THE BEDFORD SERIES IN HISTORY AND CULTURE The Influenza Pandemic of 1918– 1919 A Brief History with Documents Susan Kingsley Kent University of Colorado, Boulder For Bedford/St. Martin’s Publisher for History: Mary V. Dougherty Executive Editor for History: Traci M. Crowell Director of Development for History: Jane Knetzger Senior Editor: Heidi L. Hood Developmental Editor: Ann Kirby-Payne Production Supervisor: Lisa Chow Executive Marketing Manager: Jenna Bookin Barry Editorial Assistant: Laura Kintz Project Management: Books By Design, Inc. Cartography: Mapping Specialists, Ltd. Permissions Manager: Kalina K. Ingham Text Designer: Claire SengNiemoeller Cover Designer: Marine Miller Cover Photo: Japanese schoolgirls wear protective masks to guard against the influenza outbreak in Tokyo, February 17, 1920. © Bettmann/Getty Images. Composition: Achorn International, Inc. President, Bedford/St. Martin’s: Denise B. Wydra Presidents, Macmillan Higher Education: Joan E. Feinberg and Tom Scotty Director of Marketing: Karen R. Soeltz Director of Production: Susan W. Brown Associate Production Director: Elise S. Kaiser Manager, Publishing Services: Andrea Cava Library of Congress Control Number: 2012939219 Copyright © 2013 by Bedford/St. Martin’s All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, except as may be expressly permitted by the applicable copyright statutes or in writing by the Publisher. For information, write: Bedford/St. Martin’s, 75 Arlington Street, Boston, MA 02116 ISBN: 978-1-319-24162-9 (ePub) Acknowledgments Acknowledgments and copyrights are continued at the back of the book on page 125, which constitutes an extension of the copyright page. It is a violation of the law to reproduce these selections by any means whatsoever without the written permission of the copyright holder. Foreword The Bedford Series in History and Culture is designed so that readers can study the past as historians do. The historian’s first task is finding the evidence. Documents, letters, memoirs, interviews, pictures, movies, novels, or poems can provide facts and clues. Then the historian questions and compares the sources. There is more to do than in a courtroom, for hearsay evidence is welcome, and the historian is usually looking for answers beyond act and motive. Different views of an event may be as important as a single verdict. How a story is told may yield as much information as what it says. Along the way the historian seeks help from other historians and perhaps from specialists in other disciplines. Finally, it is time to write, to decide on an interpretation and how to arrange the evidence for readers. Each book in this series contains an important historical document or group of documents, each document a witness from the past and open to interpretation in different ways. The documents are combined with some element of historical narrative —an introduction or a biographical essay, for example—that provides students with an analysis of the primary source material and important background information about the world in which it was produced. Each book in the series focuses on a specific topic within a specific historical period. Each provides a basis for lively thought and discussion about several aspects of the topic and the historian’s role. Each is short enough (and inexpensive enough) to be a reasonable one-week assignment in a college course. Whether as classroom or personal reading, each book in the series provides firsthand experience of the challenge—and fun—of discovering, recreating, and interpreting the past. Lynn Hunt David W. Blight Bonnie G. Smith Natalie Zemon Davis Preface Appearing in the midst of the First World War, the influenza virus of 1918–1919 blazed across the globe in a matter of months, leaving in its wake a death toll that would surpass that of the war itself. It appeared suddenly and with explosive impact, and defied all previous understandings of the disease: the illness struck quickly and without warning, felling people in their homes, at work, and in the streets, and unlike previous manifestations of the disease, which tended to take infants and the elderly, this strain primarily struck men and women in the prime of their lives. Especially virulent, it moved quickly through homes, military barracks, cities, and towns, first appearing in the American Midwest and quickly making its way to South America, Africa, Europe, Asia, and Australia. Doctors and other medical professionals were helpless to understand or treat it, and governments were unable to contain or manage it. By the time the virus died out in the fall of 1919, it had taken the lives of up to sixty million people. Like the war, the pandemic shook the foundations of individuals, families, and entire societies around the globe, and its impact would continue to be felt throughout the first half of the twentieth century. Despite its global impact, the pandemic is basically unknown to many students today. Designed for students enrolled in a variety of courses from surveys of global history to courses on health and medicine, World War I and beyond, this accessible and engaging collection invites critical thought on the connections between public health, economics, politics, and historical events. The introduction to the volume provides a compelling, brief overview of the pandemic, including a thorough description of its physical symptoms and an examination of how and where it spread, as well as insights into the medical community’s understanding of— and response to—the disease. The short- and long-term impacts of the pandemic—from the lives of children orphaned by the flu to colonial rebellions for which the pandemic served as a major catalyst—are also discussed. The introduction is supported by more than sixty documents organized in four sections: The Nature and Experience of the Disease; Transmission and Mortality; Treatment Responses; and Consequences and Repercussions of the Pandemic. The documents include firsthand accounts from doctors and nurses who struggled to cope with this new strain of influenza while they treated patients ranging from anonymous rural Japanese villagers to the President of the United States. Along with newspaper accounts, government notices and statistical surveys, and memoirs and novels written by survivors, this collection of primary sources offers a glimpse into the experience of the pandemic as it unfolded, as well as its impact on individuals, communities, and entire populations in the decades that followed. To illustrate the truly global nature of the disease, the sources report on experiences from a wide range of countries, including the United States, Ireland, South Africa, Sweden, India, Nigeria, China, Sierra Leone, Germany, and beyond. Illuminating headnotes and gloss notes provide necessary context and background, while a chronology of events, questions for consideration, and a selected bibliography enhance and enrich student understanding. ACKNOWLEDGMENTS Many people contributed to the creation of this volume, and I am pleased to be able to thank them for their ideas, criticisms, suggestions, and assistance in putting it together. My dear friend Bonnie Smith got me involved in this project in the first place, for which I am most grateful. The editorial staff at Bedford/St. Martin’s —Mary Dougherty, Traci Mueller Crowell, Heidi Hood, Laura Kintz, and Andrea Cava—provided extensive hands-on help at every stage of the process. They are a warm, friendly, thoughtful, and professional bunch of people, and I enjoyed working with them tremendously. Nancy Benjamin at Books By Design carefully managed the day-to-day production work and made useful changes as copy editor. Ann Kirby-Payne, development editor extraordinaire, did so much to make this book work that the title of editor does not do her justice. She has been a wonderful collaborator, and I am deeply indebted to her for all the effort and creativity she put into the project. The external readers of the manuscript provided corrections and offered criticisms that made this a far better book than it would have been otherwise; I very much appreciate their input. Among others, I particularly wish to thank Alfred W. Crosby, University of Texas at Austin; George Fascik, Miami University, Ohio; and Nancy Fitch, California State University, Fullerton. I’d also like to thank my friend and colleague, Carol Byerly, for her generous comments and suggestions. Her own work on the 1918–1919 flu pandemic has played a crucial role in my understanding of the event; I dedicate this book to her. Susan Kingsley Kent Contents Foreword Preface LIST OF MAPS AND ILLUSTRATIONS PART ONE Introduction: “There Was No Stopping It” A Familiar, Yet Unprecedented Illness A Deadly Force Goes Global Treatment Responses: “There Was Just Nothing You Could Do” Short- and Long-Term Consequences of the Pandemic Legacy and Lessons of the Pandemic PART TWO The Documents 1. The Nature and Experience of the Disease 1. Letter from a Volunteer Nurse, October 17, 1918 2. E. T. Hsieh, The Recent Epidemic of Influenza in Peking, 1918 3. William Collier, A New Type of Influenza, October 23, 1918 4. K. Iwagawa, On Epidemic Influenza among Japanese Children, April 17, 1920 5. Great Britain Registrar-General, Age Distribution of Deaths Due to Influenza in Ireland, 1919 6. E. Oliver Ashe, Some Random Recollections of the Influenza Epidemic in Kimberley, South Africa, January 11, 1919 7. Mary E. Westphal, On Visiting Nurse Services in Chicago, November 8, 1918 8. Anne L. Colon, Influenza at Cedar Branch Camp, Michigan, 1919 9. Ijiro Gomibuchi, Personal Account of the World Influenza Epidemic, May 1919 10. Josie Mabel Brown, Recollections of a U.S. Navy Nurse, 1986 11. Sierra Leone Weekly News, Coffins, October 26, 1918 12. Sir Thomas Horder, The Post-Febrile Period, December 28, 1918 13. A. Hay-Michel, Nervous Symptoms in Influenza Patients, January 25, 1919 2. Transmission and Mortality 14. Santa Fe Monitor (Kansas), Early Reports of Influenza in the United States, January–February 1918 15. Daily Express (London), Mystery Malady Spreading in the Large Towns of Sweden, May 30, 1918 16. Daily Express (London), The Mystery War Disease: Its Appearance in Belfast, June 13, 1918 17. Daily Express (London), The New War Disease in Germany: Mystery Epidemic Now Ravaging Berlin, Doctors Powerless, June 17, 1918 18. Public Health Reports, Influenza a Probable Cause of Fever of Undetermined Nature in Southern States, June 21, 1918 19. The Times (London), Influenza Spreading in Germany, July 4, 1918 20. Lagos Standard, Influenza in Lagos, Nigeria, October 2, 1918 21. J. A. Oduenade, Spreading Influenza to the Nigerian Countryside, October 28, 1918 22. M. Cameron Blair and J. Beringer, Report on the Influenza Outbreak, Nigeria, September 5, 1919 23. The Times (London), Cape Town in the Grip of Influenza, October 10, 1918 24. C. E. L. Burman, A Review of the Influenza Epidemic in Rural South Africa, January 11, 1919 25. British Medical Journal, Influenza in India, April 5, 1919 26. William W. Cadbury, The 1918 Pandemic of Influenza in Canton, January 1920 27. Gresham Life Assurance Society, Influenza Claims Exceed War Claims, July 1, 1919 3. Treatment Responses 28. Victoria (Australia) Board of Public Health, “Spanish” Influenza, November 23, 1918 29. Journal of the American Medical Association, Failure to Quarantine in Buenos Aires, October 26, 1918 30. E. Henry Cummings, An Appeal by the Mayor of Freetown, Sierra Leone, September 7, 1918 31. E. Evelyn, A Defense of the Colonial Government’s Response to the Flu in Sierra Leone, September 25, 1918 32. Oakland, California, Health Department, Influenza! How to Avoid It! How to Care for Those Who Have It! 1918 33. United States Public Health Service, Warning Notice about Influenza, 1918 34. North Carolina State Board of Health, The Way the Germans Did It at Chateau-Thierry; The Way North Carolinians Do It at Home, October 1919 35. Government of New South Wales, Proclamation, February 3, 1919 36. Daily Express (London), Quinine and Cinnamon to the Rescue, June 22, 1918 37. Z. Dionysius Leomy, Letter to the Editor of the Sierra Leone Weekly News, September 14, 1918 38. “Why Catch Their Influenza?” 1919 39. The Daily Herald (London), On Behalf of the Invalids, December 21, 1918 40. British Medical Journal, Influenza and the Shortage of Doctors, November 2, 1918 41. Mateo Arriola Moreno, Influenza in Paraguay, 1918 42. South African Medical Record, Notes on the Influenza Epidemic, December 14, 1918 43. Indian Medical Gazette, A Criticism of Indian Physicians, February 1919 44. China Medical Journal, A Criticism of Chinese Treatment of Influenza, January 1919 45. Beulah Gribble, Influenza in a Kentucky Coal-Mining Camp, 1919 46. M. K. B., A Two Weeks’ Assignment, 1919 47. United States Navy, Awards and Commendations to Medical Staff, 1918–1919 4. Consequences and Repercussions of the Pandemic 48. New York Times, 2,000 Children Need Care: Measures Taken to Aid Chidren of Influenza Victims, November 9, 1918 49. Mary McCarthy, Orphaned by the Flu, 1946 50. Erich von Ludendorff, The Offensive in the West, 1919 51. German Office of Sanitation, Influenza Mortality, German Armed Forces, 1917–1919 52. The Times (London), Awaiting the Enemy Attack, July 12, 1918 53. Daily Express (London), New Attack in the North? July 18, 1918 54. C. W. Vining, Treatment of Influenza, November 30, 1918 55. The Union of South Africa, Bill to Make Provision for the Public Health, January 6, 1919 56. South African Medical Record, New Public Health Bill, January 11, 1919 57. Sierra Leone Weekly News, The Health of Freetown, September 21, 1918 58. Lagos Standard, Failure of British Authorities, October 2, 1918 59. Buchi Emecheta, The Slave Girl, 1977 60. Young India, Famine and Grip Sweeping India, February 1919 61. Young India, Editorial Notes and News, May 1919 62. Cary T. Grayson, Statement about Wilson’s Health at the Paris Peace Conference, 1960 63. Irwin Hood Hoover, The Truth about Wilson’s Illness, 1934 64. Herbert Hoover, Wilson at the Paris Peace Conference, 1942 APPENDIXES A Chronology of the Influenza Pandemic and Related Events (1918–1929) Questions for Consideration Selected Bibliography Index Maps and Illustrations MAPS 1. The First Wave, Spring 1918 2. The Second Wave, Autumn 1918 ILLUSTRATIONS The Age Distribution of Deaths from Influenza, 1911–1918 The American Expeditionary Force Marching through Downtown Seattle, 1918 Soldiers Being Treated for Influenza at Camp Funston, Kansas, 1918 Warning Notice about Influenza, 1919 (Document 33) The Way the Germans Did It at Chateau-Thierry ; The Way North Carolinians Do It at Home, October 1919 (Document 34) Why Catch Their Influenza? 1919 (Document 38) Influenza Mortality, German Armed Forces, 1917–1919 (Document 51) PART ONE Introduction: “There Was No Stopping It” The influenza pandemic of 1918–1919 killed at least thirty million and perhaps as many as one hundred million people throughout the world.1 Appearing in the midst of the Great War, it proved to be more deadly than any other disease since the visitations of the Black Death in the fourteenth century, and it killed more people than would any other single event of the twentieth century except World War II. George Newman, Chief Medical Officer of Great Britain’s Ministry of Health in 1918, called it “one of the great historic scourges of our time, a pestilence which affected the well-being of millions of men and women and destroyed more human lives in a few months than did the European war in five years.” It appeared with explosive suddenness, and “simply had its way. It came like a thief in the night and stole treasure.”2 Doctors estimated that eight hundred out of one thousand persons who came down with the flu contracted only a mild case; but some 80 percent of the other two hundred severely afflicted died.3 In the words of one Japanese physician who struggled to treat patients in a flu-ravaged community in rural Japan at the height of the pandemic, “There was no stopping it.”4 A FAMILIAR, YET UNPRECEDENTED ILLNESS Like all influenza viruses, the strain of 1918–1919 spread easily. It was passed from one person to another in droplets released into the air through coughing, sneezing, and even talking. It also spread through contact: Those infected, having touched their own eyes, noses, or mouths, passed the virus to others via the objects and surfaces they touched. People who contracted the flu were contagious—that is, they could pass it along—for as much as a full day before they suffered symptoms and remained contagious for another five to seven days a er they started to show signs of the illness. Environments with large concentrations of people—cities, towns, and villages, and especially military camps—enabled the virus to take hold and pass easily from one person to the next; the worldwide circulation of people and goods allowed it to move rapidly across the globe. This strain of influenza produced in many of its victims a variety of vivid and frightening physical symptoms that had not been encountered in previous incarnations of the disease. Doctors reported some patients who “spit up a quantity of frothy sputum tinged with bright blood.” “The dreaded blueness” of the face caused by heliotrope cyanosis disturbed observers—lay persons and medical professionals alike—who cited the incidence of this particular manifestation repeatedly. The “blueness” was the sign of pneumonia, of the patient’s effective drowning in the fluids that had built up in the lungs.5 The British Ministry of Health’s official report on the flu included color illustrations of the shockingly purple faces of patients suffering from “this dreaded heliotrope cyanosis.” This symptom signaled almost certain death, doctors came to understand. “It was amongst cases of this type that the great mortality of the epidemic occurred,” observed British Ministry of Health physicians. “In going round a large ward, one could, without examining the patients at all beyond looking at their countenances, pick out those who were going to die with almost uniform certainty by reason of their colour alone.”6 Unlike its predecessors, which tended to take infants and the elderly, this strain of influenza preferred men and women aged fi een to forty-five, victims in the prime of their lives (Documents 4 and 48). In the United States, the flu killed men and women aged fi een to forty-five at a rate twenty times greater than previous manifestations of the disease (see Figure 1).7 The disease took more men than women, though pregnant women suffered particularly acutely from the illness and were the most likely to die.8 It seems likely that the virulent nature of the virus compelled an immune response in bodies that itself served to exacerbate the severity of the illness: When bodies released toxins to fight the influenza virus— called cytokines—those toxins proved powerful enough to destroy lung tissue. In attacking the virus, in other words, the cytokines also attacked vulnerable respiratory tissue, making those possessing the strongest immune systems the most likely to succumb to respiratory illness, particularly pneumonia.9 Medical authorities could not explain this unusual characteristic of age and gender distribution of mortality, a phenomenon that contributed to the sense of utter incomprehension the disease produced within all segments of society throughout the world. This was an illness without precedent, whose etiology and treatment could not be discerned or determined. Figure 1. The Age Distribution of Deaths from Influenza, 1911–1918 Influenza viruses are typically most deadly for the very young and the very old, with the lowest rate of death occurring among adults in their teens, twenties, and thirties. But the 1918 virus proved markedly different, with an unprecedented death rate among adults in the prime of life. The uncharacteristic peak amongst fi een- to forty-five-year-olds, resulting in the “terrible W” seen here, differs greatly from the more typical curve shown for 1911–1917. This particular strain of influenza defied all previous understandings of the disease (Document 3). It struck quickly and without warning, felling people in their homes, in schools, in stores and businesses, and in the streets. The nature and scope of the flu compelled medical authorities to abandon their ordinarily clinical accounts and describe the situation in highly charged, graphic language. Herbert French of the British Ministry of Health recounted what he believed to be a typical situation. “In the midst of perfect health in a circumscribed community,” he wrote, “such as a barracks, or a school, the first case of influenza would occur, and then within the next few hours or days a large proportion—and occasionally even every single individual of that community—would be stricken down with the same type of febrile illness, the rate of spread from one to another being remarkable. The patient would be seized rapidly, or almost suddenly, with a sense of such prostration as to be utterly unable to carry on with what he might be doing; from sheer lassitude he would be obliged to lie down where he was, or crawl with difficulty back to bed.” The Lancet, a medical journal published in Great Britain, abandoned its scientific distance when it described the flu’s “invasion of every hitherto safe nook and cranny in the inhabited world.”10 Barracks became converted to sick rooms overnight, and hospitals became so overrun with patients that they had to turn new arrivals away. Nurses and doctors could not handle the unprecedented numbers of cases; undertakers could not fill the orders for caskets that came streaming in nor could gravediggers handle the volume requesting their services (Documents 1, 10, and 11). Some stores lost business as customers fell sick or avoided public places. One department store in Little Rock, Arkansas, noted the Arkansas Gazette on October 19, 1918, “which has a business of $15,000 daily, is not doing more than half that.” But others saw unprecedented demand for their products: Drugstores and apothecaries couldn’t keep patent medicines in stock (Document 39). As workers fell ill, labor shortages became common. Mine shutdowns in Tennessee owing to sickness reduced the production of coal there by 50 percent; some U.S. factories, already facing shortages of labor because of military conscription, reported being crippled by influenza. Public services couldn’t keep pace, as transportation and utility workers became so incapacitated by illness that they could not make it to work.11 Combatants on the western front in Europe suffered especially harsh attacks: Laid low by fever and then by opportunistic pneumonia that took advantage of the weakened conditions of the soldiers, thousands upon thousands of them had to be invalided to the rear areas. German soldiers appeared to suffer disproportionately from the disease in June and July of 1918, experiencing great losses to illness and death (Document 51). Among the British and French forces, the first wave of the pandemic, which occurred in late spring and early summer, caused illness but not terrible disability. But the second wave, arriving in the fall, hit everyone hard: U.S. forces suffered more deaths from the flu in October 1918, at the height of their offensive against the Germans, than from battle. A er the armistice in November 1918, the incidence of cases declined, but sprang back again in February of 1919. By the middle of 1919, the virus had lapsed, although it appeared again in 1920 in less lethal form. The particular configurations of this influenza virus may have been a product of the war. The conditions of this war may well have enabled a common and usually mild disease to mutate into a deadly strain that spread like wildfire around the world, killing not only the weakest in the population but the very strongest as well. Taking advantage of thousands of people congregating together in army camps and hospitals, moving constantly in and out of contact with others, and subject to conditions in the trenches that weakened immune systems, this flu took on a character unprecedented in its impact. Flu viruses mutate regularly, but most viruses do not survive long enough for the changes to take effect. In ordinary conditions, a virus that mutated into a particularly deadly strain would not have sufficient hosts to sustain itself—it would kill off its hosts too quickly to be able to reproduce and pass on its characteristics. But the conditions of warfare in 1918 ensured that sufficient hosts—young, healthy men—were continuously made available, so that the virus could survive to reproduce. As soldiers fell ill, they were brought to the rear areas and replaced by others who rotated in to the camps and trenches. The camps and trenches were thus filled with men who had been infected with the virus but were not yet sick, on the one hand, and men who had not yet been exposed to the virus to whom they could transmit it, on the other. A steady and constant supply of noninfected troops arrived to succor the virus, ensuring that its terrible virulence was not exterminated by the elimination of its hosts. Without the particular circumstances brought on by the war, the virulent strain of influenza might not have been able to maintain its presence and take down so many victims.12 While the role that the war played in the spread and mutation of the virus may be debatable, there is little doubt that the two events were intertwined in people’s minds, as patients and observers alike noted intimate connections between the flu and the war. For some, the war was incorporated in the hallucinations they suffered while feverish with the disease. London’s Daily Express cited an inquest report on a nine-year-old boy whose death from the flu followed a delirious episode when he “jumped out of bed, swinging his arms about and saying he was fighting the Germans.” For others, the war served as an obvious metaphor in which Germans and germs were equally to be feared. In October 1918, a British physician told an inquest panel that doctors were “fighting at home a foe as bad as the Huns.” Stories about the “Influenzal Hun” who attacked innocent victims appeared in Allied newspaper accounts. An advertisement in the Illustrated London News warned that the flu placed Britons “under the domination of enemies more ruthless and destructive even than the Hun.” The copy spoke of “‘Germ-Huns’ in their trenches” against whom the product touted—Kruschen Salts—“is your first line of defence.” A reporter for the Daily Express told of his visit to a London hospital “to inspect a party of the enemy who had been taken captive . . . and were at the time interned in the ‘cage’ of a microscope. They wore a pink uniform,” he noted. Gas masks were urged on the populace; indeed, doctors and scientists allowed as how “the lesions produced by poisonous gases during the last war resembled those seen in the respiratory complications of influenza.” Although there was no such medical relationship between poison gases used in the war and influenza, some accounts suggested there was (Document 23). Doctors, asserted the British Medical Journal in April 1919, who “set out to conquer [the influenza] disease have mightier opponents than Ludendorff or Hindenburg, and must face a longer campaign than that of 1914–1918.”13 American novelist Katherine Anne Porter recounted the flu’s impact in Denver, where she came down with the illness while working as a journalist during the war. In her semi-autobiographical short story about the flu epidemic, “Pale Horse, Pale Rider,” Porter offered a realistic depiction of the effects of the disease from the point of view of one of its victims. Her protagonist, Miranda (whom she based on herself), contracts the flu, becoming delirious and hallucinating scenes that explicitly recalled the war. In a set of horrifying images, she believed she saw her physician killing a child. “Across the field came Dr. Hildesheim, his face a skull beneath his German helmet, carrying a naked infant writhing on the point of his bayonet, and a huge stone pot marked Poison in Gothic letters. He stopped before the well that Miranda remembered in a pasture on her father’s farm, . . . and into its pure depths he threw the child and the poison, and the violated water sank back soundlessly into the earth. Miranda, screaming, ran with her arms over her head; her voice echoed and came back to her like a wolf’s howl, Hildesheim is a Boche, a spy, a Hun, kill him, kill him before he kills you.” In an episode of dissociation—a disruption of normal integration of conscious or physical functioning—Miranda described how “her mind, split in two, acknowledged and denied what she saw in the one instant, for across an abyss of complaining darkness her reasoning coherent self watched the strange frenzy of the other coldly, reluctant to admit the truth of its visions, its tenacious remorses and despairs.”14 As Porter’s story suggests, the flu le survivors with a variety of mental symptoms, many of them represented by physicians and the press in terms similar to those used a er the war to describe sufferers of shell shock (Documents 12 and 13). Caroline Playne of Britain noted “the plague of nervous character” following the onslaught of influenza. Pronounced fatigue, lassitude, depression, sleeplessness, hallucinations, emotional lability, and even dissociation accompanied the physical debilitation of the disease. Dr. G. Holliday wrote to the British Medical Journal on August 17, 1918, that “mental symptoms were frequent” in the cases he saw; Samuel West informed readers of The Lancet on February 1, 1919, that “the depression which follows influenza is so constant that it ought to be regarded as part of the disease.” The medical correspondent for The Times of London, having contracted the illness himself, advised readers that “the most distressing symptom was a swi loss of mental capacity and then inability to think coherently.” “All forms of hysteria have been observed a er influenza,” reported Drs. Thomson and Thomson in 1919, “such as hysterical convulsions and the so-called hystero-epileptic attacks. . . . Post-influenzal neurasthenia is very familiar,” they noted, “postinfluenzal psychoses . . . frequently observed and reported.” They cited a study that asserted that influenza, “of all the infectious diseases . . . is the most likely to be followed by mental disorder.” The Lancet declared in December 1918 that “the ‘higher centres’ [of the nervous system] suffer chiefly. Marked depression is common, emotional instability is o en seen, and suicide is by no means rare.”15 Such psychological symptoms were vividly described by British writer Ivy Compton-Burnett, who came down with the flu in the summer of 1918 and was discovered by mere chance lying unconscious on the floor of her flat. She exhibited delirium and, when recovered from the acute stage of the disease, “extreme debility, unable to read or write.” She asked to be read to, but could not tolerate much stimulus, asking her sister to “read, but don’t put any expression into it. Read in a dull, monotonous voice.” She took up mindless tasks as her recovery progressed, but “I couldn’t do brainwork,” she explained.16 A DEADLY FORCE GOES GLOBAL The flu wreaked its havoc on military and civilian populations throughout the world in three waves. Arising first, we think, in the American Midwest in the late winter and early spring of 1918, it appears to have spread from Camp Funston outside Fort Riley, Kansas, to Camp Oglethorpe in Georgia, thence rapidly to Europe on board the troopships transporting U.S. forces to the western front (Documents 14–19). Contemporaries called it the “Spanish flu,” mistakenly believing that it had originated in Spain. It had not, but Spain was one of the few countries in Europe that had not imposed an embargo on information emanating from its borders and allowed news reports of illness there to disseminate. Other European countries, engaged in a bloody, brutal, horrific war of attrition, censored what news could be put out and were quick to jump on Spain as the source of what would prove to be a terrible killer. An exhausted, emotionally and physically stressed European population proved no match for the illness, which marched through the continent, made its way to Asia and Africa, and arrived in Australasia in July 1918. (See Map 1.) Map 1. The First Wave, Spring 1918 Influenza first appeared in the American Midwest in March of 1918. By April, it had made its way to Europe, Asia, and North Africa. By July 1918, it had appeared on six continents, hitting South America and the Pacific Islands in June, and Australia the following month. This first wave was relatively mild and caused little alarm. This first wave caused little alarm, as it was a fairly mild strain and killed no more than the usual number of influenza victims, but it was followed by an onslaught of unprecedented force. By midAugust the virus had mutated, and the second wave began to make itself felt, moving speedily along commercial and military transportation routes across the globe, leaving few populations untouched. The new form of the virus landed in Freetown, Sierra Leone, in West Africa on August 15, carried by two hundred sick sailors who had traveled from Britain on board the British naval ship HMS Mantua. Within two weeks, local dockworkers had spread the flu into town, where perhaps as much as 3 percent of Sierra Leone’s population died from the disease. They also carried the flu on board other ships tied up at Freetown, thus transporting the virus to other ports along the African coast. The Shango carried the disease from Freetown to Accra, Gold Coast (present-day Ghana), and on to the Cape Coast; the SS Bida took it from Sierra Leone to Lagos, Nigeria, in mid-September, from which it then spread inland along the railway lines, bicycle and walking paths, and streams carrying canoes upriver (Documents 20–24). Troopships Jaroslav and Veronej, calling at Freetown, transported 1,300 troops from the South African Native Labour Contingent, who had seen service in France, to Cape Town. As these men made their way home, they brought the virus into southern and central Africa.17 (See Map 2.) Map 2. The Second Wave, Autumn 1918 By August 1918, the virus had mutated into a deadlier and more virulent form. Carried on board commercial and military ships, it spread quickly through port towns and cities and into inland regions. The second wave of the flu appeared in Brest, on the northwest coast of France, around August 22. Brest served as the disembarkation port for the American Expeditionary Force, some 1.6 million strong by September 1918. Some days later, influenza appeared in the United States, in Boston, the port from which a large portion of the American forces embarked en route to France. As arriving troops moved into their camps and then made their way to the western front, the virus moved with them, inflicting a heavy toll in illness and deaths among the fighting forces and the hard-pressed civilian populations of Europe. From Russia, the flu moved into Asia; it entered India through the port of Bombay in October. It made its way to Australia, New Zealand, and the Pacific Islands by November and December. From Boston, the flu traveled westward across the American continent and was also carried aboard ship to the Caribbean and to Central and South America. No part of the inhabited world escaped unscathed.18 The third wave of influenza appeared in February 1919; less virulent than the second, it nevertheless took its toll on already devastated populations. The mortality figures for the flu pandemic beggar the imagination. Where influenza epidemics in the past produced death rates of about 0.1 percent of those infected, this one killed 2.5 percent of those infected. Britain lost 250,000 people to the disease, as did France and Germany. In the Russian empire, 450,000 inhabitants died, as disease combined with revolution and civil war to decimate the population; 50,000 died in Canada. In the United States, 675,000 Americans died, and life expectancy dropped by some twelve years in 1918 as a consequence of the huge numbers of deaths recorded that year. Indigenous peoples in North and Latin America and in Australia and New Zealand suffered disproportionate mortality rates; some communities lost upwards of 80 percent of their members. Africans died in greater numbers than did Europeans: Where the latter experienced mortality rates of perhaps 1–2 percent, African rates reached upwards of 5 percent of the population. In Kenya, for example, 50,000 people, or 5.5 percent of the population, succumbed to the disease. South Africa lost perhaps 280,000. South Asia was hit hardest of all overall, India alone suffering the loss of at least six million and perhaps as many as fi een million people (Document 25). Indonesian deaths reached 1.5 million. Within some populations, there was a great disparity in mortality groups; white New Zealanders, for example, had a death rate of 5.8 per 1,000, while the indigenous Maori population died at a rate about seven times higher. China and Japan appear to have weathered the illness better than most other countries. Japan’s death rate stood at 4.5 per thousand, while Shanghai’s may have been as low as 1.3 per thousand. It is virtually impossible to know the death rate across China as a whole, as records simply do not exist that might reveal it, but what documents we do have suggest a far lower incidence of death than occurred in other parts of the world (Document 26).19 The American Expeditionary Force Marching through Downtown Seattle, 1918 The civilian population had been ordered by authorities to wear masks in order to hinder transmission of the disease, a precaution that the military found necessary as well. TREATMENT RESPONSES: “THERE WAS JUST NOTHING YOU COULD DO” Governments and public health officials responded to the epidemic in haphazard ways. At one extreme, German authorities simply refused to make public the extent to which the disease threatened the public health. In late May 1918, mention of the disease had entered Germany via foreign press agencies, which mistakenly attributed the origins of the outbreak of influenza to Spain, but a January 1918 directive had prohibited publication or public discussion of any statistics treating infections. Even when the more virulent strain of flu arrived in September, German state ministries and local bureaus denied or downplayed the incidence of illness and death.20 In other countries where wartime restrictions on the dissemination of information were not so strict, authorities took pains to try to reduce the transmission of the disease. Schools, theaters, libraries, and other sites where crowds might congregate were shut down; bars and churches, however, were not. The public and their servants—police, nurses, bus drivers, soldiers and the like —were urged to wear surgical masks (Documents 28, 32, and 35). Advertisements touted the benefits of alcohol, tobacco, patent medicines, or home remedies containing garlic, camphor, cinnamon, quinine, or sugar cubes soaked in kerosene (Documents 36, 37, and 38).21 Such remedies didn’t work. To their surprise, dismay, and chagrin, physicians did not know how to treat this disease. The documents in this volume reveal just how little Western scientists knew, misunderstanding the etiology of the illness and prescribing o en-contradictory measures to treat it. Having mistaken its source as a bacillus, which since the 1890s had been thought to be the cause of influenza, doctors resorted to treatments that could have no effect on viruses, whose role in generating influenza was not discovered until 1933. Many physicians turned to vaccines to treat their patients, but these were bound to fail in the absence of any real knowledge about the disease’s cause (Documents 29 and 42). Despite their efforts to treat the flu with almost any remedy they could think of (Documents 42 and 43), ultimately they were helpless in the face of this disease. As one American physician put it, “There was just nothing you could do.”22 Western physicians in China excoriated and mocked traditional Chinese medicine (Document 44), little realizing that the treatments advised there included compounds—such as the untranslatable mahuang xingren shigao decoction, for example—that had been shown to reduce fever. Noting the effectiveness of Chinese traditional medicine in treating epidemic disease over a number of centuries, two Chinese scientists believe that the far lower rates of mortality in China were a result of peasants turning to traditional practitioners, whose successes in reducing fever by means of herbal remedies were long-standing.23 In Japan, similarly, traditional treatments utilizing an oleo of dried ephedrine, peony, and gingerroot proved effective in reducing fever and nasal congestion. This herbal concoction was cheap and readily available to all but the poorest Japanese, and it may have helped to control the high fever that accompanied pneumonia.24 With physicians unable to make much difference during the pandemic, nursing care turned out to be one of the most effective treatments. Countries involved in fighting the Great War experienced a pronounced nursing shortage, however, so nurses were o en in short supply. They died, moreover, in fairly large numbers, given their exposure to the disease (Document 47). Despite these factors, nurses brought relief to a great many patients, and their ability to make a difference to their patients served as a pointed contrast to the lack of effective treatment that physicians could produce. Physicians o en reported their despair at making a difference; nurses, however, took pride in their ability to alleviate the suffering of many of their patients (Documents 45 and 46). SHORT- AND LONG-TERM CONSEQUENCES OF THE PANDEMIC The flu had a powerful impact on the early twentieth century, not only on the families, communities, societies, and nations that suffered such tremendous losses, but also on the politics and economics that characterized the interwar period. Individuals carried the burden of personal grief and tragedy throughout the course of their lives (Document 49). Economies suffered from the loss of workers and consumers; insurance companies faced liabilities greater than those incurred through wartime deaths (Document 27). Governments throughout the world were convinced by the experience of the flu to develop and institute public health systems. In South Africa, the Public Health Act of 1919, by removing poor white populations from slums and limiting its measures to white populations in urban centers, facilitated the racial segregation of cities. The Act did not utilize specifically racial language in its clauses, because legislators never considered that its provisions would include African populations. Thus, the racial segregation that Public Health Act helped to create lay the groundwork for the system of apartheid that emerged in South Africa a er 194825 (Document 55). Elsewhere, material and emotional stresses contributed to anticolonial revolts that broke out in the decade following the war (Documents 57–59). Although the flu epidemic appeared during the course of World War I and spread with the virulence it did via the presence of armies massed in Europe, little attention has been given to the impact the epidemic might have had on the prosecution and outcome of the war. The flu had a decided effect on the American Expeditionary Force as it engaged in its massive campaign against the Central Powers in the Meuse-Argonne battle in late September, October, and early November 1918. Of the four million men of the AEF, at least one million fell ill with flu, compelling General John Pershing, commander of the AEF, to make increasingly urgent appeals to Washington for increased medical support. “Influenza exists in epidemic form among our troops in many localities in France accompanied by many serious cases of pneumonia,” he cabled on October 3, a week into the Meuse-Argonne campaign. “Request 1500 members of Army Nurse Corps . . . be sent to France as an emergency requirement.”26 The Eighty-Eighth Division, serving on the front lines, reported that about 30 percent of its forces had come down with the flu; of these men, 45 percent died during one week in October. The Eighty-Sixth Division saw a 35 percent rate of illness among its ranks, and some companies in the division had rates of up to 73 percent. This meant that replacement troops for those killed or wounded at the front could not be readily found, and the ability to evacuate and treat the wounded was bogged down by the numbers of soldiers and medical personnel ill with influenza. Though the Americans defeated the Germans in the Meuse-Argonne sector, Pershing’s efforts were considerably hampered by the incidence of disease. More Americans died of disease than of the infliction of bullets or shells, and many thousands of men died who might otherwise have lived had they been able to reach military hospitals equipped to handle their injuries.27 The flu may also have had an impact on the German effort to end the war through a last massive offensive in the west in the spring of 1918. The treaty of Brest-Litovsk with Russia in 1918 had freed up German troops in the east, enabling their transport to the western front for use in what the German high command hoped would be a knockout blow against the British and French armies. With an additional one million experienced soldiers and three thousand guns, German forces outnumbered those of the Allies considerably, by as many as four to one in some sectors along the western front. British forces had been seriously weakened during the Battle for Passchendaele in 1917, and the French army had suffered not only heavy losses but was faced with internal disagreement at the highest levels of command. General Pershing had refused to commit American troops to the British and French armies. German generals Paul von Hindenburg and Erich von Ludendorff, directing not merely the war effort but virtually the whole government as well, realized that they had one last chance to break through Allied lines. Their hopes for victory rested upon this final assault. On March 21, the Germans launched what has come to be called the Spring Offensive. They broke through British lines near SaintQuentin; by the end of May, the Germans advanced on the Marne River, establishing artillery guns that could fire on Paris, which led the French government to prepare to evacuate from the capital. But when Ludendorff ordered a final push on July 15, 1918, his offensive failed, allowing the Allies to counterattack, which they did, beginning August 8 at the Second Battle of the Marne. Joined now by the Americans, the Allies pushed back the German forces, until Hindenburg and Ludendorff were forced to sue for peace. The armistice that ended the war in favor of the Allies went into effect on November 11, 1918. The failure of the German armies to complete their offensive in May spelled their defeat. German troops lacked sufficient food and supplies and they were sick, Ludendorff reporting that more than two thousand soldiers in each of his divisions suffered from influenza (Documents 50, 52, and 53).28 Most scholars have dismissed the flu as a major factor in this defeat, arguing that because the flu simultaneously hit all of the belligerent countries with comparable effect, it had little to do with the German defeat.29 But one recent scholar has asserted that in fact German and Austrian forces experienced a particularly virulent form of the virus during the Spring Offensive, some two months before the disease struck the Allied forces so heavily in August, September, and October (Document 51). Between the time the offensive began in March until its failure in mid-July, 1.75 million German soldiers had become ill with the flu, more than 500,000 of them in June and July. Ludendorff, by late July, was attributing his failure to continue the German offensive against the Allies in part to the effects of the pandemic (Document 50).30 Historians share the belief that had the German Spring Offensive succeeded, Britain and France would have been compelled to accede to German demands for a peace settlement. Its failure, in light of the debilitating conditions faced by the armed forces and the civilian population at home, virtually ensured an Allied victory once the Americans appeared on the scene. Some German units experienced infection rates of 80 percent, while on the home front, civilian mortality rates reached their highest level for the entire wartime period in October and November of 1918. The German workforce had become weakened considerably by flu between March and November 1918, and their productivity waned concomitantly, as measured by the records of coal mine output.31 It cannot be asserted that influenza brought about the defeat of Germany in 1918; too many other factors played important roles in the failure of the Germans to defeat their enemies. However, the incapacity of the German soldiers who had fallen ill during the flu epidemic and the inability of the German home front to supply and feed its troops contributed to the failure of the Spring Offensive. Elsewhere, the devastations caused by influenza contributed to a variety of postwar colonial revolts. In India, which had already been hit so heavily by famine and disease, the influenza epidemic struck the Punjab province particularly hard, killing up to 25 percent of the population in some villages (Document 25).32 Further, conditions in the Punjab following the war made life difficult for a broad strata of the Indian population. Wages in industries that had prospered in wartime fell dramatically, catapulting much of the population into debt. Weakened and impoverished Punjabis o en expressed their distress through protests, creating disorder throughout the province; Mohandas Gandhi and his Congress Party made a clear connection between the extent of famine, influenza, and riots throughout India in Young India, the official organ of the Congress Party (Document 60). Colonial officials sought and received exceptional new powers to deal with the disorders by means of the Rowlatt Acts, legislation that enabled the British viceroy to suspend due process of law and to imprison Indians without trial. The Rowlatt Acts inflamed Indian public opinion, and educated Indians of all political stripes submerged their differences and united against the Rowlatt Acts under Gandhi’s satyagraha (civil disobedience) movement. Demonstrations took place in a number of cities, and rioting broke out in Ahmadabad, Delhi, and a number of Punjab provinces (Document 61). When, on March 30 and April 6, 1919, a series of peaceful hartals—a kind of religious general strike— shut down much of the Punjab, rumors of mutinies and plots to end British rule swept through the Anglo-Indian population. Believing themselves to be at risk for assault and murder, British officials and civilians began to arm themselves.33 In Amritsar, British officials ordered the arrest and deportation of two local leaders, who, they believed, planned to incite the townspeople to violence. Word of their deportation spread throughout the city, and, in concert with news of Gandhi’s arrest in Palwal the previous day, spurred large crowds of Indians—unarmed —to congregate in the city center and make their way to the Civil Lines, the boundary separating the Indian from the Anglo-Indian population, to protest the arrests. Along the way, no violence occurred and no Europeans were assaulted. Upon their arrival at the bridges that crossed over the Civil Lines, however, the crowd met resistance from British troops, one of whom may have fired a shot without orders; when demonstrators tried to continue forward and began throwing stones at the troops, they were fired upon. Official accounts put the Indian dead at twelve, the wounded at twenty to thirty. The shooting set off a day of rioting that resulted in sabotage, looting, arson, assault, and the deaths by beating of five European men. Protesters cut telegraph and telephone lines and damaged the railways. Anglo-Indian women and children were hurried off to the fort occupied by British forces, but not before an Englishwoman was badly beaten and le for dead in the street.34 On April 13, 1919, Brigadier-General Reginald Dyer ordered a patrol of Indian troops under his command to fire on a crowd of some 25,000 unarmed Indian men, women, and children in the Jallianwala Bagh, a kind of walled garden, in Amritsar. About ten minutes later, their ammunition virtually spent, he ordered the troops to cease shooting. Hundreds of people lay dead, thousands more wounded littered the ground. Dyer led his troops from the Bagh, leaving the injured to fend for themselves; the curfew imposed on Amritsar kept would-be rescuers from collecting the dead and getting medical attention for the wounded until the next day. Many died overnight. The Amritsar massacre, as it came to be called, provoked a crisis in British and Indian affairs. For Indian nationalists, it marked the moment at which home rule within the empire would no longer be enough; nothing less than independence would do and the “Quit India” movement took off. In this instance, colonial revolt occurred immediately following the depredations of the influenza pandemic. In southeastern Nigeria, colonial resentments born of the pandemic would fester for a decade, slowly fostering what would eventually become a series of remarkable revolts.35 In November and December of 1929, a series of demonstrations, protests, risings, and riots involving tens of thousands of women took place in southeast Nigeria. The Aba Riots, as the British dubbed them, are known to their participants and to subsequent African memory and historiography as the Ogu Umunwaayi, the Women’s War. In the course of it, more than fi y southeastern Nigeria women were killed by British troops.36 The Women’s War marked a historical high point in the West African resistance to British colonialism, as southeastern Nigerian women sought to defend their social systems, which had been dramatically transformed by their engagement with British colonialism. A growing imbalance in socioeconomic relations between southeastern Nigerian men and women; the displacement of indigenous religious and economic practices by Christianity and European capitalism; the undermining of indigenous power structures by the British colonial administration—all these had affected southeastern Nigerian peoples since the late nineteenth century. The twin traumas of the Great War and influenza brought even more profound and extended upheaval, with the flu constituting perhaps the greatest disruption of all. The Women’s War represented an attempt on the part of women to, in effect, decolonize southeastern Nigeria, to return their societies to the practices of the past. Nigerians attributed the flu epidemic to the British, calling it “the white man’s death. They shoot it into the air, and we breathe it in and die.”37 This was a disease unlike others such as smallpox, to which Nigerians were accustomed. It felled men in their fields with virtually no warning. “Death was always so sudden that the relatives were too shocked to cry,” noted author Buchi Emecheta, who recounted her mother’s experiences during the flu in her novel, The Slave Girl (Document 59). Families and villages suffered its ravages, sometimes whole villages succumbing to death; the mortality wrought by the epidemic had the effect of undermining long-held family and community responsibilities and contributed to social disintegration, the effects of which fell disproportionately on women. Officials estimated that 250,000 people out of a population of nine million in the southern provinces of Nigeria died from the flu, although these are wildly undercounted figures. While colonial officials reported that “women suffered less than men” in the pandemic, they also noted that there was greater incidence of illness among pregnant women than in the female population more generally.38 This demographic fact resonates with women’s contentions later in the Ogu that pregnant women were perceived as the particular targets of all that had gone wrong in the land—that the “trees that bear fruit” were seen as particularly vulnerable to the social transformations and traumas associated with British rule, including the new killer, ifelunza or felenza, as Igbo-speaking people called it. Women bore the brunt of extra work imposed by the pandemic. In the generality of southeastern Nigerian households, women cared for the sick and the dying almost exclusively. When men died, married women were expected to prepare their corpses for burial and to undergo at least some of the privations of widowhood39 on top of their own illness and grief. If men survived and convalesced, married women would be expected to take care of them as well as any children that might have survived, while also maintaining their household duties. Women were also expected, during this oge ifelunza (time period of the influenza), to take on the responsibilities of cultivation when men could not work. Emecheta places the flu epidemic at the center of The Slave Girl, a story that culminates in a women’s war. The narrative thread carries the action of the novel from the devastation of family and community by the disease, to slavery, to women’s war, to freedom from slavery, to a return to home and family—opening and closing with felenza. Emecheta learned about the epidemic at her mother’s knee, and while we cannot claim the novel for historical “fact” (the flu is said to have broken out in 1916, for example), we must see in it traces of the powerful influence exerted by the influenza epidemic on southeastern Nigerian peoples; it contributed to the single most powerful memory of rebellion against colonial authority, the Women’s War of 1929. Perhaps most intriguing, the influenza epidemic may have had some role to play in the peace settlement imposed on Germany following the Great War. The major politicians charged with creating the Versailles Treaty—President Woodrow Wilson of the United States, Prime Minister David Lloyd George of Great Britain, and Prime Minister Georges Clemenceau of France—all fell victim to the flu.40 The physical and mental debilitation that Wilson suffered, in particular, may have had an impact on the kind of peace enshrined in the treaty, whose punitive nature contributed to the acceptance of fascism in Germany. In January 1918, Wilson had issued his Fourteen Points, principles according to which a non-punitive peace between the belligerent countries should be forged; it was on the basis of the Fourteen Points that Germany had signed the armistice in November 1918. Clemenceau and Lloyd George had different ideas about peace terms, looking to impose on their defeated enemy measures that would (1) require Germany to pay reparations (that is, pay the Allies for the costs they had incurred in prosecuting the war); and (2) permit the Allies to occupy the Rhineland and the Saar Basin, resource-rich areas of Germany. Wilson was determined to defeat such punitive measures and to ensure the creation of a just peace. When delegates to the peace conference arrived in Paris in the spring of 1919, the third wave of the flu had just peaked. Many of the chief actors and their behind-the-scenes aides fell ill with the disease. Disease continued into April and struck Wilson at a particularly difficult moment in negotiations. He and Clemenceau had parted ways over the issues of reparations and French annexation of the Saar Basin, and on April 3, it appeared that Wilson might walk out of the talks. That night, Wilson suddenly came down with the flu, producing a temperature of 103°F, a cough so extreme that he could hardly breathe, and debilitating diarrheal cramps. His physician, Admiral Cary Grayson, feared he might die that night. He didn’t, but over the next five days, Wilson lay prostrate, unable to get out of bed (Document 62). Ten days a er Wilson fell ill, the difficulties standing in the way of an Anglo-American-French agreement on reparations, occupation of the Rhineland, and annexation of the Saar Basin were resolved. While a great many concessions had been granted, Wilson lost by far the greatest number. Virtually none of his Fourteen Points save the establishment of a League of Nations survived, and the treaty that was forced upon the Germans contained a number of harsh terms. The loss of the Rhineland and the Saar meant that Germany’s economic recovery would be considerably hampered. Article 231, the so-called war guilt clause, compelled Germany to accept “the responsibility of Germany and her allies for causing all the loss and damage to which the Allied and Associated Governments and their nationals have been subjected as a consequence of the war imposed upon them by the aggression of Germany and her allies,” legitimating the imposition of heavy reparations payments. Germany was forced to demilitarize and to cede significant amounts of territory containing German populations. German colonies were ostensibly placed under the mandate of the League, but were effectively handed over to Britain and France. Wilson’s “peace without victory” lay in tatters.41 How did this happen? Some individuals close to Wilson attributed his failure to insist upon his principles to the effects of the flu. Not only did the disease weaken him physically, it seemed also to have produced the same mental symptoms of depression, disorientation, and delusion described earlier (Documents 63 and 64). “I never knew the President to be in such a difficult frame of mind as he is now,” wrote his secretary, Gilbert Close, on April 7, 1919. “Even while lying in bed he manifested peculiarities.” Wilson’s Secret Service agent observed that “he never did regain his physical strength, and his weakness of body naturally reacted upon his mind. He lacked his old quickness of grasp.” Lacking the energy, the intellectual capacity, and even the interest to continue his battle with Lloyd George and Clemenceau, he simply gave in and assented to a peace so unjust that, he told an aide in early May, “if I were a German, I think I should not sign it.”42 Faced with the prospect of a continuing Allied blockade that had reduced the German civilian population to starvation, German officials had no choice but to sign. The humiliations and material deprivations forced upon the German people by the Versailles Treaty, among other factors, gave ammunition to anti-democratic forces in Germany that would ultimately allow for the rise of Nazism and the ascent to power of Adolf Hitler in 1933. This is not to suggest that the influenza epidemic of 1918–1919 brought about the rise of fascism and the outbreak of the Second World War in Europe. That would be far too direct a connection and cannot be sustained by the evidence. But the epidemic may well have had a significant effect on the outcome of the peace settlement following World War I, and its potential role should not go unremarked. LEGACY AND LESSONS OF THE PANDEMIC In 1933, scientists determined that influenza was caused by a virus, not by a bacillus as they had previously believed. Isolation of the virus enabled clinicians to develop vaccines against the disease, but because virus strains contain so many subtypes and because they mutate so rapidly in a process known as antigenic dri , vaccines are not always effective from year to year—even in the unlikely event that they could be made available to large segments of the world’s population. Flu pandemics broke out again in 1957 and 1968, but none of them struck with anything like the virulence seen in 1918. Incredibly, the influenza epidemic of 1918–1919 disappeared from popular memory for more than six decades following its spectacular visitation upon the peoples of the world. As we’ve seen, individuals wrote of it in their memoirs or biographies, but public consciousness of the extraordinary losses and the traumas they brought about simply vanished. In the 1970s, two textbooks addressing the pandemic appeared,43 but the significance of the disease in the history of most nations simply did not register. We can only speculate as to why this historical amnesia settled in and lasted so long. A number of explanations suggest themselves. First, the devastations and dislocations of the Great War proved so profound in their consequences that influenza just didn’t signify. The Russian Revolution, the dismantling of world empires, the Great Depression, the rise of fascism, World War II, the cold war, and decolonization—these momentous events arose out of World War I and commanded the attention and the energies of the world for much of the twentieth century. But perhaps equally important, the experiences of the flu pandemic of 1918–1919 laid bare the inability of nations and peoples to prevent, control, or treat what had come to be regarded as an everyday illness. Science had failed; medicine had failed; governments had failed—and what were people supposed to do with that nasty bit of information? Forgetting about it may just have appealed to publics too frightened to acknowledge so grand a failure on the part of institutions and agencies they had come to rely upon for protection and safety. Whatever might have caused us to relegate the pandemic to our historical unconscious, we appear to have dredged it up again in the 1990s, no doubt in response in part to the AIDS epidemic that had engulfed the world in the 1980s. Scholarly accounts of 1918 appeared in greater profusion, and new interest, along with vastly improved technology, enabled scientists to revisit the events of 1918 with far more effective tools of investigation. In 1997 scientists under the leadership of Jeffrey Taubenberger determined the virus that had been responsible for the terrible pandemic of 1918–1919. Using preserved lung tissue samples from the body of U.S. Army Private Roscoe Vaughan, who had died of the flu at Camp Jackson, South Carolina, on September 26, 1918, Taubenberger and his colleagues performed DNA analyses. The tests revealed that the flu pandemic of 1918–1919 had been caused by an influenza A virus, H1N1. The pandemics of 1957 and 1968 were caused by different variants of the H2N2 virus, which had completely displaced H1N1 in an unprecedentedly rapid manner. Survivors of the 1918 disease enjoyed immunity from H1N1 but not from H2N2, and they and those born a er 1919 came down with the flu in large numbers. Fortunately, mortality rates remained relatively low. In 2009, H1N1 appeared in populations across the globe, spawning fears that another pandemic like that of 1918–1919 might recur. In June 2009 the World Health Organization (WHO) announced that a pandemic had indeed broken out, and public health authorities around the world mobilized quickly to provide information designed both to caution and to reassure people about the nature of the illness.44 “Wash your hands,” we were advised over and over again; “stay home if you’ve contracted the flu”; “get the H1N1 flu shot.” Vaccines to prevent the illness were rushed into production, although they did not appear in time to meet the demand for them in many parts of the United States. As it turned out, this strain of H1N1 didn’t hit with the same force as it had in 1918 and 1919, although the same pattern of illness among people aged fi een to forty-five emerged, and many people worldwide died from the virus. “At the time, the stories were coming out—we didn’t know a lot about this new virus and it was hard to know how alarmed we should be,” noted Dr. Connie Price of Denver Health Medical Center in Denver, Colorado. “I think looking back, we gave it a lot of attention and it wasn’t as severe as we initially anticipated, but we didn’t know that at the time.”45 The virus simply did not possess the virulence to attack with the same intensity it enjoyed in 1918, but the lessons learned from that unprecedented pandemic informed the decision making of public health authorities to get the word out about taking this illness seriously. Educational efforts and immediate action on the part of public health authorities are crucial elements of any response to a suspected outbreak of pandemic disease, but governments also face the problem of “crying wolf” when potential outbreaks don’t pan out, causing populations to tune out the messages they need to hear in order to protect themselves from illness and even death. The world seems to have dodged a bullet in 2009, but virologists expect that another influenza pandemic will emerge and sometimes worry that it will possess the capacity of its 1918 forerunner to outrun our ability to manage it.46 Soldiers Being Treated for Influenza at Camp Funston, Kansas, 1918 NOTES 1 Thirty million is a conservative estimate. Those estimates that go as high as one hundred million are difficult to document, but reflect extrapolations of data that have been recorded. Record keeping, in the midst of such an enormous event, can be expected to be haphazard at best, especially among medical officials fighting to keep patients alive. And many medical officials differentiated deaths from influenza from those due to pneumonia, which proved to be the real killer in the pandemic. 2 Ministry of Health, Report on the Pandemic of Influenza, 1918– 19 (London: His Majesty’s Stationery Office, 1920–1921), iv, xiv, 69. 3 Howard Phillips and David Killingray, eds., The Spanish Influenza Pandemic of 1918–19: New Perspectives (London: Routledge, 2003), 4–5; Niall Johnson, Britain and the 1918–19 Influenza Pandemic: A Dark Epilogue (London: Routledge, 2006), 162. 4 Dr. Ijiro Gomibuchi, Personal Account of the World Influenza Epidemic of 1918–1919, with Remarks on the Use of Diphtheria Serum (May 1919), trans. Edwina Palmer and Geoffrey Rice, “A Japanese Physician’s Response to Pandemic Influenza: Ijiro Gombuchi and the ‘Spanish Flu’ in Yaita-Cho, 1918–1919,” Bulletin of the History of Medicine 66 (1992): 569. 5 Letter from William Collier, The Lancet, October 26, 1918, 567; Ministry of Health, Report on the Pandemic, 72; Phillips and Killingray, The Spanish Influenza Pandemic, 5. 6 Letter from William Collier, The Lancet, October 26, 1918, 567; Ministry of Health, Report on the Pandemic, p. 72. 7 Jeffrey Taubenberger, “Genetic Characterisation of the 1918 ‘Spanish’ Influenza Virus,” in Phillips and Killingray, The Spanish Influenza Pandemic, 40, 41. 8 Douglas Almond, “Is the 1918 Influenza Pandemic Over? Long- Term Effects of In Utero Influenza Exposure in the Post-1940 U.S. Population,” Journal of Political Economy 114, no. 4 (August 2006): 681. 9 Andrew Price-Smith, Contagion and Chaos: Disease, Ecology, and National Security in the Era of Globalization (Cambridge, Mass.: MIT Press, 2009), 60–61. 10 Ministry of Health, Report on the Pandemic, 67; “The Prevention of Influenza,” The Lancet, March 1, 1919, 347. 11 Thomas A. Garrett, “Economic Effects of the 1918 Influenza Pandemic. Implications for a Modern-day Pandemic,” Federal Reserve Bank of St. Louis (November 2007): 19, 20. www.stlouisfed.org/community/development/assets/pdf/pandemicflu-report.pdf. 12 Carol R. Byerly, Fever of War: The Influenza Epidemic in the U.S. Army during World War I (New York: New York University Press, 2005), 93–94. 13 “Growing Toll of Influenza,” Daily Express, July 3, 1918, 3; Charles Graves, Invasion By Virus. Can It Happen Again? (London: Icon Books, 1969), p. 32; Illustrated London News, July 20, 1918, 83; Daily Express, October 31, 1918, 3; Daily Express, October 15, 1918, 3; David Thomson and Robert Thomson, Influenza. Annals of the Pickett-Thomson Research Laboratory , Monograph XVI, Part I (London: Baillière, Tindall & Cox, 1933), 738; British Medical Journal, April 5, 1919, 418. 14 Katherine Anne Porter, “Pale Horse, Pale Rider,” The Collected Stories of Katherine Anne Porter (New York: Harcourt Brace, 1965), 309. 15 Caroline E. Playne, Britain Holds On, 1917, 1918 (London: George Allen & Unwin, 1933), 389; British Medical Journal, August 17, 1918, 159; The Lancet, February 1, 1919, 196; qtd. in Graves, Invasion by Virus, 25–26; Thomson and Thomson, Influenza, 789, 796; Sir Thomas Horder, MD, “Some Observations on the More Severe Cases of Influenza Occurring during the Present Epidemic,” The Lancet, December 28, 1918, 872. 16 Hilary Spurling, Ivy, The Life of I. Compton-Burnett (New York: Knopf, 1984), 238, 239. 17 Phillips and Killingray, “Introduction,” The Spanish Influenza, 6, 7, 9. 18 Ibid., 6–7, 8, 10. 19 Phillips and Killingray, “Introduction,” The Spanish Influenza Pandemic, 7–10; Geoffrey W. Rice, “Japan and New Zealand in the 1918 Influenza Pandemic: Comparative Perspectives on Official Responses and Crisis Management,” in Phillips and Killingray, The Spanish Influenza Pandemic, 83; K. F. Cheng and P. C. Leung, “What Happened in China during the 1918 Influenza Pandemic?” International Journal of Infectious Diseases 11, no. 4 (July 2007): 360–64. 20 Wilfried Witte, “The Plague That Was Not Allowed to Happen: German Medicine and the Influenza Epidemic of 1918–19 in Baden,” in Phillips and Killingray, The Spanish Influenza Pandemic, 49–51. 21 Phillips and Killingray, “Introduction,” The Spanish Influenza Pandemic, 8. See also Rice, “Japan and New Zealand in the 1918 Influenza Pandemic,” in Phillips and Killingray, The Spanish Influenza Pandemic, 83; “Quinine and Cinnamon to the Rescue,” Daily Express, June 22, 1918, 3. 22 Qtd. in Nancy K. Bristow, “‘You Can’t Do Anything for Influenza,’ Doctors, Nurses and the Power of Gender during the Influenza Pandemic in the United States,” in Phillips and Killingray, The Spanish Influenza Pandemic, 61. 23 Cheng and Leung, “What Happened in China during the 1918 Influenza Pandemic?” 360–64. 24 Taubenberger, “Genetic Characterisation of the 1918 ‘Spanish’ Influenza Virus,” in Phillips and Killingray, The Spanish Influenza Pandemic, 40, 41; and Rice, “Japan and New Zealand in the 1918 Influenza Pandemic” in Phillips and Killingray, The Spanish Influenza Pandemic, 83. 25 Susan Parnell, “Creating Racial Privilege: The Origins of South African Public Health and Town Planning Legislation,” Journal of Southern African Studies 19, no. 3 (September 1993): 472, 488. 26 Byerly, Fever of War, 113; qtd. in Alfred W. Crosby, America’s Forgotten Pandemic: The Influenza of 1918 (Cambridge, U.K.: Cambridge University Press, 1989), 157. 27 Byerly, Fever of War, 112, 113, 116, 122. 28 Michael B. A. Oldstone, Viruses, Plagues, and History (New York: Oxford University Press, 1998), 173. 29 See, for example, Johnson, Britain and the 1918–19 Influenza Pandemic, 191. 30 Price-Smith, Contagion and Chaos, 68. 31 Ibid., 72. 32 Collett, Butcher of Amritsar, 223. 33 Ibid., 227. 34 Government of India, Disorders Inquiry Report, 1919–1920, Volume II (Calcutta: Superintendent Government Printing, 1920), 32, 33. 35 Matthew Heaton argues that the experience of the flu had no significant impact on the subsequent history of Nigerian anticolonial activity, but his analysis ends in 1918 and doesn’t examine long-term events. See Michael M. Heaton, “The Press, Politics and Historical Memory: The Influenza Pandemics of 1918 and 1957 in Lagos Newspapers,” in Toyin Falola and Matthew M. Heaton, Traditional and Modern Health Systems in Nigeria (Trenton, N.J.: Africa World Press, 2006). 36 See Marc Matera, Misty L. Bastian, and Susan Kingsley Kent, The Women’s War of 1929: Gender and Violence in Colonial Nigeria (Basingstoke, U.K.: Palgrave Macmillan, 2011), chap. 3. 37 Buchi Emecheta, The Slave Girl (New York: George Braziller, 1977), 25. 38 Don C. Ohadike, “The Influenza Pandemic of 1918–19 and the Spread of Cassava Cultivation on the Lower Niger: A Study in Historical Linkages,” Journal of African History 23, no. 3 (1981): 384. 39 Joseph Theresa Agbasiere, Women in Igbo Life and Thought (London: Routledge, 2000), 143–62. 40 John Barry, The Great Influenza (New York: Viking, 2004), 383. 41 See Harold Nicolson, Peacemaking 1919 (New York: Grosset & Dunlap, 1965), 41–42. 42 Crosby, America’s Forgotten Pandemic, 189–95. 43 See Richard Collier, The Plague of the Spanish Lady (New York: Atheneum, 1974), and Crosby, America’s Forgotten Pandemic. 44 See the information offered by the Centers for Disease Control at www.cdc.gov/H1N1flu/qa.htm. 45 “The H1N1 Pandemic That Hasn’t Really Happened,” 9News Web site (KUSA-TV Multimedia Holdings Corporation), March 3, 2010. 46 John S. Oxford, “A Virologist’s Foreword,” in Phillips and Killingray, The Spanish Influenza, xix. PART TWO The Documents CHAPTER 1 The Nature and Experience of the Disease 1 Letter from a Volunteer Nurse October 17, 1918 For those who cared for the victims, the influenza pandemic was an immensely personal experience. In this letter to a friend, a young Native American woman details her experiences in the autumn of 1918. Lutiant (last name unknown) attended the United States Indian Industrial Training School in Haskell, Kansas, a boarding school for Indian children that sought to eliminate their Indian ways and render them culturally and psychologically “American.” She was working for the Department of the Interior in Washington, D.C., when the flu broke out and volunteered to work as a nurse at a nearby army camp. Her (inaccurate) assertion that two German spies had masqueraded as doctors to introduce the flu to the soldiers was a recurring motif, as shown in Documents 23 and 34. Dear friend Louise: So everybody has the “Flu” at Haskell? . . . As many as 90 people die every day here with the “Flu.” Soldiers too, are dying by the dozens. So far, Felicity, C. Zane, and I are the only ones of the Indian girls who have not had it. We certainly consider ourselves lucky too, believe me. Katherine and I just returned last Sunday evening from Camp Humphrey “Somewhere in Virginia” where we volunteered to help nurse soldiers sick with the Influenza. We were there at the Camp ten days among some of the very worse cases and yet we did not contract it. We had intended staying much longer than we did, but the work was entirely too hard for us, and anyway the soldiers were all getting better, so we came home to rest up a bit. We were day nurses and stationed in the Officer’s barracks for six days and then transferred to the Private’s barracks or hospital and were there four days before we came back. All nurses were required to work twelve hours a day—we worked from seven in the morning until seven at night, with only a short time for luncheon and dinner. Believe me, we were always glad when night came because we sure did get tired. We had the actual Practical nursing to do—just like the other nurses had, and were given a certain number of wards with three or four patients in each of them to look a er. Our chief duties were to give medicines to the patients, take temperatures, fix ice packs, feed them at “eating time,” rub their back or chest with camphorated sweet oil, make egg-nogs, and a whole string of other things I can’t begin to name. I liked the work just fine, but it was too hard, not being used to it. When I was in the Officer’s barracks, four of the officers of whom I had charge, died. Two of them were married and called for their wife nearly all the time. It was sure pitiful to see them die. I was right in the wards alone with them each time, and Oh! The first one that died sure unnerved me—I had to go to the nurses’ quarters and cry it out. The other three were not so bad. Really, Louise, Orderlies carried the dead soldiers out on stretchers at the rate of two every three hours for the first two days [we] were there. Two German spies, posing as doctors, were caught giving these Influenza germs to the soldiers and they were shot last Saturday at sunrise. It is such a horrible thing, it is hard to believe, and yet such things happen almost every day in Washington. Repeated calls come from the Red Cross for nurses to do district work right here in D.C. I volunteered again, but as yet I have not been called and am waiting. Really, they are certainly “hard up” for nurses — even me can volunteer as a nurse in a camp or in Washington. . . . Letter from nurse to her friend at the Haskell Indian Nations University, Kansas, October 17, 1918. Bureau of Indian Affairs. Record held at National Archives–Central Plains Region (Kansas City). Record Group 75. 2 E. T. HSIEH The Recent Epidemic of Influenza in Peking 1918 Dr. E.T. Hsieh conducted research on patients suffering from influenza in the Laboratory at the Peking Union Medical College Hospital in what is today Beijing, China. His training and practice followed those of Western physicians; indeed, the journal in which his article is published issued English-language editions. Here, Hsieh describes the symptoms of the disease, as well as the manner in which it was then believed to be spread. The recent epidemic appeared in Peking on October 6, 1918, and soon spread all over the city. It was prevalent also in Tientsin, Paotingfu, and many cities along the railroad lines. This proved to be a serious epidemic, with a high percentage of deaths. Half of our nurses and internes [sic] were infected. . . . The onset of the disease is sudden. The initial chill is followed by a fever, reaching 102–103° F., or even 106.6° F. as I saw in one case in the Tehchow hospital. There is headache and general pain. . . . A er three or four days the crisis comes, when the patient is much relieved. Shortly a er the fall, a relapse of the fever occurs in some cases. With the rise in temperature, the respiratory symptoms are much worse, likewise the sore throat. . . . As the bacillus has very poor resistance outside the body, the infection is spread from person to person, i.e., by droplet infection. The saliva spray from an infected person while he is coughing or sneezing will reach to a distance of seven feet. The infection may also be carried by dust particles. Spitting on the streets is a dangerous practice. A third method of infection is through the use of handkerchiefs, towels, cups, and other objects contaminated by the fresh secretions. . . . In a serious attack, there is always a complicating infection in throat or lungs. E. T. Hsieh, MD, DPH, “The Recent Epidemic of Influenza in Peking,” Zhonghua yi xue za zhi (The National Medical Journal) XXII (1918): 129–32. 3 WILLIAM COLLIER A New Type of Influenza October 23, 1918 The Lancet is a medical journal published in Great Britain. In the early days of the pandemic, its pages were filled with articles and letters concerning the unusual nature of the influenza. The following letter, from Dr. William Collier of Oxford, offers vivid examples of the variety of bewildering symptoms flu patients presented to him in his practice. To the Editor of The Lancet Sir, — Surely we are seeing a type of influenza quite different from anything we have seen before. Side by side with influenza of the ordinary type we are meeting with cases which exhibit the following symptoms and physical signs. Within a few hours of seizure the patient’s temperature runs up to 105° or over, while the pulse ranges round 90; a high temperature with a slow pulse; the lips and face exhibit marked cyanosis [blueness of the skin], and epistaxis [nosebleed] frequently occurs. In the course of a day or two the patient begins to spit up a quantity of frothy sputum tinged with bright blood. . . . For the first day or two the physical signs in the lungs are very indefinite and point to capillary bronchitis rather than to a broncho-pneumonia; later on there may develop signs of patches of consolidation [of capillary bronchitis]. . . . On the postmortem table . . . distinct areas of haemorrhage into the lung tissue were present. I well remember the severe epidemic in 1889–90, and attended a large number of cases, but the signs and symptoms to which I refer, and which have been exhibited by patients I have attended during the past few days, are quite new to me. Are we dealing with a new organism or with the recognised organisms of influenza which have for some reason attained greater virulence? William Collier, “A New Type of Influenza,” The Lancet, October 26, 1918, 567. 4 K. IWAGAWA On Epidemic Influenza among Japanese Children April 17, 1920 A Japanese physician writing in The Japan Medical World, Iwagawa noted that younger children and babies appeared to contract the disease less frequently and less seriously than did older children. The infection occurred quite indifferently among people of all the ages, and occupation. Among children, it occurred more remarkably in an older one than among the younger. In the suckling, it occurred far less frequently. All the cases had unanimously an alike symptom. It developed more severely as the age advances, the suckling being only slightly affected. Prognosis also went parallel with the symptom in regard to the ages. K. Iwagawa, “On Epidemic Influenza among Children, Clinical Observation and a Case of Influenzal Meningitis,” The Nippon No Ikai (The Japan Medical World) X, no. 16 (April 17, 1920): 334. 5 GREAT BRITAIN REGISTRAR-GENERAL Age Distribution of Deaths Due to Influenza in Ireland 1919 The Registrar-General of England and Wales, and its counterpart for Scotland and Ireland, have been responsible for keeping track of population statistics — births, deaths, and marriages — in Great Britain since the 1830s. In 1919, it issued a comprehensive report on the incidence of death resulting from influenza. These charts demonstrate the effect of the pandemic on various age cohorts in Ireland. Great Britain Registrar-General, Report on the Pandemic of Influenza, 1919 (London, 1919), 53. 6 E. OLIVER ASHE Some Random Recollections of the Influenza Epidemic in Kimberley, South Africa January 11, 1919 The South African Medical Record carried regular reports of the effects of influenza on patients. Here, a London doctor describes his experience treating patients at a hospital in Kimberley, South Africa, noting the marked difference between the virus of 1918–1919 and previous epidemics. It provides one of few accounts that mentions the effect of the disease on women’s reproductive health, especially in pregnant women. Ashe also notes the prevalence and severity of the disease among native peoples and ponders whether the conditions in the Kimberley mines might be the cause of such disproportionate mortality rates. Having worked through epidemics in London (Whitechapel), Sheffield, and Maidstone nearly 30 years ago, I thought I knew what epidemic influenza meant; and when rumours of an impending outbreak began, I merely looked forward to a few weeks of extra hard work, with a rather heavy death-rate amongst the old, the feeble, and the alcoholic, though the majority of the cases would be mild. But the avalanche that fell upon us, with its special mortality amongst robust people in the prime of life, who should theoretically have stood the disease best, was something very different. . . . The severe cases were of two types: In one the main features were acute onset, rapid feeble pulse without specially high temperature, marked blueness of lips and nails, rather rapid breathing with chest pain or oppression, practically no cough and expectoration, an anxious expression, and great mental anxiety, but no discoverable lung affection. This type was invariably fatal, and the end came quickly. . . . In the other type the onset was less acute, and the early symptoms were not so severe, though the temperature ran higher (103° to 105° F.) from the start. Catarrhal symptoms, slight at first, soon become prominent, and a er two or three days the expectoration became tinged with blood, pain developed somewhere in the chest, and consolidation . . . of some part of the lung could be found. . . . The cough became more troublesome, accompanied by the expectoration of large quantities of thin, slightly frothy, red fluid. . . . Haemorrhage from the nose, mouth, and throat was common, and a few cases passed blood by the bowel. Menstruation o en came on too soon, lasted too long, and was too profuse, and this menstrual disturbance lasted for a period or two a er convalescence. Pregnancy in the middle months did not seem to be disturbed, but abortion or premature labour was very liable to happen in the early and late months, and both of these put the patient into serious danger, more in the later than the earlier months, not a few women dying a er premature labour. Severe and intractable vomiting occurred in a few of my fatal cases. . . . Sleeplessness was an almost invariable symptom in the severe cases, and delirium, o en violent, was common. . . . The a er-effects of the disease seemed endless, and there were few who did not find that they were a long time in shaking off the feeling of lassitude and debility, and keen business men complained that they could not concentrate their thoughts on their work; or remember business details with anything like their usual accuracy. . .. The epidemic abounded in tragedies, of which, perhaps, the greatest was the appalling mortality amongst the natives in the compounds. Having had nothing to do with the native work myself, I have said nothing about it, but the acuteness of the attack, the extraordinary rapidity of its progress, and the terrible death-rate were matters of common knowledge. Why the natives should have been hit so hard is an unsolved problem. Was it just because natives always stand epidemic diseases badly, having no inherited immunity, or because the type of infection was severe, or because it became virulent from concentration in the underground chambers of the mines where they worked, and where, in spite of free ventilation, there must inevitably be some deficiency of pure air? A point worth noting in view of the last arguments is that the mortality amongst the white underground employees in the two mines most affected was 24 per cent. E. Oliver Ashe, “Some Random Recollections of the Kimberley Influenza Epidemic,” South African Medical Record, January 11, 1919, 6–8. 7 MARY E. WESTPHAL On Visiting Nurse Services in Chicago November 8, 1918 Mary Westphal served as an Assistant Superintendent in the Visiting Nurse Association of Chicago. She and her colleagues ventured right into the heart of the epidemic, treating in their homes patients who had no means of getting themselves to hospitals or of paying for treatment. Her account offers a vivid picture of what daily life during the epidemic looked and felt like. Because of bad housing conditions and over-crowding, we were very hard hit on the west side of Chicago, and are still getting calls where entire families are ill. Dirty streets, dirty alleys and just as dirty houses, and lack of proper sleeping quarters have made our work more than usually difficult. The Ghetto was a hotbed of influenza and pneumonia. . . . The houses in this area are very close together and many families live under one roof. The people watched at their doors and windows, beckoning for the nurse to come in. One day a nurse who started out with fi een patients to see saw nearly fi y before night. In District 28, where the streets are narrow and the people many, sixty-five calls were made in one day, though of course not all by one nurse. Fourteen calls in a busy season is a fair average for this small district. The Visiting Nurse repeatedly started out in the morning with a definite list of calls in her hand, but sometimes before getting out of her first case, she was surrounded by people asking her to go with them to see other patients. Physicians could not get around to all of the people needing them, it was impossible to get orders, consequently the nurse had to try to be many things to all people. At first the gowns and masks which all of the nurses wore frightened the people, and several times women helpers who had come in to stay le the homes on seeing the nurses so dressed up. Gradually they became accustomed to them and in many homes we trained the husband, or wife, or whoever was supplementing our care to the sick, to wear the gowns and masks. On one of the coldest, rainiest days which we had, the nurse met on the sidewalk in front of a home, an eight-year-old boy, barefooted and in his nightdress. She quickly saw that he was delirious and coaxing him back into the house, she found the father sitting beside the stove, his head in his hands, two children in one bed, the mother and a two-weeks-old baby in another. She questioned the man, who was nearly crazed because, as he told her, he had just given his sick wife, a pneumonia patient, a spoonful of camphorated oil instead of castor oil. He had been up night and day caring for the wife and children, all with temperatures above 104, and his temperature at that time was 101.6. The nurse sent for the doctor, administered to the woman, bathed all of the patients, and sent the youngest child to the hospital, where he died a few days later. Several days a erwards, while the nurse was in the home, the mother had a severe hemorrhage from the ear. When we returned for our second call that same day we found that the patient, between our two visits, had been to the cemetery to see the child buried. With the exception of the one child, all in this family recovered. . . . In one of our families the mother, father and two children had pneumonia at the same time. The father, in attempting to get up and help his wife, had fainted and fallen on the floor, and that was the way the nurse found him on her first visit. We made two daily calls and kept two aids [sic] there for a week, and all recovered. In another district we found a man and his wife, both under thirty, fine, strong-looking, both ill with pneumonia. In another bed in the same room were two children under three with whooping cough and influenza. They were living in furnished rooms and had recently come here from another town. The man was wildly delirious from the start. We got them into separate rooms there and tried to make hospital arrangements, but were told that while there were empty beds at the three hospitals which we called, there were no nurses, so we had to keep the patients at home. We put a special nurse and an aid [sic] on, and the Visiting Nurse helped out by calling twice daily and assisting with the care. In spite of this, we lost both mother and father. The mother gave birth to an eightmonths baby the day before she died; she lived eight hours a er her husband. Both grandmothers came and each took one of the two older children, and placed the premature baby in the hospital. Four of our families lost both mothers and fathers. We tried so hard to save a twenty-eight-year-old mother of four children, with a baby nine months old. She was pregnant and died on the eleventh day. This is a district of pretty comfortable homes, with no real poverty. . . . In one of our Polish families we lost five out of one family of seven. . . . In one of our Jewish families, when the Visiting Nurse went to give care to a newly delivered mother one morning she found that a child two years old had died during the night. It was only by promising the mother that she could have the baby’s body again that we could get it away from her, and she insisted upon having the little casket where she could see it until it was carried away. The mother made a good recovery. In one of our Bohemian families six people living in three basement rooms were ill. . . . Many of our pregnant mothers died; some newly delivered mothers recovered, one young mother, twin delivery, who developed pneumonia on the third day, made an uneventful recovery. In the majority of our families most of the members were ill. Our patients were untouched until the nurse could get back to them, and each new case seemed more urgent than the last. Mary E. Westphal, “Influenza Vignettes,” The Public Health Nurse 11, no. 2 (1919): 129–33. 8 ANNE L. COLON Influenza at Cedar Branch Camp, Michigan 1919 A registered nurse in Newberry, Michigan, Colon journeyed to northern Michigan to treat flu victims in a logging camp. Her report demonstrates that the disease did not confine itself to big cities, but spread into even the most remote areas of any given country. Shall I tell you about how we took care of the influenza in a logging camp in the deep woods of northern Michigan, of the difficulty we had in reaching our patients, and what we accomplished? No, our big cedar and balsam and hardwood forests, our fresh breezes from the Great Lakes, and our isolation from the crowded districts did not save us from the deadly grip of the epidemic. We read about the big cities, the suffering, and the many deaths, but still sat back; so fearless were we, and so sure of our wonderful healthy climate, that it wasn’t until a cry for help came, that we were awakened from our dream. Our first trip was to Cedar Branch, a camp fi een miles in the woods. . . . Cedar Branch is a typical logging camp composed of a group of log cabins and tar paper shacks, all built near together in a friendly sort of way. The people are a fearless, careless, wandering tribe, followers of the great out-of-doors with little idea as to homemaking and not any conception of sanitation. They have large families which usually live in a one-roomed cabin. I shall never forget the conditions we found. Influenza was traveling like wildfire through the little huts. There was confusion, suffering, and terror everywhere. The sick and well were all huddled together. In many cases the family had only one bed, so we used rough heavy cloth, sewed the four sides, slit one side in the middle, these we filled with straw and used for extra beds. There was a roaring fire in each house, the windows were nailed down, and the doors sh...
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