By Richard Longley
The influenza pandemic of 1918 swept all continents. From the remote Pacific Islands to Canada’s Far North (where Inuit suffered dreadfully), it came in three waves: late winter 1918, fall 1918 and winter 1919.
In separate spans of a few weeks, it killed an estimated 17 million to 50 million people worldwide. That’s many more than the nine million who died in combat through the four years of the First World War.
The Black Death of the Middle Ages was worse but in terms of sheer numbers, the 1918 influenza was the deadliest pandemic in history.
The deadliest to hit Toronto was the second wave in September to October 1918.
“The epidemic struck almost like a cyclone…then subsiding almost as rapidly as it began,” said Charles Hastings, the City of Toronto’s Medical Officer of Health.
Precisely when the pandemic began is still something of a mystery.
In France and in England, there were outbreaks among soldiers of “purulent bronchitis” with symptoms similar to the flu as early as the spring of 1916.
All we know for sure is that the pandemic did not begin in Spain and it should never have been called the “Spanish Flu”.
We also know that the First World War was a global war. Millions of men and women were transported to battlefronts thousands of miles from home. This was a war in which anyone might be a vector of disease between nations and continents. Among those potential vectors and victims were Canadians.
In 1918 the population of Canada was eight million. About 490,000 people lived in Toronto. Some 60,000 Canadians, 4,904 of them Torontonians, died as a consequence of the war between 1914 and 1918. Some 50,000 Canadians, 1,750 of them Torontonians, died of influenza.
First casualty of influenza
On September 29, 1918, a schoolgirl died of influenza at Toronto General Hospital. More than 10,000 students and 1,630 teachers were discovered to be sick within a few days.
Some 650 patients were admitted at Toronto General that October. At the height of the epidemic, hospital admissions were dying at a rate of 8 to 10 a day. In the city as a whole, the rate was 50 a day.
Volunteers worked in the wards day and night. By the end of the month, eight head nurses, 70 student nurses and 20 student nurses became sick. Thirteen developed pneumonia. Three died.
At the Hospital of the Anglican Sisters of St. John the Divine on Major Street, which is now occupied by Kensington Gardens’ long-term care home, many of the patients received care for free. The nursing was strenuous. But of the 90 patients admitted, only seven were lost.
Loretto College at 387 Brunswick Avenue became an emergency facility for children as young as three months old whose parents had either died or were in the hospital.
The symptoms of the pandemic that peaked in the fall of 1918 were horrific. They included fever, clogging of the airways, coughing of blood, cyanosis—bluing of the face and fingers due to lack of oxygen—pneumonia and delirium. Death due to drowning by pulmonary edema would occur within a few days.
The 1918 influenza was a maker of widows and orphans, a taker of young men and women in their prime.
Unlike “normal” influenzas, which are most deadly among the very young and old, the 1918 flu affected mainly people between 18 and 39 years of age, the generation that sacrificed most in the war. A Canadian study has found that the peak age of death was 28.
The ferocity of the 1918 flu’s symptoms and its targeting of the strongest of its potential victims suggests that it killed by provoking “cytokine storm”, a massive overreaction of the immune system that causes inflammation, kidney damage and bleeding in the lungs.
There were no scientific remedies for influenza in 1918 but many bizarre treatments. They included aspirin in doses that were so toxic they may have caused some deaths. Among other remedies were Dr. Chase’s Menthol Bag, heroin to relieve coughing and insomnia, Epsom salts to clean out the digestive tract, Charley’s Rum and laxative Bromo quinine.
The registrar of the College of Pharmacy may have had the brightest idea, advising druggists to fill doctors’ prescriptions for six ounces of liquor, “To relieve the public from the strain of having to stand in line for hours at a liquor vendor’s, when many of them are ill and in no condition to stand the exposure.” Six ounces was the maximum allowable under the Ontario Temperance Act.
The entire city might have been overwhelmed considering how limited treatment options were.
The city was as prepared for the pandemic as it could be. Toronto’s water was chlorinated, milk was pasteurized, baby clinics were established and Public Health Nurses were dispatched into the city’s poorest neighbourhoods.
By 1915 the frequency of typhoid and other water and milk-related diseases had plummeted. And a network voluntary groups linked to the Department of Public Health had been established.
A pragmatist as well as an idealist, Hastings did not require the wearing of face masks. He also resisted calls to quarantine the sick.
Toronto in 1918 was an industrial city, as well as a centre for business and government. Factories and sweatshops were packed with workers. Living conditions were often cramped and appalling. Self-isolation and maintaining a safe distance was inconceivable.
Before the internet, when few people had access to a telephone and there was no uber-eats, working at home was impossible for the majority.
Streets were equally full. In 1918 only the rich owned a car. The majority of Torontonians walked to work or squeezed into public transit.
What Hastings could do to encourage social distancing he did. He commandeered hotels, turned them into hospitals, supplemented their staffs with hastily trained Sisters of Service. Many of them were teachers, unemployed by the flu.
He also announced a partial lockdown of “all Theatres, Moving Picture Shows and other places of amusement, including Pool Rooms, Billiard Rooms and Bowling Alleys.”
There was no visiting of family members in the hospital. Libraries remained open but there was no lending of books. Churches that had congregations of hundreds were allowed to hold just one service on Sundays—Catholics in the morning, Protestants in the evening. To those who objected, Hastings suggested there was no need to visit a church to obtain “a truer conception of God’s relationship to man and of man’s humanity to man.”
A different city then
Socially, ethnically, structurally, Toronto in 1918 was different from the city of today. Many immigrants spoke no English. Many were illiterate. There was no publicly funded health care, no sick pay, no unemployment insurance. Individuals and families depended on each other, their places of worship and their communities for survival.
Conditions were hard. Some 70,000 of the most able-bodied Torontonians went to fight overseas. Many who did come back were disabled. For families that lost their chief or sole earners, life could be desperate. The city’s informal network of support was crucial to its poorest citizens.
MacDougall notes that “One of the most striking features of the outbreak was the extent to which Torontonians of all social classes suffered and yet sought to help each other.
“The middle class and well-to-do volunteered themselves and their cars to take food, medical and nursing supplies, and doctors and visiting nurses to their patients. Workers tried to maintain essential services while citizens faced a final round of privation prior to the end of the war. Teachers, homemakers, nursing, medical, and dental students volunteered their services.”
Dalla Lana fellow in Global Journalism Karen Black describes how Ontarians came together to fight the Spanish flu.
“The Neighbourhood Workers’ Association (NWA) headquarters, located on Yonge Street across from where the Eaton Centre stands today, was ground zero for the dispensing of emergency food and medical supplies.
“With the help of a huge city map dotted with blue tacks denoting 24 supply depots…thousands of volunteers mobilized to deliver food, medical supplies, and nursing care to households across the city.”
The NWA oversaw the work of dozens of voluntary organizations. They included the YMCA, University Settlement, Imperial Order Daughters of the Empire, who operated a kitchen at Central Technical School near Bathurst and Harbord streets, and St. Christopher’s House. The collective effort helped roughly 500 families a day.
Postal workers were also enlisted to collect information and identify homes where there were sick.
But in a city where social, religious and ethnic barriers still existed, some volunteers were reluctant to serve in poor parts of the city. “This was especially problematic for poor and non-English-speaking immigrants.” MacDougall says.
Nevertheless, the Health Department staff made 17,108 visits to stricken households.
But for the survivors of influenza recovery was often difficult. Lives were cut short by the lingering effects of flu and increased vulnerability to pneumonia and tuberculosis. Expectant mothers were especially vulnerable; many who did survive lost their child. Even the unborn were affected.
Economist Craig Garthwaite studied the health outcomes of people born in the U.S. between October 1918 and June 1919. He discovered an unusually higher frequency of diabetes and kidney disease among those born to mothers afflicted with influenza late in pregnancy. And a higher frequency of heart disease among those born to mothers who were afflicted earlier during pregnancy.
Toronto was battered by the pandemic. Production in the city’s factories slowed. The construction trades were the worst hit. That did not prevent the opening of the Prince Edward viaduct on October 18, 1918. But it did speed up the ceremony. It ended when Mayor Tommy Church ordered: “We’ll not have any more speeches. If we keep you here any longer we will be violating Dr. Hastings’ regulations as to gatherings of people.”
Hunt for a vaccine
In October 1918, Charles Hastings visited the U.S. to observe the pandemic in Boston, New York and Washington. When he returned, he brought back with him samples taken from patients of the bacterium Bacillus influenzae. It was thought then to be the cause of influenza.
Medical Historian Christopher Rutty describes how bacilli were killed by heat then suspended in a salt solution to create a vaccine. The process is much simpler than the techniques being used now to the search for a COVID-19 vaccine.
Led by acting director Robert Defries, Connaught Labs worked 24/7. Seven thousand doses of influenza vaccine had been distributed—3,000 to the army, 4,000 to Toronto hospitals—by October 21. Hundreds of thousands of doses had been distributed in the province by the end of the month. Did the vaccine work?
It seemed to relieve symptoms in desperate cases. Perhaps by alleviating the effects of pneumonia that accompanied influenza in most cases. But the arrival of the vaccine after the pandemic had started and after the peak had passed made an accurate assessment difficult.
The verdict of the Toronto Star might have been about right. “If it does not do any good it cannot do any harm.”
The viral cause of influenza wasn’t confirmed for more than a decade later in 1931. It was first seen through the electron microscope in 1933.
Like everything about the flu—including knowing the number of people it continues to kill each year—this is a quest that remains elusive. Forever prone to antigenic drift and more abrupt shift, the influenza virus is a chronic mutator, a shape-shifter. It requires re-design of its vaccine at the start of every season, to be as ready as possible for the onslaught that will come next winter.
By early November 1918 the pandemic was subsiding in Toronto, the flow of influenza victims into overstretched hospitals was slowing. Schools would have opened in November if not for a coal shortage.
As described vividly by city historian Jamie Bradburn, the war would be over on November 11, and Toronto would erupt in celebration (as it had prematurely on November 7). The flu would linger into December and return in spring.
It would be severe enough then to kill Joe Hall of the Montreal Canadiens, sicken his coach and four teammates and cancel the Stanley Cup for the only time in its history. The third wave also infected U.S. President Woodrow Wilson. And disrupted his quest for a generous peace at the Versailles Peace Conference. And, in the opinion of many historians, enabled the rise of Hitler. Illness can do that kind of thing.