Influenza Encyclopedia

A few days later, on September 28, the semi-annual meeting of the state Board of Health convened at the stately Davenport Hotel in downtown Spokane. Influenza had not yet become epidemic in the northwest, but the Board realized that it likely soon would be. Several hundred men at the various Puget Sound naval stations had already been diagnosed with influenza, and sporadic civilian cases were being reported in Seattle, Tacoma, and Spokane. To prepare communities for the impending crisis, the Board of Health issued a statement letting Washington residents know that they should expect six to eight weeks of successive waves of influenza, with widespread closures of public places likely as a result. Residents were called upon to lend their assistance in preventing the spread of the disease. As Dr. T. D. Tuttle, state Commissioner of Health, stated, “The public must be brought to realize that we are facing a serious situation and that it is a patriotic duty to render every aid possible.”2

By the end of the first week of October, approximately one hundred influenza cases had appeared in Spokane. City Health Officer Dr. John B. Anderson expected many more cases to develop, and announced that Spokane would likely face a very serious crisis unless immediate action was taken. The chamber of commerce, understanding that closure orders were inevitable and hoping for a quick end to the crisis, not only pledged its support of the health department, but urged Anderson to take immediate and drastic action. For its own part, it launched a special committee on publicity to educate the public to the dangers of influenza and the personal measures that could be taken to help prevent its spread.3 Anderson did not keep the chamber of commerce waiting; on October 8, the day after the chamber met, he and 18 city physicians met to discuss the situation. The group, having just received a telegram from state Health Commissioner Tuttle urging that local communities close public places (which was a reiteration of United States Surgeon General Rupert Blue’s circular to all state health departments recommending the same), unanimously agreed that a closure order should be issued. Anderson did so immediately. Effective midnight of October 8, all places of public congregation in Spokane were officially closed. This included all theaters, schools, dance halls, poolrooms, churches and Sunday schools, conventions, and other places of public gathering and amusement. Gatherings such as public funerals and weddings were similarly banned. Spokane University was allowed to continue classes for the time being, with the understanding that students were prohibited from leaving campus. In Spokane County, Health Officer Dr. Albert E. Stuht issued a similar closure order, and asked county schoolteachers to close their classrooms immediately.4 County schoolteachers were assured they would be paid for up to three weeks should the closure last that long. Teachers and school directors who failed to comply with the order faced arrest and prosecution.5

Residents generally complied with the order, even if some did not fully believe in the danger influenza posed. As the Spokesman-Review wrote, the streets “looked as sparsely filled as in a blizzard.” Some people did stroll the streets, “but there were no whooping automobiles full of young bloods, or sidewalks filled with short skirted damsels.”6 It was fairly simple for private citizens to comply with the order, and most of them simply stayed at home. The rapidity with which the closure order was handed down left many businesses and organizations unsure of their status, however, and the work of the health department during the first day of the order was given over almost entirely to sorting out the exact details. Most but not all of the schools, for example, closed, the others either uncertain or uninformed of Anderson’s order. Once sorted out, Anderson and his staff turned their attention to related matters. First, the health commissioner ordered physicians to make daily reports of influenza cases, as no one was entirely certain just how many or few cases Spokane actually had. Next, Anderson ordered all streetcars to maintain good ventilation. At the request of the commissioner of public safety, police officers were instructed to arrest all persons caught spitting in public. One violator was unfortunate enough to be caught by Anderson himself, who ordered the man to wipe up the sidewalk or face arrest.7

Anderson stressed to the community that the measures he had just enacted were meant to be precautionary, and that “there is no condition at present to justify a panic.” Early reports indicated a rise in cases across the city, however, most noticeably in the eastern section of the Union Park neighborhood around Sheridan School. Physicians daily reported several dozen new cases, and within a few days Spokane had an estimated 500 total cases, with additional cases being reported throughout the surrounding county.8 With news of the increase in cases, Anderson augmented the closure order. He requested that department stores discontinue special sales so as not to attract large crowds. He closed poolrooms, bowling alleys, and card games in cigar stores after learning that men were congregating in these spots. Anderson did allow churches to hold outdoor services after several clergymen asked the health officer for his thoughts on the subject, but added that they might be just as dangerous as those held indoors.9 A week later he banned outdoor meetings as well.1 The city’s Christian Science Church asked for permission to hold regular indoor services, arguing that it was engaged in the healing of the sick. Anderson denied the request, arguing that, under law, he could not consider the character or the purpose of any individual meetings.11

By mid-October, Spokane’s limited health care resources were already stretched to the limit. Most of the city’s nurses were serving in the military, leaving precious few to help during the epidemic. On October 13, nurses were so busy that not a single one was available by the afternoon to attend to new cases.12 Medical supplies were also in short supply; the city’s social service bureau’s stock was exhausted, requiring it to appeal to the public for donations of linens, nightgowns, mattresses, and stoves. Hospital bed space was becoming scarce. To alleviate the pressure, the local chapter of the Red Cross met with city and county officials and representatives of the nursing and medical communities to develop a plan for establishing and outfitting an emergency hospital in one of the city’s hotels. The site they chose was the Lion Hotel at the corner of South Lincoln Street and West 1st Avenue. With a central location near Deaconess Hospital, the new emergency facility allowed for more efficient use of nurses, who could care for multiple patients at the same time rather than having to crisscross the city administering care. Some of the rooms were large enough to set up wards.13

The new emergency hospital was first and foremost designed to treat those with fewer financial resources. As a result, the rules and regulations regarding private patients were rather strict. No medicine, prescriptions, or sera were provided for private patients. Likewise, no special meal provisions could be made, and all patients received the same liquid and soft food diet. Private nurses attending to individual patients were not allowed, and physicians were required to make arrangements with the city Superintendent of Hospitals before their patients could be admitted. Once there, private patients were kept under the care of their personal physician, not the other doctors working the rooms and wards. All financially able patients were required to pay $10 in advance. The Lion Hotel management agreed to heat the building and to provide linens, with the city and county to provide jointly for all other necessary equipment and costs.14

Spokane residents were not alone in feeling the effects of influenza. Fort George Wright, a small army installation located within the city limits, was being hammered by the onslaught of cases. Even more patients arrived on October 18, when 58 sick men among a training detachment headed for Spokane’s Modern Automobile School were discovered on a train. They were immediately sent to the Fort’s hospital for care. Local military officials quickly barred civilian visitors from the Fort as well as from all nearby training schools and barracks until the danger of the epidemic had passed. Meanwhile, the Fort was in desperate need of nurses. The hospital there was already full, and one of the barracks was being used for overflow cases. The nursing staff was exhausted, most of them having worked for 48 hours continuously. The local field director of the Red Cross issued an urgent appeal for every available nurse in the city to help at Fort Wright. “The situation is critical,” he said.15 Unfortunately, the situation was no better among the civilian population, where nurses were likewise in short supply.

On October 20, Anderson, worried that some cases of influenza were being diagnosed as common colds and therefore not being reported, issued a lengthy circular to all city doctors. “Doctor,” he wrote, “you may have laudable convictions as to methods of fighting a crisis like the present at variance with the routine established by those now in authority. However, our mutual aim is identical–suppress the flu, save life.” Anderson therefore requested that henceforth doctors treat every case of the common cold as if it were influenza. Patients were to be told to keep themselves isolated at home, to deny visitors, and to remain out of public for at least three days after their temperature returned to normal. Cases, even when the physician believed them to be just a cold, were to be reported as influenza. In the case of pneumonia, case reports required the patient’s name, address, and age. Influenza reports, on the other hand, only required the total daily number of cases.16

Meanwhile, Spokane gained only the briefest appearance of relief as the number of new influenza cases dipped before suddenly rising sharply once again. By late-October, the city was headed into a second peak of influenza. Over 400 cases were reported on October 30 and October 31 alone. Anderson had been hopeful that the worst was over and that the closure order and gathering ban might soon be lifted. Now, as the epidemic continued to roll on, he was much less sanguine. Nurses at the emergency hospital were forced to work 12 to 14 hours per day to keep up with the caseload. At one point the situation became so critical that city officials had to make an appeal to Fort Wright and Camp Lewis to return the nurses that had been sent to those bases at the start of their epidemics. The latter responded by sending ten nurses back home to Spokane, where they were immediately put to work in the emergency hospital.17

With the new spike in cases, Anderson added prohibitions to the list of anti-epidemic measures, including a request that businesses stop displaying war maps in their shops to prevent crowds from gathering around them and a ban on Halloween masks. Anderson believed that costume masks were dangerous because their “promiscuous use”–by which he meant people breathing through their masks and then touching them–could lead to the spreading of germs. He even asked police to enforce the order by stopping masked trick-or-treaters on the streets. Regular gauze face masks, however, were permitted. Apparently, Anderson did not believe that people would be tempted to touch and adjust their gauze masks in the same way they would their Halloween costumes.18

While influenza made its way through Spokane, there were several institutions that, for the time being, were spared. The 285 people at Spokane’s Children’s Home, St. Joseph’s Orphanage, the Church Home for Children, Washington Children’s Home Finding Society, Deaconess Old People’s Home, the local Florence Crittenton Mission, Holy Names Academy, and Edgewood Sanitarium were all influenza free, the result, according to Anderson, of barring visitors once the epidemic began. Administrators at Edgewood Sanitarium went even further, placing their facility in protective sequestration; nurses, for example, were not allowed to leave the premises. The Salvation Army home for women, on the other hand, was not so fortunate. There, visitors were allowed. By the end of October, 43 cases had appeared among the 70 residents.19

Reports for November 4 indicated that it was the deadliest single day in Spokane since the start of the epidemic nearly a month earlier. The next day was Election Day, and Spokane officials were concerned about voters congregating at polling places. Anderson ordered inspectors to guard against overcrowding at the polls, and asked election workers to place voting booths outdoors wherever possible. Where they had to be kept indoors, he asked that no more voters than there were booths be allowed into the room at a time. Whether as a result of the precautions or other factors, inspectors making the rounds of Spokane’s poll locations on Election Day found little of which to complain.20

Meanwhile, on November 4, the Washington state Board of Health issued an order mandating the use of gauze face masks, to measure 5 by 6 inches and to be composed of not less than six layers of gauze sewed and bound together, for all state residents while aboard public conveyances, in public spaces in public buildings, hotels, lodging houses, stores and shops, restaurants, barber shops, and laundries.21 In Spokane, the order did not go into effect for two three days, after it was formally received by the city Board of Health.22 When Anderson formally announced the order, city residents made a run on Spokane’s drugstores and City Hall, where masks were made available for sale. Unfortunately, the majority of residents returned home empty-handed, as the demand far outstripped the short supply. At City Hall, for example, the 300 masks for sale lasted only 30 minutes, and two health inspectors had to control the crowd that had gathered there. Stock at the city’s drug stores lasted a bit longer, but the end result was the same: too few masks for too many people. Given the shortage, the city’s commissioner of public safety announced that police would not start enforcing the order for another day or two, giving Red Cross workers time to make more masks.23

The Red Cross quickly turned out 4,000 additional masks. Unfortunately, these new masks were slightly different from the regulation Red Cross ones (which was the version required by the State Health Department) and hung more loosely at the edges. Health Officer Anderson nevertheless approved their use. He had little choice: with the mask shortage he could either comply with the state order on mask construction or on mask use by the public, but not both simultaneously. Anderson’s decision may have put more masks in the hands–or over the faces, as the case may be–of Spokane’s residents, but it did not alleviate the central issue that masks were uncomfortable and unpopular. In general, masks were worn only so long as necessary. Once outside again, residents tended to stuff them back in their pockets if they bothered to carry or wear one at all. Some of the biggest offenders may have been police officers. The day after the mask order went into effect in Spokane, Anderson received reports that city police, who had been ordered to enforce the mask order, were ignoring it themselves. The health officer immediately notified Commissioner of Public Safety J. H. Tilsley that he would issue arrest warrants if the officers did not comply with the order forthwith. In their defense, officers protested that they had been donning their masks dutifully since the order went into effect. Anderson seemed mollified and did not press the issue any further.24 The next day Tilsley briefly stopped by police headquarters without his mask. None of the officers dared rebuke him, but their stares made him quickly realize his infraction. He slipped out of the building for a few moments to purchase the proper gear before returning with his face appropriately shrouded. Still, according to some, Tilsley’s mask had a tendency to slip below the chin more often than it should have.25

Commissioner Tilsley was undoubtedly pleased, then, by the state Board’s November 11 decision to remove the mask order. In Spokane, news of the decision was reached in the evening and immediately circulated among a population already in the midst of celebrating the end to the war. Anderson was cautiously optimistic that the rest of the restrictions could be removed within a week so long as the Victory Day festivities did not cause another uptick in influenza cases in the coming days. In the meantime, he recommended to the City Commissioners that they consider lifting closure order and gathering ban on Sunday, November 17 if there was no significant increase in the epidemic in the next two days.26

Residents, business groups, members of the clergy, and even some city officials were pleased with the prospect of their city re-opening to business and entertainment as usual. Learning that schools might soon resume classes, the Board of Education unanimously adopted a plant to lengthen school days and extend the school year to make up for the month of lost classroom time. The Superintendent of Schools O. C. Pratt even appeared before the City Commission (sitting as the Board of Health) to argue the case for removing the closure order. So, too, did some representatives of Spokane’s church community and its theater owners. They argued that the main threat had passed, and pointed out the examples of Seattle, which had already re-opened, and New York City, which had never closed.27 Many doctors, teachers, and ministers protested against re-opening the city too soon. The president of the Spokane Medical Society argued for even stricter enforcement of public health measures, including closing all non-essential businesses. Anderson maintained that he needed to gauge the trajectory of the epidemic over the next few days before a final decision could be made. When, on Thursday, November 14, the influenza tally showed 200 new cases–and thus no change from the same day of the previous week–Anderson decided to postpone lifting the bans indefinitely.28

The public did not need to wait long. On November 17, Anderson announced that the closure order and gathering ban would be lifted effective at midnight on Monday, November 18. Some restrictions remained. Theater and movie houses, for example, were required to maintain strict temperature and humidity levels and to deny entry to anyone who appeared ill. They would also have to hire a police officer at their expense to enforce the new rules. Public dances were still prohibited completely. Lastly, schools were to remain closed for an additional week, since, as officials explained it, many parents would not send their children to school again until they felt confident the conditions were safe. In addition, many teachers had been busy volunteering as nurses and caregivers and needed several days rest before returning to the classroom.29

Spokane’s epidemic was not over, and physicians continued to report significant numbers of new cases daily. By the last days of November, the epidemic appeared to be spiking once again. Anderson, concerned that Spokane might experience another shortage of nurses, made an early appeal for volunteers. “In the six weeks of quarantine [closure orders and gathering bans] thousands of people were taken ill and have recovered, practically immunizing them for the time being,” he announced. “Now these people who have had influenza should be willing to come forward and help nurse those stricken.” Already social services were being hit hard with unusually heavy demands for heating stoves, blankets and bedding, and other supplies. On November 29, the emergency hospital received more applications for admission than on any other day during the entire epidemic. Of the 75 patients already there, at least half were seriously ill and a number of them in critical condition.30

Faced with a rising tide of cases, Anderson announced that all homes with known cases of influenza would be placarded immediately. The measure was not meant as a full quarantine, however, only as a warning to potential visitors, and occupants were not confined to their homes. The new policy was in keeping with Anderson’s belief that the recent spate of cases was the result of the public’s disregard for safety. “People have let themselves loose and gathered in crowds wherever they found something to see,” he told reporters. “Crowds are breeders of influenza and so long as we have influenza and people mass together it will spread.” Yet, despite some pressure to issue more sweeping measures, Anderson did not feel it was necessary to order the closure of Spokane’s entertainment venues again. He did recommend to the Board of Education, however, that the schools be closed. School officials disagreed, arguing that they could handle the situation and suggesting that doses of anti-influenza serum be given free to children with parental permission. Anderson was temporarily mollified.31

Unfortunately for school officials, parents were not. The Board of Education office was besieged with phone calls from concerned parents questioning the decision to keep schools open in the wake of another peak in the epidemic. Many of these parents kept their children home, which, when combined with children who were ill, resulted in an absentee rate of nearly a third of the school district’s student body. Facing mounting pressure to act, on December 2 school officials asked Anderson to issue an order closing Spokane’s schools. Anderson wanted to wait another day or two so that he could study the latest flu tallies, but made it clear to all that a school closure would likely include prohibitions on children going downtown, walking the streets, or attending movie theaters.32

When reports showed nearly 300 new influenza cases for December 3, the Board of Health issued the order closing all public schools. Most of the city’s parochial schools decided to close as well. Children under 13 were barred from all places of public assemblage, including Sunday schools. The school board was not entirely pleased with the decision, with many members arguing that if the situation was severe enough to warrant closing schools then it was also severe enough to warrant closing entertainment venues and gathering spots, or at least to keep children over 13 from visiting them. As one member put it, “Already today the older pupils are running into danger by going to theaters and other places, which we hoped to prevent, but which the action of the Board of Health encouraged.” Essentially, high school students had received an unexpected vacation.33

That changed somewhat on December 6, when Anderson and the Board of Health announced a modified plan designed to end the spread of Spokane’s epidemic without resorting to another closure order. Most of the measures were aimed at allowing for ventilation and at preventing crowding. Thus, theaters were required to close alternate rows of seating (effectively halving their capacity) and to shut down daily between 5:00 pm and 7:00 pm to allow for ventilation of the building. Churches were allowed to hold devotional services, but likewise had to seat congregants in every other pew. Stores could not announce special sales. Streetcars were allowed to carry only as many passengers as there were seats, and “straphanging” was not permitted. Business colleges, art schools, academies, and private schools could remain open provided they had at least 1,000 cubic feet of air space per pupil. Elevators could only carry half their passenger capacity at any time. Conventions and special assemblies were not permitted without prior consent of the city health office. Anderson made it clear to all that if these measures did not work within a few days to a week, he would order a sweeping closure order that would effectively shut down the entire city.34

Spokane bore the new restrictions with some grumbling. The business community, looking forward to the end of the epidemic and of all restrictions on their livelihood, was particularly upset. Some theater managers were not entirely pleased with having to reduce their seating capacity by half, but others reported that attendance was already so drastically reduced by the epidemic that it mattered little. Whether the reduced revenue theaters were seeing was due to the epidemic or to the restrictions, most found it difficult to make enough to cover their operating expenses. To help theaters a bit, Health Officer Anderson shortened their mandatory closing hours by half and hour, giving managers a chance to hold two nightly performances. Poolroom and soft drink parlor owners complained that it was not fair to cut their card games while private poker and bridge games continued to thrive. Anderson told them that private games were likewise prohibited, although he must have known full well that enforcing such a restriction was nigh impossible.35 Restaurant owners received bad news on December 11, when Anderson announced they could not hold Christmas or New Year’s celebrations. As the health officer told the public, “This ban is on and will not be raised until school opens in January. There is no hope for an earlier lifting of it, even if no cases at all are reported.” He added that residents should make their holiday purchases now and not wait until later, as the situation could change for the worse, requiring further tightening of the restrictions.36

As the holidays approached, Spokane’s influenza situation slowly improved. The flu tallies for December 20 were the lightest in several weeks, a pattern that continued over the remaining days of the year. Nurses, physicians, and staff at the Lion Hotel emergency hospital were thrilled to enjoy a quiet Christmas, a drastic change from the hectic Thanksgiving they recently faced. Anderson was now convinced that the worst was over. On December 30, he announced that the epidemic restrictions would be lifted effective at noon on New Year’s Day, with schools to open on January 2.37 Anderson told the public to expect influenza to linger in Spokane until June, but assured the community that the current danger was over and the situation well under control. To help ensure that it continued to abate, he admonished residents to practice self-isolation and quarantine if feeling ill, calling it “a question of individual integrity.”38

Spokane now had the task of piecing together life as normal. Theater and movie house owners were among some of the most adversely affected by the public health measures, and they had not been shy about expressing their disagreement with the prolonged restrictions on their business. On January 10, a group of theater owners asked the City Council for a refund for the 40 days they were closed and an allowance for the time they were allowed to run at half capacity. The Council was divided on the issue, with one commissioner strongly opposed and three in favor. Tilsley, the public safety commissioner, recommended that theaters be compensated through a one-month’s rebate on their license fee. The next day, on January 11, the City Council passed Commissioner Tilsley’s recommendation, granting theaters a $21 rebate–the 40-day prorated amount of their $200 annual license fee.39

Perhaps more than any other event, it was the closing of the Lion Hotel emergency hospital on January 13 that truly signaled the end of Spokane’s epidemic. In its 89 days of operation, the hospital treated 617 patients and saw 68 deaths. The high mortality rate was to be expected given how sick most of the hospital’s patients were upon admittance. At the height of the first peak of the pandemic, the number of patients at the hospital reached as high as 140; during the second peak it got as high as 132. On average, patients remained in the hospital for nine days before doctors deemed them well enough to be released.

Overall, over 11,000 Spokane residents fell ill with influenza between October 1918 and February 1919, representing nearly 11% of the city’s population. Some 562 people died of influenza or pneumonia during that period. The result was an excess death rate of 482 out of 100,000, higher than Seattle’s 414 per 100,000, but lower than average for all Western cities combined (529 per 100,000). In that regard, Spokane’s experience was like that of many American cities–not altogether good, but not terribly bad either.

What makes Spokane’s epidemic interesting, however, is the shape of its epidemic curve. Most American cities outside of the East Coast experienced two distinct peaks of influenza deaths during the fall of 1918 and early winter of 1919. In contrast, Spokane experienced three sharp peaks. The first occurred around October 20, and led Anderson to declare that the worst was over. The number of deaths decreased for a week before suddenly cresting again, this time at nearly double the height of the first peak. Deaths abated over the course of the following two weeks before increasing sharply for a third and final time, peaking in early-December and then steadily declining over the course of the next month.