Sunday, October 14, 2018

The 1918-1919 Influenza Pandemic and its effect on Chicago.

From its start as a marshy portage for Indians and French trappers and traders, Chicago grew to a bustling city of 2.7 million by the time influenza arrived on September 8, 1918, when few sailors at the nearby Great Lakes Naval Training Station fell ill with the disease. A week later, seven army cadets from the Northwestern University SATC unit came down with influenza. Then, a few days after that, cases developed among cadets at the Lewis Institute SATC unit on South Hoyne Street in Chicago itself. The epidemic had begun... and was spreading.
Inspecting Chicago street cleaners for Spanish influenza. Officials are wearing gauze masks. 1918
Military officials acted quickly in an attempt to contain the disease. At Great Lakes Naval Training Station, officers instituted isolation and quarantine controls, ordered all 50,000 sailors to be given daily nose and throat sprays (where, presumably, they could also be quickly examined for symptoms), placed 1,000 men in isolation when they developed symptoms and an additional 4,000 sailors under quarantine for suspect contact with the ill, and cancelled all liberty leave for enlisted sailors until the epidemic had passed. Surprisingly, although sailors were prohibited from leaving Great Lakes station, civilians were still permitted to visit.

By late-September, it appeared that the epidemic at Great Lakes station had crested. Station health officers were happy to report that the number of new cases was decreasing at a rate of approximately 10% per day. In Chicago, Health Commissioner Dr. John Dill Robertson announced that officials had “the Spanish influenza situation well in hand now.” To monitor the situation, Robertson made influenza a reportable disease on September 16, but took no further action.

Chicago’s epidemic, however, had only just begun. On September 21, city health officials took note of a sudden marked rise in the number of deaths due to acute respiratory diseases. By September 30, there were 260 cases in the city. The large and sudden jump in new cases led Health Commissioner Robertson to order the immediate isolation at Cook County Hospital of all known cases. Realizing that hospital isolation would soon become impossible, he told residents to prepare to isolate themselves should they become sick. “Every victim of the disease is commanded to go to his home and stay there,” he announced. “No visitors are to be allowed.”

Robertson was hesitant to implement any further epidemic control measures that might disrupt life or lower morale, and he therefore moved in a slow, step-wise fashion. A survey of the city’s schools showed that Chicago children had thus far managed to escape the brunt of the epidemic, and attendance was still nearly normal despite excluding all students with cold or flu-like symptoms. Schools were therefore to remain open. Robertson and representatives of the city’s various child welfare agencies and organizations believed that children were better off in schools anyway, where they were under watch and kept from roaming the streets.
Despite his hesitation, Health Commissioner Robertson did ask Chief of Police John Alcock to have his officers stop all persistent sneezers and coughers who did not cover their faces with handkerchiefs. Those violators who promised to obey instructions in the future would be let go, but anyone who gave the officer a difficult time would be arrested, given a lecture on the dangers of influenza, and sent before a judge for arraignment. Robertson also warned theater managers and owners to ensure patrons used handkerchiefs or he would shut down their establishments. Churches, schools, theaters, restaurants, streetcars, and other places where people congregated were ordered to maintain proper ventilation. For the time being, these were the extent of Chicago’s control measures. Both Robertson and the Illinois Influenza Advisory Commission agreed that no closure order should be issued, arguing that the epidemic was “practically at a standstill” in Chicago and the northern part of the state.
Chicago may not have needed a public gathering ban yet, but it did need more nurses. On October 11, the Chicago chapter of the American Red Cross issued an urgent call for volunteers. Highlighting the plight of the city’s ill and playing on the heartstrings of women across the region, the Red Cross printed the story of a nurse who made a house call expecting to find a sick mother. Instead, she discovered that the entire family was stricken with influenza: the mother and two young children were all bedridden with high fevers, a 10-month old baby was starving, and the father was wandering the streets in fevered delirium, desperately trying to find a physician to care for his family. “This case,” the Red Cross coordinator wrote, “tells its own story and makes its own appeal to the womanhood of Chicago.” The city’s settlement houses likewise called for volunteers. Some turned themselves over entirely to the epidemic cause. The University of Chicago Settlement House, for example, stopped all its regular activities for several weeks during the epidemic in order to host an emergency hospital and diet kitchen, the latter serving a total of approximately 3,000 meals.

Perhaps because of the increasing occurrence of news such as this, the Illinois Influenza Advisory Commission slowly began changing its tune. The first steps it took were to pass a binding resolution on October 11 banning public dancing in all clubs, cabarets, and halls and to prohibit all public funerals across the state. The Commission reasoned that public dancing was a particularly efficient way both to transmit and contract influenza because of the close contact between dancers and the chilling of sweaty bodies that usually followed a rigorous dance. Receiving the news the next day, Health Officer Robertson notified Chief of Police John Alcock of the ruling and requested that officers stop all dances across the city starting that night – the first night in nearly 16 years that Chicago did not have a weekday public dance. 

On October 12, the Commission recommended that Chicago’s transit company keep streetcar front doors open to ensure a constant stream of fresh air into the cars. The only large gathering that was permitted in Chicago was the WWI military parade held on this day. The Commission realized there was little they could do at this late date to try to stop the event. The best that could be done was to warn parade-goers to take precautions. The Chicago health department gave very specific instructions to those attending. They were to strip, scrub their body’s areas with soap and take a laxative when they got home to prevent catching the deadly flu virus. The parade path ran south on Michigan avenue beginning from the Art Institute. Over a million spectators showed up. It resulted in an increase in the number of new influenza cases.
By now, Chicago physicians were reporting a staggering number of new cases, reaching as high as 1,200 a day and climbing. The Illinois Influenza Advisory Commission, with Health Commissioner Robertson fully participating, now had little choice but to contemplate seriously the closure of public places. On October 14, the Commission invited representatives from professional organizations, the Red Cross, clubs and trade organizations, federal and state officials, and the Liberty Loan committee to meet at the upscale Hotel Sherman, a well known night spot for celebrities, jazz musicians, and Chicago’s high society set, to discuss the possibility of issuing a general closure order. As Robertson put it, “We wish to take no rash action, and desire to be sure that whatever we do will be for the benefit of the city.”

After hearing from constituents, the Advisory Commission handed down its final decision: beginning on Tuesday October 15, all theaters, movie houses, and night schools were to close immediately for an indefinite period, and all lodge meetings and other similar gatherings were prohibited. The Commission included “all other places of public amusement” in its order, but acknowledged that further clarification was needed in order to determine the exact extent of the phrase. Churches were left off the list for the time being, since no religious services would be held for at least three more days. In the end, Chicago churches were not required to close, although clergy were asked to keep services short and their buildings well ventilated. An unintended but salutary effect was that many churches organized parishioners into soup brigades to help families stricken by influenza. At a time when charity and volunteer work was practically the only safety net, churches and synagogues were major centers and organizers of aid, and many did their best to alleviate as much of the ancillary suffering as they could.

Movie houses and theaters were the prime focus, as they were seen as the places most likely to cause the spread of influenza. Public schools were to remain open because of well-organized systems of medical inspection already in place. In fact, school health officers and nurses were instructed to drop all their routine work and concentrate solely on student inspections. Closing schools may have mattered little by this late date anyway, as absentee rates had already reached as high as thirty percent, and would spike to nearly fifty percent within a week. Not all of these absences were due to illness; some were the result of worried parents. Others were due to mischievous students who took to sniffing pepper in order to induce a coughing or sneezing fit, knowing that they would be sent home for a week.

On one horrible October day 381 people died from influenza in Chicago. Considering how badly Chicago was hit in October, it turns out to be a blessing that the World Series (Cubs versus the Red Sox) was held a month earlier because of the War. The Cubs-Red Sox World Series of 1918 remains the only World Series in history to be held in September. The President of the United States (Woodrow Wilson) had ordered the season ended on September 1st, so that any and all able men would work for the war cause and/or enter the military. He had no way of knowing it when he made that order, but it probably saved lives in Chicago and Boston. Having huge crowds come out for something like this only would have helped the influenza spread more quickly. Baseball was still affected by loss. The Boston Braves outfielder Larry Chappell died in San Francisco. Former St. Louis Browns outfielder Emmet Heidrick died in Pennsylvania. Former Pirates and Reds outfielder Jake Stenzel died in Cincinnati (he had started his career with the Cubs, but played only a handful of games for them many years earlier). American League umpire Silk O’Loughin also perished in the pandemic. As did former Tigers owner William Yawkey.

Despite the grumblings of some residents, the closure order had the desired effect. Chicago’s loop district, home to most of the city’s entertainment district, was suddenly empty at night. Newspapers reported that the sidewalks were clear, the restaurants half deserted, and the taxicabs idle. Health Commissioner Robertson was pleased with the news. Theater and movie house owners and employees, naturally, were not. Estimates as to the financial losses they would suffer varied greatly, but it was generally agreed that approximately 650 theater workers and an additional 500 movie house employees were now out of work. Lost box office receipts were difficult to ascertain, but at least one theater had already sold $80,000 in advance tickets for just a single performance. Workers were especially hard hit. “Unfortunate now are these comely young women of the chorus,” one newspaper columnist wrote of the theater closures, “for their misfortune is not their fault. It is not to preserve their health but our health that they bravely forgot their right to earn bread and rest.”
Posters like this one were posted around Chicago and at most public venues.
More businesses were about to be affected. On October 15, the Illinois Influenza Advisory Commission met to try to decide what other places of public amusement and gathering should be closed. No definite consensus could be reached, although the group did agree that ice skating rinks would be added to the list. The next day the Commission members finally concluded that all non-essential public gatherings should be banned, but that actual implementation of the recommendation should be left up to State Health Commissioner C. St. Claire Drake and local authorities. Drake immediately issued the recommendation as a statewide order, decreeing that all public gatherings of a social nature and not essential to the war effort be discontinued indefinitely. All banquets and public dinners, conventions, lectures and debates, club and society meetings, union gatherings, and athletic contests (whether indoor or out) were therefore prohibited. Saloons could remain open, as could poolrooms and bowling alleys, so long as they were properly ventilated. All other forms of gathering not expressly prohibited by the state order could continue, so long as spitters, coughers, and sneezers were kept out and crowding was not permitted. Both Illinois and Chicago officials continued to enact epidemic control measures in a stepwise manner.

During the epidemic, “Fresh Air Cars” were introduced on the elevated train systems. These were 'L' cars with the windows locked open to maximize air circulation. One sign said: “Get the fresh air habit. Dress warm enough to enjoy it.” Another sign said: “Too much fresh air is just enough.” The idea the fresh Lakefront air promoted health was widespread, especially at a time when the rest of Chicago’s air was horrendous. A result of this "Fresh Air" concept was the opening of the "Chicago Daily News Fresh Air Fund Sanitarium" in 1920.
Makeshift Hospital Ward during the 1918 Epidemic.
The epidemic raged. Sad stories of influenza-stricken Chicagoans filled the pages of the city’s newspapers: Phyllis Padula and her four young children suffering from bad cases of influenza when her husband Angelo ventured out in search of a physician, only to commit suicide by jumping into the frigid Chicago River; a Spanish-American War veteran, armed with a shotgun and two revolvers and delirious with fever, in a two-hour standoff with police; a wife suffering a mental breakdown after caring for her sick husband and five children, dousing her family’s clothing in gasoline and setting the pile ablaze as they all shivered in the cold. In another case, Peter Marazzo killed his wife and four children by slitting their throats. Brought to trial, the jury found him not guilty by reason of insanity due to his high fever brought on by influenza. An army doctor at the trial testified that the toxins from the influenza germ had “lodged in the brain cells and wrecked Marazzo’s mind.” Several physicians at the time observed that various psychoses, most notably dementia praecox (schizophrenia), seemed to develop shortly after bouts with influenza.

By the last days of October, new case reports indicated that the epidemic might be on the decline across Illinois. The Illinois Influenza Advisory Commission hesitated to recommend lifting the closure order and gather ban just yet, though, preferring to hear from local authorities as to the precise conditions in the communities. In Chicago, Health Commissioner Robertson was hopeful that the epidemic would soon be over, but believed that the control measures be kept in place for a short while longer. In the meantime, he suggested that everyone curtail his or her usual Saturday night revelry, go to bed early, and get plenty of rest on Sunday. To many, it sounded far too much like a dose of parenting.

Whether or not Chicagoans followed his advice, by Monday, October 28 the case tallies had declined enough to warrant serious consideration of removing the bans. Robertson and the Health Department drafted a tentative plan that called for the step-by-step and district-by-district return to normal city life over the course of a week. The next day, Tuesday the 29th, after gaining Drake’s approval, Robertson and the Chicago Health Department put the plan into action. Beginning that day, all music and entertainment could resume in the city’s restaurants, cafes, and hotels. On Wednesday the 30th, theaters and movie houses between Howard and Diversey Parkway could re-open. The following day, theaters and movie houses between Diversey Parkway and 12th Street could resume their hours. On Friday, November 1, the rest of the city could re-open. Public meetings were to follow a similar schedule starting on Thursday, with all meetings allowed in all parts of the city by Saturday, November 2. Theaters had to pass inspection before they could re-open their doors, coughers and sneezers were prohibited from entering, no crowding would be allowed, and all public places were required to close by 10 pm. Public dances could resume on Monday, November 4. The reason for the geographically staged schedule was simple: by the fourth week of the epidemic, the greatest number of new cases had occurred in the half of the city south of 12th Street, and Robertson believed that area needed a few more days before it was firmly in the clear.

Conditions in Chicago continued to improve even as residents mixed and mingled in theaters, movie houses, cabarets, and restaurants. In most cities, the removal of social distancing measures was met with a great deal of joy. In Chicago, it was met with some grumbling, aimed primarily at Health Commissioner Robertson. During the epidemic, Robertson had banned smoking on all streetcars, elevated trains, and suburban light rail lines. Now that the danger had passed, however, Robertson refused to remove the no-smoking ban. Reporting on the news, the Chicago Tribune referred to Robertson as “his highness.” On November 2, Robertson ruled that city entertainment venues could remain open until 10:30 pm, adding an extra half hour to Chicago’s nightlife. Robertson advised that all revelers therefore get an extra half hour sleep on Sunday morning in return. The Tribune quickly attacked him for his paternalism, referring to him as “his eminence” repeatedly. “Chicago may disport itself tonight into the late hour of 10:30 by virtue of the gracious order of Dr. John Dill Robertson, city health commissioner,” wrote the Tribune. The following day, when the last remaining flu bans were about to be removed, the Tribune continued its attack on Robertson. “Outside of the fact that you mustn’t cough, sneeze, expectorate or osculate, mustn’t smoke on street cars or in the elevated trains, can not visit sick friends and must continue to observe the food and fuel regulations and keep up your installment payments on Liberty bonds, you can get up tomorrow and do as you darn please,” the article began. Those who wished to attend one of the long-suspended public dances could glide across the floor “without fearing the intrusion of a health department chaperon with untimely remarks about the dangers of proximity.” The editorial staff of the Tribune, and likely many other residents, had thoroughly tired of Robertson’s restrictions and paternalism, especially when they had been placed on top of the already onerous wartime social restrictions and civic responsibilities.

Between the start of Chicago’s epidemic on September 21 and the removal of restrictions on November 16, the Windy City experienced a staggering 38,000 cases of influenza and over 13,000 cases of pneumonia. The white population of the city experienced an increase in deaths of 2,610 percent over the previous year. The African American population, on the other hand, experienced an increase of only 1,400 percent. Health Commissioner Roberston attributed the difference to the intrinsic immunity to influenza and pneumonia among the city’s African American population. In reality, the discrepancy was likely due to racial disparities in Chicago’s health care and access: African American Chicagoans were already much more likely to die of disease than their white counterparts. Epidemic influenza, a disease that did not respect color or socioeconomic lines, therefore only appeared to attack whites with more virulence.

Doctors and nurses worked around the clock during the crisis. Morris Fishbein, a prominent Chicago doctor and later editor of the Journal of the American Medical Association, wrote in his memoirs that most Chicago physicians visited some sixty to ninety patients each day during the height of the epidemic, unable to do much besides try to make them comfortable. Yet, despite these staggering numbers, Chicago actually did fairly well for a city of its size. In fact, with a population of 2.7 million, Chicago’s epidemic death rate for the period was only 373 out of 100,000, not much worse than much touted (and its long-time rival) St. Louis.

Chicago’s epidemic experience led to important changes in the city’s medical care infrastructure. In January 1919, with the main danger over, Health Commissioner Robertson turned his attention to correcting some of the shortcomings the city experienced during the crisis. Highest on his list was the nursing shortage. In 1907, after several failed attempts, the Illinois legislature had passed a law creating a board to register trained nurses after two years of schooling. At the time, Robertson opposed the bill, arguing that it would drive up the cost of nurses and create a system whereby those of only modest means would not be able to afford adequate care. “The nurse has become a necessity in our present civilization,” he argued, “but her cost has made her services a luxury that only those in good circumstances can enjoy.” He believed that any woman (and, following the sexism of the times, he considered women as natural nurses due to their innate ability to follow a man’s orders) with intensive training could be made a competent nurse in a matter of three to six months, not two or three years. If the army could churn out perfectly good officers in three months, he argued, good nurse educators should be able to do the same. Now, in the wake of the epidemic, Robertson felt an even greater sense of urgency in bolstering Chicago’s nursing corps.

To create a large contingent of these “practical nurses” as he called them, Health Commissioner Robertson suggested several changes. First, hospitals should immediately modify their curricula so that two classes of nurses could be trained. One track would become registered nurses, while the other would take six months of intensive training. Second, the state legislature should change current nursing law to allow for the training of these practical nurses as well as lower the number of years required of registered nurses from three to two. Lastly, Robertson suggested that if Illinois lawmakers did not act, then Chicago should take the lead in licensing practical nurses much the same way as it licensed undertakers.

His ideas were welcomed by some and angrily dismissed by others. Within a week of announcing the idea, the city’s Director of the Department of Education and Registration had already drafted a bill allowing for a one-year course of training for practical nurses, which he said he was prepared to present to the state legislature. A group of supportive physicians offered to travel to Springfield to support the bill if necessary. The Journal of the American Medical Association endorsed the idea of a separate track of practical nurses in an editorial blaming trained nurses for the current woes. A nurse should be “a true physician’s assistant and will be a household helper not too proud to assist in the kitchen or even to help care for the baby,” the editor wrote.

On February 18, 1919, the new nursing bill was introduced in the Illinois General Assembly. The bill provided for a one-year course of training for practical nurses, granted authority to the State Board of Registration to license those who passed the training, and made it illegal to pose as a registered nurse unless entitled to do so. Hospitals, which would benefit from the lower cost of practical nurses, supported the bill. Registered nurses, who stood to lose some control over their profession and who feared a decrease in their wages, naturally opposed it. In the end, the support for the proposal was simply too strong for nurses’ groups to withstand. The bill passed.

On July 21, 1919, Chicago’s Training School for Home and Public Health Nursing opened its doors. Nearly 800 women completed the inaugural class, and within two years some 3,000 women had passed the course. When influenza returned in 1920, 600 of these graduates answered the call for volunteers, exactly as Health Commissioner Robertson had hoped they would.

The program worked so well that Robertson instituted a second similar program in connection with the Municipal Tuberculosis Sanitarium in 1920. Never again would Chicago be faced with a critical shortage of nurses during a time of need.

In the two years that this flu ravaged the earth, a fifth of the world’s population was infected. It infected 28% of all Americans. An estimated 675,000 Americans died of influenza during the pandemic. 117465 Americans died in the WWI.

Compiled by Neil Gale, Ph.D. 

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