Nursing During the Spanish Flu Epidemic of 1918


Nursing During the Spanish Flu Epidemic of 1918

Fine in the morning, dead by nightfall

By Elizabeth Hanink, RN, BSN, PHN
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One of the deadliest epidemics in recorded history involved a disease far less notorious than the “Black Death” (bubonic plague) that swept Europe during the Middle Ages — and occurred less than a century ago. The devastating influenza pandemic of 1918-1919 was a pivotal moment for nursing and its impact on our profession is still felt today.

It began in the spring of 1918. With World War I still raging, parts of the U.S. and Europe fell victim to a fast-spreading, unusually severe form of influenza, popularly called the “Spanish Flu.” That epidemic lasted only about a year, but ultimately claimed the lives of more than 30 million people. In the United States, about 22 million people—more than one in four Americans —were stricken. The final U.S. death toll is estimated at 675,000. (With today’s population, the equivalent would be 2.1 million Americans dying from the flu in one year!)

A Different Kind of Flu

At the turn of the last century, much like today, “the flu” was a seasonal annoyance that could be temporarily debilitating, but was seldom life-threatening except to the very young, the very old or people with compromised immune systems.

The strain that caused the first wave of the pandemic in the spring of 1918 was much more dangerous. Transmitted through respiratory droplets, “Spanish Influenza” was not particularly virulent, at least in its milder initial form, but the crowded living conditions of the time nonetheless caused it to spread rapidly — particularly in military camps, where the epidemic probably began.

Onset was equally swift, often accompanied by massive secondary infections like pneumonia. An infected patient might be fine in the morning and dead by nightfall. Symptoms included not only the familiar fever, aches and congestion, but also pulmonary hemorrhaging, hallucinations, delirium, dyspnea and cyanosis.

“The faces [of the sick] wear a bluish cast; a cough brings up the blood-stained sputum,” wrote pathologist William Henry Welch, M.D., then president of the Maryland State Board of Health. “In the morning, the dead bodies are stacked about the morgue like cordwood.”

The virus hit the young and healthy surprisingly hard. Most fatalities were adults in their 20s and 30s. According to the National Archives and Records Administration, the pandemic reduced overall American life expectancy by about 12 years. No one was safe. Even Woodrow Wilson and Franklin Roosevelt succumbed, although both survived.

The initial epidemic subsided for a time in mid-1918, but a second wave struck that fall, just as the Great War was winding down. By the time the third and final wave had run its course in the early summer of 1919, tens of millions were dead. The exact death toll is unknown, but it may have been as high as 50 million worldwide.

Acute Nursing Shortage

Period records give us a glimpse of what caregivers could do to relieve suffering and stop the spread of the virus — in two words: not much. Even so, nursing care was crucially important, the clearest predictor of survival.

By 1918, the U.S. had a sizable nursing workforce. Long before the outbreak, the Committee on Nursing of the Council of National Defense had established an infrastructure of public health nurses, as had the Red Cross, with its Town and Country Nursing Service. The complex field of military nursing had not been neglected either. In the U.S., the Army had already established its own Nurse Corps, which got its own School of Nursing in May 1918.

Unfortunately, the first wave of the pandemic struck as the U.S. was ramping up its involvement in World War I. Most skilled nurses were overseas with the American Expeditionary Forces — including as many as 80 percent of nurses from East Coast cities like Philadelphia. This resulted in widespread nursing shortages.

One Philadelphia official declared, “If you would ask me the three things Philadelphia most needs to conquer the epidemic, I would tell you, ‘Nurses, more nurses and yet more nurses.’”

The end of the war in the fall of 1918 made the situation even worse. Returning troops carried with them a new and more virulent strain of the disease, which took a deadly toll on nurses as well as soldiers and sailors.

Some cities, like Chicago, responded to the shortage by developing a two-track scheme to supplement registered nurses with practical nurses, who received a shorter, six-month course of training. This move was popular with hospitals and the public because it made more nurses available more quickly and for less money, but registered nurses, who had fought so long for formal recognition and decent pay, opposed what they saw as a dilution of their professional status.

Clara D. Noyes, RN, head of the American Red Cross Nursing Service, expressed dismay at the proliferation of short-term “nursing” courses then cropping up left and right. “There are moments when I wonder whether we can stem the tide and control the hysterical desire on the part of thousands, literally thousands, to get into nursing,” she declared. “[T]he most vital thing in the life of our profession is the protection of the use of the word nurse.”

While the nursing shortages were primarily due to the war, the profession itself was partly to blame. During this period, nursing remained a predominantly white, almost exclusively female occupation. Black candidates still had only limited access to nursing education and employment, even in the face of strong wartime demand. Such prejudices limited the supply of skilled nurses at a time when they were needed the most.

A Grueling Battle

During the pandemic, professional discipline proved to be every bit as important for nurses as skill and training. Nurses’ exposure was great and they were just as vulnerable as were patients — especially with the added dangers posed by exhaustion. With so many afflicted and such rapid onset of symptoms, the work was hard, intense and seemingly endless.

In Chicago, the American Red Cross publicized the story of a nurse out on a house call who expected to find a sick mother, but instead found an entire family stricken, a 10-month-old baby in desperate need of food and a delirious father roaming the streets in frantic search of a doctor. As one contemporary nurse put it, “You start out to see 15 patients, but instead see 50 to 60 extremely ill people before day’s end.”

Untrained volunteers sometimes pitched in, although what they could do was limited. “We tried to be as nice to them [patients] as we could and just be with them when they died,” said one volunteer. Such Good Samaritans were rare. Neighbors and even family members were often reluctant to help, fearing that they too might become infected.

Ultimately, it was the trained nurses, even the beginners, who stuck with the job until the end. At Philadelphia General Hospital, Head Nurse S. Lillian Clayton offered to allow the hospital’s freshman nursing students to return home rather than remaining to help fight the outbreak. All of them volunteered to stay. In the end, six died during the epidemic.

Care at Home

With hospitals filled to capacity, most care occurred in the home. Even in wealthy households, the circumstances often forced nurses to assist with household chores like cooking and washing linens. Nurses also had to prepare beef broth and other common liquids to combat patients’ dehydration and electrolyte loss.

As today, nurses stressed basic hygiene and hand-washing, but preventing the spread of the illness was difficult in an era when children often slept six to a bed and multiple families frequently shared a single apartment. Many cities required anyone venturing out in public to wear a gauze mask. Some municipalities even tried to outlaw public coughing and spitting.

Ventilation was considered one of the first lines of defense. Windows of homes, businesses and streetcars were kept wide open — sometimes by law, although falling winter temperatures late in the year eventually forced a relaxation of those rules. In many cases, nurses’ duties included the grim task of arranging for the removal of the dead.

With so many casualties, some urban areas resorted to burying victims of the epidemic in improvised mass graves. Few of the dead had the luxury of coffins, which were in short supply by late 1918.

Pandemic Legacy

While the influenza pandemic was an international disaster, it gave new resolve to nurses and nursing organizations by emphasizing the vast importance of skilled nursing in times of peace as well as war. Sadly, those lessons weren’t always taken to heart at the time. For example, it wouldn’t be until after World War II that the Army retained a sizable peacetime Nurse Corps.

Above all, the epidemic spoke to the importance of public health planning. In an era where global trade and travel are commonplace, a previously obscure disease — or a mutated form of an illness that was previously just a harmless nuisance — can spread with breathtaking speed. We can’t know when another global epidemic may strike, so all we can do is be prepared.

And if the 1918 pandemic teaches us nothing else, it’s that the preparation for any potential public health crisis must include ensuring that nurses have the training, resources and support to help as only they can.



Solving Medical Mysteries

For decades, the exact nature of the 1918 pandemic puzzled researchers and public health experts. That’s no longer true: Over the past 12 years, many of the outbreak’s mysteries have been unlocked.

Back in 2005, researchers from the CDC succeeded in actually reconstructing the specific H1N1 influenza A virus that caused the outbreak. The goal was to better understand the secrets of a virus whose genetic descendants have been responsible for most subsequent influenza epidemics. (You can read the results of this project in the Oct. 7, 2005, issue of Science.)

Nine years later, researchers at the University of Arizona, Tucson took the next step: determining why the virus killed so many healthy, young adults. The study team’s theory, reported in the Proceedings of the National Academy of Sciences (PNAS) for June 3, 2014, is that the pandemic virus was a hybrid of an avian N1 strain and a human H1 virus that had appeared about a decade earlier.

Like most influenza strains, the earlier human virus had mainly affected young children and the elderly. However, it left survivors with protective antibodies that made them less susceptible to the 1918 strain, which caught the immune systems of healthier adults completely off-guard.

“[I]t may be the missing piece of the puzzle,” explains Michael Worobey, Ph.D., lead author of the PNAS paper. “Once you have that clue, many other lines of evidence that have been around since 1918 fall into place.”



Prescriptions for Hard Liquor, and Other Dubious Remedies

For most of the millions afflicted by influenza, medical science had little to offer. Although germ theory was fairly well understood, viruses were not. Some doctors mistakenly assumed the illness was caused by a bacillus and tried to treat it accordingly, which probably did more harm than good.

Several new diagnostic tests saw more widespread use during this period, including sputum, urine and blood cultures, but they did not really advance therapy. The U.S. Public Health Service’s efforts to find a vaccine were unsuccessful.

Common treatments included Bayer Aspirin, epinephrine and oxygen. Chest pain was treated with hot compresses and “pneumonia jackets”: hot water circulating through coils covered in silk or muslin. Cinnamon oils or powders were sometimes used to reduce fever while Vicks VapoRub was widely used to reduce congestion.

The outbreak also saw a boom in patent medicines. Their chief active ingredient was usually alcohol, which remained a popular sedative. In areas where hard liquor wasn’t easily obtained, doctors sometimes wrote prescriptions for it, since there was little else they could offer patients!



Why It Became the “Spanish” Flu

During the First World War, countries on both sides allowed the press to deliver only positive news. As a neutral party, Spain was the first country to publicly report the health crisis, so “Spanish Influenza” became a popular way to refer to the outbreak. Later research has suggested that the starting point of the epidemic was probably American military bases in Kansas.


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