The First Empty Beds

The night nurse at Pennsylvania Hospital did not arrive for her shift on the morning of September 29, 1918. Her replacement found the station empty at 7:00 a.m., the ward ledger open to a blank page, the keys still hanging on their hook. A telephone call to her boarding house on Spruce Street brought no answer. By 8:30, a second nurse had failed to report. The head nurse, a woman who had trained at the hospital since 1902, made a notation in the duty book: two absent without leave, influenza suspected. She did not telephone the Bureau of Health. The protocol for individual sickness did not require it.

The distance between recorded fact and recognized pattern would stretch across the coming hours, until the mechanisms of the city could no longer process what they had been built to ignore.

At 9:15 a.m., a third-year medical resident completed his rounds on the men’s medical ward and counted six beds occupied by patients admitted within the previous eighteen hours. All presented with fever above 102 degrees, cough, and prostration. Three were sailors from the Philadelphia Navy Yard. Two were civilian men who had attended the Liberty Loan parade. The sixth was a woman of sixty who had watched from her second-floor window on South Broad Street. The resident recorded the cases in his ward notebook without diagnostic comment. The symptoms resembled those he had read about in the September bulletins from the United States Public Health Service. He did not connect the six cases to each other, or to the parade, or to anything larger than the ordinary September increase in respiratory illness. The hospital’s daily census, submitted to the superintendent at noon, listed them under bronchitis and pneumonia, acute.

The parade had ended twenty-four hours earlier.

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In Washington, D.C., the office of Surgeon General Rupert Blue occupied the second floor of the Treasury Building, three rooms with tall windows facing Pennsylvania Avenue. On September 29, Blue dictated a bulletin for distribution to state and municipal health officers. The text, later printed in the Public Health Reports, advised that influenza had appeared in scattered localities and recommended fresh air, careful washing of the hands before eating, and the avoidance of crowds. The bulletin noted that the disease was mild in character and that panic was unnecessary and should be avoided. Blue’s office had received the Philadelphia Navy Yard reports by telegraph on September 20. He had read Paul Lewis’s laboratory findings. The bulletin made no mention of Philadelphia specifically, nor of any measure beyond personal hygiene. The Fourth Liberty Loan, for which subscriptions had begun on September 28, consisted of 20-year 4¼% bonds, dated Oct. 24 1918, maturing Oct. 15 1938.

The bulletin reached the Philadelphia Bureau of Health by afternoon mail. Wilmer Krusen read it at his desk on the fourth floor of City Hall. The language of reassurance matched his own assessment. The morning’s mortality returns showed 17 deaths for September 28, a figure within the seasonal average. The Bureau’s morbidity report, compiled from physicians’ voluntary notifications, listed 21 new cases of influenza for the entire city. Krusen filed the bulletin without forwarding it to the mayor or the press. The Liberty Loan committee had announced that Philadelphia had exceeded its quota of $259 million in bond subscriptions. The Philadelphia district’s quota for the Fourth Liberty Loan was $500, 000, 000, and its subscription totaled $598, 763, 650. The victory celebration was complete.

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At 11:30 a.m., the pharmacy of a major drug manufacturer at 1412 Walnut Street recorded its fourteenth sale of aspirin in one hour.

The clerk, a young man in his third year at the store, noted the figure in his daily sales book without comment. Aspirin was a common remedy for headache and fever.

The quinine requests were more unusual: seven in the same hour, when the store typically sold two or three bottles per week. Quinine was prescribed for malaria, for neuralgia, for any fever that did not respond to standard treatment. The clerk filled the prescriptions as presented. He did not ask the customers about their symptoms.

The pharmacist on duty, a man of forty years’ experience, observed the pattern and said nothing. The store had seen surges before, in hay fever season, in the annual autumn cold. The connection between the parade and the pharmacy counter required a step that no one in the store had been trained to take.

By 2:00 p.m., the Pennsylvania Hospital switchboard had logged eleven telephone calls from physicians requesting admission for patients with influenzal pneumonia. The admitting office, accustomed to managing surgical cases and chronic medical conditions, directed six of the callers to other institutions. The hospital had 293 beds. The census at noon showed 247 occupied, a comfortable margin. The head of medicine made his afternoon rounds and observed that the new pneumonia cases were unusually severe and rapid in onset. He did not convene a staff meeting. The hospital had no protocol for convening staff meetings based on clinical impression.

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At the Bureau of Health, the clerk charged with compiling the daily morbidity report worked through the afternoon of September 29 with a stack of physicians’ notification cards. The cards, printed by the city and distributed to all licensed practitioners, requested the patient’s name, address, age, and diagnosis. Reporting was voluntary and incomplete.

The clerk counted 34 cards for influenza, up from 21 the previous day. He noted in his workbook that cases were appearing in districts not previously affected, a phrase he had copied from the Navy Yard reports. The districts he named were the 7th, 12th, and 26th wards, all south of Market Street, all within walking distance of the parade route. He did not calculate a trend line.

The report, typed for Krusen’s signature, presented the numbers without interpretation. The Bureau’s function was to record disease, not to predict catastrophe. Two days later, Dr. Wilmer Krusen would conclude that the influenza was now present in the civilian population.

Krusen reviewed the report at 5:00 p.m. He had spent the afternoon in conference with the director of the Navy Yard hospital, a commander who reported that admissions had risen to 47 new cases in twenty-four hours. The commander requested additional medical personnel. Krusen promised to forward the request to the state health department. He did not mention the civilian cases building in the city hospitals. The Navy Yard was federal jurisdiction. The city’s responsibility began at the gates.

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The evening of September 29 brought a change in the weather. A cold front moved down from Canada, dropping temperatures into the forties, driving Philadelphians indoors. The Inquirer’s late edition, published at   7:00 p.m., carried no mention of influenza. The front page celebrated the Liberty Loan success with photographs of the parade and a statement from Mayor Thomas B. Smith: Philadelphia has done its duty. The Bulletin, competing for readers, led with a boxing match and a police raid on a gambling house. The weather forecast called for clearing skies and seasonable temperatures. No editorial voice suggested that the crowds of September 28 might carry a cost beyond the war bonds purchased. The evening bulletin of The Philadelphia Inquirer described the parade as ‘the first premonition of – victory’ and as ‘a great day in Philadelphia.’

At Pennsylvania Hospital, the night staff of September 29 worked with three nurses borrowed from the day shift. Two more nurses had called in sick by 6:00 p.m. The head nurse extended her own shift to cover the gap. She made a second notation in the duty book: staff shortage critical, requesting emergency list. The emergency list consisted of retired nurses and nursing students who could be called for temporary duty. She telephoned four names before 8:00 p.m. One answered and agreed to come. The other three lines rang unanswered.

The ward that the resident had rounded that morning now held eleven patients with influenza or its complications. Three had developed cyanosis, the blue discoloration of the face and extremities that signaled oxygen starvation. One, a sailor of twenty-two, died at 9:45 p.m. The resident on duty recorded the death in the ward book and notified the night supervisor. The body was removed to the hospital morgue, a basement room with capacity for twelve. The morgue held four bodies that night, two from surgical cases, two from medical. The sailor was the fifth. The supervisor did not telephone Krusen. Single deaths did not require health department notification.

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September 30 opened with fog. The Delaware River, visible from the upper floors of Pennsylvania Hospital, disappeared into gray. The morning temperature was 48 degrees. The Inquirer’s early edition, delivered to the hospital at 6:30 a.m., carried a brief item on page six: Influenza Cases Increase at Navy Yard. The story quoted the commander as stating that the situation was well in hand and that no spread to the civilian population was anticipated. The reporter had not contacted the Bureau of Health. The story ran without a Philadelphia dateline.

At 7:00 a.m., the Pennsylvania Hospital switchboard logged its first call of the day: a physician requesting admission for a woman of thirty-four with fulminating pneumonia. The admitting clerk, following established procedure, asked for the patient’s name, address, and referring doctor. He did not ask about symptoms. The hospital’s medical wards were now full. The clerk directed the call to Philadelphia General Hospital, the municipal institution on Girard Avenue. He made a notation in his log: referral to PGH, capacity.

Philadelphia General Hospital, older and larger than Pennsylvania Hospital, had 1, 200 beds. Its morning census of September 30 showed 987 occupied, a figure that had risen from 912 on September 28. The increase of 75 patients in two days was not extraordinary for an institution that served the city’s poor and working classes. The diagnoses were scattered: tuberculosis, heart disease, the chronic conditions of poverty. The admitting office had received 14 telephone requests for influenza admission since midnight. It had accepted 9 and referred 5 to smaller hospitals. The medical superintendent reviewed the morning report and observed that the pneumonia cases were younger than usual and more rapidly fatal. He dictated a memorandum to his department heads suggesting increased vigilance but no change in procedure.

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At 10:00 a.m., the Bureau of Health clerk completed his compilation for September 29. The morbidity report showed 118 new influenza cases, a figure that exceeded the total for the previous week. The clerk added a handwritten note: dispersion pattern suggests point-source exposure, date approximately September 28. He showed the note to his supervisor, a man who had worked in the Bureau for fifteen years. The supervisor read the note and asked whether the clerk had verified the diagnosis with the reporting physicians. The clerk had not. The supervisor instructed him to remove the speculative language and submit the numbers alone. The revised report, typed and signed by Krusen, listed 118 cases without comment. It was filed with the city clerk at 11:30 a.m.

Krusen spent the morning of September 30 in conference with the Liberty Loan committee. The final accounting of bond subscriptions required his signature as a member of the executive committee. The meeting, held in the boardroom of the Girard Trust Company, lasted two hours. No participant mentioned influenza. At 1:00 p.m., Krusen returned to his office and found a telegram from Surgeon General Blue, dated September 29. The telegram acknowledged the Navy Yard’s request for additional medical personnel and stated that local resources should be exhausted before federal assistance is requested. Krusen filed the telegram with the Navy Yard correspondence. He had no local resources to exhaust. The civilian hospitals were not yet reporting shortages to his office.

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The afternoon of September 30 brought a shift in the pattern of requests to Pennsylvania Hospital. The telephone calls now came not from physicians but from families: a husband describing his wife’s sudden fever, a son reporting his father’s difficulty breathing. The switchboard operator, following no established protocol for such calls, transferred them to the admitting office, which transferred them to the outpatient department, which instructed the callers to contact their private physicians or to bring the patients to the emergency entrance. The emergency entrance, designed for surgical cases and accidents, was not equipped for infectious disease. The nursing staff there had received no instructions about influenza.

By 4:00 p.m., the emergency entrance had seen 23 walk-in patients with fever and respiratory symptoms. Six were admitted to the medical wards, displacing chronic cases that were judged stable enough for discharge. Seventeen were sent home with instructions to rest in bed and call a doctor. The instructions were printed on a card that the hospital had used for influenza since 1890. No physician reviewed the discharged cases. The emergency room log, examined later, showed that three of the seventeen died at home within forty-eight hours.

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At 5:00 p.m., the pharmacy closed for the day. The clerk totaled the sales book: 89 bottles of aspirin, 31 of quinine, the highest single-day figures in his three years at the store. The pharmacist on duty, the same man who had said nothing that morning, now remarked to the clerk that there must be something going around. The clerk agreed. Neither man named the parade. The connection required a step that would have seemed, to both of them, like speculation. They locked the store and walked to the trolley stop in silence.

The evening newspapers of September 30 carried no mention of influenza. The Inquirer’s editorial page celebrated the spirit of Philadelphia demonstrated in the Liberty Loan campaign. The Bulletin reported on a City Council debate about street paving. The weather forecast predicted continued cool temperatures. The distance between recorded fact and recognized pattern had not yet closed.

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At 8:00 p.m., the head nurse completed her second consecutive double shift at Pennsylvania Hospital. She had slept for three hours in the nurses’ quarters, rising to cover another absence. The duty book now recorded seven nurses sick with influenza, suspected, two more absent without explanation. The hospital administrator, a layman who had managed the institution through the wartime expansion, had approved the conversion of two private rooms on the surgical ward to isolation quarters for infectious cases. The conversion was not complete. The six patients now occupying the rooms had been moved from the medical wards without screening or barrier nursing. The head nurse made a final notation: conditions unsatisfactory, recommend full isolation protocol. She did not specify what protocol she meant. None existed for this situation.

The night of September 30 brought 14 new admissions to Pennsylvania Hospital, all with influenza or pneumonia. The medical superintendent, awakened at 2:00 a.m. by the night supervisor, authorized the opening of an overflow ward in the basement laundry room. The laundry equipment was pushed against the walls. Cots were brought from storage. The first patient admitted to the overflow ward, a woman of twenty-six, died before morning. Her death was recorded at 5:47 a.m. on October 1, the first civilian death from influenza to be reported to the Bureau of Health.

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The morning of October 1 broke clear and cold. The temperature was 41 degrees. The Inquirer’s early edition carried a three-paragraph item on page four: Influenza Spreads in City. The story quoted Krusen as stating that the situation is under control and that there is no cause for alarm. The reporter had telephoned the Bureau of Health at 9:00 p.m. on September 30. Krusen, working late, had answered the call himself. The single civilian death was not yet known to him. The 14 overnight admissions at Pennsylvania Hospital had not been reported. The story ran with a photograph of Krusen taken at the Liberty Loan parade, his face turned toward the marching troops.

At 7:00 a.m., the Pennsylvania Hospital switchboard logged 22 telephone calls in the first hour of operation. The pattern had changed again: the calls now came from other hospitals, smaller institutions in the city and suburbs, requesting transfer of critical cases. The admitting clerk, following no protocol for inter-hospital transfer, took messages and promised callbacks. The medical superintendent, arriving at 8:00 a.m., found the switchboard jammed and the admitting office in confusion. He telephoned Krusen’s office at 8:30 a.m. The line was busy. He telephoned again at 8:45. A clerk answered and took a message. Krusen was in conference with the mayor.

The conference, held in the mayor’s office on the second floor of City Hall, concerned the Liberty Loan victory celebration scheduled for October 5. The mayor wished to stage a second parade, smaller than the first, to honor the bond volunteers. Krusen attended as a member of the planning committee. He raised no objection. The meeting ended at 9:30 a.m. Krusen returned to his office and found the message from Pennsylvania Hospital. He telephoned the medical superintendent at 9:45 a.m. The superintendent reported unusual pressure and staff shortages. Krusen promised to look into it. He did not visit the hospital. His morning schedule included a meeting with the state health commissioner, who was visiting Philadelphia to discuss winter sanitation campaigns.

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The state health commissioner, a Dr. Samuel G. Dixon, had spent the morning of October 1 reviewing reports from Pittsburgh, where influenza had appeared in late September. Dixon’s assessment, later published in the Pennsylvania Department of Health bulletin, described the Pittsburgh outbreak as moderate in severity and typical of autumnal influenza. He had not seen the Philadelphia figures. Krusen, meeting him at 11:00 a.m., presented the Bureau’s morbidity report for September 30: 118 cases, no deaths, situation under control. Dixon expressed satisfaction. The two men discussed winter sanitation and parted at noon.

That afternoon, the medical superintendent of Pennsylvania Hospital telephoned Krusen’s office three times. The third call, at 3:15 p.m., reached the health director directly.

The superintendent reported that his laundry-room overflow ward held 11 patients, that 3 nurses had collapsed on duty that day, and that the hospital could no longer accept emergency admissions without specific authorization from the Bureau of Health. Krusen asked for a written report. The superintendent promised to deliver it by messenger.

Krusen placed the telephone receiver in its cradle and sat for a moment with his hands flat on the desk. The afternoon light through the window fell on the Liberty Loan commemorative pin in his lapel. He did not remove it.

He opened his appointment book and wrote, in his own hand, a notation for October 2: visit Pennsylvania Hospital, 9:00 a.m. The notation was the first entry in his official record that acknowledged the civilian hospitals as part of his responsibility. The confidence loop, sustained for forty-eight hours by the grammar of individual cases and the syntax of reassurance, had begun to crack where hospital reality pressed against official optimism. The scattered reports of strain had coalesced into a pattern visible to frontline workers, creating undeniable pressure that must now breach the defenses of City Hall.