world has ever known. In its 10-month duration between 22 and 40 million people perished worldwide. Estimates place the death toll in the United States at over 675,000 with over 22 million becoming ill. Leading physicians of the time thought the illness a bacterium, but in fact it was something not yet discovered–a virus. American were familiar with the flu; it sent you to bed, made you miserable for 3 or 4 days with fever, muscle aches, and congestion, then left you shaky for about a week. It made millions sick, yet killed only the oldest, youngest, and most feeble.
The 1918 influenza was not the flu Americans were familiar with. It was a horror that turned victims bluish-black then drowned them with their own body fluids. the death toll was highest in the ages 15 to 40, those in the peak of health. The victims would be fine one minute and the next incapacitated, fever-racked, and delirious. Temperatures rose to 104-106 degrees, skin turned blue, purple, or deep brown from lack of oxygen. Massive pneumonia attacked the lungs, filling them with fluid; blood gushed from the nose. Death was quick, savage, and terrifying.
The America of 1918 was in its second year of involvement in World War I, and millions of young Americans were in uniform. Great military camps were established throughout the United States for the training of soldiers and filled to overflowing. Most of these camps were near large cities or well populated areas. Railroads moved these soldiers rapidly across the country toward the East Coast to pack into troopships bound for the battlefields of Europe. Sailors and merchant seamen who crowded port cities had access to all parts of the world.
Civilians flooded cities to work in the expanded war industry, huge rallies and parades were held, all to support the war effort. The country was the perfect breeding ground for the coming pandemic.
The pandemic had three distinct waves, the first coming from the American heartland, most probably Kansas. During March[,] soldiers and civilians around Ft. Riley, KS, rapidly became ill; some of them died, their lungs swollen with bloody fluid. The disease spread to other camps and port cities. Statistics of military and civilian deaths in March and April of 1918 demonstrated a sharp rise between the ages 21 to 29. The illness astounded physicians with its rapid onset, how rapidly it spread, and how quickly it killed those in the most robust of health.
Then, that summer, it subsided, and the United States was virtually free of the flu. However, the disease was on the move, riding the troopships to Europe and turning them into a nightmare of illness and death.
The influenza then arrived in Europe with the 1.5 million soldiers who brought more death with their virus than the weapons they carried. It raged across Europe and into Asia, eventually killing more American soldiers than the war. Approximately 80 percent of Spain's population contracted the flu giving rise to the rumor it started there.
Sometime, late in the summer of 1918, the virus mutated in a response to increasing human antibodies. Now in its most virulent form it returned in the same ships that took it to Europe, making landfall in Boston in September. There, it killed over 2000 people.
Philadelphia's population in 1918 was 1,700,000 with war industry adding another 300,000 transient workers. The city was teeming with large ghettos representing every oppressed ethnic group from Europe. The city's medical resources, some of the best in the country, were strained. Twenty-six percent of Philadelphia physicians and a much larger percentage of nurses were away serving with the military; 75 percent of Philadelphia's hospitals' medical and surgical staffs were overseas. Although the city's board of health knew the flu had gotten to Europe in July, and had made it to Boston by the third week of September, it still did not make it a reportable disease. The flu was coming to Philadelphia and the city was not prepared.
The disease appeared first at the sprawling naval base and shipyard on 18 September. The next day 600 sailors were ill; at the same time civilian hospitals started receiving patients. The board of health now began to act by instituting a public campaign against coughing, sneezing, and spitting. Philadelphia was about to become the American city with the highest, most rapidly accumulating, death toll in the worst pandemic in recorded history. In a single day, the death toll reached 1,700.
Dr. Paul A. Lewis, director of the Phipps Institute of Philadelphia stated he had isolated the cause of the flu, Pfeiffer's Bacillus. The Philadelphia Inquirer reported that this discovery armed the medical profession with the absolute knowledge on which to base its attack on the disease. they both were wrong! Despite the crisis, on 28 September, 200,000 people gathered in the streets to view the kickoff of the Fourth Liberty Loan Drive. The parade stretched 23 blocks through the city; death marched with it.
By 4 October the University of Pennsylvania's newspaper The Daily Pennsylvanian reported 636 new cases and 139 deaths. The paper would continue to give a daily count throughout the epidemic. On that day the board of health closed all schools, churches, theaters, and saloons. All citizens were ordered to wear gauze masks in public, “Obey the laws and wear the gauze protect your jaws from septic paws.” Those daring not to wear masks were ridiculed by being called “slackers,” the worst epithet of the day, or were physically run off the streets. A sneeze or cough sent people scurrying.
As the death toll mounted, a frantic public stripped medicines from pharmacy shelves. Students from Philadelphia College of Pharmacy and Temple University assisted in filling prescriptions, mostly for whiskey, as it was the only place one could get it. As medications disappeared, people turned to folk remedies and ridiculous concoctions sold by charlatans.
On 10 October, 528 died in the city. Thirty-fourth street, in front of Philadelphia General hospital, was crowded with vehicles of every description bringing the sick, the dying, and, in most cases, the dead to the hospital. The scene was repeating itself in front of every hospital in the city. Many of the staff of PGH were sick because this was a disease of necessity (meaning care was provided for the symptoms, not the cure), the majority of work fell to nurses. PGH School of Nursing's chief nurse, Lillian Clayton, worked 48-hour shifts. Sheer exhaustion allowed many of the nurses to become ill; four died. Miss Clayton offered to allow all preliminary (freshman) nursing students to return home rather than face the disease, yet all volunteered to stay. Six eventually died from flu.
Throughout the country the United States Health Department was besieged by calls for more nurses to care for the sick. GEN John J. Pershing, commander of all American troops in Europe sent an urgent appeal for 1,500 more nurses. Philadelphia's trained nurses were not enough; student nurse and lay volunteers were quickly utilized.
The University of Pennsylvania's School of Nursing's 1919 yearbook describes the scene: “Then came the epidemic of influenza, and our plans for service (in the armed forces) were brought to a standstill, for we had all we could manage at home. Ever in our hearts will remain the memory of those classmates, Grace Virginia Fitzgerald and Marie Luise O. Boremann who gave their lives in the influenza epidemic October twelfth and thirteen 1918.”
The frustration of Philadelphia nurses can best be illustrated by the 1919 annual report of the Chestnut Hill Hospital's School of Nursing where a passage reads, “most tragic because of the loss by death of so many nurses and because of our inability to meet the needs of the patients who came to us during the epidemic of influenza that swept the city.”
Philadelphia's well-organized Society of Visiting Nurses, “had every thought and previous action blotted from their minds,” by the great tragedy. Nurses were busy around the clock caring for the thousands of sick who could not reach a hospital. They described entering houses where all members of a family were dead. Some had both parents dead and the children starving. In some neighborhoods they were hailed as saviors. In others they were shunned due to the white gowns and gauze masks they wore.
The Philadelphia Automobile Club volunteered and effectively transported the nurses on their rounds. Care of the sick was made even more difficult by the refusal of some people to assist in the care of neighbors and even relatives for fear of contracting the disease. The Society of Visiting Nurses, in its 1918 report claimed the influenza epidemic gave it purpose and resources it never would have had otherwise. Members cared for thousands during the epidemic and some gave their lives.
A growing problem that threatened the living was the dead. Bodies started piling up in makeshift morgues and in the streets. In a vision not seen since the Black Death of medieval Europe, carts went through the street, their drivers calling for people to bring out the dead for burial. Wagonloads of bodies, some dead over a week, were buried in Potter's Field at Second and Luzerne Streets. Highway workers dug large trenches and filled them to capacity. the provmise that bodies could later be retrieved and reinterred after the epidemic subsided persuaded relatives to give up loved ones. Relatives never recovered most of the bodies.
By October 27th the epidemic began to subside as quickly as it came. Other parts of the country would continue to suffer from the pandemic well into the spring of 1919. The passing of influenza through the city left an estimated 12,191 dead. In but 4 weeks, there were 47,094 reported cases.
As soon as the dying stopped the forgetting began. The 1918 influenza pandemic is seldom mentioned, and most Americans have never heard of it. What is amazing is just how quickly the amnesia began. In researching archives, I was shocked at how little appeared in journals, yearbooks, and annual reports during the pandemic or within a year of its passing. And here was a disease that killed more people in less time than any other event in world history. It was as though it had never happened. It certaily is true that the human mind always trieds to expunge the intolerable from memory.
Medical science remains haunted by the disappearance of the virus. Where did it come from, and where did it go? Virologists are only now slowly unlocking the secrets of the Spanish Flu from recently discovered lung tissue specimens from 1918. Apparently, the virus' savageness was due to a flu strain that had undergone a mutation. Influenza viruses mutate constantly in what is known as antigenic drift, usually in such minimal ways that last year's flu or vaccine offers at least some protection against this year's outbreak. But about every decade or two, such drift may be so dramatic as to be regarded by the human body as an entirely new virus. Then it sweeps through the human population with a vengeance. In 1957 the Asian flu killed 70,000 Americans. In 1968 the Hong Kong flu killed 28,000.
In a recent report from the Centers for Disease Control and Prevention, epidemiologists believe the probability is high that another dangerous new strain of the influenza virus will emerge. Combined with the world's increased population and jet-age travel, the stage could be set for another catastrophe. This pandemic could spread so fast that research laboratories could not isolate, prepare, and distribute an appropriate vaccine in time. Jeffery K. Taubenberger of the Armed Forces Institute of Pathology and the primary researcher of the 1918 virus points out that if the records are any indication, another pandemic is inevitable. The question is when.
The Spanish Influenza's legacy is carved in stone, amid the cemeteries of cities, towns, and villages throughout [the] United States. A walk through any one of them will possibly reveal a mass grave or perhaps a poignant tombstone inscribed with the year of death–1918.
Taubenberger, J; Reid, A. “Initial Genetic Characterization of the 1918 ‘Spanish' Influenza Virus” Science 1997 275 pp. 1793-1796.
Webster, R., “1918 Spanish Influenza; the Secrets Remain Elusive.” Proceedings of the National Academy of Sciences; 1996 (Feb. 16) 116Y.
Influenza; General Information: Centers for Disease Control and Prevention. 7 January 1999 CDC Web Site.
Brown, D. “It All Started in Kansas” Washington Post, Weekly Edition, Vol. 9, Number 21. March 23-30, 1992.
Iezzoni, Lynette, Influenza 1918: The Worst Epidemic in American History. T.V. Books, LLC, New York, NY, 1999.
Crosby, Alfred, America's Forgotten Pandemic: The Influenza of 1918. Cambridge University Press, Cambridge, UK 1998.
Collier, Richard, The Plague of the Spanish Lady. Forge Village, MA. Murray Printing Co. 1974.
Lynch, E. “The Flu of 1918.” The Pennsylvania Gazette, University of Pennsylvania, 17 February 1999.
Gilbert, M., The First World War: A Complete History. Henry Holt & Co. New York, NY 1994.
“Is Another Influenza Pandemic coming soon?” Infectious Disease News, Slack Inc. 2 June 1997.
Henig, R., “Why Hong Kong's Bird Flu Signals a Serious Threat.” The Washington Post. (4 January 1998.)
“Influenza, Could it Happen again?” The American Experience, PBS 20 January 1999.
Stachniewicz, SA, Axelrod, J. The Double Frill: The History of the Philadelphia General Hospital School of Nursing. Geo. F. Stichley Co., Philadelphia, PA, 1978.
The Nursing Record, University of Pennsylvania School of Nursing, 1919 Year Book.
Chestnut Hill Hospital School of Nursing, Annual Report, 1918.
Philadelphia Society of Visiting Nurses, Annual Report, 1918.
Croskey MD, J.W., History of Blockley: A History of the Philadelphia General Hospital. F.A. Davis Co. Philadelphia 1929.
James F. Armstrong, is a flight nurse with the PENNSTAR Flight Program, University of Pennsylvania Medical Center, Philadelphia, PA.
Source: Armstrong, James F. “Philadelphia, Nurses, and the Spanish Influenza Pandemic of 1918.” Navy Medicine 92, no. 2 (March-April 2001): 16-20