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Cold Comfort

If an influenza pandemic strikes again, it could be cold comfort to know that lessons learned from the 1918 flu epidemic may offer more help than modern medicine. Here are some insights gleaned from the Dartmouth archives and from a Dartmouth graduate who studies pandemics.

By Laura Stephenson Carter

I had a little bird,
Its name was Enza.
I opened the window,
And in-flew-enza.
—Children's Rhyme, 1918

Enza was anything but a cute little bird. She was vicious. She was violent. She was a killer. In 1918, while World War I raged, 675,000 Americans died of the flu; estimates of the worldwide death toll now range from 50 million to 100 million. But maybe the children singing that ditty were on to something. Today, scientists believe that the 1918 flu was caused by a bird—or avian—virus.

Its symptoms were so brutal that many physicians mistook it at first for dengue, malaria, cholera, dysentery, typhoid, or even plague. But soon they realized it was influenza—a strain that became known as "Spanish flu," not because it had originated in Spain but because Spain was neutral during World War I and its press didn't hesitate to report on the deadly disease. The same was not true of the countries engaged in combat; in the U.S., newspapers were urged to downplay the flu's severity for fear that morale would be affected.

The flu came in three waves: the first in the early months of 1918, the second in the fall of 1918, and the third in early 1919. The second wave was the deadliest.

On September 13, 1918, U.S. Surgeon General Rupert Blue issued a bulletin warning the public that the flu's onset could be sudden—that people could be stricken on the streets or while at work in factories, shipyards, or offices. He advised anyone experiencing symptoms to go home at once, get in bed, and call a physician immediately. But so as not to alarm people, he did not go into the disease's severity. And he did not say that flu was sweeping the country—especially military installations. Camp Devens, near Boston, was hit especially hard.

Scenes like the one above—row on row of cots filled with patients stricken in the 1918 influenza epidemic—were common all across the country, including in Dartmouth College's Memorial Gymnasium, which is pictured below. No photos exist of that cavernous space filled with flu victims, although the Dartmouth archives contain many written accounts of the gym's use for that purpose. The image above was taken at a naval training station in California; the sign on the lefthand balcony prohibits spitting, to prevent the spread of the influenza virus.

"It is only a matter of a few hours then until death comes. . . . It is horrible. . . . We have been averaging 100 deaths per day."
—Military physician

"These men start with what appears to be an ordinary attack of la grippe or influenza," wrote Dr. Roy Grist, a Camp Devens physician, to a friend, "and when brought to the hospital they very rapidly develop the most vicious type of pneumonia that has ever been seen. Two hours after admission they have the mahogany spots over the cheekbones, and a few hours later you can begin to see cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the colored men from the white. . . . It is only a matter of a few hours then until death comes. . . . It is horrible. One can stand it to see one, two,

or 20 men die, but to see these poor devils dropping like flies. . . . We have been averaging 100 deaths per day. . . . It takes special trains to carry away the dead. For several days there were no coffins and the bodies piled up something fierce."

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Laura Carter is the associate editor of Dartmouth Medicine magazine. For ease of comprehension, some punctuation, spelling, and abbreviations in the historical quotations have been standardized; the wording, however, has not been altered at all.

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