On Sunday, September 15, 1918, Lieutenant Vernon Stacy, on leave from the Great Lakes Naval Training Station near East Chicago, Ill., called at the home of friend William Westphal on Milwaukee’s Second Avenue to visit his friend who was feeling unwell. Later that day, Lieutenant Stacy began feeling ill himself and was subsequently admitted to Milwaukee’s Emergency Hospital with symptoms of influenza. Westphal, despite his sickness, then traveled to nearby Racine, Wisconsin, where he died of pneumonia a day later. The Milwaukee area influenza epidemic had begun. 1

Unfortunately, as in nearly every state and community across the United States, influenza was not yet a mandatory reportable disease. As a result, Milwaukee Health Commissioner George C. Ruhland had no way of knowing how widespread the disease in his city may have been. Not taking any chances, Ruhland cautioned people to take the threat of an impending influenza epidemic seriously and assigned his second-in-command, John P. Koehler, M.D., to attend to Stacy and a second out-of-town influenza case at Emergency Hospital.2

Across the state line, three Chicago-area naval and military camps were in varying stages of their own fights with influenza. Understanding the danger they posed to Milwaukee, Health Commissioner George C. Ruhland asked military officials to keep the men clear of his city until their influenza epidemics abated.3 Over the next two weeks, the succession of self-imposed emergency quarantines at these installations had the effect of dramatically reducing the number of young men in uniform seen around Milwaukee.4

For the time being, it seemed as if influenza was off to a slow start. Suspecting that the disease might be more widely circulating in Milwaukee, however, Ruhland performed a quick telegram canvas of Milwaukee’s physicians. In response, they reported 100 cases of influenza and/or colds, a small amount for that time of year. Nevertheless, Ruhland asked physicians to promptly report all cases of influenza to the Health Department.5,6

Most physicians in the city shared Health Commissioner Ruhland’s thinking and took the infection’s threat seriously. Consequently, many honored his request for voluntary reporting. On September 26, they reported six cases of influenza to the Health Department, for an estimated total of 110 current cases. Four days later, the report was far worse when nearly 100 new cases were recorded at the Health Department in a 24-hour span. Immediately, Ruhland called a meeting with prominent Milwaukee physicians to engage their cooperation in safeguarding the public in the inevitable battle against influenza.

As a result of this meeting with the medical community, Health Commissioner Ruhland instructed the Health Department to order educational posters and flyers, and rapidly made them available to area businesses.7,8 These materials set into motion an immense public education campaign, with printed literature in various languages, including English, German, Russian, Lithuanian, Yiddish, and Italian.9 The influenza education campaign was both impressive and comprehensive because it identified speakers, speaker materials, clergy to discuss the flyers from the pulpit, physicians willing to serve as public speakers, and lantern slides for motion picture houses. Thanks to the cooperation of many in the community, all these elements came together rapidly.

Health Commissioner Ruhland also met with the city’s newspaper editors to enlist their support. All agreed that rousing the public to action without causing undue panic was the best way to support Health Department goals.10 In fact, Ruhland made a point in the succeeding months to meet with key stakeholders in the medical, business, and social services sectors to enlist their support for emergency measures to combat influenza.11

In keeping with his longstanding commitment to community involvement, Health Commissioner Ruhland appointed an emergency advisory committee consisting of Otto Falk, president of Allis-Chalmers Manufacturing Company, Dr. Hoyt E. Dearholt, Head of the Wisconsin Anti-Tuberculosis Association, Dr. Louis F. Jermain, Dean of Marquette University’s medical school, and Carl Herzfeld, president of the Boston Store, a large downtown retail establishment.12 Others were added or subtracted in succeeding months depending on the issues at hand.

On October 7, the Health Department recorded 214 new cases for the previous 24 hours, and this galvanized Health Commissioner Ruhland to enlarge his epidemic strategy. He immediately met with the County Council of Defense’ health committee and together they agreed it was time to establish multiple isolation hospitals. In doing so, they acknowledged that current hospital resources were insufficient. County government also got involved and agreed to pay fifty-percent of emergency hospital costs up to $15,000. There was one proviso: earmark the funds for the city’s poor. Milwaukee’s Common Council also came through with a unanimous appropriation for $15,000.

These monies worked wonders, and 30 hours after Health Commissioner Ruhland’s meeting with the County Council, the Milwaukee Citizen’s Bureau of Municipal Efficiency succeeded in transforming the vacant Nunnemacher residence into a fully equipped emergency hospital for 50 patients.13,14

From the beginning, Health Commissioner Ruhland planned to have several emergency hospitals at the ready, so these were prepared shortly after the Nunnemacher residence was fully outfitted for influenza cases. The two additional emergency hospitals, one for men and one for women, were set up in Milwaukee’s massive new civics center, the Milwaukee Auditorium. Rapid action by the Citizen’s Bureau of Municipal Efficiency readied its Juneau and Engelmann Halls to house 100 patients each.15 As they filled, the Nunnemacher residence was converted to an emergency hospital for children.

Securing adequate medical staffing was as important as securing facilities, so the Health Department shifted its own nurses to the three emergency hospitals, supplemented by Red Cross volunteers.16 At the same time, the Department wanted routine child welfare, tuberculosis, and school programs to remain intact. And this did happen, thanks to the Wisconsin Anti-Tuberculosis Association, whose staff and public education graduates backfilled in these three areas.

At the end of the first week in October, there were just under 1,000 active cases in Milwaukee and people began to wonder about mandatory closures. Though some groups voluntarily cancelled meetings and events, Health Commissioner Ruhland’s advisors decided on October 9 not to make such closures mandatory.

The State believed otherwise, as Milwaukee found out the next day when Wisconsin’s State Health Officer Dr. Cornelius A. Harper issued an advisory order for all parts of the state. It suggested – but did not mandate – closure for schools, churches, places of amusement and all other places of public gathering. Although Health Officer Harper’s directive wasn’t binding because the State Board of Health didn’t have the power to mandate these closings, Wisconsin’s public health officers knew the ‘advisory’ was expected to be carried out everywhere. Unfortunately, there was a snag in Milwaukee because its Health Department wasn’t officially notified in an immediate fashion. As a result, the press published the advisory before Health Commissioner Ruhland and his advisory board had a plan to implement its suggestions.17

Scrambling, Health Commissioner Ruhland asked for and received authority from the Common Council to act summarily. 18 He quickly pulled together his advisors and together they agreed to close all places of amusement, churches, meetings, and places where the public gathered, and to ban public funerals. They also ordered disinfection and better ventilation in common carriers, but agreed to delay enforcement of all orders for 24 hours. This permitted affected groups time to implement their closures or restrictions in an orderly fashion. There were a number of exceptions to these closures: courts, restaurants, hotel dining rooms, saloons, and retail stores stayed open.19 Since he was still without an actual state document for reference, the Ruhland also added schools to the list of exceptions.20

Saturday, October 12, dawned with a grim tally of the disease’s toll: 3,084 cases since September 1, and 67 deaths. This clearly called for a new look at the school situation, so Health Commissioner Ruhland gathered his advisors and various school board members from Milwaukee’s public and private school systems. In spite of the short notice, the group closed schools effective Monday morning, leaving school officials scrambling to notify 4,000 public and 61,000 parochial school children and their 1,700 teachers.

The closures freed up public and parochial school doctors and nurses, and these were deployed to the three emergency hospitals and in making home visits. 21 Teachers were also freed up, and 300 responded to Health Commissioner Ruhland’s request for teachers to conduct a door-to-door canvass to help locate unreported sick Milwaukeeans.

Even with these shifts in school medical personnel, there still weren’t enough physicians and nurses at the three emergency hospitals. Thankfully, the epidemic was on the wane at the Great Lakes Naval Training Station, and its quarantine lifted.22 Captain W. A. Moffett, the station’s commandant, generously sent nurses, aides, and orderlies to Milwaukee and other nearby Wisconsin and Illinois communities as their situations worsened.

Back in Milwaukee, saloons presented a dilemma. All of them were open, even the ones without food service. The problem was, of course, that people lingered at the bar or collected for long periods at the tables. Health Commissioner Ruhland’s solution: dining as usual, but for patrons stopping by for liquid refreshment: drink quickly and leave.23 More than one clergyman wondered why saloons were open and churches closed, and some petitioned the Health Department unsuccessfully to resume religious services.24

Overcrowding in streetcars was another problem that defied correction, so in mid-October, the Health Commissioner requested stores and factories to stagger their hours. To make sure retailers understood the importance of the request, the advisory board met with retailers, who agreed to close stores every Saturday night at 5 p.m. for the duration of the epidemic.25,26

By October 18, the daily tally of new cases dipped below 300 for the first time in a week. Nonetheless, patients crowded into the three emergency hospitals, creating a need for more health workers, so the Health Department invited the Red Cross to set up a central registration bureau for nurses. They did this gladly and as a result, the distribution of nurses to institutions, hospitals, and private homes became more effective.27

The number of new cases continued to decline and by the third week in October, people including Milwaukee’s theater owners believed the influenza was almost over. Accordingly, they organized and sent a number of pleas to Health Commissioner Ruhland to lift the bans on public gatherings, but to no effect. As more businesses clamored for relief, Ruhland pointed out the consequence of overconfidence in other cities, where lifting bans prematurely resulted in a resurgence of the infectious disease.28

By the end of October, when the Health Department was confident influenza was in a significant decline, though still present, it announced plans to transfer patients from the two Auditorium hospitals to the Nunnamacher residence, and henceforth operate just the one emergency hospital. There were fewer than 500 active cases registered with the Health Department when Health Commissioner Ruhland and his advisors set Sunday, November 3 as the last day for citywide bans, with two exceptions: his orders against overcrowding in saloons and street cars remained in force.29

Throughout November, influenza maintained such a tenacious grip on Milwaukee that Health Commissioner Ruhland continued to meet with his advisory board, gradually opening the meetings to include physicians, hospital administrators, businessmen, and Red Cross and other relief agency leaders. Together, they readied another plan to eliminate influenza in Milwaukee.30 The first step occurred the day after Thanksgiving, when the Health Department reopened the Nunnemacher residence and made arrangements for other area hospitals to transfer their influenza patients. The Common Council appropriated $5,000 immediately for the Health Department, and another $25,000 in contingency funding, and Milwaukee’s health delivery system geared up for another bout with influenza.

Much of what Milwaukee did to suppress influenza in December paralleled October’s steps. However, there were some differences. For example, although the Nunnemacher residence stayed open to treat children, the Health Department reversed itself and arranged for the city’s hospitals to care for adults. Presumably this change represented an opportunity for improvement over the emergency hospital method of care delivery. Health Commissioner Ruhland also organized nurses to provide home care, and recommended that people wear gauze masks.31,32

Other departures from the October plan were characterized by a shift in responsibility to members of the public and in this way, to avoid outright bans on public gatherings, churches, and places of amusement. And for the first time, Health Commissioner Ruhland turned to placarding. Only the state had the power to order placarding, so Ruhland conferred with State Health Officer Cornelius A. Harper on the best way to introduce placarding in Milwaukee. In keeping with Ruhland’s philosophy to enlist cooperation whenever possible, the pair chose a voluntary approach, but added the full weight of the state for good measure. Thus, the letter sent to Milwaukee’s physicians requesting they placard homes of influenza patients was signed by Harper, rather than Ruhland.33,34

For this second bout with influenza, Health Commissioner Ruhland ordered schools closed, along with several specific public buildings and all municipal gathering places, but everything else was open: saloons, theaters, churches, and all public gatherings. However, Ruhland mandated severe, detailed restrictions governing the amount of personal space surrounding people in public. For example, every other row was vacant in theaters and churches, and retail customers surrounded themselves with six square feet of vacant space. Milwaukee used several different types of streetcars, and each was assigned a maximum number of riders per car. As an extra measure to ensure success, more cars were pressed into service. Ruhland banned children under 15 from theaters, churches or other public gatherings, nor were they allowed on streetcars after 7 p.m.35

These changes in Milwaukee’s campaign against influenza made little difference – the December epidemic was as severe as its October counterpart. The daily tally of new cases exceeded 450 on the same day schools closed, and for much of December, two and three thousand people at a time were bedridden with influenza or pneumonia, according to the Health Department.

Often, editions of Milwaukee’s major papers reported complaints of non-compliance, but Health Commissioner Ruhland’s commitment to communication paid off once again: because he met almost daily with representatives from offending theaters and churches and pressed for compliance, Ruhland never felt compelled to exercise his power to order a total closure.

Resources were stretched seemingly to the limit, so the City introduced a number of new approaches to care for the sick. When invalids outside the hospitals needed care, social service agencies addressed their needs. When busy druggists cut short their customers’ health questions, Deputy Health Commissioner John P. Koehler placed doctors in some of the pharmacies to provide self-care information.36 When invalids needed nourishment, the Defense Council opened a kitchen and provided soups, gelatins, and custards to influenza patients. The Red Cross provided home delivery services for these foods, which were prepared at cost for those able to pay, and free to anyone in need.37

The pressures to deliver services continued to mount. Fortunately, just as hospitals ran out of room in mid-December, the number of new cases began a downward decline. In spite of this decline, the city still needed more funds to care for the needy, so Health Commissioner Ruhland turned again to the Common Council. This time, there was some dissent in chambers, but Ruhland still got the funding he wanted.38 Finally, just in time for Christmas, the number of new cases reported in one day slipped below 100, prompting Ruhland to lift restrictions for everyone, with one exception: couples on the dance floor continued to wear face masks into the new year.39

Conclusion

Even with two influenza episodes between October and December 1918, the magnitude of Milwaukee’s brush with the epidemic was less severe than most other large U.S. cities. The excess death rate in this city of 457,147 was 292 per 100,000 people. By comparison, Chicago experienced an excess death rate of 373 per 100,000.40

Health Commissioner George C. Ruhland believed there were three reasons Milwaukee had better outcomes than many other large cities: 1) readiness of the public to comply with regulatory measures “for which they had been prepared by reports of what happened in other cities”; 2) early closing orders and wide publicity; and 3) the splendid cooperation which the Health Department had from the Common Council and various community groups.41

Further, he understood that closures don’t prevent influenza: they help to flatten the peak incidences of the infection, resulting in less crisis in allocating health workers and supplies. He stated that “it must be recognized that the closure order could do no more than stagger the peak in the incidence of the infection. By avoiding the simultaneous development of large numbers of cases, for which neither an adequate number of physicians nor hospital facilities were available, the spread of the disease itself undoubtedly was checked as well as the number of deaths lessened.”42