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The Forgotten Flu

February 01, 2008

In 1918, an outbreak of influenza swept over the earth, becoming the deadliest pandemic in history. Between 50 and 100 million people died, including 675,000 Americans.1 One-third of the world's population and one-fourth of Americans were infected.2

In this article, we provide an overview of how the pandemic affected American society. We also examine the impact on psychiatric hospitals. As we prepare for the next flu pandemic, the lessons learned from the 1918 outbreak remain relevant and instructive.

A Global Catastrophe

Despite intensive investigations, much about the virus (H1N1) that caused the 1918 pandemic remains a puzzling mystery.2 We do know that it first infected birds before transforming to infect swine and humans.3 Although some evidence suggests that human infection began in Canton, China, most historians say the pandemic began in Kansas near an Army base in February 1918.1,3

Fort Riley was a huge Army training facility in Kansas that had nearly 60,000 soldiers. As Barry states in The Great Influenza: The Epic Story of the Deadliest Plague in History, “It is impossible to prove that someone from Haskell County, Kansas, carried the influenza virus to Camp Funston [which contained Fort Riley's infirmary]. But the circumstantial evidence is strong.” 1 At Fort Riley thousands of military personnel developed the flu in the spring, summer, and fall of 1918. The first official influenza sick call at Camp Funston occurred on March 4, 1918, and within three weeks at least 1,000 soldiers required hospitalization for severe symptoms. 1

Although people dutifully wore masks, these provided only a very limited protection against the influenza virus. when it came to treating influenza patients, doctors, nurses, and druggists were at a loss during the flu pandemic.
Photos provided by the U.S. Office of the Public Health Service Historian; Used with permission. These photos are representative of the period; they may not have been taken during the height of the pandemic.

Although people dutifully wore masks, these provided only a very limited protection against the influenza virus. When it came to treating influenza patients, doctors, nurses, and druggists were at a loss during the flu pandemic.

The virus spread east in the United States and on to Europe, Asia, the South Pacific, and Australia. By May 1918 influenza was epidemic in Spain. Spain, a neutral country during World War I, did not have press censorship. Thus, reports of the large numbers of influenza cases circulated widely, and the illness became known as the Spanish Flu or La Grippe.1 Influenza advanced around the world in three waves: spring 1918, fall 1918, and winter 1919.2

The 1918 flu had three significant clinical features: rapid death, fatal secondary bacterial infection, and highest mortality among those 20 to 40 years old (People born before 1889 were thought to have some immunity from exposure to a prior epidemic2). More U.S. soldiers died from the flu than from combat.4

Reactions at Home

Denial. Many Americans denied the outbreak's seriousness, based on limited news coverage and the stance of local and federal authorities. For example, officials in Philadelphia downplayed the significance of early cases and, in fact, encouraged large public gatherings.5 Yet if the public had known of the flu's dangers, more might have participated in quarantine efforts which, when complete, were surprisingly effective.

Hatchett et al compared the flu's peak mortality rates in different U.S. cities to demonstrate the proven effectiveness of nonpharmacologic interventions (NPIs).5 Communities that used several such interventions (e.g., preventing public gatherings and closing schools) had a reduction in peak incidence of influenza cases by 50%, although the overall number of cases was reduced by only 20% (still an impressive figure). Philadelphia had one of the highest mortality rates of major U.S. cities, attributed to a failure to implement NPIs and to allowing a citywide parade on September 28, 1918, which 200,000 people attended.

Mistrust. Some saw influenza as a German weapon brought to the United States by U-boats.1 Others blamed the outbreak on immigrants. For example, Denver residents singled out Italians.1

With denial of the pandemic becoming impossible as more people died, the public lost trust in local and federal authorities. As Barry says, “The terror among Americans about the 1918 influenza was a direct result not of the disease itself but the result of the way in which authorities and the media systematically destroyed trust.”6

Panic. Many feared that influenza would not only disrupt life but also would cause the end of civilization.1 Suicide rates in the United States increased during the pandemic.7 In rural areas, such as in Kentucky, flu victims starved to death because their neighbors were afraid to bring them food.6 In many U.S. cities, social gatherings (e.g., church services and public performances) were suspended and schools were closed.8 Corpses remained uncollected in homes and on streets, and morgues overflowed with bodies.1

The Psychiatric Impact

When considering the psychiatric impact of the virus that caused the 1918 pandemic, one has to remember the state of psychiatric research at the time. With that consideration in mind, influenza infection was said to cause delirium, described succinctly by a French clinician (quoted by Barry) as follows: “The mental disturbances during Influenza sometimes took the form of acute delirium with agitation, violence, fear and erotic excitation.” Less commonly, “The main symptom was of a depressive nature…fear of persecution.”1 A U.S. Army report (quoted by Barry) noted, “Nervous symptoms appeared early, restlessness and delirium being marked.”1

Some patients reportedly became self-destructive as a result of delirium. Starr, who was a medical student during the pandemic, described how “Mike a piano mover was poised on the window ledge ready to jump.” Following Starr's intervention, “Mike, delirious had turned the bed over on top of himself and was moving up the ward on his back. He lasted only a few hours after that.”8

After the pandemic, influenza was an area of interest for psychiatric researchers. In 1926, Menninger hypothesized that pregnant women who had influenza produced children who later developed schizophrenia.9 Others speculated that the infection disturbed fetal development and led to lower birth weights, and that this was the mechanism through which influenza led to schizophrenia.10 While these hypotheses have not been proven, the long-term effect of in utero infection remains an area of schizophrenia research interest.11

Effect on Psychiatric Hospitals

Public mental hospitals in the United States in 1918 were self-contained communities,12 but this relative isolation did not spare them from the pandemic. Many hospitals remained open to admissions, providing a source of infection. The Worcester State Hospital (Massachusetts) 1918 annual report states:

When the epidemic of Spanish influenza first broke out in our district, the institution was placed under a fairly strict quarantine. As the disease first appeared on the receiving wards, we believe it was brought to us by newly admitted patients. It spread somewhat to other parts of the institution but at no time reached serious proportions. There was a total of 140 cases with 2 deaths from influenza and 31 due to complications from pneumonia.13

In 1918, the hospital's population was 1,774, yielding a 0.11% death rate from influenza alone or a combined “excess” pneumonia and influenza death (CEPID) rate of 0.67%, which is similar to the CEPID death rate of 0.65% in cities employing several quarantine-type control measures.5 This CEPID figure is based on the assumption that 10 of the 31 pneumonia cases reported in 1918 at Worcester State Hospital were “excess” (i.e., beyond what would have been expected in a typical year). Prior to the epidemic, about 21 patients died from pneumonia annually.

At Dorothea Dix Hospital in North Carolina, only 18 patients and 2 staff members died as a result of the flu, and only 317 patients had the flu.14 At that time the hospital's patient population was approximately 1,900.15 At the New Hampshire State Hospital, “During the fall of 1918 we took our brunt of the influenza epidemic, 243 cases developing within the hospital with 16 deaths.”16 During the flu outbreak, the hospital had an average census of 1,368 patients.

Although the three state hospitals we examined did not seem to be significantly affected by the pandemic, Torrey and Miller report that the pandemic had a large impact on patient populations: “The only event that slowed this inexorable ascent [of insanity] was the influenza pandemic of 1918, which temporarily decreased the prevalence of insanity by killing large numbers of patients in the asylums.”17

Across the Atlantic, in Amsterdam the pandemic was at its height in October of 1918, and admissions to mental hospitals actually increased during that month (although not a statistically significant difference). There is no evidence of any attempt to deny admission to patients to achieve quarantine.18

Final Thoughts

The 1918 pandemic offers important lessons for the next influenza outbreak. As Barry points out, the government needs to be honest and open to achieve positive results.6 It's important to note that in many instances quarantine did reduce morbidity and mortality.

Yet it's remarkable how little the pandemic of 1918 is noted or discussed today, particularly outside academic circles. If not for the current concern about the avian flu, one has to wonder if this historic event would have continued to be neglected. After all, the human ability to forget, deny, and avoid unpleasant topics and memories is extraordinary. Langer's An Encyclopedia of World History, published just 40 years after the pandemic, fails to note it and the 50 to 100 million people who died.19 But there are still some who remember the pandemic firsthand: Dr. Bazemore's father, now 101 years old, recalls running errands for ill people in Massachusetts while a Boy Scout during the outbreak.

Stephen M. Soreff, MD, is President of Education Initiatives in Nottingham, New Hampshire, and is on the faculty of Metropolitan College at Boston University, Fisher College, Worcester State College, and Southern New Hampshire University.
Patricia H. Bazemore, MD, is an Associate Professor in the Departments of Psychiatry and Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester. She also is a member of the medical staff at Worcester State Hospital.

To contact the authors, e-mail


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