Philadelphia, 1918

1
Philadelphia, 1918
The Great Influenza
By Paul Rega MD, FACEP
2
Introduction

• The past several years have witnessed intentional
  and natural infectious disease outbreaks in the
  United States Anthrax, SARS, Monkeypox,
  Norovirus, among others.
• We have been inundated with new terminology such
  as surge capacity and alternative treatment
  sites and old terminology is being resurrected,
  namely isolation and quarantine.
• The infectious disease outbreaks that are
  transmissible from person-to-person will be the
  ones that have the potential to not only create
  the most morbidity and mortality, but will have a
  significant negative impact on a communitys
  ability to respond and rebound. This belief,
  however, is not well-disseminated among the
  various layers of our social and infrastructural
  fabric.
• The following resource material will illustrate
  how one community was confronted with such an
  outbreak.

3
Cast of Characters

• Wilmer Krusen, Department of Public Health and
  Charities
• Political appointee
• Gynecologist
• Lt. Commander RW Plummer, Chief Health officer
  for Philadelphia Naval District
• Woodrow Wilson, President of the United States

4
Prologue

• US population, 1870 40 million
• US population, 1917 105 million
• 1916 140,000 civilian doctors (1/2 incompetent
  per state boards)
• Flu origins Haskell Co., KS (Jan-Feb, 1918)
• America on war footing
• Recruits come together
• Barracks overcrowded
• Cold winter
• Camp Funston (3/4/18)
• In 3 wk 1100 hospitalized, thousands more ill,
  38 dead
• From Camp Funston to rest of military in US

5
President Wilson

• A reluctant warrior who developed a scorched
  earth policy to have all America in war effort,
  to make USA one weapon against the Hun
• Espionage Act Post Office censorship, Library of
  Congress
• New Sedition Act Clear and Present Danger
• FBIs American Protective League
• 200,000 spies
• Committee on Public Information Propaganda
  machine
• Sauerkraut Liberty Cabbage

6
The Flu Marches On

• People massed together in cities and camps for
  first time
• Resources to war effort
• 776 MDs in 1918 to 38,000 in 1921
• ARC 107 chapters to 3,800 chapters
• No media information
• April- June Europe
• September New Zealand/Australia

7
Flu in Select Cities

• June, Louisville, KY
• Flu to Fulminating Pneumonia
• Death in 1-2 days
• 40 mortality in the 20-35 yr. age group
• More malignant second flu wave begins
• September, 1918, Ft. Devens (Boston)
• In one day, gt1500 ill, 75 hospitalized
• 100 deaths in one day
• Inadequate care HCWs fall ill

8
The Flu

• Severe headaches, extreme arthralgias, fever,
  chills, malaise, anorexia, intense cough, nausea,
  vomiting
• Nasal congestion, oropharyngeal, tracheal,
  pulmonary congestion, severe earaches
• Intense cyanosis (blue-black)
• Gasping for breath
• Blood from mouth, nose, GI tract, conjunctiva
• Delirium

9
Autopsy Reports

• No organ untouched
• Kidneys, liver, adrenals, testes
• Marked hyperemia of the brain
• Pericarditis, myocarditis
• Lungs Plague lungs or lungs exposed to toxic gas

10
US Flu Stats

• 47 of all US deaths from flu
• 1918-1919 675,000 dead
• Equivalent to 1,750,000 now
• 15 times as many civilians died as military
• Most vulnerable Pregnant females
• Anywhere from 23-71 depending on area

11
TYPICAL INFLUENZA
Mortality Incidence
Young
Old
12
1918 INFLUENZA
Mortality Incidence
Young Young Adult
Old
13
Philadelphia in 1917

• 1.75 million
• Slums worse than in NYC
• Housing scarce
• 4 families/apartment sleeping in shifts
• the worst-governed city in America. L Steffens
• Political machine
• Graft, corruption
• Social services suffered
• City government power split among political boss,
  precinct captains, and mayor

14
September 7

• Sailors arriving in Philadelphia Navy Yard

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September 11

• Flu settles on sailors

16
September 15

• 600 sailors hospitalized at Navy Hospital
• More sent to civilian Pennsylvania Hospital in
  city
• 5 doctors and 14 nurses collapse 2 days later
• Krusen denies threat
• 1000 die in Boston
• Has meeting with local medical experts and agree
  to monitor events

17
Between September 15 and 20

• Plummer and Krusen
• Have handle on situation
• Municipal Hospital for Contagious Diseases opened
  to Navy ill
• Civilians begin dying with regularity

18
September 21

• Board of Health announces flu to be a
  reportable disease
• To public
• Stay warm
• Keep feet dry
• Keep the bowels open
• Avoid crowds

19
Avoid Crowds??

• 9/28 Great Liberty Loan Parade scheduled
• US on war footing
• Keep morale high
• Keep free speech to minimum
• Union halls raided
• 1200 union workers locked in boxcars
• Eugene V. Debs jailed 10 yrs for opposing war
• Meanwhile local ID experts and doctors wanted to
  cancel Parade
• Concerns never published in newspapers

20
September 26

• 1400 sailors hospitalized so far
• Local Red Cross opens first alternative care site
  in city
• 500 bed United Service Center

21
September 27

• Out of 200 hospitalized that day, 123 were
  civilians

22
September 28

• The Great Liberty Loan Parade takes place
• Several hundred thousand attend
• Incubation period was less than 48 hours

23
September 30

• Krusen announces an epidemic is occurring in
  Philadelphia

24
October 1

• All beds in all 31 hospitals filled
• Hospitals refuse admission unless patient had a
  doctor or police order
• Nurses refuse 100 bribes
• Lines of people waiting to get into Pennsylvania
  Hospital
• No doctors, no medicines
• 117 die that day

25
October 3 Krusen Acts

• All public meetings banned
• All churches, schools, theaters, courts closed
• No public funerals
• Saloons stay open
• Key voting bloc for political machine
• Closed next day by State Health Commissioner
• Another alternative care site open in City
  Poorhouse (Emergency Hospital 1)
• 500 beds filled in single day
• Eventually 12 such sites open

26
In 10 Days

• From a few hundred ill civilian cases and 1-2
  deaths per day to hundreds of thousands ill and
  hundreds of dead per day
• Newspapers stay mute!

27
Placards Disseminated

• Avoid Crowds
• Use Handkerchiefs
• Spitting Equals Death
• Arrested if caught spitting
• 60 arrested in 1 day

28
October 5

• 254 deaths that day
• Announcement Peak has been reached

29
October 6

• 289 dead that day
• gt300 on October 7
• gt300 on October 8

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October 9

• 428 deaths
• Would approach double that figure in the next few
  weeks
• 2/3 of the dead were under 40 years of age

31
The Dead

• Pile up
• Gravediggers refuse to bury them
• Caskets pile up in funeral homes
• Coffin shortage
• Guards posted by unused coffins
• Dead bodies lying next to the ill
• At home families pack their dead in ice
• Stench
• Bodies on porches to be picked up, wrapped in
  sheets, by dead wagons (1 atop another)
• Mom wanted to place her dead child in a macaroni
  box

32
City Morgue

• Capacity 36
• Jammed with 200 bodies
• Stench!

33
Mental Stress

• People increasingly isolated
• Avoid each other
• No social activities
• Phone company allowed only emergency calls

34
Philadelphia General Hospital

• 8 doctors 54 nurses hospitalized (43)
• 10 nurses die
• Board of Health appeals for retired nurses and
  doctors
• One old doctor treating patients with purging and
  venesection!

35
Medical/Pharmaceutical Students

• 5 medical schools and 1 pharmaceutical school
• Dispatch their students to assist
• 1 medical student in charge of an entire floor at
  one of the Emergency Hospitals
• ¼ of his patients die each day

36
More Help?

• National Red Cross Nothing
• PHS Nothing
• City Nothing
• ..death toll for 1 day in Philadelphia alone was
  more than the death toll from France for the
  whole American army for one day.
• Real action begins October 7

37
The Women Take Charge

• Oldest, wealthiest families
• Council of National Defense
• Emergency Aid Society
• Provide organization and leadership
• Had money

38
Emergency Aid Society

• Used existing system to distribute anything from
  medical care to food
• Divided city into 7 districts
• Dispatched doctors according to geography
• Developed list of physicians
• 24 hour phone bank for info and referrals
• Soup kitchens in public schools for the ill
• Volunteers (thousands)
• Private cars as ambulances
• Drove physicians on rounds

39
Krusen Wakes Up

• Gives women control of nurses
• Seizes 100,000 in the emergency fund and 25,000
  in the war emergency fund
• Supplies hospitals
• Hires doctors (twice what PHS paid)
• Sends doctors to police stations
• Cleans streets
• Requests Feds not to draft Phillys doctors
• Approved

40
Krusen, The Women, The Catholic Church, The
Dead

• Police priests clear bodies (wore masks)
• 33 cops die by mid-October
• 6 alternative morgues
• Streetcar company builds coffins
• Enlist embalming students and morticians from 150
  miles away
• Seminary students dig graves
• Heavy equipment to dig mass graves

41
October 10

• 759 dead
• Before the flu, death from all causes averaged
  485 per week in Philadelphia
• Orphans abound

42
The Unsung Heroes

• Attrition rate for volunteers high
• Medical profession continued
• Few fled
• Police continued
• Request for 4 volunteers to remove decomposed
  bodies
• 118 responded

43
Week of October 16

• 4,597 deaths
• Worst week of the epidemic

44
Thenthe numbers began dropping

• 10/26 Ban on public gatherings lifted
• 11/11 The flu officially gone from Philadelphia

45
Epilogue

• The 1918 influenza epidemic in Philadelphia
  illustrates the good, bad, and ugly of American
  responses to a galloping infectious disease
  outbreak. There were heroes and there were
  goats. Both personal courage and political
  ineptitude were on display. Altruism played a
  tug-of war with profit.
• As George Santayana said, Those who do not know
  history are condemned to repeat it.

46
Bibliography

• Barry JM. The Great Influenza- The Epic Story of
  the Deadliest Plague in History. Viking Press,
  New York. 2004.
• Influenza 1918. A Robert Kenner Films Production
  for The American Experience. 1998.