Calm, Cool, Courageous: Nursing and the 1918 Influenza Pandemic

In 1918, influenza, as it does every year, spread throughout the world. Unlikely most years, this strain was faster and deadlier, becoming a pandemic within weeks.

The 1918 influenza virus, erroneously known as Spanish Flu, presented first in late spring. During its second wave in late summer, doctors quickly noted it was different than the normal seasonal flu, even at times misdiagnosing it. This strain caused tremendous stress on the body, had a higher rate of death, and was atypically seen more in young adults than in the rest of the population. Ordinary flu has a higher death rate in young children and older adults; this strain of influenza caused a spike in young adults contracting and dying from the disease. It would kill an estimated 50 million people world-wide. In the United States 25 million people were infected with influenza, about 25% of the population, and would kill 675,000.

In Philadelphia over 12,000 people would die

Philadelphia had one of the highest death rates in the country, 4 times higher than Boston. The daily death toll from influenza alone in Philadelphia would exceed the city’s average weekly death toll from all causes. In a single day, 759 people died from the pandemic alone. In an average week, 485 died from all causes. Within 10 days the city went from 2 deaths and hundreds ill to hundreds dead each day and hundreds of thousands ill. Every hospital bed in 31 hospitals were filled. People who were healthy a couple days ago were fighting for their lives, some dying within a day of contracting influenza. For over three weeks, influenza paralyzed the city. Schools were closed. Public meetings were banned. Yet the population continued to get sick. Despite declarations on October 4th and 5th, the peak of the pandemic didn’t happen until the week of the 19th when 4,597 died from influenza or pneumonia. Despite the numerous deaths though, many more survived and recovered from the illness.

As influenza spread, so too did fear. People isolated themselves, not speaking to anyone, avoiding crowds, not having anywhere to go but stay at home, where there may be people sick or dead. The rapid rate of death, and the fact there were so many dying, meant the city and it’s undertakers and morgue couldn’t keep up with dead bodies.  The city morgue was designed to hold 36 bodies. It was quickly overrun, with nearly 200 bodies crammed into every available space. Exacerbating the overload, besides the rapid influx of the dead, was the lack of available undertakers and grave diggers. For some families, it was easier for them to dig a grave themselves than wait for someone else.

During the height of the flu the city established 5 additional temporary morgues, but even that wasn’t enough. Bodies piled up in hospitals, on porches, on the streets, and in the home. Rooms, if there were any to spare, were sectioned off when family members couldn’t arrange for or find someone to take care of the body. Without embalming, the bodies began to decay; bodies oozed and blood would flow out. The smell was everywhere. Philadelphians could walk down the street seeing and smelling dozens and dozens of bodies. Death was everywhere.

Nurses were at the forefront of care

Thousands of patients reported the classic symptoms of influenza- fever, aches, sore throat, and headache. However, this strain struck more severely and soon some patients turned blue at the fingers, arms or face, had trouble breathing, and even bled. More shocking was these were young men and women suffering from these terrible symptoms. Doctors had few resources and few medicines to assist at the time though they did their best. Nurses could help. Nursing care was critical in the day-to-day battle against influenza. Nurses were overwhelmed with numbers of patients, either at the hospital, at home, or in the field, yet they continued to do their job in the face of overwhelming numbers.

There weren’t enough hands to help each patient- some died within 12 hours before being seen by a nurse or a doctor. Fresh laundry, water, and fluids and food were critical to combating the flu, but with so many patients it was difficult to obtain supplies. Medicines to ease the pain ran out. Clean linens and soups were used as quickly as they were made.

Visiting nurses from the Visiting Nurse Society of Philadelphia, which provided nursing care in the home, took on some of the earliest cases of the flu and were overwhelmed before the Liberty Bond Parade. By the end of the first week of October, these nurses would see on average 20-30 cases in a day, with the highest at 40 cases in a single day. And each case might be more than one patient. Nurses often cared for most of one family in a single call. Some arrived too late to provide care and instead found bodies and orphans.

Visiting Nurse Society of Philadelphia annual report with mention to Influenza

“… In a crib beside the mother’s bed was a six-week- old baby who had not been bathed for four days and was wet and cold. Though the father … running a temperature of 103 degrees, had to get out of bed … to care for his wife and children… . The family had no coal, and the three well children were shivering and hungry. The nurse gave care to the sick and bathed and fed the baby. She made a wood fire in the stove and prepared food for the other children. She then found a kind neighbor to continue to look after the children.”

Heroes and martyrs

Whether it was in the home or in the hospital, nurses made their rounds to as many patients as they could, saving those when they could. Nurses put themselves on the line knowing they themselves could contract the same illness. The nurses remained professionals.

Patient care in hospitals remained the same. In an apprenticeship that provided hospitals with free labor, student nurses received on the job experience by caring for hospital patients while also attending various lectures on procedures, medications, and nursing care. When influenza spread throughout the country, nursing students were on the front lines caring for desperately ill patients. These students often fell ill themselves and saw fellow students get sick and even die, from the influenza. It wasn’t uncommon for training schools to report at least one student fatality from influenza. 

Regardless of where they worked nurses remained calm, cool, and courageous in the midst of the deadly outbreak.

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Content created by Jessica Clark, with assistance from Elisa Stroh and Patricia D’Antonio, PhD, RN, FAAN.