Journal Review

A firsthand account from the frontlines of 1918 flu

Antibiotics could have made all the difference

Starr, I. Influenza in 1918: Recollections of the Epidemic in Philadelphia. Ann Intern Med 2006; 145(2). On the web in early release at

The editors do us a fascinating and frightening favor by reprinting this historical firsthand account by a physician-in-training facing the 1918 flu pandemic at the University of Pennsylvania School of Medicine in Philadelphia. In light of the current threat of an influenza pandemic, a memoir originally published in the journal in 1976 is reprinted in grim, firsthand detail. Here is an excerpt:

"Soon, the beds were full, but nobody on my floor was very ill," he recalls. "The patients had fever but little else. Many seemed to have sought admission chiefly because everybody in the family was sick and no one was left at home who could take care of them. Unhappily, the clinical features of many soon changed drastically. As their lungs filled with rales, the patients became short of breath and increasingly cyanotic. After gasping for several hours, they became delirious and incontinent, and many died struggling to clear their airways of a blood-tinged froth that sometimes gushed from their nose and mouth. It was a dreadful business. . . . The deaths in the hospital as a whole exceeded 25% per night during the peak of the epidemic. To make room for others, the bodies were being tossed from the cellar into trucks, which when filled carted them away. . . . While this was going on in my ward, the life of the city had almost stopped. Public assembly was forbidden, so there were no plays, movies, concerts, or church services. Schools were closed. Some stores and businesses stayed open, some did not. All train schedules were reduced to those of Sunday, and these could not always be kept."

In addition to the original memoir, the article includes an author's note written 60 years after the great pandemic in which he marvels at his own survival and that of his co-workers. He also reaches a surprisingly optimistic conclusion about the ability to fight subsequent pandemics with a weapon he did not have: antibiotics.

"Perhaps the masks, gowns, and hand washing did more to protect us than we had a right to expect," he recalled. "Certainly, with death all around us, we had every encouragement to be as careful as we could, but we were so busy and so tired that we forgot about precautions, and patient after patient coughed into our faces as we tended to their needs. . . . While certainly not proved, the hypothesis that the initial mild illness was of viral origin and the pulmonary complications of bacterial origin fits the facts as we saw them in 1918. If the antibiotics available today will prevent or cure the complicating pneumonia, as they do bacterial pneumonias of so many other types, there should be little or no mortality in a future epidemic of influenza."